title: National Transportation Safety Board link: https://www.ntsb.gov/ description: Completed investigation reports from the National Transportation Safety Board of the United States. generator: ITSB last-modified: 2024-03-28T13:40:41Z language: en-US errorsto: lucidiot@brainshit.fr title: DCA21SR003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103683/pdf description:
Unique identifier
103683
NTSB case number
DCA21SR003
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-09-28T04:00:00Z
Location
Injuries
null fatal, null serious, null minor
Has safety recommendations
true
creator: NTSB last-modified: 2023-09-28T04:00:00Z guid: 103683 uri: 103683 title: LAX75FUJ49 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/170175/pdf description:
Unique identifier
170175
NTSB case number
LAX75FUJ49
Transportation mode
Aviation
Completion status
Completed
Occurrence date
1975-01-05T05:00:00Z
Publication date
2027-02-27T05:00:00Z
Event type
Accident
Location
GRAND CANYON, Arizona
Airport
(null)
Weather conditions
VFR
Injuries
0 fatal, 1 serious, 0 minor

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7GCBC
Amateur built
false
Engines
1 Reciprocating
Registration number
N5136T
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
Damage level
Destroyed
Events
last-modified: 2027-02-27T05:00:00Z guid: 170175 uri: 170175 title: NYC77FA058 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/158237/pdf description:
Unique identifier
158237
NTSB case number
NYC77FA058
Transportation mode
Aviation
Completion status
Completed
Occurrence date
1977-05-20T04:00:00Z
Publication date
2023-06-23T04:00:00Z
Event type
Accident
Location
PLYMOUTH, Massachusetts
Airport
PLYMOUTH (null)
Weather conditions
VFR
Injuries
0 fatal, 1 serious, 0 minor

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
1 Reciprocating
Registration number
N8661Y
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Scheduled flight
Damage level
Substantial
Events
last-modified: 2023-06-23T04:00:00Z guid: 158237 uri: 158237 title: ATL83MA084 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6222/pdf description:
Unique identifier
6222
NTSB case number
ATL83MA084
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-01-09T18:44:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Event type
Accident
Location
CHERRY POINT, North Carolina
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
7 fatal, 0 serious, 0 minor
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
D55
Amateur built
false
Engines
1 Reciprocating
Registration number
N7142N
Operator
HENRY H. TIFFANY
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TE-497
Damage level
Destroyed

Vehicle 2

Aircraft category
Airplane
Make
McDonnell Douglas
Model
F4C
Amateur built
false
Engines
1 Turbo jet
Registration number
AFNG
Operator
Second pilot present
false
Flight conducted under
Armed Forces
Flight operation type
Public aircraft
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
637536
Damage level
Substantial
creator: NTSB last-modified: 2023-04-20T04:00:00Z guid: 6222 uri: 6222 title: DEN83LA052 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/16034/pdf description:
Unique identifier
16034
NTSB case number
DEN83LA052
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-01-19T11:45:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Mount Pleasant, Utah
Airport
MT. PLEASANT (43U)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
BEFORE DEPARTING SALT LAKE CITY, UT, THE PILOT OBTAINED INFORMATION ABOUT THE WEATHER AND DESTINATION AIRPORT AT MT PLEASANT, UT. THE WEATHER WAS REPORTED VFR AND THE MT PLEASANT MUNICIPAL AIRPORT WAS REPORTED OPEN. DURING ARRIVAL, THE PILOT OBSERVED FURROWS OF PLOWED SNOW ON BOTH SIDES OF THE RUNWAY AND SAW WHAT HE THOUGHT WAS A LIGHT COVERING OF NEW SNOW ON THE FURROWS AND RUNWAY. HOWEVER, THE SNOW ON THE RUNWAY WAS 6 INCHES THICK AND COVERED WITH A CRUST OF ICE. THE PILOT ELECTED TO LAND. AFTER TOUCHDOWN, THE PLANE CONTINUED NORMALLY FOR 75 TO 100 FT, THEN THE MAIN WHEELS BROKE THROUGH THE CRUST AND THE AIRCRAFT NOSED OVER. AN INVESTIGATION REVEALED THAT THE AIRPORT WAS UNMANAGED AND NO OFFICIAL OPERATIONS WERE CONDUCTED THERE DURING THE WINTER MONTHS. THEREFORE, NO NOTICE OF THE FIELD CONDITION WAS GIVEN TO THE FSS. SINCE THE FSS WAS UNAWARE OF THE EXTENT OF THE SNOW COVERING, NO NOTAM WAS ISSUED.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N9672P
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
187509015
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 16034 uri: 16034 title: NYC83LA018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/35141/pdf description:
Unique identifier
35141
NTSB case number
NYC83LA018
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-01-29T13:00:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Dansville, New York
Airport
DANSVILLE (DSV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
DURING LANDING THE FLANGE ON THE RIGHT MAIN LANDING GEAR STRUT BROKE OFF ALLOWING THE SHOCK CORD TO COLLAPSE.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N7523D
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-5251
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 35141 uri: 35141 title: MKC83LA075 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33388/pdf description:
Unique identifier
33388
NTSB case number
MKC83LA075
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-03-07T17:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Ollie, Iowa
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE STUDENT REPORTED THAT THE ENG LOST APRX 500 RPM WHILE HE WAS PRACTICING TURNS & STALLS AT AN ALTITUDE OF APRX 3500 FT MSL. REPORTEDLY, THE SITUATION BECAME WORSE & HE WAS UNABLE TO MAINTAIN ALTITUDE. HE APPLIED CARBURETOR HEAT, BUT IT DID NOT HELP. SUBSEQUENTLY, A PRECAUTIONARY LANDING WAS MADE. DURING THE LANDING ROLL, THE NOSEWHEEL SANK IN SOFT TERRAIN & THE ACFT NOSED OVER. AN EXAM & DISASSEMBLY OF THE ENG DID NOT DISCLOSE ANY EVIDENCE OF A MALFUNCTION OR FAILURE THAT CONTRIBUTED TO THE POWER LOSS. THE TEMP & DEW POINT WERE 40 DEG, RESPECTIVELY. ACCORDING TO ICING PROBABILITY CHARTS, SERIOUS CARBURETOR ICING COULD OCCUR AT GLIDE POWER & SERIOUS CARBURETOR ICING CONDITIONS EXITED FOR CRUISE POWER.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N8803G
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15062903
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 33388 uri: 33388 title: FTW83LA344 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20983/pdf description:
Unique identifier
20983
NTSB case number
FTW83LA344
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-04-20T15:30:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
New Braunfels, Texas
Airport
NEW BRAUNFELS (3RT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT MADE A HARD LANDING WHICH WAS HARD ENOUGH TO BLOW THE NOSE GEAR TIRE AND COLLAPSE THE NOSE GEAR ASSEMBLY.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172D
Amateur built
false
Engines
1 Reciprocating
Registration number
N2419U
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17250019
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 20983 uri: 20983 title: CHI83LA202 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/12165/pdf description:
Unique identifier
12165
NTSB case number
CHI83LA202
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-05-06T14:15:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Lansing, Michigan
Airport
LANSING MUNI (3HA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT OVERRAN THE RWY AND SLID ON WET GRASS INTO A DITCH. THE RWY WAS 2432 FT LONG AND THE WIND WAS FROM 180 DEGREES AT 12 KTS GUSTING TO 29 KTS. THE PLT SAID THAT JUST PRIOR TO TOUCHDOWN THE AIRSPEED SEEMED TO INCREASE AND THE ACFT FLOATED FARTHER DOWN THE RWY THAN USUAL. NO ACFT PROBLEMS OR MALFUNCTIONS WERE REPORTED. THE PLT SAID A GO-AROUND WAS NOT POSSIBLE BECAUSE HIS AIRSPEED WAS TOO LOW.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
P210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N734NX
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Executive/Corporate
Commercial sightseeing flight
false
Serial number
P210-00608
Damage level
Substantial
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 12165 uri: 12165 title: FTW83LA220 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20892/pdf description:
Unique identifier
20892
NTSB case number
FTW83LA220
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-05-11T07:00:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Bastrop, Louisiana
Airport
MOLLICE FARM ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
AFTER ARRIVING, THE PLT MADE A PASS OVER THE TURF STRIP TO INSPECT IT BEFORE LANDING. HE ELECTED TO LAND; HOWEVER, DURING THE LANDING ROLL-OUT, HE SAW A DITCH RUNNING LATERALLY ACROSS THE STRIP, BUT BY THEN, HE WAS UNABLE TO AVOID IT. SUBEQUENTLY, THE ACFT HIT THE WASHED OUT AREA & NOSED OVER.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
G-164A
Amateur built
false
Engines
1 Reciprocating
Registration number
N6743Q
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
1715
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 20892 uri: 20892 title: FTW83LA263 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/20920/pdf description:
Unique identifier
20920
NTSB case number
FTW83LA263
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-06-04T22:45:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Texarkana, Arkansas
Airport
TEXARKANA MUNI (TXK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT LANDED SHORT OF THE RWY AND THE LANDING GEAR COLLAPSED DURING A NIGHT LANDING. ELECTRICAL FAILURE OCCURRED ON THE ACFT SHORTLY AFTER TAKEOFF. WHEN ELECT RECAL POWER COULD NOT BE RESTORED THE PLT ELECTED TO RETURN TO TEXARKANA AND LAND USING VASI. THE PLT COULD NOT ACTIVATE THE RWY LIGHTS. THE PASSENGER HELD A FLASHLIGHT TRYING TO SEE THE GROUND ON SHORT FINAL. THE PLT REALIZED HE NEEDED THE LIGHT ON HIS AIRSPEED IN TRYING RETRIEVE IT THE ACFT BEGAN TO BUFFET. THE PLT LOWERED THE ACFT NOSE AND HIT THE GROUND 50-75 FT SHORT OF THE RWY. BECAUSE OF IMPACT DAMAGE THE ELECTRICAL SYSTEM COULD NOT BE CHECKED AFTER THE ACCIDENT.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N57328
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
34-7450051
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 20920 uri: 20920 title: CHI83FU003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/12036/pdf description:
Unique identifier
12036
NTSB case number
CHI83FU003
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-06-08T21:08:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Fraser, Michigan
Airport
FRASER (D13)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
A WITNESS REPORTED THAT THIS ULTRALIGHT WAS 1 OF 3 THAT TOOK OFF ON RWY 18, THEN TURNED 180 DEG TO A NORTHERLY HEADING. HE REPORTED THAT THE ULTRALIGHT WAS IN LEVEL FLT AT APRX 200 FT WHEN IT SUDDENLY PITCHED NOSE DOWN, THEN IT NOSED UP. AT ABOUT THAT TIME, HE NOTICED THAT THE LEFT WING WAS PARTIALLY BROKEN & THE OUTERMOST PART OF THE WING WAS FLAPPING INDEPENDENTLY FROM THE MOTION OF THE REST OF THE ACFT. THE WITNESS STATED THAT THE ULTRALIGHT ENTERED A STEEP NOSE DOWN ATTITUDE, BECAME INVERTED & CRASHED. REPORTEDLY, THE ACCIDENT OCCURRED WHEN 1 OF THE WING SUPPORT WIRES SEPARATED.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Ultralight
Make
SUNBURST
Model
1
Amateur built
true
Engines
1 Unknown
Registration number
UNREG
Operator
Second pilot present
false
Flight conducted under
Part 103: Ultralight
Flight operation type
Personal
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 12036 uri: 12036 title: ATL83FKG08 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/5965/pdf description:
Unique identifier
5965
NTSB case number
ATL83FKG08
Transportation mode
Aviation
Completion status
Completed
Occurrence date
1983-06-10T20:30:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Ashburn, Georgia
Airport
TURNER COUNTY (75J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
THE PLT REPORTED THAT AFTER THE 4TH PASS, HE HAD JUST COMPLETED A TURN OVER A WOODED AREA WHEN THE ENGINE POWER WENT TO IDLE RPM. HE WAS FORCED TO LAND IN THE TREES, ADJACENT TO THE FIELD THAT HE WAS SPRAYING. NO PREIMPACT, MECHANICAL FAILURE WAS FOUND. THE PLT REPORTED ONLY 1 HR OF PREVIOUS FLT EXPERIENCE IN THIS MAKE & MODEL.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188B
Amateur built
false
Engines
1 Reciprocating
Registration number
N21830
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
18801065
Damage level
Destroyed
last-modified: 2023-06-27T04:00:00Z guid: 5965 uri: 5965 title: ATL83LA250 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6108/pdf description:
Unique identifier
6108
NTSB case number
ATL83LA250
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-07-02T09:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Tuscaloosa, Alabama
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
-
Analysis
THE ACFT COLLIDED WITH A POWER LINE SPANNING A RIVER DURING A LOW PASS OVER THE WATER. THE PILOT SAID THE PURPOSE OF THELOW PASS WAS TO LOOK FOR HIS FATHER IN A BOAT. HE SAID HE THOUGHT HE SAW THE BOAT AND IN PULLING UP THE ACFT HIT THE POWER LINE. CONTROL WAS LOST AND THE ACFT COLLIDED WITH THE WATER AND SANK.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N8876U
Operator
WILLIAM FRANKLIN
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
78010
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 6108 uri: 6108 title: LAX83FUA05 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/23539/pdf description:
Unique identifier
23539
NTSB case number
LAX83FUA05
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-07-11T19:10:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Long Beach, California
Airport
DAUGHERTY (LGB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
WHILE TURNING DOWNWIND IN A CLOSED PATTERN THE ENG LOST POWER. THE ACFT CRASH LANDED IN A RISIDENTIAL STREET & STRUCK POWER LINES & POLES. A PORTION OF THE SPONGE MATERIAL ATTACHED TO THE CARBURETOR INLET SCREEN HAD BECOME DETACHED & LODGED IN THE THROAT OF THE CARBURETOR.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N6554S
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15067354
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 23539 uri: 23539 title: NYC83FHD04 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/35102/pdf description:
Unique identifier
35102
NTSB case number
NYC83FHD04
Transportation mode
Aviation
Completion status
Completed
Occurrence date
1983-08-02T14:45:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Atlantic City, New Jersey
Airport
BADER FIELD ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT MADE 2 ATTEMPTS TO TAKEOFF. ON THE SECOND ATTEMPT, THE ACFT LIFTED OFF TO ABOUT 30 FT. THE PLT STATED THAT THE ENG LOST RPM (FROM 2450 TO 1700 RPM), SO HE ABORTED THE TAKEOFF. THE ACFT PORPOISED ABOUT 3 TIMES & CONTINUED OFF THE END OF THE RWY & CAME TO REST IN A BAY. A WITNESS SAID THE ENG WAS CUTTING OUT DURING BOTH ATTEMPTS TO TAKEOFF.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172L
Amateur built
false
Engines
1 Reciprocating
Registration number
N9862G
Operator
MIKE F. MOONEY
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
59762
Damage level
Substantial
last-modified: 2023-06-13T04:00:00Z guid: 35102 uri: 35102 title: MKC83LA186 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33466/pdf description:
Unique identifier
33466
NTSB case number
MKC83LA186
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-08-11T17:15:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Storm Lake, Iowa
Airport
STORM LAKE MUNI (SLB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT RAN OFF THE RIGHT SIDE OF THE RWY AND COLLAPSED THE RIGHT LANDING GEAR. THE ACFT LANDING ON RWY 35 WITH THE WIND FROM THE NORTHEAST AT 7 TO 10 KTS. THE PILOT SAID THE ACFT TURNED LEFT AFTER TOUCHDOWN AND SHE CORRECTED WITH RIGHT RUDDER, THEN THE ACFT TURNED RIGHT. AS THE PILOT TRIED TO REGAIN CONTROL THE ACFT SWERVED LEFT AND RIGHT AGAIN ANDRAN OFF THE RIGHT SIDE OF THE RWY. THE ACFT COLLIDED WITH 3 RWY LIGHTS AND THE RIGHT GEAR BROKE OFF. NO MECHANICAL DEFICIENCIES WERE NOTED WHICH WOULD HAVE CONTRIBUTED TO THE LOSS OF CONTROL.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-301
Amateur built
false
Engines
1 Reciprocating
Registration number
N84581
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-8206004
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 33466 uri: 33466 title: ATL83LA345 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6183/pdf description:
Unique identifier
6183
NTSB case number
ATL83LA345
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-08-30T13:50:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Middlebourne, West Virginia
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
THE PLT REPORTED THAT EN ROUTE, THE ENG BEGAN TO RUN ROUGH. REPORTEDLY, HE APPLIED CARBURETOR HEAT, FULL RICH MIXTURE & FULL THROTTLE, BUT WAS UNABLE TO SIGNIFICANTLY INCREASE THE POWER. HE CIRCLED FOR A SHORT TIME, THEN MADE AN EMERGENCY LANDING. AN EXAM OF THE ENG REVEALED SOOTED SPARK PLUGS & OIL FOULING OF THE #2 & #4 LOWER SPARK PLUGS. NO APPARENT MECHANICAL FAILURE OR MALFUNCTION WAS VERIFIED. THE TEMP & DEW POINT WERE 87 & 67 DEG, RESPECTIVELY. DAMAGE HAD OCCURRED DURING THE LANDING ROLL WHEN THE ACFT ENCOUNTERED A GULLEY.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172E
Amateur built
false
Engines
1 Reciprocating
Registration number
N5331T
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17251231
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 6183 uri: 6183 title: DEN83LA204 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/16149/pdf description:
Unique identifier
16149
NTSB case number
DEN83LA204
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-08-31T14:10:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Manning, North Dakota
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT COLLIDED WITH THE GROUND AFTER AN ENG FAILURE WHILE STRINGING POWER LINES. THE ACFT WAS IN A RIGHT SIDE LOW, NOSE HIGH ATTITUDE PULLING A WIRE ATTACHED TO THE LEFT SIDE OF THE ACFT. THE WIND WAS FROM THE RIGHT REAR QUARTER WHEN THE LOSS OF POWER OCCURRED WITHOUT WARNING. THE ACFT ROTATED 45 DEGREES & THE PLT ONLY HAD TIME TO LEVEL THE ACFT AND MAKE A PITCH PULL PRIOR TO IMPACT FROM THE LOW ALTITUDE OF 150 FT AGL. THE ACFT IMPACTED LEVEL WITH NO FORWARD SPEED, THE SKIDS FAILED AND THE ACFT ROLLED OVER. THE PLT SUSPECTED FUEL STARVATION DUE TO ACFT ATTITUDE AND INERTIA. THE ACFT HAS ONE FUEL PICK-UP IN THE TANK.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HILLER
Model
UH-12E
Amateur built
false
Engines
1 Reciprocating
Registration number
N400AH
Operator
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Business
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
1177
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 16149 uri: 16149 title: ATL83LA359 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6197/pdf description:
Unique identifier
6197
NTSB case number
ATL83LA359
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-09-08T13:50:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Fairmont, West Virginia
Airport
FAIRMONT MUNICIPAL (4G7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT REPORTED THAT DURING ARRIVAL, HE FLEW OVER THE FIELD, CHECKED THE WIND INDICATOR, THEN ELECTED TO LAND ON RWY 4. WHILE IN THE TRAFFIC PATTERN, HE NOTICED TALL TREES AT THE APCH END OF THE RWY & THAT THE RWY DROPPED OFF AT THE OTHER END. HE MADE HIS APCH OVER THE TREES, THEN TOUCHED DOWN ABOUT HALFWAY DOWN THE DOWNWARD SLOPING RWY. THE ACFT BOUNCED & HE ADDED POWER TO RECOVER. HE STATED THAT HE DID NOT FEEL THERE WAS SUFFICIENT RWY REMAINING TO CLEAR TREES AT THE DEPARTURE END OR TO STOP PRIOR TO RUNNING OFF THE END WHERE THE TERRAIN DROPPED OFF. THEREFORE, THE PLT ELECTED TO GO OFF THE RWY & GROUND LOOP THE THE ACFT. WHEN HE DID THIS, THE GEAR COLLAPSED & THE ACFT SKIDDED ABOUT 100 FT BEFORE COMING TO REST.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
AA-5B
Amateur built
false
Engines
1 Reciprocating
Registration number
N28706
Operator
FALCON AERO CLUB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA580767
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 6197 uri: 6197 title: SEA84FA005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39777/pdf description:
Unique identifier
39777
NTSB case number
SEA84FA005
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-10-05T16:50:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Event type
Accident
Location
Kootenai, Idaho
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
ACCORDING TO THE PLT HE WAS CRUISING AT 11500 MSL WHEN SMOKE STARTED COMING FROM THE LOWER FORWARD SECTION OF THE COCKPIT AND A FIRE DEVELOPED AROUND HIS FEET. THE ENGINE WAS SHUT DOWN AND THE FIRE SUBSIDED OR WENT OUT. DURING THE GLIDE FOR LANDING THE ENGINE WAS RESTARTED AND THE FIRE RETURED. THE PLT EXECUTED A CONTROLLED, FORCED LANDING WITH THE FIRE IN PROGRESS.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HORDEMANN
Model
RV-4
Amateur built
true
Engines
1 Reciprocating
Registration number
N488RV
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
88
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-28T04:00:00Z guid: 39777 uri: 39777 title: ATL84LA014 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6365/pdf description:
Unique identifier
6365
NTSB case number
ATL84LA014
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-10-06T17:45:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Vicksburg, Mississippi
Airport
VICSBURG (VKS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
THE ACFT LANDED SHORT OF THE RWY DURING A FORCED LANDING AFTER THE ENGINE LOST POWER DURING CRUISE FLT. THE PLT REPORTEDTHAT POWER WAS LOST AT 2000 FT 10 MILES NORTH OF VICKSBURG. HE APPLIED THE FUEL BOOST PUMP AND SUCCESSFULLY RESTARTED THE ENG BUT IT QUIT AGAIN AND HE WAS UNABLE TO RESTART DESPITE CHANGNG FUEL TANKS. DURING THE LANDING THE ACFT COLLIDED WITH BUSHES AND GROUND LOOPED COLLAPSING THE LANDING GEAR. THE ACFT WAS EXAMINED; ALL TANKS WERE EMPTY OF FUEL EXCEPT THE RIGHT AUXILIARY. THE FUEL SELECTOR WAS FOUND OUT OF DETENT FOR THE RIGHT MAIN TANK.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N7691P
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-290L
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 6365 uri: 6365 title: CHI84LA013 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/12471/pdf description:
Unique identifier
12471
NTSB case number
CHI84LA013
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-10-07T19:50:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Delaware, Ohio
Airport
DELAWARE MUNI (DLS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN
Model
AA-1A
Amateur built
false
Engines
1 Reciprocating
Registration number
N9237L
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
0137
Damage level
Substantial

Vehicle 2

Aircraft category
Airplane
Make
PIPER
Model
PA-38-112
Amateur built
false
Engines
1 Reciprocating
Registration number
N2333B
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
38-79A0013
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 12471 uri: 12471 title: ATL84FA028 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6229/pdf description:
Unique identifier
6229
NTSB case number
ATL84FA028
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-10-23T19:33:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Brentwood, Tennessee
Airport
NASHVILLE METRO (BNA)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT CRASHED WHILE THE PLTS WERE ATTEMPTING AN ILS APPROACH TO NASHVILLE. ONE PLT WAS NOT INSTRUMENT RATED. THE OTHER WAS RATED BUT WAS LIMITED IN EXPERIENCE. THE INSTRUCTIONS FOR RADAR VECTORING TO THE APPROACH WERE NOT FOLLOWED AND DISORIENTATION WITH LOSS OF CONTROL FOLLOWED. THE ACFT CRASHED INTO A FIELD AT HIGH SPEED ABOUT 3.5 MILES SOUTH OF THE DOBBS L0M. WITNESSES REPORTED A LOW CEILING AND SAID IT WAS 'MISTY' AT THE TIME OF THE CRASH. THE ACFT CRASHED ON A HEADING OF 305 DEGREES, THE APPROACH WAS FOR RWY 02L.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
TU206G
Amateur built
false
Engines
1 Reciprocating
Registration number
N7338G
Operator
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
U20503764
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 6229 uri: 6229 title: CHI84LA066 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/12509/pdf description:
Unique identifier
12509
NTSB case number
CHI84LA066
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-11-26T11:00:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
La Porte, Indiana
Airport
PRIVATE STRIP ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT VEERED OFF THE RWY, HIT A DITCH AND NOSED OVER DURING TAKEOFF. THE PLT REPORTED THAT HE LOST CONTROL OF THE ACFT DURING THE TAKEOFF ROLL AND IT RAN OFF THE SIDE OF THE RWY INTO AN OPEN FIELD AND NOSED OVER.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108-3
Amateur built
false
Engines
1 Reciprocating
Registration number
N6881M
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
108-4881
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 12509 uri: 12509 title: ATL84FA054 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6236/pdf description:
Unique identifier
6236
NTSB case number
ATL84FA054
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-11-27T15:46:00Z
Publication date
2023-06-30T04:00:00Z
Report type
Final
Event type
Accident
Location
Lexington, Tennessee
Airport
()
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT COLLIDED WITH THE GROUND IN A VERTICAL DESCENT DURING IMC WEATHER ON A X-COUNTRY FLT. THE PLT HAD FILED AN IFR FLT PLAN BUT HE WAS A STUDENT WITH LIMITED EXPERIENCE AND WAS NOT INSTRUMENT RATED. ALSO HE WAS CARRYING A PASSENGER. THE CONTROLLER WHO HAD BEEN WORKING THE FLT HAD NOTED A LACK OF PROFESSIONALISM ON THE PART OF THE PLT IN HIS HOLDING OFHEADINGS AND REPORTING PROCEDURES. WHEN THE FLT FINALLY ENCOUNTERED THUNDERSTORMS AND TURBULENCE RADIO CONTACT WAS LOST.THE LAST RADIO CONTACT WAS AT APPROXIMATELY 1346. THE MKC FSS SPECIALIST STATED TO MEMPHIS CENTER AT 1346:07 THAT THE PLT REPORTED THAT HE WAS IN SEVERE TURBULENCE & DID NOT KNOW HIS LOCATION. THE ACFT CRASHED ABOUT 4 MILES EAST OF LEXINGTON, TN.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N5396L
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-4705
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-30T04:00:00Z guid: 6236 uri: 6236 title: DCA84AA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15800/pdf description:
Unique identifier
15800
NTSB case number
DCA84AA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-12-20T14:17:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Sioux Falls, South Dakota
Airport
JOE FOSS FIELD (KF3D)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 2 minor
Factual narrative
-
Analysis
DURING LANDING THE CREW ACQUIRED VISUAL REFERENCE WITH THE GROUND & APCH LIGHTS ABOUT 200 FT AGL, FOLLOWED BY VISUAL SIGHTING OF THE RWY. SINCE THE ATIS REPORTED BLOWING SNOW, THE CREW EXPECTED TO SEE, & WAS NOT SURPRISED TO SEE, SNOW BLOWING ACROSS THE RWY ABOUT 2,000 FT BEYOND THE THRESHOLD. AT ABOUT 2,200 FT DOWN THE RWY THE ACFT ENTERED A CLOUD OF SNOW, & THE RIGHT WING STRUCK A LARGE SNOW SWEEPING VEHICLE WHICH WAS TRAVELING IN THE SAME DIRECTION & TO THE RIGHT OF THE RWY CENTERLINE. THE ACFT'S RIGHT WING SEPARATED & IT SWERVED OFF THE RWY. NEITHER THE APPROACH CONTROLLER NOR THE LOCAL CONTROLLER ADVISED THE FLT OF SNOW REMOVAL OPERATIONS, NOR DID THE LOCAL CONTROLLER COMMUNICATE WITH THE SWEEPER AFTER HE TOOK THE HAND-OFF OF THE FLT FROM APPROACH CONTROL. HE ALSO STATED HE DID NOT KNOW WHERE THE SWEEPER WAS WHEN HE CLEARED THE FLT TO LAND.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DOUGLAS
Model
DC-9-31
Amateur built
false
Engines
1 Turbo fan
Registration number
N994Z
Operator
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight operation type
Unknown
Flight service type
Passenger/Cargo
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
47097
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 15800 uri: 15800 title: FTW84FA102 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/21095/pdf description:
Unique identifier
21095
NTSB case number
FTW84FA102
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1983-12-24T10:38:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Hughes, Arkansas
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 2 serious, 0 minor
Factual narrative
-
Analysis
THE PLT & OBSERVER WERE ON A FLT TO RESCUE 2 DUCK HUNTERS, STRANDED IN A BOAT THAT BECAME STUCK IN ICE, 500 TO 600 FT FROM SHORE. AFTER REMOVING THE RGT DOOR, THEY PLANNED TO PICK UP 1 HUNTER AT A TIME ON THE RGT SKID WHILE THE OBSERVER HELD ONTO HIM THRU THE OPEN DOOR. AFTER CIRCLING IN GUSTY WINDS, THE PLT WAS ABLE TO HOVER AT THE BOW OF THE BOAT. AS THE 1ST HUNTER CLIMBED ONTO THE RGT SKID, THE HELICOPTER BANKED TO THE RGT, AND SUBSEQUENTLY, ENTERED A SPIN TO THE RGT.HOWEVER, THE PLT REGAINED CONTROL & CONTINUED TO THE LANDING AREA WHILE REMAINING IN A CONSTANT RGT TURN. AS HE ENTERED A 5 FT HOVER TO LAND, THE ACFT PITCHED FORWARD. THE PLT PULLED THE COLLECTIVE TO GAIN ALT, BUT THE ACFT ENTERED A RGT ROLL & TURN, AND SUBSEQUENTLY STRUCK SEVERAL TREES & CRASHED. AN INVESTIGATION REVEALED THE CG EXCEEDED THE FORWARD LIMIT BY .33 INCHES & THE RIGHT CG LIMIT BY 5.2 INCHES. THE ACFT WAS NOT EQUIPPED FOR LATERAL LOADS & NO LATERAL CG LIMITS WERE LISTED IN THE FLT MANUAL. THOSE EQUIPPED FOR LITTERS (LATERAL LOADS) WERE RIGGED WITH ADDITIONAL CYCLIC CTL.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
47G-2A-1
Amateur built
false
Engines
1 Turbo shaft
Registration number
N124CD
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Public aircraft
Commercial sightseeing flight
false
Serial number
3750
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 21095 uri: 21095 title: FTW84LA109 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/21241/pdf description:
Unique identifier
21241
NTSB case number
FTW84LA109
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-01-07T17:36:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
New Orleans, Louisiana
Airport
LAKEFRONT (NEW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
DURING ARRIVAL, THE ACFT LOST POWER AFTER A DESCENT FROM 3000 TO 2000 FT. AT THAT TIME, THE PLT NOTED THAT THE FUEL GAGES INDICATED EACH TANK WAS 1/8 FULL, BUT HE DID NOT APPLY CARB HEAT UNTIL HE WAS IN AN EMERGENCY DESCENT. HE ELECTED TO LAND ON A BOULEVARD. DURING THE LANDING, THE LEFT MAIN GEAR HIT THE RIGHT TAIL LIGHT OF A VEHICLE, THE THE ACFT HIT A ROAD SIDN AND A CONCRETE RETAINDER. AN EXAM OF THE ACFT REVEALED FUEL WAS STILL REMAINING IN BOTH TANKS. NO MECHANICAL MALFUNCTION OR FAILURE WAS FOUND & THE ENG WAS RUN & OPERATED NORMALLY.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N9468U
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 21241 uri: 21241 title: LAX84LA177 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/24170/pdf description:
Unique identifier
24170
NTSB case number
LAX84LA177
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-02-13T11:00:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
Mammoth Lakes, California
Airport
MAMMOTH JUNE LAKES (MMH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
THE PLT REPORTED THAT THE ACFT WAS BLOWN OVER AS HE TAXIED FOR TAKEOFF. ALSO, HE REPORTED THE WIND TO BE FROM 200 DEGREES AT 20 KTS. THE RECORDED WIND FROM 180 DEGREES AT KTS GUSTING TO 40 KTS. THE MAXIMUM DEMONSTRATED CROSSWIND COMPONENT FOR THIS ACFT IS 15 KTS FOR LANDING AND 20 KTS FOR TAKEOFF.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182L
Amateur built
false
Engines
1 Reciprocating
Registration number
N3194R
Operator
56 FLYING CLUB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18258594
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 24170 uri: 24170 title: SEA84LA059 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/39878/pdf description:
Unique identifier
39878
NTSB case number
SEA84LA059
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-02-22T11:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Grangeville, Idaho
Airport
IDAHO COUNTY (S80)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT GROUND LOOPED DURING LANDING ON AN ICY RWY AND NOSED OVER AFTER LEAVING THE RWY. THE LANDING WAS MADE WITH A RIGHT QUARTERING TAILWIND.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172RGII
Amateur built
false
Engines
1 Reciprocating
Registration number
N6522R
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0191
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 39878 uri: 39878 title: FTW84LA159 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/21277/pdf description:
Unique identifier
21277
NTSB case number
FTW84LA159
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-03-06T17:30:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Lamesa, Texas
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
SHORTLY AFTER TAKEOFF FOR AN AERIAL APPLICATION FLIGHT A PARTIAL LOSS OF POWER OCCURRED. A HARD FORCED LANDING WAS MADE IN AN OPEN FIELD WHICH RESULTED IN BOTH MAIN GEARS COLLAPSING. INSPECTION OF THE ENGINE REVEALED BOTH MAGNETO DISTRIBUTOR BLOCKS WERE CRACKED AND EVIDENCE OF CARBON STREAKING WAS FOUND ON THE MAGNETO LEADS.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-36
Amateur built
false
Engines
1 Reciprocating
Registration number
N57584
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
36-7560118
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 21277 uri: 21277 title: DEN84LA111 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/16351/pdf description:
Unique identifier
16351
NTSB case number
DEN84LA111
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-03-19T14:15:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Riverton, Wyoming
Airport
RIVERTON REGIONAL (RIW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT STATED THAT A CONVAIR 580 HAD LANDED BEFORE HIM. THE PLT FLEW A NORMAL GLIDE SLOPE & PLANNED TO LAND ON THE APPROACH END OF THE RWY. ON SHORT FINAL AT 50 FT AGL, THE ACFT SUDDENLY BANKED 'OVER 90 DEGREES' TO THE LEFT OUT OF CONTROL. THE ACFT THEN HIT THE GROUND 50 YDS SHORT OF THE RWY IN A LEFT WING LOW ATTITUDE.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12-115
Amateur built
false
Engines
1 Reciprocating
Registration number
N4378M
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-3314
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 16351 uri: 16351 title: LAX84LA228 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/24208/pdf description:
Unique identifier
24208
NTSB case number
LAX84LA228
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-03-23T16:00:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Holbrook, Arizona
Airport
PRIVATE STRIP ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE ACFT COLLIDED WITH A MOUND OF RUBBLE DURING AN ABORTED TAKEOFF. THE TAKEOFF WAS ATTEMPTED UPHILL TO AVOID BUILDINGS AND WIRES ACCORDING TO THE PLT. THE DENSITY ALT WAS 6200 FT.AFTER THE COLLISION THE ACFT NOSED OVER.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N66390
Operator
THUNDERBIRD ACADEMY
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15076014
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 24208 uri: 24208 title: MIA84LA152 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/31129/pdf description:
Unique identifier
31129
NTSB case number
MIA84LA152
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-04-26T10:22:00Z
Publication date
2023-07-03T04:00:00Z
Report type
Final
Event type
Accident
Location
VALDOSTA, Georgia
Airport
VALDOSTA MUNICIPAL (VLD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE INSTRUCTOR PLT (CFI) STATED THAT HE WAS GIVING A PRIVATE PLT A BIENNIAL FLT REVIEW & THAT THE PRIVATE PLT WAS THE PLT-IN-COMMAND (PIC). WHILE IN THE TRAFFIC PATTERN FOR THEIR 2ND LANDING, THEY HEARD ANOTHER ACFT ENTERING THE PATTERN, BUT THEY WERE NOT SURE OF ITS LOCATION. THEY WERE LOOKING FOR THE OTHER ACFT AS THEY CONTINUED THE APCH & SUBSEQUENTLY LANDED WITH THE GEAR RETRACTED.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7059P
Operator
DOUGLAS M. REDDICK
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
24-2209
Damage level
Substantial
creator: NTSB last-modified: 2023-07-03T04:00:00Z guid: 31129 uri: 31129 title: NYC84IA225 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/35445/pdf description:
Unique identifier
35445
NTSB case number
NYC84IA225
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-06-27T23:34:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Incident
Location
Portland, Maine
Airport
PORTLAND (PWM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
-
Analysis
CAPTAIN HEARD LOUD 'POP' AND OBSERVED AN ELECTRICAL PANEL INTERRUPTION ALONG WITH ILLUMINATION OF RT 'BUS OFF' & 'GEN OFF BUS' LIGHTS. NO GENERATOR AMPS OR FREQS WERE OBSERVED. FAINT ODOR OF SMOKE. CAPT STARTED APU AND PUT APU GENERATOR ON RT SIDE. 'BUS OFF' LIGHT EXTINQUISHED. WITHIN A MINUTE, SMOKE LEVEL INCREASED. CAPT REMOVED APU & CALLED FOR ELECTRICAL SMOKE AND FIRE CHECKLIST. EMERGENCY LANDING PERFORMED DURING WHICH ALL 4 MAIN GEAR TIRES FAILED. CREW & PAX PERFORMED EMERGENCY EVACUATION. INSPECTION OF ACFT DISCLOSED THE FAILURE IN THE GENERATOR CONTROL UNIT OCCURRED IN A CAPACITOR INSTALLED IN THE CIRCUIT. FAILURE OF THE #2 GENERATOR CONTROL UNIT RENDERED THE ANTI-SKID SYSTEM INOP RESULTING IN THE TIRE FAILURES.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-130
Amateur built
false
Engines
1 Turbo fan
Registration number
N417PE
Operator
PEOPLE EXPRESS
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight operation type
Unknown
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
19794
Damage level
Minor
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 35445 uri: 35445 title: MKC84FA229 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33541/pdf description:
Unique identifier
33541
NTSB case number
MKC84FA229
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-07-23T07:30:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Bertrand, Nebraska
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA 36-375
Amateur built
false
Engines
1 Reciprocating
Registration number
N3930E
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
368302023
Damage level
Substantial

Vehicle 2

Aircraft category
Airplane
Make
PIPER
Model
PA-36-375
Amateur built
false
Engines
1 Reciprocating
Registration number
N3968E
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
368302024
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 33541 uri: 33541 title: MKC84FU007 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33568/pdf description:
Unique identifier
33568
NTSB case number
MKC84FU007
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-08-14T19:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Mount Hope, Arkansas
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
THE NEWLY ACQUIRED ULTRALIGHT HAD BEEN FLOWN FOR ABOUT 10 HOURS DURING THE 2 WEEK PERIOD OF OWNERSHIP. ON THIS DAY, THE WIND WAS BLOWING AT 15 MPH AND THE OWNER WAS FLYING DOWNWIND OVER A HAY FIELD AT ABOUT 50 FT AGL WHEN THE RIGHT ENGINE ON THE TWIN ENGINE VEHICLE QUIT. THE PLT TURNED RIGHT TO TRY TO LAND INTO THE WIND, BUT LOST CONTROL AND CRASHED. AFTER THE ACCIDENT, DIRT WAS FOUND IN THE FUEL SYSTEM WHICH HAD NO FILTER BETWEEN THE TANK AND THE CARBURETOR. WHEN THE CARBURETOR WAS DISASSEMBLED DIRT WAS FOUND OBSTRUCTING THE NEEDLE VALVE ORIFICE.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Ultralight
Make
Gemini Int'l.
Model
HUMMINGBIRD
Amateur built
true
Engines
1 Reciprocating
Registration number
UNREG
Operator
Second pilot present
false
Flight conducted under
Part 103: Ultralight
Flight operation type
Personal
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 33568 uri: 33568 title: DCA84AA034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15813/pdf description:
Unique identifier
15813
NTSB case number
DCA84AA034
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-08-24T11:18:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
San Luis Obispo, California
Airport
SAN LOUI OBISPO (SBP)
Weather conditions
Visual Meteorological Conditions
Injuries
17 fatal, 0 serious, 0 minor
Probable cause
Has safety recommendations
true

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C-99
Amateur built
false
Engines
1 Turbo prop
Registration number
N6399U
Operator
WINGS WEST AIRLINES, INC.
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Unknown
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
U-187
Damage level
Destroyed

Vehicle 2

Aircraft category
Airplane
Make
Rockwell
Model
112TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N112SM
Operator
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
13020
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 15813 uri: 15813 title: CHI85LA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/12932/pdf description:
Unique identifier
12932
NTSB case number
CHI85LA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-10-13T11:10:00Z
Publication date
2023-06-27T04:00:00Z
Report type
Final
Event type
Accident
Location
St. Cloud, Minnesota
Airport
HAVEN (3MN7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
-
Analysis
THE PLT STATED THAT HIS GROUND SPEED WAS TOO FAST DURING A LANDING DUE TO NO WIND. DURING THE GO-AROUND THE ACFT COLLIDED WITH TREE TOPS & CRASHED. THE PLT REPORTED THAT HE DELAYED HIS DECISION TO PERFORM A GO-AROUND.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-16
Amateur built
false
Engines
1 Reciprocating
Registration number
N5221H
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
16-23
Damage level
Substantial
creator: NTSB last-modified: 2023-06-27T04:00:00Z guid: 12932 uri: 12932 title: ATL85LA051 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6719/pdf description:
Unique identifier
6719
NTSB case number
ATL85LA051
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1984-12-09T18:47:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Fremont, North Carolina
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE STUDENT PLT REPORTED THAT HE LANDED HARD & BOUNCED TWICE BEFORE SETTLING TO THE RWY. HE APPLIED FULL BRAKING & THE ACFT SKIDDED OFF THE END OF THE RWY.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
AA-5B
Amateur built
false
Engines
1 Reciprocating
Registration number
N74636
Operator
WILSON CAROLINA FLYING SER.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA-5B-0306
Damage level
Substantial
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 6719 uri: 6719 title: SEA85LA127 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40167/pdf description:
Unique identifier
40167
NTSB case number
SEA85LA127
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-06-06T06:49:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
North Las Vegas, Nevada
Airport
NORTH LAS VEGAS AIR (VGT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
LOSS OF DIRECTIONAL CONTROL OCCURRED DURING THE STUDENT PILOT'S SECOND ATTEMPTED TOUCH AND GO. THE AIRCRAFT VEERED LET, STRUCK A BERM WITH THE NOSEWHEEL AND THEN NOSED OVER. FAA INSPECTORS ATTEMPTED TO PHYSICALLY CHECK FLIGHT CONTROLS BUT MOVEMENT WAS LIMITED DUE TO IMPACT DAMAGE.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N69236
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15282578
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 40167 uri: 40167 title: SEA85LA155 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40191/pdf description:
Unique identifier
40191
NTSB case number
SEA85LA155
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-07-02T09:00:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Roosevelt, Washington
Airport
NONE ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
A TOTAL LOSS OF POWER OCCURRED WHILE ON A CFR 137 FLIGHT, DUE TO FUEL EXHAUSTION. ALTHOUGH THE FUEL GAUGE SHOWED 1/2 TANK OF FUEL, THE PILOT FAILED TO VISUALLY CHECK THE FUEL PRIOR TO THIS FLIGHT. DURING AUTOROTATION ONTO A WHEAT FIELD A HARD LANDING OCCURRED SUBSTANTIALLY DAMAGING THE TAIL BOOM.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
47G2
Amateur built
false
Engines
1 Reciprocating
Registration number
N11VH
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
2027
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 40191 uri: 40191 title: ATL85LA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/6832/pdf description:
Unique identifier
6832
NTSB case number
ATL85LA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-07-13T19:00:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Owensboro, Kentucky
Airport
OWENSBORO-DAVIESS COUNTY ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT HAD A SINGLE ENG LAND RATING & WAS PREPARING FOR A MULTI-ENG CHECK RIDE. WHILE PRACTICING A TOUCH-&-GO LANDING, THE ACFT BOUNCED. THE PLT APPLIED POWER, MADE A GO-AROUND & LANDED WITHOUT FURTHER INCIDENT. HOWEVER, DURING A POST-FLT EXAM, SUBSTANTIAL STRUCTURAL DAMAGE WAS FOUND THRU-OUT THE FUSELAGE & THERE WAS DAMAGE TO THE #2 PROP.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
95-B55
Amateur built
false
Engines
1 Reciprocating
Registration number
N3001S
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
T 797
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 6832 uri: 6832 title: MKC85LA162 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33992/pdf description:
Unique identifier
33992
NTSB case number
MKC85LA162
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-07-20T14:00:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Indianola, Nebraska
Airport
LAVERTY (IA41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
N4848Q WAS LOADED TO MAX GROSS WT AND WAS TAKING OFF ON A 2,350 FT, TURF RWY. THE PLT SAID THE WIND WAS LIGHT AND FAVORED RWY 29 BEFORE TAKEOFF. THE DENSITY ALT WAS ABOUT 2,500 FT. THE PLT SAID THE ACFT DID NOT SEEM TO BE DEVELOPING QUITE THE POWER IT SHOULD HAVE DURING THE TAKEOFF BUT THE INSTRUMENTS INDICATED NORMAL OPERATION. THE ACFT USED THE FULL LENGTH OF THE RWY TO TAKEOFF BUT WAS UNABLE TO CLEAR A FENCE OFF THE END. THE ACFT HIT THE TOP OF THE FENCE AND CRASHED IN THE FIELD BEYOND. THE PLT SAID THAT AS HE WAS WALKING BACK TO THE AIRPORT AFTER THE ACDT HE NOTED THAT THE AIRPORT WINSOCK SHOWED THE WIND WAS FROM THE NORTHEAST.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188B
Amateur built
false
Engines
1 Reciprocating
Registration number
N4848Q
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
18802584
Damage level
Substantial
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 33992 uri: 33992 title: FTW85FA310 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/21567/pdf description:
Unique identifier
21567
NTSB case number
FTW85FA310
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-08-08T12:15:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Saint James, Louisiana
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
ACFT WAS AT A 150' HOVER PREPARING TO PICK UP A LOG WHEN IT EXPERIENCED A POWER LOSS. WITNESSES STATED THAT THEY HEARD A LOUD 'BANG' AND THE PILOT RADIOED 'GET OUT OF THE WAY'. ACFT AUTOROTATED THRU 60' TO 80' TREES WITH VERY LOW ROTOR RPM AND IMPACTED WITH NO HORZ SPEED AND HIGH VERTICAL SPEED. INVESTIGATION REVEALED THAT ENG HAD EXPERIENCED SEVERE INTERNAL DAMAGE. FOUR COMPRESSOR BLADES FROM THE 4TH STAGE ROTOR WERE FOUND TO HAVE SUFFERED PROGRESSIVE FATIGUE FAILURE, WHICH IN TURN CAUSED THE REMAINDER OF THE BLADES ON THE 4TH AND 5TH STAGES TO SEPARATE LEADING TO AN ENG SURGE AND LOSS OF POWER. THE ACCIDENT OCCURRED IN A FLT REGIME FROM WHICH THE PLT COULD NOT AFFECT A RECOVERY FROM THE ENG FAILURE.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
UH-1B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N1385W
Operator
SKYLINE AIR SERVICE, INC.
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Other work use
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
62-2072
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 21567 uri: 21567 title: MKC85FA179 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/33848/pdf description:
Unique identifier
33848
NTSB case number
MKC85FA179
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-08-10T13:12:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Palisade, Nebraska
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
WHILE ON A SWATH RUN OVER A CORNFIELD, THE PLT ATTEMPTED TO MANEUVER UNDER POWER LINES THAT WERE SPANNING A LARGE DITCH. THE RIGHT WING STRUCK ONE OF THE THREE LOWER CABLES WHICH CUT INTO THE WING STRUCTURE. THE CABLE FINALLY SEPARATED RELEASING THE ACFT. THE ACFT BEGAN TO ROLL INVERTED & IMPACTED THE GROUND WITH THE LEFT WING FOLLOWED BY THE FUSELAGE. THE IMPACT & ENSUING FIRE DESTROYED THE ACFT. THE PLT DID NOT REMEMBER ESCAPING FROM THE BURNING ACFT. THE LOWER SET OF CABLES WERE LEVEL WITH THE DITCH RIM & WERE VERY DIFFICULT TO SEE WHILE IN FLT.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-25-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N8941L
Operator
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
255406
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 33848 uri: 33848 title: NYC86LA008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/30245/pdf description:
Unique identifier
30245
NTSB case number
NYC86LA008
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1985-10-14T13:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Norwood, Massachusetts
Airport
NORWOOD MEM. (OWD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
ACCORDING TO THE PILOT, DURING THE TAKEOFF CLIMB THE AIRCRAFT DID NOT DEVELOP SUFFICIENT POWER TO MAINTAIN ALTITUDE. THE PILOT TURNED THE AIRCRAFT TO THE RIGHT IN AN ATTEMPT TO RETURN TO THE AIRPORT. DURING THE APPROACH TO THE AIRPORT, THE AIRCRAFT COLLIDED WITH WOODED TERRAIN NEAR THE INTERSECTION OF THE RUNWAYS.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WACO
Model
UPF-7
Amateur built
false
Engines
1 Reciprocating
Registration number
N39714
Operator
FRED SNYDERMANN
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
5847
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 30245 uri: 30245 title: SEA86LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40344/pdf description:
Unique identifier
40344
NTSB case number
SEA86LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-01-15T11:16:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
North Bend, Washington
Airport
NORTH BEND MUNICIPAL (OTH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
WHILE ON FINAL THE FSS GAVE THE PILOT THE CURRENT WINDS AND THE FAVORED RUNWAY. THE PILOT WAS ATTEMPTING TO LAND THE AIRCRAFT ON RUNWAY 04 WITH A RIGHT GUSTING QUARTERING TAIL WIND AND WET RUNWAY. HYDROPLANING OCCURRED AND THE PILOT ELECTED TO GO-AROUND WHEN THE AIRCRAFT WAS MORE THAN 1/2 WAY DOWN THE RUNWAY. DURING CLIMB OUT LOCALIZER ANTENNAS WERE STRUCK. THE PILOT THEN LANDED ON RWY 13.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
501
Amateur built
false
Engines
1 Turbo fan
Registration number
N414CB
Operator
VISALIA AIRMOTIVE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
179
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 40344 uri: 40344 title: DEN86LA086 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/16926/pdf description:
Unique identifier
16926
NTSB case number
DEN86LA086
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-03-01T12:00:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Wisdom, Montana
Airport
WISDOM (7S4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
-
Analysis
THE STUDENT PLT DEPARTED MINDEN, NV ON AN UNAUTHORIZED X-CO FLT THAT TERMINATED IN THE ACCIDENT AT WISDOM, MT. DURING THE LANDING ROLL AT AN ABANDONED ARPT AT WISDOM, THE NOSE OF THE ACFT DUG INTO THE SNOW COVERED RUNWAY AND THE ACFT NOSED OVER. THE PLT RECEIVED MINOR INJURIES.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N69043
Operator
JACK AND KAY HOUK
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15282456
Damage level
Substantial
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 16926 uri: 16926 title: LAX86LA135 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/25087/pdf description:
Unique identifier
25087
NTSB case number
LAX86LA135
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-03-05T15:30:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
El Toro, California
Airport
()
Weather conditions
Unknown
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
A HELICOPTER CRASHED INTO A MOUNTAIN SLOPE EAST OF EL TORO, CA WHILE ON A BUSINESS FLT. WHILE THE ACFT APPROACHED THE MOUNTAIN PEAK THE PLT EXPERIENCED AN INCREASE IN THE RATE OF DESCENT AND ABORTED THE LANDING. DURING THE GO-AROUND, AT ADECREASED MAIN ROTOR RPM, THE ACFT CONTINUED TO SETTLE AND THE TAIL ROTOR STRUCK THE GROUND. THE PLT REPORTED NO MECHANICAL DIFFICULTIES OR FAILURES WITH THE ACFT PRIOR TO THE ACCIDENT.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON
Model
R-22
Amateur built
false
Engines
1 Reciprocating
Registration number
N9072Z
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
0217
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 25087 uri: 25087 title: SEA86LA097 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40382/pdf description:
Unique identifier
40382
NTSB case number
SEA86LA097
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-04-08T17:14:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Emigrant Pass, Nevada
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT WAS INFORMED DURING A WX BRIEFING THAT VFR FLT WAS NOT RECOMMENDED. THE PLT ELECTED TO TAKEOFF REGARDLESS AND ENCOUNTERED LOW CEILINGS AND VISIBILITIES. WHILE LOOKING FOR AN AREA OF A HIGHWAY TO LAND THE ACFT, PWR LINES WERE CONTACTED WITH THE TOP OF THE VERTICAL STABILIZER. THE PLT THEN CONTINUED TO AN ARPT WHERE AN UNEVENTFUL LANDING WAS ACCOMPLISHED.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180K
Amateur built
false
Engines
1 Reciprocating
Registration number
N644FM
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
18052859
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 40382 uri: 40382 title: MIA86LA124 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/31604/pdf description:
Unique identifier
31604
NTSB case number
MIA86LA124
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-04-18T10:00:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
St. Augustine, Florida
Airport
ST. AUGUSTINE (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PRIVATE PILOT WITH A TOTAL OF 36.2 HOURS OF LOGGED FLIGHT TIME, STATED THAT SHE LANDED HARD ON THE NOSE WHEEL AND THE NOSE STRUT FAILED DURING A FULL STOP LANDING.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N121SU
Operator
ROBERTA A. HINTERLACH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17271347
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 31604 uri: 31604 title: MIA86LA125 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/31605/pdf description:
Unique identifier
31605
NTSB case number
MIA86LA125
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-04-19T20:15:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Event type
Accident
Location
St. Augustine, Florida
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
-
Analysis
THE PILOT IN COMMAND DID NOT ASSURE THAT THE FUEL SELECTOR FOR THE LEFT ENGINE WAS SELECTED AND IN THE DETENT PRIOR TO TAKEOFF. ON THE INITIAL CLIMB THE FUEL SELECTOR MOVED SLIGHTLY AND THE LEFT ENGINE FAILED DUE TO FUEL STARVATION. THE PILOT THEN DID NOT EXECUTE THE APPROPRIATE EMERGENCY PROCEDURES AND LEFT THE LANDING GEAR DOWN AND DID NOT FEATHER THE LEFT PROPELLER. THE PILOT THEN LOST CONTROL OF THE AIRCRAFT AND CRASHED INTO THE WATER.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B95A
Amateur built
false
Engines
1 Reciprocating
Registration number
N951Q
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TD-491
Damage level
Substantial
creator: NTSB last-modified: 2023-06-23T04:00:00Z guid: 31605 uri: 31605 title: MKC86LA104 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/34172/pdf description:
Unique identifier
34172
NTSB case number
MKC86LA104
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-05-10T20:00:00Z
Publication date
2023-06-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Louisburg, Kansas
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
DURING A FLY-BY OVER A PVT AIRSTRIP OWNED BY THE PLT, THE ACFT CONTACTED POWER LINES BORDERING THE SOUTH END OF THE AIRSTRIP WHICH THE PLT STATED HE FORGOT ABOUT. THE PLT REPORTED HE FAILED TO PULL UP DURING THE OVER FLY AND FLEW UNDER THE POWER LINES. THE ACFT STRUCK THE LINES WHICH SUBSTANTIALLY DAMAGED THE VERTICAL AND HORIZONTAL STABILIZERS. THE ACFT WAS ABLE TO CONTINUE FLIGHT TO ANOTHER PVT AIRSTRIP WHERE A LANDING WAS PERFORMED. THE PLT'S PVT AIRSTRIP WAS RECENTLY SEEDED AND THE PLT WAS OBSERVING THE RWY SURFACE FROM THE AIR.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
175
Amateur built
false
Engines
1 Reciprocating
Registration number
N7027M
Operator
JIM KAPELLER
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
55327
Damage level
Substantial
creator: NTSB last-modified: 2023-06-12T04:00:00Z guid: 34172 uri: 34172 title: CHI86FET01 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/13335/pdf description:
Unique identifier
13335
NTSB case number
CHI86FET01
Transportation mode
Aviation
Completion status
Completed
Occurrence date
1986-05-31T07:56:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Rolling Prairie, Indiana
Airport
LARRY COMMINGS AIRSTRIP ()
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
-
Analysis
DURING A GO-AROUND FROM AN ABORTED LANDING THE ACFT STRUCK UNMARKED POWER LINES AT THE DEPARTURE END OF THE LANDING RWY. THE ACFT COLLIDED WITH TERRAIN DURING THE RESULTING UNCONTROLLED DESCENT. THE RWY BEING USED WAS A 2400 FT LONG AND 50 FT WIDE SOD PRIVATE STRIP. THIS STRIP WAS NOT CERTIFIED SO NO OBSTRUCTION WARNINGS WERE AVAILABLE. THE PLT FAILED TO REPORT RWY IDENT OR HEADING.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-20
Amateur built
false
Engines
1 Reciprocating
Registration number
N7734K
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
20-557
Damage level
Substantial
last-modified: 2023-06-21T04:00:00Z guid: 13335 uri: 13335 title: SEA86LA187 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/40460/pdf description:
Unique identifier
40460
NTSB case number
SEA86LA187
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-07-31T12:30:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Vancouver, Washington
Airport
CLARK COUNTY (0S6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE PLT REPORTED THE ENGINE STARTED RUNNING ROUGH NEAR WOODLAND, WASHINGTON AND AN APPROACH WAS SET UP, BUT DUE TO MANY AIRCRAFT IN THE PATTERN THE PILOT ELECTED TO GO TO SCAPPOSE, WASHINGTON (ABOUT 10 NM SOUTH OF WOODLAND). AT SCAPPOSE, WASHINGTON THE PILOT NOTED 'X'S' ON THE RUNWAY AND DECIDED TO TRY TO MAKE IT TO EVERGREEN (17 NM SE OF SCAPPOSE). ENROUTE TO EVERGREEN THE ENGINE QUIT AND A FORCED LANDING WAS ATTEMPTED TO CLARK COUNTY. THE ACFT BOUNCED OFF THE ROOF OF THE RESTAURANT AND CAME TO REST INVERTED BESIDE THE BLDG. A CERTIFIED A&P MECHANIC REMOVED AND VISUALLY TESTED THE SIGHT FUEL GAUGE. THE FUEL LEVEL INDICATOR (CORK FLOAT) MOVED FREELY FROM THE FULL POSITION TO A POINT (IN THE GAUGE) WHERE ABOUT 10 GALLONS WOULD BE INDICATED AND BECAME STUCK AT THAT POINT. THE PLT REPORTED THE FUEL GAUGE HAD BEEN 'VISUALLY CALIBRATED' AT THE LAST ANNUAL INSPECTION.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
PT13/17
Amateur built
false
Engines
1 Reciprocating
Registration number
N1307N
Operator
ROBERT E. BURTON
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-5135
Damage level
Substantial
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 40460 uri: 40460 title: FTW86FA154 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/21916/pdf description:
Unique identifier
21916
NTSB case number
FTW86FA154
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-08-29T18:48:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Big Sandy, Montana
Airport
()
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
STUDENT PILOT ON UNAUTHORIZED CROSS COUNTRY FLIGHT DEPARTED UNIMPROVED FIELD ON VFR FLIGHT FOR THE PURPOSE OF SPOTTING GAME. WEATHER CONDITIONS IN THE AREA WERE CONDUCIVE FOR LIGHT TO MODERATE TURBULENCE. WITNESSES REPORTED THE ACFT WINGS ROCKED VIOLENTLY AFTER TAKEOFF. THE ACFT THEN ENTERED A STEEP RIGHT TURN AND DESCENDED TO GORUND IMPACT.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N2532M
Operator
KIRK E. JOHNSON
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-1023
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-13T04:00:00Z guid: 21916 uri: 21916 title: CHI86LA223 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/13523/pdf description:
Unique identifier
13523
NTSB case number
CHI86LA223
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-09-13T15:30:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Event type
Accident
Location
Danville, Indiana
Airport
TEMPLE FIELD (79I)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE AIRCRAFT VEERED OFF THE LEFT SIDE OF THE GRAVEL RUNWAY DURING THE TAKEOFF GROUND ROLL. THE PILOT STATED THAT THE AIRSTRIP WAS SURROUNDED BY CORNSTALKS, AND THAT ON THE LEFT SIDE OF THE AIRSTRIP, THERE WAS DEEP LOOSE GRAVEL. REPORTEDLY, THE LOOSE GRAVEL CAUGHT THE LEFT WHEEL AND SWERVED THE AIRCRAFT INTO THE CORN FIELD.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7277P
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
242453
Damage level
Substantial
creator: NTSB last-modified: 2023-06-28T04:00:00Z guid: 13523 uri: 13523 title: NYC87FA023 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/30472/pdf description:
Unique identifier
30472
NTSB case number
NYC87FA023
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-10-19T20:20:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Rockwood, Tennessee
Airport
ROCKWOOD (RKW)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE AIRCRAFT WAS OBSERVED DEPARTING AT APPROX 2010 HOURS, REVERSING COURSE AND FLYING OVER THE AIRPORT AT 300-400 FT AGL. THE AIRCRAFT CRASHED 3/4 MILES SOUTH OF THE AIRPORT IN UNPOPULATED, MOUNTAINOUS/HILLY TERRAIN AT AN ELEVATION OF 1560 FEET, WHICH IS 104 FEET LOWER THAN THE AIRPORT ELEVATION. THE WRECKAGE WAS FOUND APPROX 2 DAYS LATER. THE PILOT, THE SOLE OCCUPANT, WAS FATALLY INJURED. THE AIRCRAFT WAS DESTROYED. THERE WAS NO FIRE. RECORDS INDICATE THAT THE PILOT HAD 6.1 HOURS OF NIGHT TIME, WITH LAST NIGHT FLIGHT BEING 23 MONTHS PRIOR TO THE ACCIDENT. A TOTAL OF 155 HOURS FLYING TIME WAS ACCUMULATED OVER A 9 YEAR AND 2 MONTH PERIOD. THERE WAS NO EVIDENCE OF MALFUNCTION WITH THE AIRCRAFT OR RELATED EQUIPMENT.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
R172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N7526V
Operator
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1722308
Damage level
Destroyed
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 30472 uri: 30472 title: FTW87LA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/22292/pdf description:
Unique identifier
22292
NTSB case number
FTW87LA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-10-28T11:00:00Z
Publication date
2023-06-21T04:00:00Z
Report type
Final
Event type
Accident
Location
Pollok, Texas
Airport
POLLOCK MUNI (LA34)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
THE DUAL STUDENT WAS RECEIVING EMERGENCY LANDING TRAINING. POWER WAS REDUCED WHILE ON APPROACH WHICH RESULTED IN A LOSS OF AIRSPEED AND A HIGH SINK RATE. CORRECTIVE ACTION WAS INITIATED TOO LATE AND THE AIRCRAFT TOUCHED DOWN A FEW FEET SHORT. THE LANDING GEAR CONTACTED AN ELEVATED LIP AT THE END OF THE HARD SURFACE OF THE RUNWAY AND THE NOSE GEAR COLLAPSED.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N1325T
Operator
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7225464
Damage level
Substantial
creator: NTSB last-modified: 2023-06-21T04:00:00Z guid: 22292 uri: 22292 title: DCA87MA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15870/pdf description:
Unique identifier
15870
NTSB case number
DCA87MA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1986-11-13T13:25:00Z
Publication date
2023-04-24T04:00:00Z
Report type
Final
Event type
Accident
Location
NEWARK, New Jersey
Airport
NEWARK INTERNATIONAL (EWR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
-
Analysis
ON NOVEMBER 13, 1986, THE REAR MAIN SPAR OF THE RIGHT WING FAILED AS DELTA FLT 194 TOUCHED DOWN ON RWY 29 AT NEWARK AIRPORT. THE PILOTS STATED THAT THERE WAS MODERATE TURBULENCE ON FINAL APPROACH AND INITIAL TOUCHDOWN WAS ON THE RIGHT MAIN GEAR FIRST. THE TOUCHDOWN WAS FIRM BUT NOT HARD WHICH WAS CONFIRMED FROM THE 1.4G RECORDED ON THE DFDR. THE 1.4G FORCE IS WELL WITHIN THE LANDING GEAR CERTIFICATION LIMITS. THE SPAR WEB FAILURE WAS CAUSED BY A FATIGUE CRACK THAT ORIGINATED AT A 'HI - LOC' FASTENER HOLE LOCATED AT THE LOWER INBOARD CORNER OF A DOUBLER THAT SURROUNDS THE FUEL FILLER VALVE WHICH IS MOUNTED VERTICALLY ON THE SPAR WEB. THE FATIGUE ZONE IN THE SPAR WEB HAD PROGRESSED ABOUT 6 3/4 INCHES BEFORE THE WEB FAILED AS THE AIRPLANE TOUCHED DOWN. THE FRACTURE IN THE SPAR WEB EXTENDED DIAGNALLY DOWNWARD AND OUTBOARD AT 45 DEGREES FROM INBOARD WING STATION 241.0 TO INBOARD STATION 293.5. THE FLIGHT CREW DID NOT REPORT ANY AIRPLANE MALFUNCTION DURING THE FLIGHT.
Probable cause
Has safety recommendations
true

Vehicle 1

Aircraft category
Airplane
Make
LOCKHEED
Model
L1011
Amateur built
false
Engines
1 Turbo fan
Registration number
N714DA
Operator
DELTA AIRLINES
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight operation type
Unknown
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
193C1090
Damage level
Substantial
creator: NTSB last-modified: 2023-04-24T04:00:00Z guid: 15870 uri: 15870 title: SEA89TL006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41690/pdf description:
Unique identifier
41690
NTSB case number
SEA89TL006
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
1988-10-13T13:35:00Z
Publication date
2023-07-03T04:00:00Z
Report type
Final
Event type
Accident
Location
Cottonwood Canyon, Nevada
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
SEE ATTACHED COPY OF NTSB FORM 6120.1/2 AS REQUIRED BY PL 100-223. "INVESTIGATED BY" DATA BLOCK WAS ENTERED IN ERROR ONLY TO SATISFY THE COMPUTER ENTRY REQUIREMENTS. -
Analysis
ON A FLIGHT TO MONITOR ANIMAL HEALTH OF HORSES, THE PILOT WAS ATTEMPTING TO LAND TO A SUITABLE LANDING SITE. DURING FINAL APPROACH ON THE THIRD ATTEMPT, THE AIRSPEED WAS ABOUT 5 MPH AND ALTITUDE ABOUT 15 FEET AGL, WHEN THE HELICOPTER STARTED TURNING TO THE RIGHT. THE PILOT ATTEMPTED TO CORRECT THE SITUATION, BUT THE HELICOPTER 'SETTLED-IN VERTICALLY' WITH SUFFICIENT FORCE TO DAMAGE THE HELICOPTER. THE WIND WAS REPORTED TO BE FROM 180 TO 225 DEGREES AT 5 GUSTING 15 KNOTS.
Probable cause
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
47G-3B2
Amateur built
false
Engines
1 Reciprocating
Registration number
N46073
Operator
BUREAU OF LAND MANAGEMENT
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Flight service type
Unknown
Flight terminal type
UNK
Scheduled flight
UNK
Commercial sightseeing flight
false
Serial number
6797
Damage level
Substantial
creator: NTSB last-modified: 2023-07-03T04:00:00Z guid: 41690 uri: 41690 title: HWY21IH004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102568/pdf description:
Unique identifier
102568
NTSB case number
HWY21IH004
Transportation mode
Highway
Investigation agency
Other
Completion status
Completed
Occurrence date
2019-11-28T12:33:00Z
Publication date
2023-10-10T04:00:00Z
Report type
Final
Event type
Accident
Location
Fallbrook, California
Injuries
6 fatal, 1 serious, 0 minor
Probable cause
No probable cause determined.
Has safety recommendations
false

Vehicle 1

Traffic unit name
1997 Ford Crown Victoria Sedan
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2018 Ford Ambulance
Traffic unit type
Single Vehicle
Units
Findings
creator: Other last-modified: 2023-10-10T04:00:00Z guid: 102568 uri: 102568 title: ERA20FA096 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100914/pdf description:
Unique identifier
100914
NTSB case number
ERA20FA096
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-02-08T11:13:00Z
Publication date
2023-05-25T04:00:00Z
Report type
Final
Event type
Accident
Location
Fairmount, Georgia
Weather conditions
Instrument Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) contained guidance on spatial disorientation, which stated the following: …under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome. The handbook also advised, "unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided." Airplane Flying Handbook The AFM stated the following about spatial disorientation: The pilot must believe what the flight instruments show about the airplane's attitude regardless of what the natural senses tell. The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately send the attitude changes which occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. FAA Advisory Circular 60-4A, "Pilot's Spatial Disorientation," stated the following on spatial disorientation: The attitude of an aircraft is generally determined by reference to the natural horizon or other visual reference with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of orientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.'…Surface references and the natural horizon may at times become obscured, although visibility may be above flight rule minimums. Lack of natural horizon or such reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions…. The disoriented pilot may place the aircraft in a dangerous attitude… therefore, the use of flight instruments is essential to maintain proper attitude when encountering any of the elements which may result in spatial disorientation. Recognizing a work overload situation is also an important component of managing workload. The first effect of high workload is that the pilot may be working harder but accomplishing less. As workload increases, attention cannot be devoted to several tasks at one time, and the pilot may begin to focus on one item. When a pilot becomes task saturated, there is no awareness of input from various sources, so decisions may be made on incomplete information and the possibility of error increases. When a work overload situation exists, a pilot needs to stop, think, slow down, and prioritize. It is important to understand how to decrease workload. For example, in the case of the cabin door that opened in VFR flight, the impact on workload should be insignificant. If the cabin door opens under IFR different conditions, its impact on workload changes. Therefore, placing a situation in the proper perspective, remaining calm, and thinking rationally are key elements in reducing stress and increasing the capacity to fly safely. This ability depends upon experience, discipline, and training. - According to FAA records, the airplane was manufactured in 1981, and was most-recently registered to a corporation in January 2019. In addition, it was equipped with two Pratt & Whitney Canada, JT15D-1A series, engines, which could each produce 2,200 pounds of thrust. The most recent maintenance performed on the airplane was completed on February 5, 2020. At that time, a Phase B inspection was performed in accordance with the airframe manufacturer's maintenance manual, and at that time, the airplane had accumulated 8,078.7 hours of total time. In addition, the left engine had accumulated 8078.7 hours of total time since new and the right engine had accumulated 8034.7 hours of total time since new. According to the airplane flight manual, the airplane was equipped with anti-ice and deice systems. “The anti-ice system consists of bleed air heated engine inlets, bullet nose, stators, windshields (left and right), electrically heated pitot tubes, static ports, angle-of-attack probe (if installed) and wing leading edge segments ahead of each engine. The wing outboard of the electric elements, the horizontal stabilizer and vertical stabilizer are deiced by pneumatic boots. Windshield alcohol anti-ice is also provided as a backup system for the left windshield.” Furthermore, in the limitations section of the airplane flight manual it stated that the minimum flight crew for all operations was “1 pilot and 1 copilot or 1 pilot in the left-hand seat and the following equipment operative: 1 autopilot with approach coupling, 1 flight director, 1 boom microphone or headset mounted microphone, transponder ident switch on the pilot’s control wheel.” - On February 8, 2020, at 1013 eastern standard time, a Cessna 501, N501RG, was substantially damaged after an inflight breakup near Fairmount, Georgia. The private pilot, commercial pilot, and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to a fuel receipt, the airplane was "topped off" with 104 gallons of Jet A fuel that was premixed with a fuel system icing inhibitor prior to departing on the accident flight. According to an instrument flight plan filed with a commercial vendor, the accident flight was scheduled to depart at 0930 from Falcon Field (FFC), Atlanta, Georgia, and arrive at John C. Tune Airport (JWN), Nashville, Tennessee, around 1022. Another flight plan was filed from JWN back to FFC departing at 1030 and arriving at FFC around 1119. In addition, the accident flight plan noted in the remarks section that the flight was a "training flight” and both flight plans indicated that the pilot in the right seat was the pilot-in-command. A review of air traffic control communications and radar data revealed that the flight departed FFC at 0949 (see figure 1). A controller issued local weather information and instructed the flight to climb to 7,000 ft mean sea level (msl). The controller provided a PIREP for trace to light rime icing between 9,000 ft and 11,000 ft, and one of the pilots acknowledged. The controller then instructed the flight to climb to 10,000 ft and to turn right to 020°. Figure 1 -Overview of flight track data. Magenta line depicts the airplane’s flight track for the accident flight and orange arrows indicate the direction of flight. The controller observed the airplane on a northwesterly heading and asked the flight to verify their heading. A pilot responded that they were returning to a 320° heading, to which the controller instructed him to maintain 10,000 ft. The controller asked if everything was alright, and a pilot responded that they had a problem with the autopilot. The controller instructed the flight again to maintain 10,000 ft and to advise when they were able to accept a turn. The controller again asked if everything was alright or if they needed assistance; however, neither pilot responded. The controller again asked if everything was under control and if they required assistance, to which one of the pilots replied that they were "OK now." The airplane climbed to 10,500 ft and the controller instructed the flight to maintain 10,000 ft and again asked if everything was under control. A pilot responded in the affirmative and stated that they were "playing with the autopilot" because they were having trouble with it, and the controller suggested that they turn off the autopilot and hand-fly the airplane. The airplane descended to 9,000 ft and the controller instructed the pilots to maintain 10,000 ft and asked them if they could return to the departure airport to resolve the issues. One of the pilots requested a higher altitude to get into visual flight rules (VFR) conditions, and the controller instructed him to climb to 12,000 ft, advised that other aircraft reported still being in the clouds at 17,000 ft, and asked their intentions. The pilot requested to continue to their destination. The controller instructed him to climb to 13,000 ft, maintain wings level, and to change radio frequencies. One of the pilots established communication with the next controller at 11,500 ft and stated they were climbing to 13,000 ft on a 360° heading. The controller instructed the pilot to climb to 16,000 ft and inquired if their navigation issues were corrected. A pilot advised the controller that they had problems with the left side attitude indicator and that they were working off the right side. From 1011:23 to 1011:55, the airplane climbed from 12,000 ft to 15,000 ft. The controller cleared the airplane direct to JWN and asked if they were above the clouds as they were climbing through 15,000 ft. The airplane then began a descending left turn and soon after radar contact was lost at 1013. The controller attempted numerous times to contact the pilots with no response. There was no emergency call received from the pilots prior to the accident. - Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified rosuvastatin in the left seat pilot’s blood and urine. This drug was not considered impairing. An autopsy was performed on the left seat pilot by the Division of Forensic Sciences, Georgia Bureau of Investigation. The cause of death was multiple blunt traumatic injuries, and the manner of death was accident. An autopsy was performed on the right seat pilot by the Division of Forensic Sciences, Georgia Bureau of Investigation. The cause of death was multiple blunt traumatic injuries, and the manner of death was accident. The examination was limited by the severity of injury. The autopsy noted “coronary artery disease” without any further description. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified diphenhydramine (in an amount too low to quantify and lower than the lowest level believed to result in symptoms) and losartan in the right seat pilot’s blood and urine. While losartan is not considered impairing, diphenhydramine is sedating. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under the names Benadryl and Unisom. Diphenhydramine carries the following FDA warning: may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Compared to other antihistamines, diphenhydramine results in marked sedation; it is also classed as a CNS depressant and this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. - The 1015 recorded weather observation at an airport that was about 9 miles to the west of the accident location, included wind from 330° at 3 knots, visibility 3/4 mile, light snow, vertical visibility 500 ft above ground level (agl), temperature 0° C, dew point 0° C; and an altimeter setting of 30.29 inches of mercury. The High-Resolution Rapid Refresh (HRRR) numerical model data indicated that the freezing level was at 2,026 ft and predominantly light rime type icing conditions between 1,300 ft through 15,000 ft with a shallow layer of moderate rime ice at 7,500 ft. The National Weather Service issued a Graphic-AIRMET at 0945 that advised of mountain obscuration conditions, moderate turbulence between 10,000 ft and 18,000 ft, and for moderate icing between the freezing level through 16,000 ft. In addition, AIRMET Sierra update 2 was issued at 0945 that indicated instrument meteorological conditions in the area of the accident around the time of the accident. PIREPs were reviewed and indicated that icing conditions were below 12,000 ft and turbulence conditions above 15,000 ft to 24,000 ft. Of the icing PIREPs the intensity or severity of icing ranged from NIL, (2 reports), a trace, (1 report), light (12 reports), and moderate (2 reports). Icing type ranged from rime type ice (11 reports), mixed (1 report), and clear or glaze ice (1 report), which could indicate variable droplet size or temperature range where the ice was encountered. The icing layer reported ranged from 4,000 ft up to 12,000 ft with most of the reports of icing between 9,000 ft and 10,000 ft. A search of the FAA contract Automated Flight Service Station (AFSS) provider Leidos indicated that they had no contact with the pilots on the day of the accident and did not provide any weather briefing or flight planning services. A search of other third-party vendors indicated that the left seat pilot had a ForeFlight account. He did not view any static weather imagery or graphic images during the period prior to departure but obtained other textual observation and forecast products for Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama, Nashville International Airport (BNA), Nashville, Tennessee, and Jeffries Farm Airport (6KY6), Louisville, Kentucky. Another third-party weather vendor, FltPlan.com had recorded that the right seat pilot obtained a weather briefing for the route of flight twice on February 7th at 1114 and then later at 1948. The forecasts and advisories in that briefing were updated several times before the flight’s departure and the accident and were not reflective of the current conditions the flight encountered on February 8th. There were no other weather briefings recorded on the day of the accident. - According to Federal Aviation Administration (FAA) airman records, the right seat pilot, the pilot-in-command, held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, airplane single-engine sea, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine, airplane multiengine, and instrument airplane. He was also type rated in the CE-500. His most recent second-class medical certificate was issued December 10, 2019. According to the pilot's logbook, he accumulated 5,924.4 total hours of flight time, of which, he accumulated 88.6 hours of flight time in the same make and model as the accident airplane in the year before the accident. The logbook also indicated that he accumulated 573.4 total hours of instrument flight time, of which, 40.7 hours were in the year prior to the accident. According to FAA airman records, the left seat pilot, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent third-class medical certificate was issued January 10, 2019, at which time he reported 805 hours of total flight experience. According to an email and training materials located in the wreckage, the pilot was scheduled to attend flight training to obtain a CE-500 type rating. - The main wreckage of the airplane was located in a wooded area, inverted, and partially submerged in a creek at an elevation of 703 ft msl. Several parts of the airplane were not located in the vicinity of the main wreckage but were in the wooded area surrounding the main wreckage, consistent with an inflight breakup. The debris path was about 7,000 ft long along a 005° magnetic heading. The wreckage was recovered to a salvage facility for further examination, which included the identification of parts that were separated in flight and were located along the debris path. The top of the fuselage was crushed downward, and the wings were wrinkled. Control cable continuity was established from the flight controls in the cockpit to all flight control surfaces through multiple overload failures. The pitot-static system was examined, and no blockages were noted. The wing deice inspection light, on the left side of the fuselage, was examined and the filament was not stretched. The left wing remained attached to the fuselage and exhibited crush damage. The left aileron remained attached to the left wing. The left flap remained attached to the wing and was in the retracted position. In addition, the left speed brake was in the stowed position. The outboard 8 ft section of the right wing was separated and located along the debris path. The aileron was separated from the outboard section of wing and the midsection was located along the debris path. The inboard section of the wing remained attached to the fuselage and was impact damaged. The fractured section of the spar caps of the right wing were examined and were bent in an upward direction. The fracture surfaces exhibited rough 45° angle surfaces, consistent with overload failures. Several sections of wing skin were located along the debris path. The horizontal stabilizers and elevators separated and were located along the debris path. The outboard 6 ft of the left horizontal stabilizer was separated from the inboard section and located along the debris path. The fractured section of the spar caps of the left horizontal stabilizer were bent in a downward direction. The inboard 2 ft of the left elevator was separated from the horizontal stabilizer and located along the debris path. The forward spar of the vertical stabilizer remained attached to the fuselage, was bent aft, and twisted to the right. The aft spar of the vertical stabilizer was located along the debris path. The rudder was separated from the fuselage and the 3 ft top section and 5 ft bottom section were recovered from the debris field. The engines remained attached to the fuselage and were submerged in creek water. They were removed from the fuselage to facilitate recovery and examination. The engine cowling was removed and both low-pressure compressors would not rotate. Both low-compressor turbine blades exhibited damaged and were bent the opposite direction of rotation. The inner stator vanes did not exhibit any damage. The fuel and oil filters were examined with no anomalies noted. There were no anomalies with the engines that would have precluded normal operation prior to the accident. Examination of the cockpit switches showed that they were compromised during impact which revealed unreliable switch positions during the accident sequence. The compass directional gyro and vertical gyro instruments were removed from the wreckage and examined. Both gyros exhibited rotational scoring. The left position attitude indicator was removed, examined, and no anomalies were noted with the instrument that would have precluded normal operation before the accident. The autopilot computer was examined and disassembled. There were no anomalies noted with the autopilot system that would have precluded normal operation before the accident. The three pneumatic ejector flow control valves (EFCV) for the deice boots were removed and examined. The valves were two-way, two-position, solenoid-operated poppet type valves that used regulated engine bleed air to provide either vacuum or pressure to the de-icers. When power was removed from the EFCVs the conical main spring pushed the poppet valve and stainless-steel ball out to close the inflate port. When power was applied to the EFCV, the solenoid opened the poppet against the spring. It could not be determined if the valves were exposed to the creek water or precipitation at the accident site prior to removal. Examination of all three valves revealed that the poppets were in the closed position. Examination of the left wing EFCV revealed that when power was initially applied to the solenoid there was no movement. When the solenoid was pushed by hand, the solenoid moved. On subsequent applications of power, the solenoid moved very slowly. The right wing EFCV passed the functional test with the solenoid and poppet both showing movement when electrical power was applied. When the poppet was moved by hand, no anomalies were noted. The tail EFCV was examined and when assistance was provided to the solenoid to change position, the resultant valve flows were within specifications. If the valve solenoid was not given assistance, the valve would partially open, and the resultant flows were below specifications. All EFCV valves contained corrosion in the assembly when they were disassembled. -
Analysis
While on an instructional flight in icing and instrument meteorological conditions (IMC), the pilots indicated that they were having instrumentation difficulties to air traffic control. They initially reported a problem with the autopilot, then a navigational issue, which they later indicated were resolved, and finally they reported it was a problem with the left side attitude indicator. After air traffic control cleared them to their destination, the airplane entered a descending left turn, which continued into a 360° descending turn. An inflight breakup resulted, with the wreckage being scattered over 7,000 ft of wooded terrain. Examination of the engines revealed there were no anomalies that would have precluded normal operation prior to the accident. Control cable continuity was established from the flight controls in the cockpit to all flight control surfaces through multiple overload failures. The pitot-static system was examined, and no blockages were noted. Since there was rotational scoring noted on the vertical gyro and the directional gyro, it’s likely they were operating at the time of the accident. Furthermore, the left side attitude indicator examination revealed that there were no anomalies with the instrument. Examination of the deice valves for the deicing boots revealed that the left wing deice valve did not operate. Corrosion was visible in all three valves and it could not be determined if the corrosion was a result of postimpact environmental exposure. Furthermore, since the cockpit switch positions were compromised in the accident, it could not be determined if the pilots were operating the deicing system at the time of the accident. However, most of the pilot reports (PIREPs) in the area indicated light icing and the airplane performed a 6,000 ft per minute climb just before the loss of control. Given this information, it is unlikely the icing conditions made the airplane uncontrollable. A review of the pilots’ flight experience revealed that the pilot in the left seat did not hold a type rating for the accident airplane model but was scheduled to attend flight training to obtain such a type rating. The pilot in the right seat, who also held a flight instructor certificate, did hold a type rating for the airplane. Given that the remarks section of the filed flight plan described the flight as a “training flight” and the left-seat pilot’s plan to obtain a type rating for the accident airplane model, it is likely the pilot in the left seat was the flying pilot for the majority of the flight. Although the right-seat pilot's autopsy noted coronary artery disease, the condition was poorly described. The circumstances of the accident are not consistent with sudden physical impairment or incapacitation; therefore, it is unlikely it contributed to the event. Toxicology testing identified diphenhydramine, which can cause significant sedation, in the right-seat pilot’s blood. However, the level present at the time of the accident was too low to quantify. Therefore, it is unlikely effects from diphenhydramine contributed to the accident. Prior to entering the descending right turn, air traffic control noted that the airplane was not following assigned headings and altitudes and the pilots’ reported having autopilot problems. Subsequently, the pilots’ reported they were using the right attitude indicator as they had difficulties with the left-side indicator. Information was insufficient to evaluate whether the reported difficulties were the result of a malfunction of the autopilot or the pilots’ management of the autopilot system. However, the reported difficulties likely increased the pilots’ workload, may have diverted their attention while operating in IMC and icing conditions, resulting in task saturation, and may have increased their susceptibility to spatial disorientation. It is also possible that the onset of spatial disorientation was the beginning of the pilots’ difficulties maintaining the airplane’s flight track and what they perceived to be an instrumentation problem. Regardless, since the left seat pilot was not rated to fly the airplane, the right seat pilot’s workload would have increased by having to diagnose the issue, assess the situation, and maintain positive airplane control. The airplane’s track data are consistent with the known effects of spatial disorientation, leading to an inflight loss of control and subsequent inflight breakup.
Probable cause
The pilots’ loss of control in flight in freezing instrument meteorological conditions due to spatial disorientation and the cumulative effects of task saturation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Cessna
Model
501
Amateur built
false
Engines
2 Turbo fan
Registration number
N501RG
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
501-0260
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-25T04:00:00Z guid: 100914 uri: 100914 title: CEN20LA442 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193472/pdf description:
Unique identifier
193472
NTSB case number
CEN20LA442
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-03-11T22:45:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-12T19:03:03.2Z
Event type
Accident
Location
Sterling City, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported to local law enforcement that while conducting an aerial application flight, the helicopter impacted power lines. He said that while he had crossed over the power lines multiple times during the application flight; however, the sun was blocked by a cloud and the power line was not visible due to the lack of a reflection off the line. The helicopter sustained substantial damage to the main rotor mast. According to a Federal Aviation Administration inspector that examined the helicopter on scene, he reported that there were no mechanical malfunctions or failures that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain clearance from power lines during an aerial application flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Registration number
N4386W
Operator
AERIAL CRANE ENTERPRISES LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
12847
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-12T19:03:03Z guid: 193472 uri: 193472 title: CEN20LA197 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101334/pdf description:
Unique identifier
101334
NTSB case number
CEN20LA197
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-05-27T14:58:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Event type
Accident
Location
Cambridge, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to maintenance documentation, on February 5, 2019, at 3,861.1 total airframe hours, the installed Continental IO-470-K engine was removed and replaced with a factory rebuilt Continental IO-470-N engine, s/n 1036858, in accordance with supplemental type certificate (STC) No. SA5527SW. Additionally, a McCauley 3A36C434/80VEA propeller, s/n 190011, and McCauley C290D3/T35 propeller governor, part number (p/n) D20309-31, s/n 180680, were installed in accordance with STC No. SA00718CH. The last annual inspection of the airplane was completed on March 15, 2019, at 3,872.9 total airframe hours, at which time the engine had accumulated 11.8 hours since the factory rebuild. According to a Federal Aviation Administration (FAA) incident data, on February 3, 2020, the pilot inadvertently landed the airplane with the landing gear retracted at Ohio State University Airport (OSU), Columbus, Ohio. According to maintenance logbook documentation, after the wheels-up landing, the Continental IO-470-N engine, s/n 1036858, was shipped to Continental Services, Fairhope, Alabama, to be disassembled, inspected, and repaired for any propeller strike damage. After the engine was inspected, it was reinstalled on the airplane on May 22, 2020, at 4,056.8 total airframe hours, by the Ohio State University Airport certified repair station with a new McCauley 3A36C434/80VEA propeller, s/n 191236, and an overhauled McCauley C290D3-R/T35 propeller governor, s/n 180680. Postaccident review of recorded engine data revealed that on May 22, 2020, following the engine/propeller installation, the engine was run at least twice, accumulating about 10.8 minutes. The first engine run was 9 minutes in duration and included a fuel flow of 22.3 gph during an evident max power cycle. The second engine run was about 1.8 minutes in duration and did not appear to include a max power cycle. A review of the engine data for both test runs did not reveal any anomalies, and the maximum fuel flow during the first test run was consistent with the manufacturer’s specification of 22 gph for the engine at rated power. On May 27, 2020, at 4,057 total airframe hours, the damaged flaps were removed, and a serviceable pair of flaps were installed by a mechanic representing Plane Care, LLC, a certified repair station at Hagerstown Regional Airport (HGR), Hagerstown, Maryland. The mechanic disabled the flaps in the up position by pulling and collaring the flap circuit breaker. The landing gear was disabled in the extended position by pulling and collaring the landing gear circuit breaker. On May 27, 2020, the FAA issued a ferry permit for the airplane to be flown from OSU to HGR where additional airframe repairs were to be completed. At the time of the accident, the airframe total time was about 4,058.1 hours. The engine had accumulated about 197 hours since the factory rebuild and 1.3 hours since it was reinstalled on the airframe after the propeller strike inspection. Figure 3 – Engine Monitor Data During Engine Test Run on May 22, 2020 - On May 27, 2020, about 1458 eastern daylight time, a Beech 35-A33 airplane, N123JB, was substantially damaged when it collided with trees during a forced landing near Cambridge, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. According to airplane track data, at 1403:43, the airplane was established in a climb after it departed from runway 27L at Ohio State University Airport (OSU), Columbus, Ohio. The airplane flew to the west before it entered a climbing right turn to a northeast course. The airplane continued the climb to 3,000 ft mean sea level (msl) before it turned to an east-southeast course, as shown in figure 1. The airplane then climbed to a final cruise altitude of 3,500 ft msl and maintained an east-southeast course. Figure 1 – Aircraft Track Data According to engine monitor and airplane track data, during takeoff and initial climb the fuel flow was 22- to 23 gph. As the airplane climbed to 3,500 ft msl the fuel flow was 20 to 25.5 gph. According to Beech 35-A33 performance data, the fuel flow is about 22 gph when the engine is operated at the rated horsepower and manifold pressure, and the fuel flow is about 13.4 gph when the engine is operated at 75% power and leaned for cruise flight at 3,500 ft. Between 1423:45 and 1425:45, the fuel flow averaged 22 gph in cruise flight at 3,500 ft msl. Between 1425:45 and 1428:28, the fuel flow gradually increased to 28 gph. About 25 minutes into the flight, at 1428:28, the fuel flow decreased rapidly from 28 gph to 11 gph with corresponding decreases in EGT and CHT at each cylinder, as shown in figure 2. Within 6 seconds, the fuel flow returned to 28 gph with corresponding increases to EGT and CHT at each cylinder. As the airplane continued cruise flight at 3,500 ft msl, between 1430 and 1446, the average fuel flow and EGT were 29 gph and 1,482° F, respectively. At 1442:45, the pilot contacted Cleveland Air Route Traffic Control Center (ARTCC) to continue visual flight rules flight following. At 1443:48, Cleveland ARTCC lost radar contact with the airplane when it flew into an area of reduced radar coverage at 3,500 ft msl. The controller and the pilot remained in radio contact for the remainder of the flight. Beginning about 1445, the No. 3 cylinder EGT and CHT decreased at a higher rate when compared to the other cylinders, while the fuel flow remained at 28-29 gph. Over the next 8-10 minutes, the No. 3 cylinder EGT continued to decrease and became inconsistent with normal engine operation, as shown in figure 2. At 1448:31, the pilot told the controller that he was conducting a ferry flight with the landing gear down and that the airplane’s speed was about 110 knots. At 1450:15, the airplane began to descend from 3,500 ft msl. At 1452:33, the pilot reported an unspecified issue and that he was going to divert to Barnesville-Bradfield Airport (6G5), Barnesville, Ohio, and asked the controller if the airport had an automatic terminal information service (ATIS). At 1453:20, the controller told the pilot that 6G5 did not have an ATIS and provided him with the common traffic advisory frequency (CTAF). At 1454:04, the pilot declared an emergency due to a loss of engine power and reported that he had an airport at his one o'clock position, which he subsequently identified as Cambridge Municipal Airport (CDI), Cambridge, Ohio. The pilot then asked the controller to verify the CTAF frequency at CDI. Between 1454:20 and 1454:25, the fuel flow increased from 27.7 to 30.1 gph. At 1454:34, the No. 5 cylinder EGT and CHT started to decrease and became inconsistent with normal operation, as shown in figure 2. At 1455:28, the pilot stated that he did not believe he was going to reach the airport. At 1455:51, the controller asked the pilot what he was doing. The pilot did not respond. At 1456:04, the controller again inquired if the pilot was still on the frequency. At 1456:10, the pilot replied that he could still hear the controller and that the airplane was about 3 miles from CDI at 2,000 ft msl. The controller told the pilot to advise when he saw the airport, and to provide the airplane’s current bearing. At 1456:21, the pilot replied that the airplane was on a 210° bearing. At 1456:27, the pilot stated that the airplane was north of CDI, lined up with an unknown runway. The controller told the pilot that the hard surface runway at CDI was runway 4/22. At 1456:39, the pilot confirmed that the airplane was lined up with runway 22 at CDI. Between 1456:40 and 1457:30, as shown in figure 2, the No. 5 cylinder EGT increased about 420°, while the No. 1 cylinder EGT decreased about 100°, Nos. 2-, 4-, and 6-cylinder EGT decreased 300-500°, and the No. 3 cylinder EGT continued to decrease and was significantly lower than the other cylinders. At 1457:16, the pilot stated again that he was not going to make it to CDI. At 1457:24, the engine monitor ceased recording EGT for the No. 3 cylinder after it decreased below 450° F. At 1457:30, the pilot stated, “[unintelligible] off to my left, I’ll have to put it down.” At 1457:34, the pilot told the controller that he was going to land in a field. The controller asked the pilot if he could write down a phone number. At 1457:40, the pilot replied “ah, not right now sir.” There were no additional radio transmissions from the pilot. Between 1458:00 and 1458:22, the fuel flow decreased from 26.7 to 9.6 gph with a corresponding significant decrease in EGT for all cylinders below 550° F. The engine monitor did not record data past 1458:22. There were numerous witnesses that reported seeing the airplane flying at a low altitude with a noticeable engine issue. Several of these witnesses reported hearing the engine "sputtering" or "misfiring" before the airplane descended out of their sightline behind trees. One witness reported seeing a “noticeable but faint, wispy, transparent film” trailing the aircraft and “white or light gray puffs” near the exhaust. Figure 2 – Engine Monitor Data - An autopsy of the pilot was performed by the Franklin County Forensic Science Center, Office of the Coroner, Columbus, Ohio, which identified the cause of death as blunt force injuries of the head, and the manner of death was accident. No significant natural disease was identified during the autopsy. Toxicological testing completed by the Federal Aviation Administration’s Forensic Sciences Laboratory identified the sedating antihistamine diphenhydramine in the pilot’s urine but not in his blood. The gastric reflux medication famotidine was detected in his urine and in his muscle tissue and the asthma medication albuterol was detected in his lung tissue; these two medications are considered non-impairing. - The airplane wreckage was at the edge of a field located about 3 nautical mile northeast of CDI, as shown in figures 4 and 5. There was no evidence that the airplane's wheels contacted the ground before the airplane flew into the trees at the eastern edge of the field on an east heading. Based on the damage to the trees and the airplane, the airplane impacted the trees a few feet above ground level in a level pitch attitude, as shown in figure 6. Fuel was present in both main fuel tanks and the fuel filter assembly, and there was no water or particulate matter observed in fuel samples recovered from both main fuel tanks. The fuel selector valve handle was found in the left main tank position. The fuel selector valve functioned as designed when tested. About 16 gallons of fuel remained in the fuel system when the airplane was recovered from the accident site. Visual examination of the fuselage’s exterior revealed fuel streaks emerging from a louvered vent and access panel at the lower right side of the engine compartment, and continued aft along the lower right fuselage, as shown in figures 7-11. There was no evidence of fuel pooling or streaking on the internal surfaces of the engine cowling, but there were a few rivet bucktails that exhibited fuel staining. The fuel lines forward of the firewall exhibited no evidence of fuel leaks. All fuel lines from the firewall to the fuel manifold were clear of obstructions when air was blown through them. All fractured fuel line fittings exhibited features consistent with impact related damage. There was no damage, debris, or obstructions to the fuel manifold, stainless steel injector lines, or fuel injector nozzles Nos. 1-4 and No. 6. The No. 5 fuel injector nozzle exhibited impact related damage but appeared clear of debris. The No. 3 cylinder head exhibited blue fuel stains on several cooling fins located on the forward-facing side of the intake port, as shown in figures 12-13. There were no apparent cracks or fuel stains around the fuel injector nozzle or spark plug ports. The inter-cylinder baffle between the No. 3 and 5 cylinders exhibited prominent fuel straining and streaking, as shown in figure 14. The intake flange gasket compression faces were flattened around the inner diameter hole and there were no apparent kinks or tears. The No. 3 cylinder intake elbow and cylinder intake port flange face did not exhibit any fuel stains. The remaining cylinders and engine components did not exhibit any visible fuel stains. The postaccident engine examination did not reveal a mechanical failure that would have prevented normal operation. Figure 4 – Aerial Photograph Showing Accident Site Location (FAA Photo) Figure 5 – Aerial Photograph Showing Accident Site Location (FAA Photo) Figure 6 – Main Wreckage at Accident Site (AMF Aviation Photo) Figure 7 – Fuel Streaks on Lower Right Engine Cowl Figure 8 – Fuel Streaks on Lower Right Engine Cowl Figure 9 – Fuel Streaks on Lower Right Side of Fuselage (FAA Photo) Figure 10 – Fuel Streaks on Lower Right Side of Fuselage (FAA Photo) Figure 11 – Fuel Streaks on Lower Right Side of Fuselage (AMF Aviation Photo) Figure 12 – Fuel Stains on No. 3 Cylinder and Inter-Cylinder Baffle Figure 13 – Fuel Stains Near No. 3 Cylinder Intake and on Inter-Cylinder Baffle Figure 14 – Fuel Streaking on Inter-Cylinder Baffle Between Cylinders Nos. 3 and 5 -
Analysis
The pilot was conducting a ferry flight after the engine was disassembled, inspected, and reinstalled following a wheels-up landing incident that occurred a few months before the accident. About 51 minutes after takeoff the pilot declared an emergency with the air traffic controller due to a loss of engine power and stated that the airplane did not have sufficient altitude to land at the nearest airport. The pilot maneuvered the airplane to land in a nearby field, but he was unable to touch down before the end of the field where the airplane impacted trees a few feet above the ground in a level pitch attitude. Several witnesses reported seeing the airplane flying at a low altitude with a noticeable engine issue. Some of these witnesses reported hearing the engine "sputtering" or "misfiring" before the airplane descended out of their sightline behind trees. One witness reported seeing a “noticeable but faint, wispy, transparent film” trailing the aircraft and “white or light gray puffs” near the exhaust. According to recorded engine monitor data, during takeoff and initial climb, the fuel flow was 22 to 23 gallons per hour (gph), which was consistent with the airframe manufacturer’s engine performance charts at rated horsepower and manifold pressure. However, as the flight continued, the fuel flow increased to 29 to 30 gph, which was more than double the expected fuel flow for a leaned engine operating at 75% power during cruise flight. About 41 minutes into the flight, the No. 3 cylinder exhaust gas temperature (EGT) and cylinder head temperature (CHT) began decreasing and at a higher rate when compared to the other cylinders. Similarly, about 4 minutes before the accident, the No. 5 cylinder EGT/CHT also decreased and was inconsistent with the remaining four cylinders. Postaccident examination of the airplane revealed fuel streaks emerging from a louvered vent and access panel at the lower right side of the engine compartment, continuing aft along the lower right fuselage. There was no evidence of pooling or fuel streaking on the internal surfaces of the engine cowling. The fuel lines forward of the firewall exhibited no evidence of fuel leaks or obstructions, and all fractured fuel line fittings exhibited features consistent with impact related damage. The No. 3 cylinder head exhibited fuel stains on several cooling fins located on the forward-facing side of the intake port; however, there were no apparent cracks or fuel stains around the fuel injector nozzle or spark plug ports, and the No. 3 fuel injector line did not exhibit any damage or leaks. The No. 3 intake flange gasket compression faces were flattened around the inner diameter hole and there were no apparent kinks or tears. The No. 3 cylinder intake elbow and cylinder intake port flange face did not exhibit any fuel stains. The inter-cylinder baffle between the No. 3 and 5 cylinders exhibited prominent fuel straining and streaking. The remaining cylinders and engine components did not exhibit any visible fuel stains. The postaccident engine examination did not reveal a mechanical failure that would have prevented normal operation. Based on the excessive fuel flow and engine operation irregularities with the Nos. 3 and 5 cylinders during the flight, the fuel stains on the No. 3 engine cylinder near the intake, and the fuel streaks on the inter-cylinder baffle and the lower right side of the fuselage, the loss of engine power was likely due to a fuel injection system leak at or near the No. 3 cylinder.
Probable cause
A fuel injection system leak at or near the No. 3 cylinder that resulted in a partial loss of engine power during cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Beech
Model
35-A33
Amateur built
false
Engines
1 Reciprocating
Registration number
N123JB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
CD-313
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-08T04:00:00Z guid: 101334 uri: 101334 title: HWY20IH009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101909/pdf description:
Unique identifier
101909
NTSB case number
HWY20IH009
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-06-12T04:51:00Z
Publication date
2023-10-13T04:00:00Z
Report type
Final
Event type
Accident
Location
Arlington TWP, Wisconsin
Injuries
0 fatal, 0 serious, 1 minor
Probable cause
No probable cause determined.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2019 Hino Straight Truck
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2018 Ford Explorer
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 3

Traffic unit name
2010 International Dump Truck
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 4

Traffic unit name
Highway Worker 1
Traffic unit type
Pedestrian
Findings

Vehicle 5

Traffic unit name
State Trooper 1
Traffic unit type
Pedestrian
Findings

Vehicle 6

Traffic unit name
State Trooper 2
Traffic unit type
Pedestrian
Findings

Vehicle 7

Traffic unit name
2014 Ford Explorer
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-10-13T04:00:00Z guid: 101909 uri: 101909 title: CEN20LA234 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101453/pdf description:
Unique identifier
101453
NTSB case number
CEN20LA234
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-06-17T18:00:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Event type
Accident
Location
Pine Bluff, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 17, 2020, about 1800 central daylight time, an Air Tractor AT-402 airplane, N1532H, was substantially damaged when it was involved in an accident near Pine Bluff, Arkansas. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was spraying applicant over a field and that a partial loss of engine power occurred when he began the first climbing turn to reverse course and make a second pass. The airplane subsequently descended and impacted terrain in a near-vertical attitude. The pilot also reported that the airplane owner had previously told him that the engine could potentially have 15% less power and had a history of engine problems. Maintenance log entries did not show a history of engine problems. Postaccident examination of the engine and its components discovered multiple signatures of rotational scoring and rubbing. The fuel control unit, fuel pump, starting flow control unit, overspeed governor, and propeller governor showed no preimpact anomalies but did show signs of contamination consistent with the presence of agricultural fertilizer. The engine case and components were damaged by impact. -
Analysis
The pilot reported that, during an aerial application flight, a partial loss of engine power occurred while he was performing the first climbing turn to reverse course. The airplane subsequently descended and impacted terrain in a nearvertical attitude. Postaccident examination of the engine and its components revealed no preimpact anomalies. The reason for the partial loss of engine power could not be determined with the available evidence for this accident investigation. Given the airplane’s near-vertical descent, it is likely that the pilot exceeded the airplane’s critical angle of attack during the climbing turn, which resulted in an aerodynamic stall and a loss of airplane control from which the pilot was unable to recover.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack, which led to an aerodynamic stall and a loss of airplane control. Contributing was a partial loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR
Model
AT402
Amateur built
false
Engines
1 Turbo prop
Registration number
N1532H
Operator
FARM BROTHERS FLYERS A LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
402-0852
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-26T04:00:00Z guid: 101453 uri: 101453 title: CEN20LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101616/pdf description:
Unique identifier
101616
NTSB case number
CEN20LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-07-03T08:30:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Event type
Accident
Location
Des Arc, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 3, 2020, about 0830 central daylight time, an Air Tractor AT-602 airplane, N8506E, was substantially damaged when it was involved in an accident near Des Arc, Arkansas. The pilot was not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 137 as an aerial application flight. According to the pilot, after completing the aerial application, he flew to survey another field. During the second turn over the field, the engine lost total power. The pilot selected another field to perform a forced landing and had to slip the airplane so that it would not overrun the field. As the airplane approached the ground, inadequate airspeed remained to straighten the airplane. The airplane touched down in a slip, which caused the right main landing gear to collapse and substantial damage to the left wing. Postaccident examination of the engine revealed no preimpact anomalies that would have precluded normal operation of the airplane. Fuel was found in the fuel tanks. The engine’s fuel control unit, fuel pump, and oiltofuel heater were sent to Pratt & Whitney Canada (the engine manufacturer) to be examined and bench tested; no anomalies were detected that could have caused or contributed to a loss of engine power. -
Analysis
While the pilot was conducting an aerial survey of a field, the airplane’s engine lost total power, and the pilot performed a forced landing to a field. During the landing, the airplane touched down in a slip, which caused the right main landing gear to collapse and substantial damage to the left wing. Fuel was found in the fuel tanks. Postaccident examination of the engine and fuel system components revealed no anomalies that would have resulted in a loss of engine power. Thus, the reasons that the airplane lost total engine power during the accident flight could not be determined based on the evidence available for this investigation.
Probable cause
A total loss of engine power for reasons that could not be determined from all available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Air Tractor
Model
AT 602
Amateur built
false
Engines
1 Turbo prop
Registration number
N8506E
Operator
Bell's Ag Service Inc
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
602-0657
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-26T04:00:00Z guid: 101616 uri: 101616 title: CEN20LA306 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101668/pdf description:
Unique identifier
101668
NTSB case number
CEN20LA306
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-07-25T11:36:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Event type
Accident
Location
Grant, Nebraska
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The Air Tractor AT-502B airplane flight manual (AFM) states that spray passes should be flown at 130-140 mph to ensure proper spray penetration into the crop, and an abrupt pull-up at the end of a spray pass should be avoided to maintain adequate airspeed during the turn between spray passes. The AFM states that a maximum altitude loss of 220 ft is expected during a recovery from a wings-level aerodynamic stall at a gross weight of 8,000 lbs; however, an aerodynamic stall during an uncoordinated turn will result in a sharp decrease in airplane pitch and a significant loss of altitude. The AFM prohibits all aerobatic maneuvers, including spins. - On July 25, 2020, about 1136 mountain daylight time, an Air Tractor AT-502B airplane, N502KJ, was substantially damaged when it was involved in an accident near Grant, Nebraska. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 agricultural flight. According to data downloaded from the airplane’s Satloc GPS guidance system, at 1108, the flight departed Grant Municipal Airport (GGF), Grant, Nebraska, and proceeded south toward the field to be sprayed. After arriving over the field, the pilot completed several orbits of the field before he began spraying using a series of east/west flightpaths, as shown in figure 1. As the flight progressed, the airplane made a climbing left turn after each spray pass, the frequency of spray passes increased, the elapsed time between spray passes decreased, and the maximum altitude achieved between spray passes increased, as shown in figure 2. During the final 5 minutes of the flight, the airplane's groundspeed was 160-165 mph during each spray pass and 104-120 mph while in the turn between spray passes; the airplane routinely climbed 450-520 ft after each spray pass. At 1136:48, the final track point recorded the airplane in a climb on a west heading near the end of a spray pass at the northern edge of the field being sprayed. The final track point was about 1/4 mile northeast of the accident site. The airplane's final recorded groundspeed and estimated altitude above ground level were 152 mph and 136 ft, respectively. The Satloc GPS guidance system has a 6-second delay between data acquisition and when data are saved to non-volatile memory and, as such, the final moments of the flight were not recorded. Another agricultural pilot, who was spraying a nearby field at the time of the accident, reported that he maintained radio contact with the accident pilot throughout most of his flight and that he saw the accident airplane consistently climb 450-500 ft after each spray pass. He stated that the climbs between spray passes were higher than required for an aerial-application flight. The last time he saw the accident airplane, it was flying to the west in a climb before it rolled right-wing-down into a 90°-100° bank with a 10°-12° nose-up pitch attitude. The accident airplane was turning toward north when it pitched down through the horizon, consistent with a lazy eight flight maneuver. The pilot lost sight of the accident airplane when he turned his airplane after a spray pass. The pilot was unable to reestablish radio contact with the accident pilot and continued to spray his assigned field. The pilot subsequently saw the airplane wreckage in the cornfield directly west of the field that the accident pilot had sprayed, as shown in figure 3. Figure 1. GPS Ground Track Data Figure 2. Altitude, Groundspeed, and Ground Track Angle Data Figure 3. Aerial Photo Taken of Accident Site (Source: Aurora Cooperative Elevator Company) - An autopsy of the pilot was performed by Western Pathology Consultants, Scottsbluff, Nebraska, which identified the cause of death as blunt force trauma with the manner of death an accident. No significant natural disease was identified during the autopsy. Toxicological testing, completed by the FAA Forensic Sciences Laboratory, detected ethanol at 0.058 g/dL in cavity blood, 0.128 g/dL in muscle tissue, and 0.036 g/dL in brain tissue. N-propanol and methanol were detected at low levels in cavity blood. N-butanol was detected at low levels in cavity blood and muscle tissue. Ethanol is a type of alcohol that is the intoxicating substance of beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. However, consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can also be produced by microbes in a person’s body after death. Postmortem ethanol production can affect multiple specimens from the same individual to different degrees, which can result in the specimens having significantly different ethanol levels from one another. N-propanol and n-butanol are alcohols that can be produced by microbes in a person’s body after death. Methanol is wood alcohol; it occurs naturally in the body at very low levels, is present in some foods and drinks, and is a solvent in a variety of industrial products. At low levels, n-propanol, n-butanol, and methanol are not impairing. - The operator’s chief pilot reported that he previously observed the pilot use “aggressive” flying techniques during an evaluation flight and told the pilot that a hammerhead maneuver between spray passes was not acceptable during agricultural flights. The chief pilot told the pilot that turns between spray passes should consist of three separate phases (field departure, procedure turn, and field reentry) and should not be combined into a single maneuver. At the recommendation of the chief pilot, the pilot agreed to review a National Agricultural Aviation Association endorsed training video, Turn Smart, that discussed and demonstrated the proper turning techniques to be used during agricultural flights. - The accident site was in a cornfield about 8.7 miles south-southeast of GGF. An onsite examination was conducted by a Federal Aviation Administration (FAA) inspector and an Air Tractor accident investigator. Based on the damage to the cornstalks immediately surrounding the wreckage, the airplane impacted terrain in an estimated 45° nose-down flightpath angle. There were no discernable ground impacts or debris path preceding the wreckage. The airplane wreckage was found upright with significant impact damage to the forward fuselage and the leading edge of both wings. The fuselage was oriented on an east-northeast heading. Flight control continuity could not be established due to damage; however, all observed separations were consistent with impact-related damage. The rudder control cables were continuous from the rudder pedals to the rudder control horns. The aileron drooping system was continuous from the flap torque tube to the aileron bellcrank support assembly. The flap actuator measured 2.875 inches and was consistent with the flaps extended about 20° at impact. The aft fuselage and empennage exhibited minor impact-related damage. Both landing gear legs separated from the fuselage during impact. Both wing fuel tanks ruptured during impact and the odor of Jet-A fuel was present at the accident site. The engine and the propeller were found buried about 3 ft below ground level. The propeller exhibited various impact-related blade damage including a separated blade, blade twist, and tip curl that was consistent with engine operation at impact. -
Analysis
The pilot was conducting an agricultural flight. Recorded GPS track data showed that as the flight progressed, the airplane made a climbing left turn after each spray pass, the frequency of spray passes increased, the elapsed time between spray passes decreased, and the maximum altitude achieved between spray passes increased. During the final 5 minutes of the flight, the airplane's groundspeed was 160-165 mph during each spray pass and 104-120 mph while in the turn between spray passes; the airplane routinely climbed 450-520 ft after each spray pass. Another agricultural pilot, who was spraying a nearby field at the time of the accident, reported that he maintained radio contact with the accident pilot throughout most of the accident flight and saw the accident airplane consistently climb 450-500 ft after each spray pass. He stated that the climbs between spray passes were higher than required for an aerial-application flight and reported seeing the airplane exit the field in a climb following a spray pass before it rolled right-wing-down into a 90°-100° bank with a 10°-12° nose-up pitch attitude. The airplane then pitched down, consistent with a lazy eight flight maneuver. This pilot lost sight of the accident airplane when he turned his airplane after a spray pass. The airplane's final recorded groundspeed and estimated altitude above ground level were 152 mph and 136 ft, respectively. There were no witnesses to the airplane’s final descent and impact with the ground. The operator’s chief pilot had previously counseled the accident pilot about his “aggressive” flying techniques, including his use of a hammerhead flight maneuver for turns between spray passes. The airplane flight manual (AFM) states that an abrupt pull-up at the end of a spray pass should be avoided to maintain adequate airspeed during the turn between spray passes. The AFM states that a maximum altitude loss of 220 ft is expected during a recovery from a wings-level aerodynamic stall at a gross weight of 8,000 lbs; however, an aerodynamic stall during an uncoordinated turn will result in a sharp decrease in airplane pitch and a significant loss of altitude. The airplane wreckage was found upright in a cornfield with significant impact damage to the forward fuselage and the leading edge of both wings. There were no discernable ground impacts or debris path preceding the wreckage. Postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation of the airplane. The lack of a wreckage debris path and an estimated 45° nose-down flightpath angle at impact are consistent with an unsuccessful attempted recovery from an aerodynamic stall at a low altitude. The pilot’s postmortem toxicological testing detected ethanol in all tested specimen types. However, the differences between the ethanol levels in the various specimens were greater than is typically seen after ethanol consumption alone and suggest that at least some of the detected ethanol was likely from sources other than ingestion. While it is likely that at least some of the ethanol detected in the pilot’s specimens was from postmortem production, the possibility that the pilot may also have consumed ethanol is not excluded by the toxicology results. However, there is no clear operational evidence that the pilot was impaired. Given the high-risk nature of spraying operations and a pilot known to fly aggressively, positing impairment is not necessary to plausibly explain the accident circumstances. Thus, whether ethanol effects contributed to the accident cannot be determined.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack while maneuvering during an agricultural flight, which resulted in an aerodynamic stall and a loss of control at too low of an altitude to recover. Contributing to the accident was the pilot’s excessive climb technique between spray passes.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Air Tractor
Model
AT502
Amateur built
false
Engines
1 Turbo prop
Registration number
N502KJ
Operator
Aurora Cooperative Elevator Company
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
502B-2821
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-03T04:00:00Z guid: 101668 uri: 101668 title: CEN20LA328 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101760/pdf description:
Unique identifier
101760
NTSB case number
CEN20LA328
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-08T11:00:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Marathon, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
3 fatal, 1 serious, 0 minor
Factual narrative
According to the helicopter’s maintenance records, in November 2019 at Van Horn Aviation, Tempe, Arizona, for main rotor blade A092, the tip abrasion strip and trim tab were removed and replaced due to a trim tab debonding. For main rotor blade A093, the trim tab was removed and replaced for inspection. Both blades had a component total time of 829 hours. Main rotor blades serial Nos. A092 and A093 were installed on the accident helicopter on March 1, 2020, at a total helicopter time of 14,917 hours, and both blades had a component total time of 928 hours. Three 100-hour/12-month inspections were performed after installation, including an inspection performed on August 2, 2020 (6 days before the accident). On July 1, 2020, the engine was removed and replaced due to reports of a high turbine outlet temperature and low power. According to the helicopter’s flight manual and the helicopter’s most recent weight and balance records, the helicopter’s maximum gross weight was 3,200 pounds, and the empty weight was 1,908 pounds. The operator estimated that the helicopter’s weight at the time of the accident was 2,700 pounds. The helicopter was not equipped with, and was not required to be equipped with, a crash-resistant flight recorder or cockpit image recorder. - On August 8, 2020, about 1100 central daylight time, a Bell 206B helicopter, N284S, was destroyed when it was involved in an accident near Marathon, Texas. The pilot was seriously injured, and the three passengers were fatally injured. The flight was operated as a Title 14 Code of Federal Regulations Part 91 aerial survey flight. The flight was conducting an aerial survey in the Texas Black Gap Wildlife Management Area. The pilot reported that, about 5 minutes before the helicopter was to be refueled, he felt a “slight” vibration; at that time, the helicopter was operating at an altitude of about 800 ft above ground level and an airspeed of about 69 knots. The pilot further reported that the vibration, which lasted less than 30 seconds, started as a “slight vertical vibration” but “immediately intensified to a severe lateral vibration” that made the helicopter “impossible to control.” The pilot stated that the vibration affected the main rotor system blades and that he felt most of the vibration through the collective and airframe with no vibration in the anti-torque pedals. The pilot informed the passengers that he would be conducting an emergency landing. The pilot recalled that during the emergency landing, he observed two distinct blade paths prior to impact. The helicopter lost lift and subsequently impacted terrain short of the intended landing area. A postimpact fire ensued. The pilot stated that the engine was producing power at the time of the accident. - The pilot reported the temperature about the time of the accident was “heating up pretty good pushing around 100 degrees [Fahrenheit]” and did not recall the density altitude. - The pilot reported that he had accumulated about 2,500 flight hours in Bell 206L and 206B helicopters conducting aerial surveys in Texas, Alaska, Utah, and New Mexico. - The helicopter impacted hilly, rocky terrain in a remote area of west Texas at an elevation of about 5,160 ft. An on-scene examination revealed that most of the wreckage was in a compact area with the farthest piece of wreckage, a tip end section of a main rotor blade, estimated to be about 80 ft from the main wreckage. The postimpact fire consumed most of the main wreckage (the fuselage, engine, transmission, and portions of the main rotor blades). The tailboom had separated and was located near the fuselage; and the tailboom had sustained limited thermal damage. Further examination of the tailboom showed that it was fractured in two large segments: the forward section containing the horizontal stabilizer and the aft section containing the vertical stabilizer and tail rotor. The aft end of the forward tailboom section was deformed to the right and showed evidence consistent with contact by a main rotor blade. The forward landing gear cross-tube exhibited significant deformation; the aft crosstube showed minor deformation. The left and right skid tubes were fractured in multiple locations. The main rotor assembly, including the yoke, mast, and swashplate, exhibited thermal damage, and no anomalies that would have precluded normal operation were noted with the assembly. Both main rotor blades’ inboard section remained attached to the yoke, displayed fractures located about 48 inches outboard of the yoke, and exhibited thermal damage. Large midspan-to-outboard end segments were found near the tail rotor and vertical stabilizer. A 20-inch section of one main rotor blade tip (referred to as blade A) was found about 80 ft from the main wreckage. Smaller sections of blade skin and foam core were distributed within the main wreckage area. The main transmission housing was partially consumed by the postcrash fire. The engine-to-transmission driveshaft remained attached to the main transmission input quill and remnants of the freewheeling unit. Rotational scoring was noted on the driveshaft. The tail rotor remained installed on the tail rotor gearbox output shaft, and both tail rotor blades remained installed on the tail rotor yoke. Both tail rotor blade tips displayed impact damage, and the remainder of the blades were relatively intact. No anomalies that could have precluded normal operation were noted with the tail rotor system. The tail rotor drive train exhibited fragmentation. All drive shaft segments were located, and rotational scoring was noted at the hanger bearing locations within the tailboom sections. Continuity through the tail rotor gearbox was noted when the gearbox was manually rotated. No evidence indicated any binding or abnormal sounds. Flight control continuity could not be established due to thermal and impact damage. Various pieces of connection hardware and bellcranks for the flight control system did not exhibit evidence of separation at their respective fasteners. The engine was located within the main wreckage on its left side at its normally installed location. The engine did not exhibit signatures of uncontainment or separation between its modules. Disassembly of the engine revealed no anomalies that would have precluded normal operation. The engine fuel system and components were unable to be tested due to thermal and impact damage. The cockpit instruments, including the caution and warning panel, exhibited significant damage due to impact and thermal damage. Materials Laboratory Examination Portions of the main rotor blades were sent to the National Transportation Safety Board’s Materials Laboratory for further examination. Because the data plates for the main rotor blades had separated from their blades due to exposure to the postcrash fire, the main rotor blades were identified as “blade A” and “blade B” for this work. Blade A Examination Six primary pieces of the main rotor blade were recovered; the largest portion of the blade was about 9 ft long and consisted of part of the constant chord section, which was fractured at both ends. The trailing edge was separated along the entire length, and the interior of the blade was exposed. The lower skin fracture surfaces on the outboard section were predominantly translaminar and slanted inboard about 45° relative to the chord direction, consistent with bending loading. Two impact marks were observed on the leading-edge abrasion strip, and both corresponded to locations of chordwise fractures through the blade skins. One impact mark, located about 18 inches inboard of the outboard end of the abrasion strip, showed areas of dark gray and blue material transfer. The other impact mark was located at the outboard end of the abrasion strip. The upper surface of the abrasion strip was deformed inward and aft with spanwise scratches and periodic streaks of a light silver appearance. X-ray fluorescence spectroscopy indicated that the composition of the streaks was mostly aluminum. The leading-edge abrasion strip on the tapered tip section was fractured chordwise about 19 inches inboard from the blade tip. The fracture surface was relatively flat and featureless for about 2.4 inches from the lower aft edge except for a spanwise secondary crack that intersected the primary fracture at the origin, which was about 1.5 inches forward of the lower aft edge. Areas of blue, white, and gray material transfer were observed near the crack. Visible curved crack arrest marks on multiple offset planes were observed propagating for about 0.4 inches, consistent with progressive fracture under dynamic loading conditions (as evidenced by fluctuations in stress amplitude and load path). The terminus of the crack arrest marks was located about 2 inches forward of the upper aft edge of the abrasion strip. The fracture surface from the crack terminus to the upper aft edge of the strip exhibited a slanted fracture surface and dull appearance, consistent with a shear lip as a result of final separation due to overstress. The flat/progressive fracture was observed over about 58% of the leading-edge abrasion strip fracture surface at that location. Striations observed on the fracture surface were consistent with fatigue. Scratches and witness marks were observed along the abrasion strip outboard of the tip piece. The witness marks appeared gray, blue, white, and silver, and gold/brown in color. X-ray fluorescence spectroscopy identified elevated amounts of aluminum at the lighter gray/silver marks, consistent with material transfer. Circular marks, with elongated streaks emanating from them, were observed about 14.5 inches inboard from the blade tip and were equally spaced within 1 inch, consistent with a structure rivet pattern. Refer to the NTSB Materials laboratory Factual Report located in the public docket for additional materials laboratory examination details for Blade A. Blade B Examination The recovered blade was about 11 ft long, and evidence of thermal damage was observed over most of the blade. The inboard end was fractured and exhibited a 45° slanted fracture relative to the span. Visible buckling deformation and tearing separation was observed in the leading-edge abrasion strip about mid-span. The trailing edge strip was fractured chordwise with a predominantly flat, translaminar fracture surface with inter- and intralaminar separation extending away from the chordwise fracture. The fracture features were consistent with aft bending loading before fracture. Blade tip fragments that were recovered did not exhibit visible thermal damage, consistent with tip fragmentation before the postcrash fire. A witness mark, consistent with impact damage, was observed on the upper surface of the leading-edge abrasion strip about 6 inches inboard of the outboard end of the constant chord section abrasion strip. -
Analysis
During an aerial survey flight when the helicopter was about 800 ft above ground level, the pilot felt a slight vertical vibration through the collective and airframe. The vibration immediately intensified to a severe lateral vibration in the main rotor system, and the pilot could not control the helicopter. While maneuvering for an emergency landing, the helicopter lost lift and impacted terrain short of the intended landing area, and a postimpact fire ensued. The pilot stated that the engine was producing power at the time of the accident. No evidence indicated an in-flight structural breakup, and all damage to the airframe occurred during the ground impact sequence. A fatigue crack was found on the leadingedge abrasion strip of one of the main rotor blades. Given the flat fracture features of the fatigue cracking, the fatigue crack was present before the accident flight. However, this fatigue cracking showed no evidence of propagation into the blade spar and, therefore, was likely not a factor in this accident. The main rotor blade damage was likely due to ground and tailboom impacts; the examined portions of the main rotor blades showed no evidence of an in-flight failure of the main rotor blades. In addition, no evidence showed any flight control disconnections, and further postaccident examination to determine if the flight control system had fractured could not be performed due to the extensive thermal damage. The helicopter’s hydraulic system was unable to be tested due to the damage resulting from the postcrash fire. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The reason for the in-flight loss of control could not be determined based on the available evidence for this accident investigation. The helicopter was not equipped with, and was not required to be equipped with, crashresistant flight recorders. The lack of flight recorder data for this accident precluded further evaluation of the accident circumstances and pilot actions. This accident demonstrates the need for crash-resistant flight and image recorders aboard turbine-powered, nonexperimental, nonrestricted-category aircraft that are not currently required to be so equipped, as previously recommended by the National Transportation Safety Board.
Probable cause
The in-flight loss of helicopter control for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Bell
Model
206
Amateur built
false
Engines
1 Turbo shaft
Registration number
N284S
Operator
Southwest Heliservices Llc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
2393
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 101760 uri: 101760 title: CEN20LA381 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101921/pdf description:
Unique identifier
101921
NTSB case number
CEN20LA381
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-18T11:00:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Event type
Accident
Location
Ord, Nebraska
Airport
Evelyn Sharp Field Airport (ODX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 18, 2020, about 1100 central daylight time, a Piper PA-36-285 airplane, N57607, was substantially damaged when it was involved in an accident near Ord, Nebraska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 agricultural flight. The pilot stated that the engine startup was normal and that he observed a calm surface wind while taxiing to runway 31. The pilot initially observed dark/black engine exhaust while he cycled the propeller during an engine runup before takeoff, but he did not observe any anomalies with the engine or the engine exhaust during a second engine runup and propeller cycle that he completed before takeoff. The pilot stated that the takeoff on runway 31 was uneventful and that after liftoff he kept the airplane in ground effect until it accelerated to a normal climb airspeed. The pilot stated the initial climb was uneventful until the first turn when he observed the airspeed decreasing despite the engine and propeller operating normally at takeoff power. Although he was able to maintain altitude in the turn, the airplane’s airspeed continued to decrease closer to an aerodynamic stall speed. The pilot chose not to dump the load of liquid herbicide because he thought it could have a negative effect on being able to control the airplane and cause it to enter an aerodynamic stall. The airplane's right wing dropped shortly before impact with the ground, which the pilot attributed to the airplane flying at or near aerodynamic stall. The airplane collided with terrain in a right wing down attitude. The pilot stated that before the flight the airplane was loaded with 40 gallons of fuel and 155 gallons of liquid herbicide. He stated he previously flew the airplane with similar or heavier loads without any adverse effects to airplane performance. He reported that the weather conditions earlier in the morning included some rain showers associated with the passage of a weather front; however, at the time of the accident, the wind was calm and there was no precipitation. The pilot reported that there were no mechanical malfunctions or failures of the airplane or its engine during the flight. The airplane’s fuselage and both wings were substantially damaged during the accident. The airplane was partially disassembled and recovered from the accident site before the National Transportation Safety Board or the Federal Aviation Administration (FAA) were notified of the accident. A FAA examination of the airplane and its engine did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal flight. -
Analysis
The pilot was departing on an agricultural flight when the airplane’s airspeed began to decrease while in a turn shortly after takeoff. The pilot confirmed that the engine and propeller were operating normally at takeoff power, but the airspeed continued to decrease closer to an aerodynamic stall speed while in the turn. The pilot chose not to dump the load of liquid herbicide because he thought it might have had a negative effect on controlling the airplane and cause it to enter an aerodynamic stall. The airplane’s right wing dropped shortly before it impacted with the ground, which the pilot attributed to the airplane flying at or near aerodynamic stall. The airplane collided with terrain in a right wing down attitude. The airplane’s fuselage and both wings were substantially damaged during the accident. The pilot stated that he previously flew the airplane with similar or heavier loads without any adverse effects to airplane performance. He reported that the weather conditions earlier in the morning included rain showers associated with the passage of a weather front; however, at the time of the accident, the wind was calm and there was no precipitation. The pilot reported that there were no mechanical malfunctions or failures of the airplane or its engine during the flight. Postaccident examination of the airplane and its engine did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal flight. Based on the available evidence, it is likely that the pilot did not maintain adequate airspeed while in the turn during initial climb, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall at a low altitude from which a recovery was not possible.
Probable cause
The pilot’s failure to maintain adequate airspeed while in a turn during initial climb and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Piper
Model
PA36
Amateur built
false
Engines
1 Reciprocating
Registration number
N57607
Operator
Green Medows Aviation
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
36-7660006
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-05T04:00:00Z guid: 101921 uri: 101921 title: DCA20LA138 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101865/pdf description:
Unique identifier
101865
NTSB case number
DCA20LA138
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-19T04:47:00Z
Publication date
2023-07-12T04:00:00Z
Report type
Final
Event type
Accident
Location
Los Angeles, California
Airport
Los Angeles International (KLAX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
The Boeing 767 Aircraft Maintenance Manual, dated April 22, 2020, described the removal and installation instructions for the MLG brake rods; these instructions were in effect at the time of the last No. 6 brake rod removal and replacement. FedEx used a customized version of this manual; the version that was current at the time of the No. 6 brake rod removal was dated August 21, 2019. Review of both sets of instructions revealed no major issues concerning the brake rod removal and installation procedures, but some minor areas for improvement were identified. On August 22, 2021, Boeing released a revision to its Boeing 767 Aircraft Maintenance Manual that, among other things, included information in figures and notes that clarified the brake rod installation steps. On the basis of a 1995 exemption that the Federal Aviation Administration granted to FedEx, its fleet of 767-300 airplanes was not required to be equipped with evacuation slides or slide/rafts at the main boarding doors. Instead, the airplanes were equipped with inertial reel descent devices and harnesses for each airplane occupant. Each cockpit was also equipped with an escape rope. The FedEx Flight Crew Operating Manual and Aircraft Systems Manual both showed the step-by-step use of both the inertial reels and escape rope but did not provide specific information about which device should be used as the primary means for evacuating the airplane. Further, neither the Aircraft Systems Manual nor the FedEx Boeing 767 Flight Training Manual mentioned the use of heat-resistant gloves and chemical gloves during evacuations. After the accident, FedEx reviewed its internal safety processes and modified its pilot evacuation training program to (1) emphasize the flight crew evacuation decision-making process and (2) prioritize the use of an inertial reel rather than an escape rope during an evacuation. - The accident airplane was manufactured in 2017 and had accumulated 5,958 hours and 2,608 flight cycles. FedEx reported no deferred items per the minimum equipment list during the accident flight. The Boeing 767 is equipped with left and right MLG assemblies and a nose landing gear assembly. Each MLG assembly consists of four wheels (two forward and two aft); each wheel has an independent brake. The MLG extension and retraction system includes door- and gear-operated sequence valves, door and latch actuators, transfer cylinders, truck positioners, and drag and side brace lock actuators. The landing gear control lever in the cockpit is moved to the down or up position to extend or retract the gear, respectively, using center hydraulic system pressure. An alternate extension system is available to unlock the landing gear and doors if the MLG extension system is unable to do so. The MLG was designed to rest on the closed MLG doors when the gear is up. The alternate extension system simultaneously releases the left and right MLG doors and the nose gear, which causes all three gears to drop into the down-and-locked position. If a gear is jammed in the retracted position, the alternate extension system would still extend the other gear. A brake rod, which is installed between each brake assembly housing and the shock strut, transfers the torque generated by the brake to the MLG. The brake rod is connected to the torque arm on the brake assembly housing using a pin, a tang washer, a retaining bolt, and two lock screws secured by safety wire, as shown in figure 1. Figure 1. Brake rod attaching hardware. (Copyright © Boeing. Reproduced with permission.) Postaccident examination of the left MLG assembly revealed that the No. 6 brake rod (corresponding to the aft inboard wheel) was not connected to the torque arm on the No. 6 brake assembly housing. Of note, the head of the pin would be in the down direction when the gear was in the up (retracted) position. (Other findings from the postaccident examination are discussed later in this report.) FedEx stated that the most recent removal and replacement of the No. 6 brake rod occurred during a No. 6 brake assembly change on July 18 and 19, 2020, and that the airplane had accumulated 73 flight cycles between this maintenance and the accident flight. The maintenance personnel who performed the No. 6 brake assembly change did not recall anything unusual or concerning about the installation of the No. 6 brake assembly or brake rod. A review of the airplane’s maintenance history between June 18, 2020 (1 month before the No. 6 brake rod change), and August 19, 2020 (the accident date), revealed no other related maintenance activities. - On August 19, 2020, about 0447 Pacific daylight time, Federal Express (FedEx) flight 1026, a Boeing 767-300, N146FE, was substantially damaged after the airplane’s left main landing gear (MLG) failed to extend at Los Angeles International Airport (LAX), Los Angeles, California. The first officer sustained a serious injury while exiting the airplane using the cockpit emergency escape rope; the captain was not injured. The flight was operating under Title 14 Code of Federal Regulations Part 121 as a domestic cargo flight from Newark Liberty International Airport (EWR), Newark, New Jersey, to LAX. The captain and the first officer provided statements to the National Transportation Safety Board about the circumstances leading to the accident. The captain stated that the preflight and the departure and en route portions of the flight were uneventful. During those flight portions, the first officer was the pilot flying, and the captain was the pilot monitoring. In preparation for landing, Los Angeles approach control cleared the airplane for the ILS approach to runway 24R. When the airplane had descended to an altitude of about 1,800 ft, the landing gear handle was activated to lower the landing gear. The crew then received a “GEAR DISAGREE” message from the engine indicating and crew alerting system; the message illuminates when the gear position disagrees with the landing gear lever position. The captain stated that he and the first officer elected to discontinue the approach and climbed the airplane to 5,000 ft to perform the quick reference handbook Gear Disagree checklist procedure. The checklist directed the crew to lower the landing gear using the alternate gear extension system, but the left MLG still did not extend. The next step in the checklist instructed the crew to land the airplane with all available landing gear. The captain requested and obtained permission to fly a low approach to runway 24L so that the tower controller could try to see if the left MLG was extended. The airplane descended to an altitude of about 500 ft above ground level, but the tower controller could not tell whether the left MLG was extended. The crew then declared an emergency, the captain became the pilot flying, and he flew another low approach—this time at an altitude of about 200 to 300 ft above ground level and with airport operations personnel positioned along the runway to get a better view of the airplane. The second low approach determined that the left MLG was retracted. Los Angeles approach control then directed the crew to climb the airplane to 5,000 ft and vectored the airplane away from the airport and over the water while the crew consulted with FedEx maintenance about the left MLG. FedEx maintenance suggested that the flight crew attempt to maneuver the airplane “in such a way as to possibly release the unsafe gear,” which the crew did without success. The flight crewmembers then discussed the remaining items on the Gear Disagree checklist and the techniques that would best accomplish the gear-up landing. The captain stated that, once the fuel “was down to the point where it was time to execute the gear up approach/landing,” Los Angeles approach control vectored the airplane for an ILS approach to runway 25R, which was the longest runway at LAX. The captain also stated that he flew the coupled approach to about 200 ft, disconnected the autopilot, and made a “normal landing touchdown” while trying to keep the left engine nacelle from contacting the runway as the airplane decelerated. The captain further stated that, after the left engine contacted the runway, he maintained directional control “with ailerons, rudder and finally right wheel braking.” After the captain manually deployed the speedbrakes, the airplane came to a stop on the runway centerline about 2,000 to 3,000 ft from the end of the runway. The crew executed the Evacuation checklist, and the captain reported that the left engine fire lights and bell activated. The crew began evacuating through the first officer’s (right-side) window (due to concerns about a possible fire on the left side of the airplane) using the escape rope. The first officer, who reported that he was wearing “safety gloves” at the time, lost his grip on the escape rope, fell to the runway, and fractured his left heel. As the captain was preparing to evacuate from the first officer’s window, airport rescue and firefighting personnel informed him that no fire was present and that they would provide a vehicle with a platform and stairs so that he would not have to use the escape rope. The captain evacuated the airplane uneventfully. - The airplane was found resting on the left engine nacelle and the right MLG (see figure 2), and the nose gear and tail were found suspended in the air. The left MLG door was open, but the left gear had not deployed. Figure 2. Airplane after accident landing. (Copyright © Boeing. Reproduced with permission.) The left engine cowling and left MLG door were damaged from contact with the runway during the landing. Further examination revealed deformation of and cracking on the left engine pylon structure. Examination of the left MLG assembly revealed that the No. 6 brake rod remained connected to the lugs on the shock strut but was not connected to the torque arm on the No. 6 brake assembly housing. All attaching hardware was missing. The brake rod was found “hung up” on the landing gear upstop (see figure 3), which is inside the left landing gear bay. No damage was found on the brake assembly or the associated hydraulic line. EWR and LAX airport operations personnel performed a search of the departure and landing runways, respectively, and no brake rod attaching hardware components were found. Location where brake rod should have been secured by attaching hardware Brake rod location as found Figure 3. Location of brake rod during postaccident examination (Source: FedEx). The damaged left MLG door was disabled, and the brake rod was secured to the brake assembly housing torque arm. Normal gear extensions and retractions and alternate gear extensions were then performed; no anomalies were identified. The No. 6 brake rod was examined by Boeing’s Equipment Quality Analysis Laboratory. Visual examination of the No. 6 brake rod revealed shallow gouges and chipped paint on the forked end, consistent with the brake rod contacting and becoming hung up on the landing gear upstop. No evidence (scrape marks or gouging) indicated that the brake rod had previously contacted a runway during a takeoff or landing. All measurements of the brake rod end bores were found to be within specification drawing limits. The brake pin assemblies from the other seven brake rods were also examined by Boeing’s Equipment Quality Analysis Laboratory using techniques such as fluorescent penetrant inspection and magnetic particle inspection. The examination of the seven brake rod pins and all attaching hardware (tang washer, bolt, and screws) found no defects that could indicate the existence of an airplanespecific problem or a hardware manufacturing lot problem that would have precluded normal extension of the left MLG. -
Analysis
In preparation for landing, LAX air traffic control cleared FedEx flight 1026 for an instrument landing system (ILS) approach to runway 24R. When the airplane descended to an altitude of about 1,800 ft, the flight crew moved the landing gear handle to lower the landing gear. The crew then received a “GEAR DISAGREE” message from the engine indicating and crew alerting system. The crew discontinued the approach and climbed the airplane to 5,000 ft to perform the quick reference handbook Gear Disagree checklist procedure. The checklist directed the crew to lower the landing gear using the alternate gear extension system, but the left main landing gear (MLG) still did not extend. The flight crew then flew a low approach to the runway so that the tower controller could try to see if the left MLG was extended. The airplane descended to an altitude of about 500 ft above ground level, but the tower controller could not tell whether the left MLG was extended. The crew then declared an emergency and flew another low approach—this time at an altitude of about 200 to 300 ft above ground level and with airport operations personnel positioned along the runway to get a better view of the airplane. The second low approach determined that the left MLG was retracted. The captain stated that, once the fuel was at an appropriate point to execute the gear-up approach and landing, air traffic control vectored the airplane for an ILS approach to the longest runway at the airport. The captain also stated the airplane made a “normal landing touchdown” and that, after the left engine contacted the runway, he maintained directional control with the ailerons, rudder, and right wheel braking. After the captain manually deployed the speedbrakes, the airplane came to a stop on the runway centerline about 2,000 to 3,000 ft from the end of the runway. A brake rod, which is installed between each brake assembly housing and the shock strut, transfers the torque generated by the brake to the MLG. Each brake rod is connected to the torque arm on the brake assembly housing using, among other things, a pin that is secured by a retaining bolt. Postaccident examination of the left MLG assembly revealed that the No. 6 brake rod (corresponding to the aft inboard wheel) was connected at the shock strut end but was not connected to the torque arm on the brake assembly housing. The brake rod pin was likely in place during the accident flight takeoff given that no scrape marks or gouging were found on the brake rod, indicating that the brake rod had not contacted the runway while the airplane was moving, which would likely have happened if the brake rod was connected only at the shock strut end while the left MLG was in its extended position. The flight crew was unable to extend the left MLG during the approach because the pin had come loose during the flight, which allowed the brake rod to move out of its normal position and become hung up on the landing gear upstop. The airplane had accumulated 73 flight cycles since the last No. 6 brake assembly change, which would have been the last time that the No. 6 brake rod was removed and reinstalled. The maintenance personnel who performed the No. 6 brake assembly change did not recall anything unusual or concerning about the installation of the brake assembly or brake rod. The No. 6 brake rod attaching hardware components from the accident airplane were not located after the accident, precluding a determination of why the pin was in place for the takeoff but not when the crew tried to lower the landing gear. As a result, on the basis of the available evidence for this accident, the investigation was unable to determine the reason that the brake rod pin came loose during the accident flight.
Probable cause
The left main landing gear’s failure to extend due to the separation of the brake rod retaining hardware from the aft inboard wheel for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Boeing
Model
767
Amateur built
false
Engines
2 Turbo fan
Registration number
N146FE
Operator
Federal Express
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
43551
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T04:00:00Z guid: 101865 uri: 101865 title: WPR20LA280 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101831/pdf description:
Unique identifier
101831
NTSB case number
WPR20LA280
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-19T09:45:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Event type
Accident
Location
Coalinga, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On August 19, 2020 about 0945 Pacific daylight time, an Arrow-Falcon Exporters, Inc., UH-1H, N711GH, was destroyed when it was involved in an accident near Coalinga, California. The pilot, the sole occupant was fatally injured. The helicopter was operated as a public use firefighting flight. The accident flight was the pilot’s first day working the Hills Fire, which had started 4 days prior. The pilot took off at 0846 followed by another pilot who was flying a Bell 212 helicopter for another operator. After departure, both helicopters flew south until reaching a small lake/reservoir (the dip site) to fill up the external load buckets attached to their respective helicopters. Thereafter, they flew to a predetermined area and began to unload their water on the fire. After releasing the water, they would return back to the dip site. After the accident pilot delivered about two buckets of water to one location he moved to another location delivering about five buckets of water. The Bell 212 pilot recalled that after he departed the dip site with a bucket of water, he heard the accident pilot communicate over the air-to-air radio that he felt "abnormal noises and vibrations" and that he was going to make a precautionary landing. The Bell 212 pilot dumped his water and caught up to the accident helicopter with the intention of assisting the pilot in finding a good area to land. He remained a few hundred feet behind and above the accident helicopter. The accident helicopter was about 1,000 ft above ground level and maneuvering at an airspeed between 60 to 70 kts. The accident pilot then stated that the helicopter's "temps and pressures are good." A few seconds later the accident pilot stated "it's my hydraulics." The Bell 212 pilot relayed that he should make a right turn and fly down the ravine to less mountainous terrain (the flats). Figure 1: Radar Data The helicopter started to make a right turn and then banked back to the left while losing airspeed. The Bell 212 pilot noticed the helicopter still had its 100 ft longline and external load bucket attached and told the accident pilot to "release your long line and get forward airspeed," The accident pilot then stated "Mayday, Mayday, Mayday." The left turn steepened remaining in a level pitch attitude, and the helicopter began to make three or four 360° rotations (rapidly swapping the front and back), while drifting north-east. The helicopter then pitched in a nose-low, near vertical attitude and collided into terrain (see figure 2 below). A fire immediately erupted and the Bell 212 pilot made multiple trips to the dip site to fill his bucket and drop water on the accident site. Figure 2: Pilot’s Statements Prior to Accident WRECKAGE AND IMPACT The helicopter came to rest on a 35° slope with the main wreckage about 25 yards downslope from the initial impact. Most of the wreckage was consumed by fire; the tail rotor assembly was intact. The tail rotor blades were intact, with no evidence of rotational scoring. The wreckage was recovered to a secure location for further investigation. Airframe/Controls The wreckage was highly fragmented and mostly consumed by a post-crash fire. The airframe sections that remained were parts of the tailboom, tail rotor, engine deck, cabin doors, landing skid tubes, one cross tube, and the engine. The main rotor head, blades, stabilizer bar, and upper transmission including the rotor mast were lost during the wreckage recovery. The cockpit was highly fragmented and damaged by fire, with most of the instruments destroyed and unreadable. The engine control panel were separated from the center console and all the switches on the panel were deformed downward. The caution warning panel, located within the wreckage debris and separated from the instrument panel, sustained fire damage and the front plate was illegible due to sooting/melting. The interior of the panel exhibited similar damage and the individual annunciator capsule positions had shifted as a result so the original location of individual bulbs could not be determined. Nine intact bulbs with filaments were removed from the remnants of the panel, of which two exhibited hot filament stretching; their associated position could not be determined. The fuel valve switch had evidence of damage associated with impact and was unreliable for determining the switch position before impact. Portions of the cockpit flight controls were identified, but a majority of the system was consumed by fire. The main flight control servos were separated from their input and output control rods. Fragments of both sections of the cyclic lateral control tubes and the lower mixing assembly were identified. The upper flight controls, consisting of the stationary and rotating swash plates and drive links, were not present for examination because they were dropped during recovery. The tail rotor control bell crank quadrant was not located. The tail rotor hydraulic servo was detached from the structure and sustained thermal damage; the input and output fittings were fractured. The tail rotor control forward cables, speed-rig turnbuckles, and aft cables remained within the tailboom. The elevator spar remained in the tail section, and the left spar extended out of the left side of the tail boom. The elevator control horn assembly was in place in the tail section, and three elevator control bell cranks were identified. Continuity of the hydraulic system could not be confirmed due to fire damage sustained following impact. The hydraulic pump was separated from the transmission and was missing the splined drive shaft. The hydraulic filter was separated from its mount, and the input/output connectors were fractured. The filter screen was removed, inspected, and no debris was identified. The main rotor head, both main rotor blades, upper transmission, and rotor mast were not recovered, but both stabilizer bar dampers were recovered. Photos from on scene showed chordwise marks on various portions of the unburned blade. The burned blade was too damaged to identify surface score marks from the photos taken. Segments of the tail rotor drive shaft were numbered from 1 to 6, starting at the tail rotor drive output of the lower transmission. Drive shaft segments 1 to 3 were not recovered and were presumed to have been consumed by the post-crash fire. The drive-shaft bearing-end that connects to the transmission tail rotor drive quill was identified, as well as the drive shaft ends that mate with the support bearings for segments 1 to 3. The aft end of segment 4 was connected to segment 5 through the support bearing. Drive segment 5 was connected to the 42° gearbox, and drive segment 6 was connected from the 42° gearbox to the tail rotor 90° gearbox. One tail rotor blade showed no observable damage, while the other blade had chordwise dirt streaks and heat damage on the outboard half of its trailing edge. On the reverse side of that blade, the outboard 2/3 of the blade had fire damage to the skin and underlying layers. The blade also had a crease in the chordwise direction about 8 inches from the root. The photos of the cargo hook on-scene and the post examination revealed that the hook portion had separated from its attachment hardware. The final location of the external load bucket is unknown, but the witness said he did not see the bucket being released. Servos The National Transportation Safety Board (NTSB) Materials Laboratory examined the left lateral hydraulic servo; right lateral hydraulic servo and its irreversible valve assembly; and the collective hydraulic servo for the main rotor of the helicopter. The collective actuator, left lateral actuator, right lateral actuator, and an irreversible valve assembly were subjected to x-ray radiograph and computed tomography (CT) scanning to document each component’s internal condition. The results of the scan identified high density (metal) particles deep within the irreversible valve assembly. The right lateral servo showed indications of exposure to a fire, including an oxide layer on the outer surface, micro-cracks, resolidified metal, and deformation damage. The upper housing was disassembled, and the ring seals were found to be fractured. The lower housing contained two circumferential inserts that functioned as raceways, which showed no evidence of wear or damage. The piston portion of the rod contained a groove that incorporated a ring seal, which also fractured into multiple pieces. The hydraulic servo cylinder contained an internal spool and sleeve assembly, but an attempt to pull the push-pull rod out of the port failed. No evidence of corrosion, gouge, or wear damage was found in any of the examined parts. Disassembly of an irreversible valve assembly for a right lateral servo, revealed the internal valves, including a sequence valve, check valves "A" and "B," a differential pressure relief valve, and an accumulator valve. During disassembly, evidence of bending deformation damage was observed on the cover for the sequence valve, and the inner surface of the cover showed evidence of an oxide layer and micro-cracks. The piston head and sleeve contained ring seals that were fractured and could not be removed with needle-nose pliers. The internal parts of the sequence valve, check valves "A" and "B," and the differential pressure relief valve were intact, except for the fractured ring seals. The seat portion for the check valve "A" showed evidence of wear damage, while the seat portion for check valve "B" showed no evidence of wear. The left lateral and collective servos were disassembled in a manner that was similar to the right lateral servo. The observations made on those servos were similar to those found on the right lateral servo, with the exception that the left lateral servo’s piston was completely retracted (the other servos were in various positions, but not at such an extreme). It could not be definitively determined if this signature could have been indicative of a left hard-over condition and a simulation was not available to support this inquiry. It could not be determined if any of the servos were capable of function normally prior to impact. Heat from the postcrash fire caused carbonization and multiple fractures of the elastomer seat rings, while foreign particles were found in the hydraulic system. It is unknown how much of the debris was introduced into the hydraulic system during the postcrash fire-fighting phase. The servos and irreversible valve do not have a specified time-in-service before overhaul requirement and are considered an “on condition” part. Engine The engine sustained damage as a result of the impact. The inlet guide vanes displayed tearing and battering, and all five stages of the axial compressor blades were bent opposite the direction of rotation at the tips and displayed leading and trailing edge damage. Vanes on all four stages of the compressor vane assembly displayed leading and trailing edge damage. The interstage bleed centrifugal compressor impeller showed rotational scoring on the shroud line edges of the blades at the inducer with corresponding rotation scoring through 360°. The inducer of the impeller housing assembly and the centrifugal compressor impeller had material build-up on the leading-edge concave side of the blades. Vanes on the first stage power turbine nozzle and blades on the first stage power turbine rotor displayed trailing edge damage, all of which were consistent with the engine operation/rotation at the time of impact. Metallurgical analysis of the first and second stage gas producer turbine blades identified aluminum, stainless steel, and magnesium deposits on the suction side and pressure side of the blades. These metal spray deposits are consistent with the engine operating at the time of impact. Additionally, white dust-like material covered the interior of the combustion liner. The NTSB Materials Laboratory analysis of the white residue material identified it as magnesium oxide using dispersive x-ray spectroscopy, and the source of the magnesium can be attributed to the engine case which is constructed of magnesium. The source of the stainless steel can be attributed to the compressor section components such as the blades and stator assemblies. The source of the aluminum alloy is not internal to the engine. Rotorcraft Flight Manual The US Army UH-1H flight manual (TM 55-1520-210-10) emergency procedures section identifies the following: Section 9-37. Hydraulic Power Failure. Hydraulic power failure will be evident when the force required for control movement increases; a moderate feedback m the controls when moved is felt, and/or the HYD PRESSURE caution light illuminates. Control movements will result m normal helicopter response. In the event of hydraulic power failure: 1. Airspeed - Adjust as necessary to attain the most comfortable level of control movements. 2. HYD CONT circuit breaker - Out. If hydraulic power is not restored: 3. HYD CONT circuit breaker - In. 4. HYD CONT switch - OFF. 5. Land as soon as practicable at an area that will permit a run-on landing with power. Maintain airspeed at or above effective transitional lift until touchdown. Section 9-38. Control Stiffness. A failure within the irreversible valve may cause extreme stiffness in the collective or two of the four cyclic control quadrants. If the failure is in one of the two cyclic irreversible valves, caution is necessary to avoid over controlling between the failed and operational quadrants. 1. HYD CONT switch - OFF then ON. Check for restoration of normal flight control movements. Repeat as necessary. If control response is not restored: 2. HYD CONT switch - OFF. If normal operation is not restore! 3. Land as soon as practicable at an area that will permit a run-on landing with power. Maintain airspeed at or above effective transitional lift until touchdown. 9-39. Flight Control Servo Hardover. a. Cyclic hardover is caused by a sequencing valve failure within the Irreversible valve on either or both cyclic servos. Cyclic servo hardover will cause the cyclic to move full night forward, full left rear, full left forward, or full right rear. b. Collective hardover is caused by a sequencing valve failure within the Irreversible valve on the collective servo. The collective will move to the full up or full down position. c. A failure of any flight control servo may render the helicopter uncontrollable unless the following action is taken. 1. HYD CONT select - Select opposite position. 2. LAND AS SOON AS POSSIBLE at an area that will permit a run-on landing with power. Maintain airspeed at or above effective translational lift at touchdown. MEDICAL AND PATHOLOGICAL According to the Fresno County Sheriff-Coroner’s Office, Fresno, California autopsy report, the cause of the pilot’s death was multiple skeletal and visceral injuries due to blunt impact and the manner of death was accident. The medical examiner did not identify any significant natural disease. Toxicology testing performed by the Fresno County Sheriff-Coroner’s Office detected ethanol at 0.11 grams per deciliter (gm/dL) in the pilot’s peripheral blood and at 0.068 gm/dL in gastric contents; toxicology testing was negative for tested-for drugs of abuse in blood and gastric contents. The FAA Forensic Sciences Laboratory toxicology testing detected ethanol at 0.082 gm/dL in cavity blood and 0.082 grams per hectogram (gm/hg) in muscle tissue but did not detect ethanol in brain tissue. N-propanol was detected in the pilot’s cavity blood and muscle tissue and methanol was detected in his cavity blood. Tissue samples were reported as exhibiting putrefaction. The antidepressant citalopram was detected in the pilot’s blood at 5,857 nanograms per milliliter (ng/mL) and in his liver tissue; its active metabolite n-desmethylcitalopram was detected at 602 ng/mL in blood and in liver tissue. The anti-anxiety medication buspirone was detected in the pilot’s blood at 1.1 ng/mL and in his liver tissue. -
Analysis
The pilot was engaged in external load fire-fighting operations when the accident occurred. After dropping several loads of water, the pilot reported abnormal noises and vibrations and stated "it's my hydraulics" before he lost airspeed and control of the helicopter. The helicopter made several uncontrolled rotations before colliding with terrain and erupting in flames. The wreckage was highly fragmented and most consumed by the postimpact fire. The hydraulic system continuity could not be confirmed due to fire damage. The servos exhibited exposure to fire, including an oxide layer on the outer surface, micro-cracks, resolidified metal, and deformation damage. Foreign high-density particles were found in the hydraulic system. Hydraulic flight control stiffness and hard-over conditions are most likely a result of a malfunction of the servo irreversible valve. Only one of the three irreversible hydraulic valves was not destroyed in the postcrash fire. Examination of this valve found high-density metal particles deep within the valve assembly and preexisting damage to the seat of a check valve. Since all the servos were operated from a single hydraulic pressure source, it is likely that the other two irreversible valves also had similar particles within their assemblies. Foreign high-density particles and a worn check valve within the irreversible valve could have interfered with the valves’ proper operation and resulted in control stiffness or a hard-over condition. There was no evidence of preexisting mechanical damage on the three servo actuator pistons or rods as the internal moving parts within the servo actuators showed no evidence of gouging. There was no wear damage in the bushing areas or around the housing ball assembly. Toxicological tests detected the antidepressant medication citalopram and an augmenting agent buspirone in the pilot’s system. Given that the pilot was performing complex firefighting tasks when the helicopter developed mechanical problems and he made reasonable decisions to attempt to land the helicopter, he appears to have been functioning at a high level. It appears unlikely that the pilot’s use of the antidepressants or his depression were factors in the accident. The pilot’s declaration that he had a hydraulic problem and the final uncorrected right hand descending spiral turn flightpath are consistent with what would be expected if the helicopter experienced control stiffness or a hard-over condition. However, due to the extent of the impact and postimpact fire damage, the reason for the loss of control could not be conclusively determined.
Probable cause
The pilot’s inability to maintain control of the helicopter due to a hydraulic system failure for reasons that could not be fully determined due to the thermal destruction from the postimpact fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Arrow-Falcon Exporters, Inc.
Model
UH-1H
Amateur built
false
Engines
1 Turbo shaft
Registration number
N711GH
Operator
Guardian Helicopters Inc
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Firefighting
Commercial sightseeing flight
false
Serial number
65-1002
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-06-14T04:00:00Z guid: 101831 uri: 101831 title: WPR20LA283 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101856/pdf description:
Unique identifier
101856
NTSB case number
WPR20LA283
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-24T18:00:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Event type
Accident
Location
Pine Grove, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
In April 2009, Kaman received a report that the accident helicopter (at the time registered as N361KA) experienced an inflight separation of a left white blade servo flap. The entirety of the servo flap had separated from its attachment brackets. The pilot was able to land the helicopter with no additional damage to the airframe. On June 16, 2010, in Donnelley, Idaho, a K-1200 helicopter was involved in an accident. The investigation found the afterbody of a servo flap had completely separated. The NTSB determined the probable cause was the collision of two counter-rotating main rotor blades for undetermined reasons, which resulted in a loss of control. For more information, see case number WPR10FA295 at the NTSB’s website. The manufacturer conducted a demonstration on a whirl stand to show the effects of a rotor system with one of the two blades’ servo flap having its inboard closeout removed. For this demonstration, an exemplar blade set was placed on a whirl stand and the inboard closeout was removed from the red blade servo flap. The blade set was operated at varying rotor speeds from 130 rpm to the maximum 270 rpm. Power was applied up to a maximum torque of 150%. According to the manufacturer, the demonstration yielded no signs of flutter or out-of-track conditions, and the flight control loads were not out of any limits. The blades (servo flaps) showed no signs of cracking in the bond lines, especially around the flap horn. - The K-1200 helicopter had two counterrotating, side-by-side, intermeshing rotors with two blades per rotor (for a total of four blades). The rotors were out of phase by 90° and were tilted outward to allow each blade to clear its opposing rotor hub. The two rotor systems were mounted to, and driven by, a common transmission. When viewed from above, the left rotor system turned counterclockwise, and the right rotor system turned clockwise. The two blades for each rotor system comprised a matched set that was balanced at the helicopter manufacturer’s factory; each set had an “A” blade (colored white at the tip) and a “B” blade (colored red at the tip). Figure 2 shows the accident helicopter. The helicopter was not equipped with, or required to be equipped with, a flight data recorder. Figure 2. Accident helicopter (Source: Central Copters). The K-1200 rotor system used servo-flaps to control rotor blade pitch changes. The Kaman K-1200 Maintenance and Servicing Instructions document states the following about servo flaps: A servo-flap is mounted on each blade near the 3/4 radius and is controlled by [control] rods which transfer conventional cockpit flight control inputs through the azimuth assemblies to each servo flap. The servo-flap controls the pitch of the rotor blade and acts as an aerodynamic stabilizer. Because the servo-flap uses energy drawn from the air stream to twist the blade, control forces need only be high enough to deflect the small servo-flap. The accident helicopter was maintained under the manufacturer’s approved airworthiness inspection program. Recurring inspections for the rotor blade servo flaps in the K-12 maintenance manual included the preflight inspection and the 100 hour/annual or zone one progressive inspection. A review of the maintenance logbooks revealed that the last zone one inspection occurred on February 25, 2020. - On August 24, 2020, about 1747 Pacific daylight time, a Kaman K-1200 helicopter, N314, was substantially damaged when it was involved in an accident near Pine Grove, Oregon. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 external load flight. The helicopter was operated under an exclusive-use contract with the United States Forest Service (USFS) and had been conducting water bucket/fire suppression activities for the White River fire at Mt. Hood National Forest, Oregon. The air attack controller, who was in radio contact with the pilot, reported that the pilot indicated that he needed to return to the heliport to refuel after “one more bucket.” The pilot provided no further transmissions to the air attack controller. About 15 minutes later, the air attack controller contacted dispatch and learned that the helicopter had not returned to the heliport. The air attack controller then flew to the dip site, where he observed the helicopter lying on its right side in the river at the dip site. No “mayday” radio call was received from the accident pilot. Onboard GPS instrumentation revealed that, about 1745 on the day of the accident, the helicopter was about 0.75 miles southwest of the accident dip site. The helicopter returned to the dip site and began to slow down and descend over the dip site. The last recorded data point was about 138 ft above ground level at 0 knots and was about 15 ft from the location of the main wreckage; see figure 1. Figure 1. Flightpath showing the helicopter’s height above ground level and speed. Note: The spacing between each vertical line represents a 1-second interval. - According to a family member, the pilot had about 10 years of flight experience in the helicopter make and model, and he performed the “more difficult operations” for the operator. - The dip site, where the helicopter came to rest, was lined on three sides by trees with a height of about 100 ft. No evidence indicated an in-flight impact with any of the trees surrounding the accident site. The entire airframe was found at the accident site, and no evidence indicated an in-flight fuselage breakup. The nose of the helicopter had crushed aft and inward, which was consistent with contacting the river in an inverted attitude. The tailboom exhibited deformation on its underside immediately aft of the horizontal stabilizer, resulting in downward bending of the aft portion of the tailboom. The left horizontal stabilizer remained installed. The right horizontal stabilizer had fractured and separated but was found next to its normally installed location. The main and nose landing gears remained attached to the fuselage. The vertical fin remained attached to the tailboom, but its top end was impact damaged. The 140-ft-long line, which remained attached to the cargo hook of the helicopter, had wrapped around the fuselage in a direction consistent with the fuselage rolling to the left around the long line (or, conversely, the long line wrapping above and to the right of the fuselage). The water bucket remained attached to the end of the long line and was found about 40 ft upstream of the accident site. The long line was not damaged, and the water bucket sustained minor damage. The engine and transmission remained attached in the helicopter. Both left and right transmission pylons had separated from the main transmission center housing and were found adjacent to the main transmission. Examination of the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Examination of the rotor blades found damage that included (but was not limited to) root end fractures on the left main rotors and contact marks on the left and right rotors. All blade dampers separated from their respective rotor systems; one was recovered. Both the left and right blade sets exhibited damage consistent with the blades leading and lagging beyond the stops. Flight control continuity was established for the cyclic, collective, and pedal controls. The control tubes and bellcranks from the cockpit controls to the azimuth control installation exhibited impact fractures but no evidence of disconnection. The left and right azimuth controls remained attached to the lower side of the main transmission. Left Rotor System The white rotor blade fractured into three sections and separated from the hub near the root ends. The largest section of the white blade was found in a wooded area about 560 ft from the main wreckage. The tip section was located near the largest blade section and exhibited significant deformation in multiple locations. The inboard section of the white blade remained attached to its rotor head grip. The white blade’s servo flap spar remained attached to the blade, but the servo-flap afterbody had completely fractured and separated from the spar and was found about 192 ft from the main wreckage. Both the upper and lower fractures of the servo-flap afterbody were nearly straight in the spanwise direction. The red blade fractured into two locations. Most of the red blade was found in a wooded area about 500 ft from the main wreckage. The tip section was found in the wooded area about 570 ft from the main wreckage. The underside of the blade exhibited a dark-colored triangular-shaped rub mark, similar in color to the leading-edge coating of the rotor blades, as well as impact marks on the spar, core, and skin, consistent with a scuff and blunt impact marks along the leading edge of the right white blade. The inboard section of the left red blade remained attached to its rotor head grip. The red blade servo flap was whole and remained attached to the blade. Right Rotor System The right white blade remained attached to the rotor head but fractured and partially separated in four locations. Most of the right white blade was found adjacent to the main wreckage. The right white servo flap was whole and remained attached to the blade. The right red rotor blade fractured in one location, with most of the blade found about 81 ft from the main wreckage. The inboard section remained attached to its rotor head grip. The right red servo flap was whole and remained attached to the blade. Damage was observed at the outboard end of the right red servo flap. The outboard closeout had cracked along the upper and lower bond lines. The cracks started near the mid-afterbody I-beam and extended forward and aft. The lower afterbody skin was cracked in the spanwise direction at the outboard end. One crack coincided with the trailing side of the spar, and the other crack coincided with the forward end of the trailing edge. Servo Flap Examination The four servo flaps were further examined at the National Transportation Safety Board (NTSB) Materials Laboratory. The separation of the left white servo flap afterbody occurred generally at the spar-to-afterbody transition along the spanwise direction with some regions of peel separation, as shown in figure 3. The separation started in the lower skin at the inboard end of the flap at the spar-to-afterbody transition. The fracture progressed outboard staying at or near the transition and the channel ply exhibited peel separation from the spar along the entire spanwise length. Electron microscope examination of the ply fibers revealed fiber contact damage, tensile fractures, and buckle fractures, consistent with alternating stresses. Along the upper surface, the separation also started at the inboard end of the flap and progressed outboard. The skin plies initially peeled from the spar, before transitioning to fracturing at or near the spar-to-afterbody transition, similar to the lower skin. Electron microscope examination of upper skin ply fibers in this region showed similar features as those observed for the lower skin. The channel ply also exhibited peel separation from the upper edge of the spar up to approximately 23 inches from the inboard end. Figure 3. Separated servo-flap assembly from the left rotor/white main rotor blade showing the flap upper side (labeled a) and the flap lower side (labeled b). The left white servo-flap closeouts were located at the inboard and outboard ends of the afterbody (see figure 4). Figure 4. Separated servo flap as viewed from the inboard end looking outboard (labeled a) and the outboard end looking inboard (labeled b). Both inboard and outboard closeouts exhibited bonding tab separation. The inboard closeout tab, which bonds the closeout to the inboard aluminum fitting, was missing (see figure 5). A green epoxy adhesive and a piece of scrim cloth had been used to bond the closeout tab to the aluminum fitting. Much of the area appeared to be unbonded. In some areas, the surface exhibited a dark brown color with a plain weave surface texture that was consistent with a remnant layer from the bonding tab. Figure 5. Inboard closeout separation spar side (labeled a) and afterbody side (labeled b). Crack propagation features in the fractured adhesive were used to trace the fracture path from around the perimeter to an origin at the lower inboard location of the bonding region. Along the lower edge of the bonding region, lines radiated downward and outboard. Along the inboard edge, lines and crack arrest marks were consistent with a crack progressing from the lower side toward the upper side of the fitting. The features traced back to an origin area at the lower inboard region of the perimeter. The outboard closeout was cracked along the upper lower edges of the bond line with the afterbody, as shown in figures 6 and 7. The crack along the lower edge started near a mid-body I-beam stiffener and progressed forward and aft about 1 inch, arresting before reaching the spar or trailing edge. Along the upper edge, a crack also extended forward and aft of the I-beam, and a closeout tab that was bonded to the forward portion of the upper afterbody skin was missing. The tab had peeled from the skin, and adhesive and carbon-fiber ply imprints were left behind. Examination of the delamination surface indicated that the tab delamination proceeded inboard and toward the leading edge. The damage to the outboard end of the flap was consistent with the onset of high-amplitude reverse bending loads. Figure 6. Outboard closeout overview (labeled a)and end of crack along lower edge and peel region of bonding tab along upper edge (labeled b). Figure 7. Outboard closeout bonding tab separation on the spar side (labeled a) and afterbody side (labeled b). The remaining three servo flaps from the accident helicopter were examined visually for signs of cracks, particularly around the inboard closeout, and the bond between the closeout and aluminum fitting was evaluated. All flaps exhibited cracking along the bond line between the closeout and the aluminum fitting, but the extent of cracking varied. The right red servo flap was sectioned in an area that passed through a crack along the underside of the flap. The cross-section through the crack indicated that the outer and inner skin plies were fractured beneath the surface crack, as shown in figure 8. Figure 8. Lower side of closeout (labeled a) and cross-section through the lower skin plies (labeled b). -
Analysis
The pilot had been conducting fire suppression activities for the United States Forest Service using a water bucket suspended at the end of a 140-ft longline. The pilot informed the controller that he would need to return to the base for fuel after another bucket of water, which was the last communication between the controller and the pilot. The helicopter was subsequently located in a river at the dip site. No mayday call was received. Onboard global position system (GPS) data revealed that the helicopter had arrived at the dip site and was hovering at an altitude of 138 ft above the water, which would place the helicopter about 40 ft above the treetops. The water bucket would have been near or in the water. No evidence showed any signs of rotor system contact with the trees. However, evidence did show that the helicopter rolled to the left as it descended and the 140-ft longline wrapped around the fuselage during the descent. The helicopter then struck the river in an inverted position and continued to roll to the left until it came to rest on its right side. The lack of damage to the longline demonstrated that both rotor systems and pylons had separated from the fuselage while the helicopter was in flight. The left rotor blades were found 560 ft away from the main wreckage. Postaccident examination revealed that the damage observed on the right rotor blades, right hub, and right pylon occurred after they were struck by the left rotor blades while the helicopter was above the dip site. The damage observed on the left rotor system occurred when it hit the right rotor system while in flight. This intermeshing contact resulted in the in-flight separation and breakup of the left rotor blades. The failure of the left white blade servo flap started as a fracture of the lower skin at the spar-to-afterbody transition and peel separation of the upper skin before transitioning to fracture of both upper and lower skins at the transition. The transition between separation modes, onset of reverse bending damage at the outboard closeout, and the extent of damage to the left white blade servo flap compared to the servo flaps from the remaining three blades indicates that the left white blade servo flap was cracked at its inboard end prior to the collision between the left and right rotor systems. The inboard end crack grew progressively and compromised the structural integrity of the servo flap leading to the failure and eventual separation of the afterbody. Failure of the left white blade servo flap resulted in a loss of control of the left white blade. However, it could not be determined why the left white blade servo flap failure ultimately resulted in a collision between the left and right rotor systems in this accident. A past event involving a servo flap separation demonstrated that the loss of a servo flap does not always result in catastrophic consequences. It is likely that flight control inputs, including the pilot’s responses to an abnormal vibration in the rotor system, were a factor to the catastrophic outcome of the servo flap failure in this accident. The lack of flight data precluded analysis of the control inputs leading up to the collision between the left and right rotor systems.
Probable cause
An in-flight breakup resulting from contact of the left rotor system with the right rotor system after an in-flight failure of a servo flap from a left rotor blade.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Kaman
Model
K 1200
Amateur built
false
Engines
1 Turbo shaft
Registration number
N314
Operator
Central Copters Inc
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Firefighting
Commercial sightseeing flight
false
Serial number
A94-0032
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-26T04:00:00Z guid: 101856 uri: 101856 title: ANC20LA083 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101863/pdf description:
Unique identifier
101863
NTSB case number
ANC20LA083
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-25T07:00:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Event type
Accident
Location
Ninilchik, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On August 25, 2020, about 0709 Alaska daylight time, a Eurocopter (Airbus) AS350 B2 helicopter, N160SH, was substantially damaged when it was involved in an accident near Ninilchik, Alaska. The commercial pilot sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 air taxi flight. The pilot reported that he was operating at the Johnson River Tract mining camp located in the Alaska Range mountains west of the Cook Inlet. He was transporting workers to and from various mining sites about 3 miles from the main camp. On the morning of the accident, he conducted a preflight and sumped fuel from the helicopter's main fuel tank and the airframe fuel filters. All samples were clear and bright. The fuel level was about 40%, which corresponded to about 55 gallons of Jet A. There were no known discrepancies. He had flown the helicopter most every day for the previous 2 months and was very familiar with it. On the morning of the accident, the pilot departed the main camp about 0655 with 4 passengers and disembarked 2 of them at a low-elevation drill pad, and then he flew to a high mountainside helipad, which was located about 2,750 ft msl cut into a rocky steep slope and disembarked the other 2 passengers. He flew the helicopter to a nearby site and waited a short time for the off going workers to be ready for pick up. He departed and made another approach to the helipad. The pilot stated that when the helicopter was about 25 ft from the landing site, at very slow forward airspeed, the engine "flamed out" and the helicopter yawed right. Witnesses reported seeing a puff of smoke and hearing loud alarms when the engine lost power. The pilot continued the right turn, lowered the collective and attempted to autorotate to a level area about 600 ft below the helipad. When the pilot realized that the helicopter could not make the intended site, he slowed down by applying some aft cyclic and increasing collective to cushion the touchdown. The helicopter landed on the skids facing down the mountain and continued to slide. The left skid impacted a rock and the helicopter rolled over and continued down the mountain, resulting in the tail boom separating. The helicopter came to rest on a drill pad under construction about 200 ft below the helipad, on its left side. Refer to figure 1. The tail section, fuselage and main rotor blades sustained substantial damage. The mining workers at the helipad called for assistance, hiked down to the site, and assisted the pilot. Figure 1. The accident site and wreckage. (Courtesy of Soloy Helicopters.) The helicopter was recovered from the remote camp and examined by the investigative team. The Honeywell LTS101-700D2 turbine engine was secure on the airframe and intact. No airframe or engine anomalies, other than impact damage, were observed. The engine was shipped to Honeywell Engines division for further examination. Engine Examination On February 18, 2021, the engine was placed on an engine test cell and run for 1 hour 14 minutes and with five starts. The engine demonstrated the ability to meter and control fuel flow, and the power turbine governor operation and performance was demonstrated. No abnormal operation of the engine was observed. On February 23, 2022, the engine was placed on an engine test cell to conduct testing on the engine overspeed system, and it was run for 1 hour 9 minutes with four starts. Three tests were conducted that demonstrated the ability of the overspeed system to detect the overspeed, command the overspeed solenoid to activate, vent pneumatic control pressure, command the fuel control minimum fuel flow, and the engine to remain operating at the minimum flow condition. It also demonstrated the ability of the system to deactivate once the input speed dropped below the reset value, and the engine to recover to normal operation. -
Analysis
The pilot reported that he was transporting workers to and from various mining sites about 3 miles from the main camp. The pilot flew to a high mountainside helipad, which was located about 2,750 ft mean-sea-level (msl) cut into a rocky steep slope and disembarked 2 passengers. He flew the helicopter to a nearby site and waited a short time for the off going workers to be ready for pick up. He departed and made another approach to the helipad. The pilot stated that when the helicopter was about 25 ft from the landing site, at very slow forward airspeed, the engine "flamed out" and the helicopter yawed right. The pilot continued the right turn, lowered the collective and attempted to autorotate to a level area about 600 ft below the helipad. When the pilot realized that the helicopter could not make the intended site, he slowed down by applying some aft cyclic and increasing collective to cushion the touchdown. The helicopter landed on the skids facing down the mountain and continued to slide. The left skid impacted a rock and the helicopter rolled over and continued down the mountain, resulting in the tail boom separating. The helicopter came to rest on a drill pad under construction about 200 ft below the helipad. The tail section, fuselage and main rotor blades sustained substantial damage. The examination of the airframe did not reveal any discrepancies. The engine was placed on an engine test cell and two tests were run for a total of 2 hours 23 minutes with 9 starts. The engine demonstrated normal operation during testing. No abnormal engine operation, uncommanded shutdown, or loss of power control was observed.
Probable cause
A loss of engine power for an undetermined reason.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
AS350
Amateur built
false
Engines
1 Turbo shaft
Registration number
N160SH
Operator
Soloy Helicopters
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
2739
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-29T04:00:00Z guid: 101863 uri: 101863 title: ANC20LA085 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101873/pdf description:
Unique identifier
101873
NTSB case number
ANC20LA085
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-08-27T13:53:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Event type
Accident
Location
Fairbanks, Alaska
Airport
Chena Marina (AK28)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 2 serious, 0 minor
Factual narrative
On August 27, 2020, about 1353 Alaska daylight time, a Cessna 185 airplane, N714KH, was destroyed and a Piper PA-18 airplane, N7498L, was substantially damaged when they were involved in an accident near Fairbanks, Alaska. The pilot and one passenger on the Cessna 185 were fatally injured, and the other passenger sustained serious injuries. The pilot of the PA-18 also sustained serious injuries. The Cessna 185 was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand charter flight. The PA-18 was operated as a Title 14 CFR Part 91 personal flight. The Cessna 185, operated by Flying Moose Alaska, based at Chena Marina Airport (AK28), was transporting two hunters from a remote camp back to AK28. The PA-18 was departing AK28 for a flight to Bradley Sky-Ranch Airport (95Z), North Pole, Alaska, when the accident occurred. AK28 is an uncontrolled airport located about 3 miles west of Fairbanks International Airport (FAI), inside of the FAI class D airspace. All pilots arriving or departing from AK28 are required to contact the FAI air traffic control tower (ATCT) before entering the class D airspace to ensure they don’t conflict with FAI traffic. FAI air traffic control (ATC) tower recordings indicated that at 1344:24 the Cessna 185 pilot reported to FAI tower that he was 14 miles north of Fairbanks inbound to AK28. The tower controller responded, “proceed to chena marina advise down.” The airplane was not equipped with a transponder; however, primary ATC radar revealed that the Cessna 185 entered a left downwind for runway 36 and flew a left base to the final approach. The PA-18 pilot reported he performed his preflight, started the engine, and dialed in the FAI tower frequency to monitor air traffic control while the engine warmed up. He taxied to the north end of the airport where he fueled the airplane then taxied back to the south end of the airport in preparation for his takeoff to the north. The PA-18 pilot reported he monitored the FAI tower frequency as he taxied and did not recall hearing any traffic in the AK28 area nor did he see any traffic. He reported he pulled off the side of the runway, facing east, where he performed an engine runup and checked the automatic terminal information service. At 1352:19, while the Cessna 185 was turning from base to final approach, the pilot of the PA-18, transmitted his intentions to FAI tower for a north takeoff and southeast departure. The FAI tower controller responded, "report airborne off chena marina traffic on short final is a sky wagon." At 1352:30, the PA-18 pilot responded, “nine eight [unintelligible}.” In a postaccident interview, the PA-18 pilot did not recall the traffic advisory part of this transmission. The tower controller immediately advised the Cessna 185 "skylane four kilo hotel traffic departing chena marina super cub northbound." At 1352:38, the Cessna 185 pilot replied, "Yeah I'm right over him four kilo hotel." No further communications were received from either airplane. Figure 1 shows the flight track for the Cessna 185. Figure 1. Accident site and approximate Cessna 185 flight track in blue. During the postaccident interview, the PA-18 pilot reported that he visually looked to the north, the south, then back to the north before he taxied onto the runway. He recalled the tower controller communicating with another airplane and asking that pilot if he had an airplane in sight, to which the other pilot answered in the affirmative. The PA-18 pilot stated although his impression had been that the other airplane was not at AK28, the tower communication led him to check to the north and south again for traffic before taxiing onto the runway. The PA-18 pilot recalled taking off and reaching for the “mic button” to inform the FAI tower that he was airborne when he heard a “loud crack,” and the airplane began to slowly turn to the left while “falling out of the sky.” He did not know what happened but recalled being on the ground and another airplane crashing about 30 yards from his location. Multiple persons at AK28 heard the collision and assisted the occupants of both airplanes, including helping a passenger out of the Cessna 185 before it was consumed by fire. Airport Information AK28 is listed in the Alaska Chart Supplement as a private airport. A common traffic advisory frequency (CTAF) of 118.3 MHz is listed. The additional remarks section states: Use at own risk. Both pilots were in contact with the FAI control tower on this frequency when the accident occurred. In a letter of agreement, signed on March 23, 2000, between the Federal Aviation Administration (FAA), Fairbanks Airport traffic control tower and the Chena Marina Float Pond and Runway Association, outlines the operating procedures for the airport. Item D. states, in part: “Radio transmissions of pattern positions at Chena Marina are strongly discouraged unless requested by FAI tower.” Radar information was provided by the FAA and the source sensor is in Fairbanks, Alaska. Because the Cessna did not have an operational transponder, altitude information was not available. No flight track data was captured for the PA-18 as it likely never reached an altitude of radar coverage. Aircraft Information Neither airplane was equipped with automatic dependent surveillance broadcast, nor were they required to be. Pilot Information The PA-18 pilot reported that he normally wore hearing aids when not flying. When flying, he wore a noise cancelling headset without hearing aids or earplugs. Wreckage and Impact Information A home surveillance video located near midfield captured the moments immediately after the initial collision from about 70 ft above ground level. The Cessna 185 descended while rolling left and impacted the surface in a nose-down inverted attitude heading east, then slid north about 20 ft. The PA-18 simultaneously descended vertically in a flat attitude as its wings folded upward, coming to rest on a west heading. The debris field began about 255 ft south of the PA-18 and consisted primarily of PA-18 plexiglass and small parts. The Cessna 185 came to rest about 107 ft north of the PA-18 (see figure 2). According to responding witnesses, the Cessna became engulfed in flames soon after impact. Cessna 185 The fuselage was consumed by postimpact fire from the front of the horizontal stabilizer to the firewall. The empennage exhibited thermal damage. The left and right horizontal stabilizers and elevators remained attached at their respective attachment points. The vertical stabilizer and rudder were bent to the left with crush damage to the top of the vertical stabilizer and thermal damage to the bottom. The inboard section of both wings was destroyed by the postimpact fire. A 3-foot outboard section of the right wing and right aileron remained partially attached to the inboard section of the right wing. The outboard section of the left wing with a section of the aileron attached sustained thermal and leading edge impact damage. All non-consumed portions of the flight controls remained attached to their respective attach points. All flight control cables were connected to their respective flight control surfaces. The engine sustained thermal damage. Two of the propeller blades exhibited ‘S’ bending and leading edge gouges. The third blade was bent aft 90° near the outboard end of the blade and about 5-inches of the blade tip had separated. No preimpact failures/malfunctions of the airplane were identified during the examination. PA-18 The left and right horizontal stabilizer, elevators, vertical stabilizer, and rudder sustained impact damage. Control continuity was established from the control surfaces to the cockpit controls. Both wings were separated from the fuselage and both wings had propeller slash marks near their wing root and aluminum fuel tank cover. The right wing root area contained eight propeller slash marks and the left wing root area contained five propeller slash marks. The propeller slashes indicate an angle of about 10° relative to the longitudinal axis of the airplane. The ailerons and flaps remained attached to their respective wings. Aileron control continuity was established for both the left and right wing ailerons. The pilots shoulder harness separated near its upper attach point and exhibited features consistent with having been cut by the propeller. Figure 2. Both wreckage and debris locations. Additional Information Title 14 CFR 91.113 Right-of-way rules: Except water operations states, in part: (b) General. When weather conditions permit, regardless of whether an operation is conducted under instrument flight rules or visual flight rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear. (g) Aircraft, while on final approach to land or while landing, have the right-of-way over other aircraft in flight or operating on the surface, except that they shall not take advantage of this rule to force an aircraft off the runway surface which has already landed and is attempting to make way for an aircraft on final approach. The FAA Pilot’s Handbook of Aeronautical Knowledge, Chapter 14, Airport Operations, addresses communications at nontowered airports. This chapter states, in part: A nontowered airport does not have an operating control tower. Two-way radio communications are not required, although it is a good operating practice for pilots to transmit their intentions on the specified frequency for the benefit of other traffic in the area. The key to communicating at an airport without an operating control tower is selection of the correct common frequency. The acronym CTAF, which stands for Common Traffic Advisory Frequency, is synonymous with this program. A CTAF is a frequency designated for the purpose of carrying out airport advisory practices while operating to or from an airport without an operating control tower. The CTAF may be a Universal Integrated Community (UNICOM), MULTICOM, Flight Service Station (FSS), or tower frequency and is identified in appropriate aeronautical publications. The Recommended Communication Procedures chart, Figure 14-1, in the handbook shows that without an operating control tower at the airport, it is recommended that inbound aircraft announce their position when 10 miles out from the airport, when entering downwind, base and final, and again when leaving the runway. FAA Order JO 7110.65Z Air Traffic Control, Pilot/Controller glossary states, in part: Note 2: Traffic advisory service will be provided to the extent possible depending on higher priority duties of the controller or other limitations; e.g., radar limitations, volume of traffic, frequency congestion, or controller workload. Radar/nonradar traffic advisories do not relieve the pilot of his/her responsibility to see and avoid other aircraft. Pilots are cautioned that there are many times when the controller is not able to give traffic advisories concerning all traffic in the aircraft’s proximity; in other words, when a pilot requests or is receiving traffic advisories, he/she should not assume that all traffic will be issued. -
Analysis
A Cessna 185 was landing on a runway at an uncontrolled airport, and a PA-18 had just taken off from the same runway when they collided midair. Both airplanes came to rest on the runway. The pilot and one passenger on the Cessna 185 were fatally injured, and the other passenger sustained serious injuries. The pilot of the PA-18 also sustained serious injuries. The Cessna 185 was destroyed by postimpact fire. The uncontrolled airport where the collision occurred is within the class D airspace of an international airport located about 3 miles away. All pilots arriving or departing from the uncontrolled airport are required to contact the air traffic control tower (ATCT) at the international airport before entering the class D airspace to ensure no conflicts with the larger airport’s traffic. The ATCT does not issue takeoff and landing clearances for aircraft operating at the uncontrolled airport but provides traffic advisories to the extent possible depending on higher priority duties of the controller or other limitations. The Cessna 185 and PA-18 pilots were in contact with the ATCT before the collision. About 9 minutes before the accident, the Cessna 185 pilot reported to the ATCT that he was 14 miles away and inbound to land at the uncontrolled airport. The ATCT controller instructed the pilot to report when he landed. Radar data indicated that as the Cessna was turning from base to final to land, the PA-18 pilot reported to the ATCT that he was preparing to takeoff from the same runway to the north. The ATCT controller instructed him to report being airborne and advised him of traffic that was on short final, to which the PA-18 pilot responded “nine eight [unintelligible].” The controller then immediately advised the Cessna 185 pilot of departing traffic northbound. The Cessna pilot replied that he “was right over him.” No further communications were received from either airplane. Postimpact examination of both airplanes did not reveal any preimpact failures or malfunctions that would preclude normal operation. Propeller slash marks found along the top of the PA-18 indicate the Cessna 185 was above and overtaking the PA18 when the collision occurred. Neither airplane was equipped with automatic dependent surveillance broadcast, nor were they required to be. Although the ATCT controller advised the PA-18 pilot of traffic on final approach, the pilot later reported that he did not recall hearing the traffic advisory. It is unknown why he did not hear the traffic advisory. The PA-18 pilot reported that he looked for traffic to the north and south twice before he taxied onto the runway for takeoff. The Cessna 185 pilot likely saw the PA-18 at the end of the runway, but it is unknown when or if he realized that the PA-18 was taking off and not holding short of the runway. The only indication that the Cessna pilot saw the PA-18 was when he informed the controller that he was “right over” him just before the collision. There is no record that the Cessna 185 pilot made any radio calls announcing that he was entering the traffic pattern or what runway he was landing on. Except for the radio call immediately before the impact, the only radio call the Cessna 185 pilot made was when he was 14 miles away from the airport. Although Title 14 Code of Federal Regulations 91.113, “Right-of-way rules: Except water operations,” states that, regardless of whether an operation is conducted under instrument flight rules or visual flight rules, it is the responsibility of each person operating an aircraft to maintain vigilance so as to see and avoid other aircraft. The regulation specifically states that an aircraft on final approach to land or while landing has the right-of-way over other aircraft in flight or operating on the surface, except that they shall not take advantage of this rule to force an aircraft off the runway surface which has already landed and is attempting to make way for an aircraft on final approach. Thus, the landing Cessna 185 had the right-of-way over the PA-18.
Probable cause
The PA-18 pilot’s failure to see and avoid the Cessna 185 as it was landing. Contributing to the accident was the PA-18 pilot’s failure to hear the traffic advisory provided by the air traffic control tower.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Cessna
Model
A185
Amateur built
false
Registration number
N714KH
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
18504400
Damage level
Destroyed
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
Piper
Model
PA18
Amateur built
false
Engines
1 Reciprocating
Registration number
N7498L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-7609017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-26T04:00:00Z guid: 101873 uri: 101873 title: CEN20LA440 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102619/pdf description:
Unique identifier
102619
NTSB case number
CEN20LA440
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-09-04T21:02:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-02-11T02:11:59.459Z
Event type
Accident
Location
San Antonio, Texas
Airport
San Antonio International Airport (SAT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 4, 2020, about 2002 central daylight time, a Swearingen SA227-AC airplane, N362AE, was substantially damaged when it was involved in an accident at the San Antonio International Airport (SAT), San Antonio, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 cargo flight. According to the pilot, the airplane was flying wings level on a ¾ mile final approach to runway 13L when the airplane yawed right, but he was able to regain control of the airplane with a left rudder input as he continued with the landing approach. The pilot stated that airplane remained wings level with the nose aligned with the runway heading and on a normal glidepath to the runway until the airplane crossed over the runway 13L threshold. The airplane entered a right roll shortly after he reduced engine power for the landing flare, and that the roll became more pronounced as the landing flare continued. He was unable to regain control of the airplane before it landed hard on the right main landing gear with the airplane rolled about 20° right-wing-down. The airplane departed off the right side of the runway where the nose landing gear collapsed. The pilot postulated that the right roll during landing flare was due to a right engine malfunction. According to automatic dependent surveillance-broadcast (ADS-B) data, at 2001:07, the airplane was on a northeast ground track as it crossed perpendicular over runway 13L at 2,677 ft mean sea level (msl) and 182 knots calibrated airspeed (KCAS), as shown in Figure 1 and Figure 3. At 2001:16, the airplane entered a left turn to join the downwind leg for runway 13L at 2,700 ft msl and 165 KCAS. At 2001:38, the airplane was abeam the runway 13L threshold while on a 1 nautical mile (nm) wide left downwind at 2,629 ft msl, 138 KCAS, and a 702 feet per minute (fpm) descent rate, as shown in Figure 2 and Figure 3. About 10 seconds later, the airplane was in a left turn toward the base leg descending about 1,976 fpm at 135 KCAS. The operator’s general operations manual provides the criteria for a stabilized approach beginning at 1,000 ft above the touchdown zone elevation. Among other criteria, a stabilized approach is defined by the airplane being wings level on final approach at 300 ft above the touchdown zone elevation, the indicated airspeed not more than 10 knots above the specified approach speed (130 knots) for the aircraft landing weight (12,000 lbs) and not less than the required approach speed, the airplane’s descent rate shall not exceed 1,000 fpm, and only small changes in heading and pitch are required to maintain a correct flight path to the runway. The operator’s general operations manual requires a go-around in the event an approach is not stabilized at 1,000 ft above the touchdown elevation, or if the approach becomes destabilized at any point. The reference airspeed (Vref) was 106 knots at the airplane’s landing weight of 12,000 lbs. According to ADS-B data, at 2002:08, the airplane was 1,000 ft above the runway 13L threshold while in a 2,055 fpm descent at 125 knots, as shown in Figure 2 and Figure 3. At this time, the airplane was descending more than double the operator’s allowed descent rate and was 5 knots below the specified approach speed. At 2002:17, the airplane was descending at 2,929 fpm with an airspeed of 134 KCAS. At this time, the airplane was still in the left turn toward the final approach course with a 31° left-wing-down roll angle, as shown in Figure 4, and the descent rate was nearly 3 times the operator’s limitation. At 2002:28, the airplane was 300 ft above the runway 13L threshold, as it briefly flew through the final approach course for runway 13L. At this time, the airplane had a 16° left-wing-down bank angle and was flying at 135 KCAS while descending at 1,376 fpm. At 2002:36, the airplane was established on the extended runway centerline and was flying at 120 KCAS while descending at 1,250 fpm. At this time, the airplane was about 0.14 nm and 0.31 nm from the runway 13L threshold and touchdown zone, respectively. At 2002:41, the airplane crossed over the runway 13L threshold at 840 ft msl (43 ft above ground level) while flying at 111 KCAS (Vref +5 knots) and descending at 1,015 fpm. About 3 seconds later, at 2002:44, as the airplane touched down, the airplane was 36 ft right of the centerline with a ground track about 1.5° right of the runway course. At this time, the airplane’s airspeed, descent rate, flight path angle, and roll angle, were 104 KCAS, 733 fpm, -3.9°, and 3.7° right-wing-down, respectively. The airplane came to rest in the grass infield between runway 13L and taxiway M, about 525 ft south-southeast from the final ADS-B track point. Figure 1 –Airplane’s Ground Track During Traffic Pattern Figure 2 – Airplane’s Final Approach to Runway 13L Figure 3 – Airplane Altitude, Calibrated Airspeed, and Vertical Speed Figure 4 – Airplane Ground Track/Heading, Bank Angle, and Flight Path Angle Postaccident examination of the airplane revealed substantial damage to the fuselage, right engine nacelle structure, right-wing main spar, and the forward pressure bulkhead. Flight control continuity was confirmed from the individual control surfaces to their respective cockpit controls, and the measured range-of-travel for the aileron, elevator, and rudder where within maintenance manual limits. There were no discrepancies noted with the stabilizer trim control system, and its full travel time was within maintenance manual limits. A borescope inspection of both engines did not reveal any evidence of an internal gas path component failure. The turbine of each engine rotated freely during the borescope inspection. No airfoil damage or debris was observed during the borescope inspection. Both fuel control unit filter bowls contained fuel. Both propellers exhibited impact-related damage. -
Analysis
The pilot was concluding the Part 135 cargo flight when the airplane landed hard and departed off the right side of the runway. The pilot reported that the airplane was flying wings level with the nose aligned with the runway and on a normal glidepath to the runway until it crossed over the runway threshold. He stated that the airplane entered a right roll shortly after he reduced engine power for the landing flare, and that the roll became more pronounced as the landing flare continued. He was unable to regain control of the airplane before it landed hard on the right main landing gear with the airplane rolled about 20° right-wing-down. The airplane then departed off the right side of the runway where the nose landing gear collapsed. The fuselage, right engine nacelle, right-wing main spar, and forward pressure bulkhead were substantially damaged during the hard landing. A review of automatic dependent surveillance-broadcast (ADS-B) data revealed that the pilot did not fly a stabilized approach as defined by the operator’s general operations manual. Specifically, the airplane’s descent rate exceeded the operator’s 1,000 feet per minute (fpm) limitation, the airplane’s airspeed was not maintained at the specified approach speed, and the airplane was not wings level and aligned with the runway at 300 ft above the touchdown zone elevation. At 1,000 ft above the touchdown zone elevation, the airplane was descending on the base leg at 2,055 fpm and was 5 knots below the specified approach speed. During the left turn from base leg to final approach the airplane’s descent rate reached 2,929 fpm, which was nearly 3 times the operator’s limitation for a stabilized approach. The airplane crossed over the runway threshold about 43 ft above ground level while in a 1,015 fpm descent. About 3 seconds later, the airplane touched down on the runway while descending 733 fpm and 36 ft right of the centerline with a ground track about 1.5° right of the runway course. The airplane came to rest in the grass infield between the runway and a taxiway. Although the pilot postulated that the right roll during the landing flare was due to a right engine malfunction, his recollection of the airplane’s flight path to the runway was not consistent with the recorded ADS-B data. The pilot’s failure to fly a stabilized approach resulted in an excessive descent rate, hard landing, and loss of control. Additionally, postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation of the airplane.
Probable cause
The pilot’s failure to fly a stabilized approach which resulted in a hard landing and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SWEARINGEN
Model
SA227
Amateur built
false
Engines
2 Turbo prop
Registration number
N362AE
Operator
Ameriflight LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
AC-677B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-02-11T02:11:59Z guid: 102619 uri: 102619 title: CEN20LA421 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102048/pdf description:
Unique identifier
102048
NTSB case number
CEN20LA421
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-09-28T13:52:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2020-09-29T00:59:52.605Z
Event type
Accident
Location
Lago Vista, Texas
Airport
Lago Vista - Rusty Allen Airport (RYW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 1 minor
Factual narrative
On September 28, 2020, about 1352 central daylight time, a Beech A36 airplane, N104RK, was substantially damaged when it was involved in an accident near Lago Vista, Texas. The pilot and one passenger were seriously injured, and another passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane was fueled on the evening of September 24, 2020, at Rusty Allen Airport (RYW), Lago Vista, Texas, in preparation for a cross-country flight the following afternoon from RYW to South Padre Island International Airport (BRO), Brownsville, Texas. The pilot fueled the airplane using the self-serve fuel pump at RYW and the airplane was not flown again before he departed for BRO on the afternoon of September 25, 2020. The pilot stated that he preselected 20 gallons to be dispensed at the self-serve fuel pump; that the right tank was filled to the point of overflowing, but the self-serve pump shutoff before left tank was completely full. The airplane’s analog fuel tank quantity gauges for both main fuel tanks indicated “full” before he departed on the outbound flight to BRO. The pilot reported that the wingtip auxiliary tanks were empty at departure. The pilot reported that after departing RYW he made an intermediate landing at Cameron County Airport (PIL), Port Isabel, Texas, due to thunderstorm activity along his planned route-of-flight to BRO. According to automatic dependent surveillance-broadcast (ADS-B) track data, about 1.8 hours of flight time elapsed during the flight from RYW to PIL. The pilot stated that he waited for the weather to improve before he departed PIL and continued toward BRO. According to ADS-B track data, about 0.2 hours of flight time elapsed during the second flight leg from PIL to BRO. The pilot stated that he only used fuel from the right main fuel tank during both flight legs from RYW to BRO. The combined flight time for both flight legs was about 2 hours. On September 28, 2020, before he departed BRO for the return flight to RYW, he asked the fixed-base operator to add 10 gallons of fuel to the right main tank that was “slightly below half.” The pilot noted that he did not use fuel from the left main fuel tank during the flight legs from RYW to BRO and, as such, the left main fuel tank remained “nearly full” from the previous fueling on September 24, 2020. Based on his flight planning, the pilot estimated that he departed on the accident flight with 56 gallons of fuel; however, he did not directly ascertain how many gallons of fuel were in the main fuel tanks before departure. The wingtip auxiliary tanks remained empty. The pilot stated that the flight departed with the fuel selector positioned on the left main fuel tank where it remained until the airplane lost engine power while in the traffic pattern at RYW. The pilot reported that the cross-country flight was uneventful until the landing approach at RYW. He stated that the airplane was not stabilized on his first landing approach to runway 33 at RYW, so he made a go-around and entered left traffic for a second landing attempt. The airplane had a loss of engine power while the airplane was on a left base leg to runway 33. The propeller continued to windmill after the loss of engine power, but there was no indication that the engine was operating. The pilot was unable to restore engine power by switching fuel tanks (from the left main fuel tank to the right main fuel tank), verifying that the mixture control was full rich, and selecting each magneto separately before returning the ignition switch to BOTH. As he prepared his passengers for a forced landing, the pilot heard the airplane’s stall horn shortly before the airplane rolled right. The pilot does not recall the final moments of the flight after the airplane entered an aerodynamic stall at a low altitude. The airplane impacted vegetation and terrain in a nose low attitude. The airplane came to rest inverted, with the fuselage suspended above the ground, against vegetation. The airplane sustained substantial damage to both wings and the fuselage. According to ADS-B track data, the airplane flew at various cruise altitudes between 8,500 and 10,500 ft mean sea level, and the elapsed time enroute was about 1 hour 57 minutes. At 1351:47, the final ADS-B track datapoint was about 50 ft above ground level and about 78 ft west of the accident site. On September 28-29, 2020, an onsite examination completed by a Federal Aviation Administration (FAA) airworthiness inspector revealed that the airplane came to rest nose down and inverted in a wooded area. The fuel selector valve was positioned to use fuel from the right main fuel tank. First responders to the accident site reported that there was fuel leaking from the damaged right wing. There was no evidence of fuel in the fuel lines connected at the fuel selector valve, in the fuel lines forward of the firewall, fuel strainer assembly, engine-driven fuel pump, fuel manifold valve, or the fuel injector lines. About ½ tablespoon of fuel was recovered from the fuel metering assembly. A disassembly of the engine-driven fuel pump confirmed the drive coupler remained intact. On January 7, 2021, before the wreckage was recovered, an additional onsite examination was completed by a FAA airworthiness inspector with the assistance of an airframe manufacturer investigator. The fuselage and both wings exhibited impact related damage. There was flight control cable continuity between the individual flight control surfaces and their respective cockpit controls. The landing gear and flaps were found fully extended. There was no evidence of fuel in the main fuel tanks or the auxiliary tip tanks. The fuel selector valve functioned as designed during an operational test. The engine was found upside down and partially attached to the airframe through control cables. The propeller separated from the engine at the crankshaft flange. All blades remained attached to the hub and exhibited polishing and some minor leading-edge damage. The upper spark plugs exhibited features consistent with normal engine operation. Internal engine continuity and valve train continuity were confirmed while the crankshaft was rotated. Cylinder compression was confirmed by placing a finger over the open spark plug holes and feeling suction and expelled air from each cylinder while the crankshaft was rotated. Both magnetos provided spark when rotated by hand. There was no evidence of fuel in the engine fuel lines or fuel-related engine components. The airplane was equipped with two 40-gallon (37 gallon usable) main fuel tanks and two 15-gallon wingtip auxiliary tanks. Based on available performance data for the cruise altitudes flown during the flight, the expected fuel consumption rate at 75% engine power is 13.5-15.2 gallons per hour (gph). However, the amount of fuel used during the flight could not be calculated with an appreciable level of accuracy because the airplane was not equipped with an engine monitor or fuel flow meter with data recording capability. Additionally, although the pilot estimated the airplane had about 56 gallons of fuel available at departure, the investigation could not determine with an appreciable level of accuracy how that fuel was distributed between main fuel tanks. According to the airplane’s Pilot Operating Handbook, the Before Landing Checklist requires pilots to select the fullest main fuel tank before landing. -
Analysis
The pilot was conducting a personal cross-country flight when there was a loss of engine power while in the traffic pattern at the destination airport. The pilot’s attempts to restore engine power, including switching fuel tanks, were unsuccessful. The pilot heard the airplane’s stall warning horn shortly before the airplane rolled right and entered an aerodynamic stall at a low altitude. The airplane impacted vegetation and terrain in a nose low attitude. The airplane came to rest inverted, with the fuselage suspended above the ground, against vegetation. The airplane sustained substantial damage to both wings and the fuselage. The pilot did not directly ascertain how many gallons of fuel were in the main fuel tanks before departure. The wingtip auxiliary fuel tanks were empty at departure. The pilot estimated that the flight departed with about 56 gallons of fuel available; however, based on available information, the investigation could not determine with an appreciable level of accuracy how many gallons of fuel was available before the flight and how it was distributed between the two 40-gallon (37 gallon usable) main fuel tanks. The pilot stated that the flight departed with the fuel selector positioned on the left main fuel tank where it remained until the airplane lost engine power while in the traffic pattern at the destination airport. According to track data, about 2 hours of flight time had elapsed when the accident occurred. The pilot repositioned the fuel selector valve to the right main fuel tank after the loss of engine power, but that action did not restore engine power. Postaccident examination revealed that the fuel selector valve was positioned to use fuel from the right main fuel tank. First responders to the accident site reported that there was fuel leaking from the damaged right wing. There was no evidence of fuel in the left main tank or the auxiliary wingtip fuel tanks. Additionally, there was no evidence of fuel in the lines connected at the fuel selector valve, in the fuel lines forward of the firewall, fuel strainer assembly, engine-driven fuel pump, fuel manifold valve, or the fuel injector lines. About ½ tablespoon of fuel was recovered from the fuel metering assembly. A disassembly of the engine-driven fuel pump confirmed the drive coupler remained intact. A postaccident engine examination did not reveal a mechanical failure that would have prevented normal operation; the loss of engine power was likely due to an interruption of fuel flow to the engine. Based on available performance data for the cruise altitudes flown during the flight, the expected fuel consumption rate at 75% engine power is 13.5-15.2 gallons per hour (gph). However, the airplane was not equipped with an engine monitor or fuel flow meter with the ability to record how the engine was operated during the flight and, as such, the amount of fuel used during the flight could not be calculated with an appreciable level of accuracy. Based on the available evidence, if the pilot switched to the fullest main fuel tank before landing, as required by the airplane’s Before Landing Checklist, there likely would have been sufficient fuel remaining to safely land at the destination airport. The loss of engine power was likely due to fuel starvation resulting from the pilot’s mismanagement of the fuel system.
Probable cause
The pilot’s mismanagement of the fuel system which resulted in fuel starvation and a total loss of engine power. Contributing to the accident was the pilot’s failure to maintain airspeed which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N104RK
Operator
FHLS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-1450
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2020-09-29T00:59:52Z guid: 102048 uri: 102048 title: WPR21LA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102120/pdf description:
Unique identifier
102120
NTSB case number
WPR21LA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-10-06T16:33:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2020-10-22T02:55:26.351Z
Event type
Accident
Location
Spirit Lake, Idaho
Airport
Treeport Airport (ID22)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
The experimental, light-sport, high-wing amphibious airplane was manufactured in 2008. It was equipped with a 100-horsepower Rotax 912-S engine which drove a three-bladed composite propeller manufactured by Warp Drive. The basic empty weight was recorded as 732 lbs and with a maximum gross weight of 1,320 lbs. A Ran’s Pilot Operating Handbook (POH) was not available for the amphibious configuration. The Ran’s POH for a tailwheel configuration airplane indicated that normal takeoffs are accomplished with flaps up or half extended. With the flaps retracted, the normal climb speed was 65 to 70 mph. The POH further stated that, with the flaps half extended during takeoff, they should be left in that position until all obstacles were cleared, airspeed exceeds 60 mph, and the airplane gains a minimum altitude of 100 ft above ground level (agl) is reached. The POH stated that the stall speed at maximum gross weight in a flaps-retracted position was 50 mph. Stall speed for flaps at half retracted was 48 mph. The stall recovery procedure advised the pilot to smoothly move the control stick forward to accelerate to normal flight speed. The passenger estimated that the airplane contained about 11.25 gallons of fuel at the time of departure. According to Rans Aircraft, the accident airplane would have been under gross weight and well within the center-of-gravity envelope. - On October 06, 2020, at 1533 Pacific daylight time, a Rans S-7 Courier amphibious airplane, N55893, was substantially damaged when it was involved in an accident near Spirit Lake, Idaho. The pilot sustained fatal injuries and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and pilot-rated passenger were departing from the 3,000-ft-long grass runway. During the initial takeoff, the airplane stayed in ground effect. The passenger thought the pilot was going to land and taxi back, but then the pilot pulled aft on the control stick. The airplane climbed above the trees at the end of the runway (about 40 ft tall) and at about 50 ft above ground level (agl), the airplane’s left wing stalled. The airplane impacted the ground nearly inverted. A review of video of the takeoff revealed that the airplane became airborne about 1,100 ft down the runway. (see figure 1.) As the departure continued, the airplane’s wings rocked as it slowly climbed above the tree line. (see figure 2.) The airplane turned left (to the north) and then descended below the tree line. The airplane came to rest about 900 ft north of the runway centerline. (see figure 3.) Figure 1: Runway Diagram Figure 2: Excerpts of Video Capturing Takeoff Figure 3: Accident Site in Reference to the Runway In an effort to determine the estimated ground track, ground speed, altitude, orientation angles and engine speed of the airplane, the NTSB completed a performance study using the video of the accident takeoff as well as data recorded by an onboard multi-functional display (MFD) and GPS receiver. The track data indicated that, after becoming airborne, the airplane’s groundspeed increased from 47 to 60 mph, then decreased to 58 mph as the airplane climbed over the treeline. The video revealed that, after departing the runway surface and about 22 seconds after becoming airborne, the airplane reached a maximum altitude of about 75 ft above the runway, and subsequently began descending. The angle of attack (AOA) of the wing was derived from the video footage evaluating the difference between the wing pitch angle and the flight path angle (because wind was reported as calm, wind was not factored into the calculations). The wing stalled about 15 seconds after becoming airborne, resulting in the large 19° roll angle change between 13.67 and 18 seconds. At 25 seconds, the estimated angle of attack was 20°, which exceeded the wing’s critical AOA. The airplane impacted the ground about 650 ft from the last data point. The sound spectrum analysis of the video revealed that the estimated engine speed was about 5,446 rpm, equating to about 94% of the rated engine speed of 5,800 rpm. The engine and the propeller were operating about that speed when the airplane was losing altitude, consistent with normal engine operation. - Utilizing a temperature of 27 degrees Celsius and the airport elevation, the density altitude at the time of the accident was computed to be approximately 4,453 feet msl. - The pilot’s personal flight records were not recovered. On his most recent application for a Federal Aviation Administration medical certificate in October 2019, the pilot reported a total flight time of 10,000 hours. He purchased the airplane on May 7, 2000. -
Analysis
The pilot and pilot-rated passenger were departing from a grass runway. The passenger stated that the airplane remained in ground effect for a large duration of the takeoff and then climbed above the treeline. At an altitude of about 75 ft above ground level, the airplane’s left wing stalled, and the airplane collided with terrain. Analysis of video of the accident takeoff and GPS data indicated that the airplane’s wing reached its critical angle of attack before it began to lose altitude and descend into terrain. Sound spectrum analysis of the engine indicated that it was producing power at the time of the accident. Given the weights of the pilot, passenger, and fuel onboard, the airplane was under its maximum gross weight and within its center-of-gravity limits at the time of the accident. The circumstances of the accident are consistent with the pilot’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall and loss of control.
Probable cause
The pilot’s exceedance of the airplane's critical angle of attack during the initial climb after takeoff, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RANS
Model
S-7
Amateur built
false
Engines
1 Reciprocating
Registration number
N55893
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0207459
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2020-10-22T02:55:26Z guid: 102120 uri: 102120 title: CEN21LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102209/pdf description:
Unique identifier
102209
NTSB case number
CEN21LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-10-26T15:10:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2020-10-29T20:09:38.129Z
Event type
Accident
Location
Crystal Beach, Texas
Airport
Grass Airstrip (None)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 26, 2020, about 1410 central daylight time, a Piper PA-28-140 airplane, N32458, was substantially damaged when it was involved in an accident near Crystal Beach, Texas. The flight instructor and his student were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the accident occurred during a takeoff from a private airstrip. He estimated that the grass airstrip was about 2,500 ft long by 35 ft wide, and the grass runway condition was dry and had been recently used by other airplanes. The takeoff was made to the south-southeast. The airplane had about 26 gallons of fuel onboard before the flight, and the weight-and-balance and takeoff performance were verified and determined to be “suitable for the flight.” The flight instructor and his student taxied the airplane to the north end of the airstrip where they completed a before-takeoff engine runup. The pilots completed a before-takeoff engine runup with no anomalies or malfunctions reported. The flight instructor noted that the airplane was configured with 10° of flaps before a soft-field takeoff was initiated with about 12 knots of headwind. The flight instructor reported that his student performed the soft-field takeoff. After the airplane became airborne, the student reduced airplane pitch to remain in ground effect and allowed the airspeed to increase to 80 knots. The flight instructor reported that during initial climb there was a drop in engine speed (rpm). He confirmed the throttle control was full forward, but there was “no significant engine performance.” The flight instructor took control of the airplane from his student, reduced pitch, and banked to avoid the highway and powerlines located at the end of the airstrip. The flight instructor stated that a lack of engine performance resulted in a forced landing before the airplane completed 90° of turn from the takeoff heading. The airplane landed on the northside of the highway, collided with a power pole, and came to a stop. The flight instructor stated that following the accident the fuel selector, ignition switch, and electrical switches were turned off before he and his student exited the airplane uninjured. The student reported that after liftoff the airplane remained in ground effect until the airspeed increased to 75 knots, at which time his flight instructor took control of the airplane when it did not “react” after he increased airplane pitch to climb out of ground effect. The student reported that his flight instructor reduced airplane pitch and flew the airplane to the ground. A postaccident wreckage examination was completed by Federal Aviation Administration (FAA) inspectors and two aviation mechanics. The left wing and engine mount were substantially damaged during the accident. Flight control cable continuity was confirmed for the ailerons, stabilator, and rudder. The flaps were extended 10° and the flap handle was in the first notch. Engine control continuity was confirmed for the throttle, mixture, and carburetor heat controls. The gascolator contained a fluid similar to the color and odor of uncontaminated 100 low-lead aviation fuel. Examination of the engine revealed low cylinder compression and an oil-fouled lower spark plug for the No. 1 cylinder. Otherwise, the examination revealed no anomalies. The engine was subsequently started and run several times without any issues; however, the engine was not accelerated to maximum static rpm during the examination due to a damaged engine mount and the airplane being supported on jack-stands. According to a carburetor icing probability chart contained in FAA Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, the recorded temperature and dew point at the time of the accident were in the range of susceptibility for the formation of serious carburetor icing at glide power. According to the bulletin, a pilot should use carburetor heat when operating the engine at low power settings or while in weather conditions in which carburetor icing is probable. The Piper PA-28-140 Owner’s Handbook required the flaps to be extended 25° for soft-field and short-field takeoffs. The flight instructor reported that there was a laminated checklist in the cockpit that indicated the flaps be extended 10° for a soft-field takeoff. -
Analysis
The flight instructor and his student were departing on an instructional flight from a private grass airstrip. The pilots completed a before-takeoff engine runup with no anomalies or malfunctions reported. The flight instructor reported that his student performed the soft-field takeoff. After the airplane became airborne, the student reduced airplane pitch to remain within ground effect, and allowed the airspeed to increase to 80 knots. The flight instructor reported that during the initial climb there was a drop in engine speed (rpm). The flight instructor confirmed the throttle control was full forward, but there was “no significant engine performance.” The flight instructor took control of the airplane from his student, reduced pitch, and banked to avoid the highway and powerlines located at the end of the airstrip. The flight instructor stated that a lack of engine performance resulted in a forced landing before the airplane completed 90° of turn from the takeoff heading. The airplane landed on the northside of the highway, collided with a power pole, and came to a stop. The airplane’s left wing and engine mount were substantially damaged during the accident. According to the flight instructor, the airplane’s flaps were extended 10° for the soft-field takeoff based on a laminated checklist in the cockpit. The airplane’s owner’s handbook requires the flaps to be extended 25° for a soft-field takeoff. However, according to the flight instructor, the airplane became airborne and accelerated to a safe airspeed before it climbed out of ground effect. As such, the incorrect flap extension likely did not contribute to the accident. Postaccident engine examination revealed low cylinder compression and an oil-fouled lower spark plug for the No. 1 cylinder. Otherwise, the examination did not reveal any anomalies. The engine was subsequently started and run several times without any issues; however, the engine was not accelerated to maximum static rpm during the examination due to a damaged engine mount and the airplane being supported on jack-stands. The flight instructor reported a decrease in engine rpm during initial climb out of ground effect. Although engine performance would be diminished by a low cylinder compression and an oil-fouled lower spark plug for the No. 1 cylinder, those discrepancies would not result in a sudden loss of engine rpm during flight. As such, the low cylinder compression and/or oil-fouled spark plug likely did not result in the reported decrease in engine rpm as described by the flight instructor. The temperature and dewpoint at the time of the accident were in the range of susceptibility for the formation of serious carburetor icing at glide power. Although a formation of carburetor ice before takeoff could have resulted in a sudden decrease in engine rpm, the pilots completed a before-takeoff engine runup with no anomalies or malfunctions reported. The reason for the partial loss of engine power could not be determined.
Probable cause
The partial loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N32458
Operator
Coastal Skies Aero Club
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7525070
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2020-10-29T20:09:38Z guid: 102209 uri: 102209 title: ANC21LA006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102247/pdf description:
Unique identifier
102247
NTSB case number
ANC21LA006
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-11-06T17:20:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Last updated
2023-08-04T02:23:11.498Z
Event type
Accident
Location
Pacific Ocean, Pacific Ocean
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 6, 2020, about 1520 Pacific standard time, a Pilatus PC-12, N400PW, was substantially damaged when it was ditched in the Pacific Ocean about 1,000 miles east of Hilo, Hawaii, following a total loss of engine power. The two pilots sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. According to the PIC, he and another pilot were ferrying a new airplane from California to Australia. The first transoceanic leg was planned for 10 hours, from Santa Maria Airport (KSMX), Santa Maria, California, to Hilo Airport (PHTO), Hilo, Hawaii. A subsidiary of the airframe manufacturer had an auxiliary ferry fuel line and check valve installed in the left wing after delivery of the aircraft to the United States. About 1 month before the trip, the PIC hired a ferry company to install an internal temporary ferry fuel system for the trip. The pilots attempted the first transoceanic flight on November 2, but the ferry fuel system did not transfer properly, so they diverted. The system was modified with the addition of two 30-psi fuel transfer pumps that could overcome the airplane’s ejector fuel pump pressure and the ferry system check valve. The final system consisted of two aluminum tanks, two transfer pumps, transfer and tank valves, and associated fuel lines and fittings. The ferry fuel supply line was connected to the newly installed ferry fuel line fitting at the left-wing bulkhead, which then fed directly to the main fuel line through a check valve and directly to the engine fuel system. The installed system was ground- and flight-checked before the trip. According to Federal Aviation Administration (FAA) automatic dependent surveillance broadcast (ADS-B) data, the airplane departed KSMX about 1000. For the accident flight, the main fuel tanks were full with 402 gallons, the No. 1 ferry tank contained 100 gallons, and the No. 2 ferry tank contained 60 gallons. The fuel utilization procedure for the flight was: 1) Use main tanks until their quantity decreased to 300 gallons; 2) Transfer half of ferry tank number two or when the main tanks reach 350 gallons; 3) Use main tanks until their quantity decreased to 300 gallons; 4) Transfer half of ferry tank number one or when the main tanks reach 350 gallons; 5) Repeat until ferry tanks are empty. The first halves of the ferry tanks were transferred without any issues except for the occasional illumination of the FUEL IMBALANCE caution light, but that was expected as excess transfer fuel was sent back to the main tanks after passing through the engine. Then the ferry system was used to transfer the remaining fuel from the No. 2 ferry tank. The airframe manufacturer noted that this ferry tank utilization procedure did not give the flight crew a reliable situational awareness of the airplane’s fuel state, as it relied on information the crew did not have (motive flow rate) and on fuel quantity indications on the tanks that were not accessible to the crew while transferring fuel. About 3.5 to 4 hours into the flight, the airplane was light enough to climb from FL 200 to FL 280. About 5 hours into the flight, the No. 2 ferry tank was almost empty so the pilots prepared to stop transferring fuel from that tank. The ignition switch was placed ON. After the transfer pump was turned OFF, with fuel still visible in the supply line, the FUEL LOW PRESSURE light illuminated. The PIC had already placed the ignition switch to ON during the ferry transfer, and now set the two in-aircraft boost pumps to the ON position for the end of the transfer process and confirmed the pumps were on with the green L PUMP and R PUMP lights on the Fuel System Status Window and green IGNITION message on the Primary Flight Display (PFD) Engine Window. About 5 seconds after the low-pressure light illuminated, the engine surged and then completely shut down and feathered. The pilots estimated that the engine lost power about 20 seconds after turning the transfer pump off. The fuel quantity in the main tanks and No. 1 ferry tank was about 450 gallons at the time. The fuel temperature in the wing tanks was unknown. The engine stopped while the aircraft was at FL 280. Although the pilots could not recall what altitude the air start procedures were performed, they knew that 20,000 ft was the maximum altitude for restart according to the Pilot’s Operating Handbook. The pilots used the checklist to perform an air start and the engine started and the propeller unfeathered; however, the engine never reached idle rpm and manipulation of the power control lever did not affect the engine. The engine did not fully start. They shut off the engine per the checklist and then attempted another air start. During the next start sequence, the engine made a loud grinding noise and then a loud catastrophic “bang.” There was no evidence of smoke or flames from the exhaust on either side of the aircraft. The CAS panel had numerous messages. At some point, the Engine and Propeller Electric Control System (EPECS) FAIL light illuminated, but the pilots could not recall exactly when. As the airplane descended, they attempted multiple air starts, including the procedures for when the EPECS FAIL light was on. The propeller never moved and the engine never started. About 8,000 ft, the pilots committed to ditching the airplane and they commenced the ditching checklist. After preparing the survival gear, donning life vests, and making mayday calls on VHF 121.5, the PIC performed a full-flaps, gear-up landing at an angle to the sea swells and into the wind. He estimated that the swells were 5 to 10 ft high with crests 20 feet apart. During the landing, the PIC held back elevator pressure for as long as possible and the airplane landed upright. The pilots evacuated through the right over-wing exit and boarded the six-person covered life raft. A photograph of the airplane revealed that the bottom of the rudder was substantially damaged. The airplane remained afloat after ditching. The pilots used a satellite phone to communicate with Oakland Center. The United States Coast Guard (USCG) coordinated a rescue mission with a nearby oil tanker, the M/V Ariel, for rescue of the crew. According to the pilots, during the night, many rescue attempts were made by the M/V Ariel; however, the ship was too fast for them to grab lines and the seas were too rough. After a night of high seas, the M/V Ariel attempted rescue again; however, they were unsuccessful. That afternoon, a container ship in the area, the M/V Horizon Reliance, successfully maneuvered slowly to the raft, then the ship’s crew shot rope cannons that propelled lines to the raft, and they were able to assist the pilots onboard. They had been in the raft for about 22 hours. The airplane was lost at sea. Aircraft Information On April 15, 2020, the FAA issued a Standard Certificate of Airworthiness for the accident airplane. On this model Pilatus PC-12, the aircraft was certified without an air separator in the engine fuel feed line. An air separator in the engine fuel feed line was included on previous models of the PC-12. In addition, the production fuel system design of the accident airplane was such that a Fuel System Icing Inhibitor (FSII) was not required. On June 9, 2020, the ferry fuel system provisions were designed and installed by the aircraft manufacturer as a major alteration per FAA Form 337. The FAA Form 337, in Section 2.0, stated “The ferry tank provisions feed directly into the engine's fuel supply line.” It also stated, “Ferry tank installations should ensure that no air is introduced into the fuel system.” In addition, the drawings and schematics showed the ferry system connected directly to the engine's fuel supply line. The FAA Form 337 submitted by the company that installed the ferry system fuel tanks on October 28, 2020, stated in Section 3.0, “The ferry fuel feed is directly to the left main tank.” During the positioning flight on November 1, 2020, and an attempted ferry flight on November 2, 2020, the ferry fuel system would not transfer any fuel from the ferry tanks. The ferry fuel system was further modified on November 2-5, 2020, by installing two pumps to provide enough fuel pressure (30 psi) to overcome the aircraft’s delivery fuel ejector pump pressure (10 psi) and supply fuel to the engine fuel supply line. The pumps were installed so that either pump could transfer fuel from either ferry tank. Due to the additional changes made to the airplane’s ferry fuel system, a new FAA Form 337 should have been submitted to the FAA before the flight. On November 6, 2020, the airplane was returned to service. The pilots flew from Merced Airport (KMCE), Merced, California, to KSMX and tested the ferry fuel transfer process with both the front and rear internal tanks and both transfer pumps up to an altitude of 17,500 ft. The system worked as tested. There were no further tests conducted of the ferry fuel system. They refueled at KSMX and departed for Hawaii about 1000. Fuel System The installed ferry fuel system altered the fuel flow characteristics of the airplane as compared to the production fuel distribution system. As originally designed, the fuel distribution system transferred fuel from the left and right main wing tanks into the respective collector tanks through one-way valves located between the two fuel tanks. The transfer was facilitated by a transfer ejector pump located in each main tank. Fuel was fed from the collector tanks, through a common manifold, toward the engine primarily via delivery ejector pumps. The nominal output pressure of the delivery ejector pumps was 10 psi. The ejectors were energized by heated, high pressure, regulated motive flow from the engine fuel system. The delivery ejector pumps have a flap valve installed in the outlet to prevent reverse flow through the delivery ejector pumps. An electric fuel boost pump, located in each collector tank, was used to provide fuel if either of the delivery ejector pumps could not supply the required fuel pressure. The nominal output pressure of the boost pumps was 31 psi. The boost pumps are also used to provide fuel pressure for engine start, and to laterally balance the fuel load. From the wing tanks, fuel flowed forward through a firewall shutoff valve, a low-pressure engine-driven pump, an oil/fuel heat exchanger, a fuel filter, and a high-pressure engine-driven pump to the fuel control unit. Unused fuel is returned to the wing tanks through the motive flow line. Unlike the production fuel system, the ferry fuel system moved fuel to the engine feed line from ferry tanks through a check valve. The ferry system transfer pumps provided fuel at a higher pressure than the delivery ejector pumps, which closed the flap valve in the delivery ejector pumps. The ferry system provided fuel to the engine through a firewall shutoff valve, a low-pressure engine-driven pump, an oil/fuel heat exchanger, a fuel filter, and a high-pressure engine-driven pump to the fuel control unit. The excess fuel was then returned to the wing tanks through the motive flow circuit. Unlike the production fuel system, the motive flow fuel going to the delivery ejector pumps would flow out the pump inlet because the flap valve was closed. The fuel in the motive flow line refilled the wing fuel tanks. FAA Advisory Circular 23-10 The FAA Advisory Circular 23-10 “Auxiliary Fuel Systems for Reciprocating and Turbine Powered Part 23 Airplanes” states the following: “The requirements for a direct feed auxiliary fuel system are considerably more stringent than those for a transfer auxiliary fuel system. In general, these requirements ensure that an uninterrupted flow of fuel at the required pressure and flow rate is provided to each engine for all operating conditions of the airplane. For turbine engine airplanes, these provisions should be automatic to meet the requirements of §23.955(f)(2). These requirements also address altitude performance effects and low and high temperature fuel aspects as well as providing fuel system independence in at least one configuration. Failure Mode and Effects Analyses (FMEA) are needed to ensure that no hazardous conditions exist due to a failure of the auxiliary system. Continuous engine operation should be verified when the auxiliary tank system is depleted of fuel in order to prevent engine flameout or other unacceptable operating conditions.” The Advisory Circular 23-10 also stated that the auxiliary tank depletion characteristics should also be evaluated to ensure that air entrainment, etc., do not alter main tank performance. After the ferry fuel system was installed on the airplane, there were no tests or evaluations that 1) addressed altitude performance effects and low and high temperature fuel aspects on the production system due to the ferry system operation; 2) completed an FMEA to ensure that no hazardous conditions existed due to a failure of the auxiliary system; or 3) verified continuous engine operation when the auxiliary tank system was depleted of fuel in order to prevent engine flameout or other unacceptable operating conditions as required in Advisory Circular 23-10. There was no evaluation of 1) the ferry system’s impact on the production fuel system operating temperature; 2) whether an FSII should be required; and 3) if not having an air separator in the engine fuel feed line would impact the system. Although such an evaluation was not required and was advisory, the underlying certification provisions are required to ensure continuous operation of the fuel system. -
Analysis
The new production airplane was ditched in the ocean about 1,000 miles from its destination following a total loss of engine power during its first 10-hour transoceanic leg. The two pilots sustained no injuries, and the airplane was lost at sea. A subsidiary of the aircraft manufacturer installed an auxiliary ferry fuel line and check valve in the left wing as a major alteration (per FAA Form 337) that stated, “The ferry tank provisions feed directly into the engine’s fuel supply line.” It also stated that “ferry tank installations should ensure that no air is introduced into the fuel system.” Another company installed the ferry fuel system that initially consisted of two aluminum tanks, transfer and tank valves, and associated fuel lines and fittings. The company submitted a FAA Form 337 that stated, “The ferry fuel feed is directly to the left main tank.” The ferry fuel supply line was connected to the newly installed ferry fuel line fitting at the left-wing bulkhead, which then fed directly to the main fuel line through a check valve and directly to the engine fuel system. The pilots’ first attempt at the transoceanic flight failed because the ferry fuel system did not transfer any fuel. The system was further modified with the addition of two 30 pounds-per-square-inch (psi) fuel pumps that could overcome aircraft’s ejector fuel pump pressure (10 psi) and the ferry system’s check valve. The airplane was returned to service. The pilots flew a positioning flight and tested the ferry fuel transfer process, with both the front (No. 1) and rear (No. 2) internal tanks and both transfer pumps, up to an altitude of 17,500 ft. The system worked as tested and there were no further tests conducted of the ferry fuel system. The pilots departed on the 10-hour flight and the ferry fuel system worked initially as they used the operating procedures that were supplied by the installer. About 3.5 to 4 hours into the flight, the airplane was light enough to climb from flight level (FL) 200 to FL 280. About 5 hours into the flight, the No. 2 ferry tank was almost empty, and the No. 1 tank was about 1/2 full. The pilots were concerned about introducing air into the engine as they emptied the No. 2 ferry tank, so the pilot in command (PIC) placed the ignition switch to ON. The non-flying pilot then turned the ferry tank fuel transfer pump to off and soon after the engine surged and flamed out. The pilots commenced the pilot operating handbook’s emergency checklist procedures for emergency descent and then loss of engine power in flight. They attempted multiple engine air starts without success. About 8,000 ft mean sea level, the pilots committed to ditching and performed an emergency landing in the ocean. The pilots evacuated through the right over-wing exit, boarded the covered life raft, and were rescued about 22 hours later. The installed ferry fuel system altered the fuel flow characteristics of the airplane when it was used to transfer fuel from the ferry fuel tanks. The delivery ejector pumps had a flap valve installed in the outlet to prevent reverse flow. However, the ferry system transfer pumps provided fuel at a higher pressure than the delivery ejector pumps, which closed the flap valve in the delivery ejector pumps. Also, the unused fuel returned to the wing tanks through the motive flow line would flow out the delivery ejector pumps’ inlet because the delivery ejector pumps’ flap valve was closed. It is possible that the loss of engine power was due to air being introduced into the fuel line from the ferry system, although the boost pumps, if operating properly, should have compressed the air and forced it through the fuel line. It is also possible that ice built up in the aircraft fuel tanks during the fuel transfer operations, and when the ferry system was turned OFF, fuel flow to the engine stopped or was restricted because 1) the left- and right-wing fuel was too viscous; and/or 2) the ejector flap valves were stuck closed. The aircraft was certified without an air separator in the engine fuel feed line. In addition, the production fuel system design of the accident airplane was such that a Fuel System Icing Inhibitor (FSII) was not required. Although not required, neither the aircraft manufacturer nor the company that installed the ferry fuel system evaluated 1) the ferry system’s impact on the production fuel system operating temperature; 2) if an FSII should be required; and 3) if not having an air separator in the engine fuel feed line would impact the system. The loss of engine power likely was caused by fuel starvation as a result of 1) air in the fuel line from operating on the ferry fuel system; or 2) a build-up of ice in the production fuel system due to operating on the ferry fuel system. However, because the airplane was lost at sea and was not available for postaccident examination, the exact cause of the fuel starvation could not be determined.
Probable cause
A total loss of engine power due to fuel starvation for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PILATUS
Model
PC12
Amateur built
false
Engines
1 Turbo prop
Registration number
N400PW
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
2003
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-04T02:23:11Z guid: 102247 uri: 102247 title: CEN21LA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102340/pdf description:
Unique identifier
102340
NTSB case number
CEN21LA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2020-11-26T14:59:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2020-11-27T09:39:00.484Z
Event type
Accident
Location
Telluride, Colorado
Airport
Telluride Regional Airport (TEX)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s maintenance logbooks were not located during the investigation. According to the airplane kit manufacturer, the airplane had a useable fuel capacity of 32 gallons distributed evenly between two wing fuel tanks. According to a fuel purchase receipt, before departing on the flight from TEX to DRO, the pilot dispensed 23.87 gallons of 100 low-lead aviation fuel using the self-serve fuel pump at TEX. - According to Federal Aviation Administration airport documentation, the traffic pattern altitude for runway 27 at TEX was 10,484 ft msl, about 1,414 ft above the runway 27 threshold elevation. - On November 26, 2020, about 1259 mountain standard time, a Vans RV4 airplane, N87LW, was substantially damaged when it was involved in an accident near Telluride, Colorado. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the airport manager for the Telluride Regional Airport (TEX), the pilot told an employee with the fixed base operator (FBO) at the airport that he intended to fly from TEX to Durango-La Plata County Airport (DRO), Durango, Colorado, to retrieve a passenger and then return to TEX. According to automatic dependent surveillance-broadcast (ADS-B) data, at 1125, the airplane departed TEX on runway 27 and flew direct to DRO and landed on runway 3 at 1150. At 1229, the airplane departed DRO on runway 3 and proceeded north back toward TEX, as shown in figure 1. About 1256:39, the airplane turned onto a left downwind for runway 27 at TEX. A FBO employee at TEX reported that she was monitoring the airport’s UNICOM frequency when the pilot transmitted that he was on the downwind leg for runway 27. The FBO employee told the pilot to park in the hangar after landing and the pilot replied “cool.” Further review of the recorded ADS-B data indicated that the airplane entered the traffic pattern while descending through 10,000 ft mean sea level (msl) and flew the downwind leg about 1 statute mile (sm) south of the runway 27 centerline, as shown in figure 2 and figure 3. The airplane continued to descend about 250 feet per minute (ft/min) during the downwind leg. The airplane entered the traffic pattern at 100 knots calibrated airspeed (KCAS) and decelerated during the downwind and base legs. Figure 1 – ADS-B Track Data for Flight Figure 2 – ADS-B Track Data for Airplane in Traffic Pattern Figure 3 – Altitude, Speed, and Vertical Speed About 1258:12, the airplane entered a left turn toward the base leg for runway 27 and continued to descend and decelerate. About 1258:58, the airplane entered a left turn from the base leg toward a 0.5 sm-final-approach-course to runway 27. During the final 4 seconds of recorded ADS-B data, the airplane decelerated to 50 KCAS and the descent rate increased from 600 ft/min to 3,850 ft/min, as shown in figure 4. The airplane’s calculated roll angle was left-wing down and varied between 23° and 88° during the final 4 seconds of data, as shown in figure 5. According to the airplane kit manufacturer, the airplane’s wings-level aerodynamic stall speed at a maximum gross weight of 1,500 lbs was 47 KCAS. Figure 4 – Altitude, Speed, and Vertical Speed Figure 5 – Ground Track Angle, Roll Angle, and Flight Path Angle According to the FBO employee monitoring the airport’s UNICOM frequency, at exact time unknown, there was a brief transmission where the pilot exclaimed “oh [expletive].” The FBO employee noted that the airplane disappeared from the FBO’s flight tracking system a few minutes after the pilot’s final transmission and that a representative with the United States Air Force Search and Rescue called the airport inquiring about an emergency locator transmitter signal that had been detected. Airport security camera footage showed the airplane in a left-wing down, nose down, descending turn into mountainous terrain east of the airport. There was no video evidence of a postimpact fire or explosion. There were multiple witnesses who reported seeing the airplane enter a steep left turn toward the airport followed by a nose-down descent toward terrain. One witness reported that the airplane completed 3 or 4 spins while it descended nose down in a vertical descent and that the sound of the engine was “quite loud.” - According to the autopsy authorized by the San Miguel County Coroner’s Office, Telluride, Colorado, the pilot’s cause of death was multiple traumatic injuries, and the manner of death was an accident. No significant natural disease was identified during the autopsy. Toxicological testing, completed by the Federal Aviation Administration Forensic Sciences Laboratory, detected the opiate narcotic morphine in the pilot’s urine at 34 nanograms per milliliter (ng/mL) but not in his cavity blood. The non-impairing pain reliever acetaminophen, commonly marketed as Tylenol, was detected in his cavity blood and urine. Morphine is prescribed for pain relief but may be present as a metabolite of the pain reliever codeine. The plasma half-life of codeine is around 3 hours and the half-life of morphine is around 4 hours. Both morphine and codeine are impairing medications and patients should not drive or operate dangerous machinery until they know how they react to the medication. Codeine is often prescribed in combination with acetaminophen. - The pilot’s flight logbook was not located during the investigation. - The airplane impacted mountainous terrain about 0.5 sm east-southeast of the runway 27 threshold at TEX. The elevation of the accident site was about 8,877 ft msl. The airplane impacted nose-down into steep terrain. All major airframe structural components and flight control surfaces were present at the accident site, as shown in figure 6. The wreckage was recovered to a secure facility where it was examined. The postaccident examination did not reveal any evidence of a preexisting mechanical malfunction or failure that would have prevented normal operation. All physical damage to the airframe, engine, and propeller was consistent with ground impact. Figure 6 – Main Wreckage at the Accident Site -
Analysis
The pilot and passenger were concluding a cross-country flight and were flying in the traffic pattern at their intended destination when the airplane pitched nose down and descended rapidly into mountainous terrain during the turn from the base leg to final approach. There were multiple witnesses who reported seeing the airplane enter a steep left turn toward the airport followed by a nose-down descent toward terrain. One witness reported that the airplane completed 3 or 4 spins while it descended nose down in a vertical descent and that the sound of the engine was “quite loud.” Airport security camera footage showed the airplane in a left-wing down, nose down, descending turn into terrain east of the airport. According to automatic dependent surveillance-broadcast (ADS-B) data, shortly after the airplane entered the left turn from the base leg to final approach, the airplane decelerated to 50 knots calibrated airspeed (KCAS) and the descent rate increased from 600 to 3,850 ft/min. According to the airplane kit manufacturer, the airplane’s wings-level aerodynamic stall speed at a maximum gross weight was 47 KCAS. The airplane maneuvering in the traffic pattern would require turns and, as such, there was a corresponding increase to aerodynamic stall speed during the turns. Additionally, the airplane’s left-wing-down roll was increasing when the airplane entered the rapid descent. Postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation of the airplane. Based on the surveillance video footage, witness accounts, and the recorded ADS-B data, it is likely the pilot did not maintain adequate airspeed during the left turn from the base leg to final approach, which resulted in the airplane exceeding its critical angle of attack and inadvertently entering an aerodynamic stall/spin at a low altitude over mountainous terrain. Toxicology testing detected morphine in the pilot’s urine but not in his blood. The detection of acetaminophen suggests that the pilot had taken codeine with acetaminophen for mild to moderate pain relief. Since no morphine was present in the blood, no impairing effects would be expected. Thus, the effect of the pilot’s use of morphine or opiate pain reliever was not a factor in this accident.
Probable cause
The pilot’s failure to maintain adequate airspeed during the turn from the base leg to final approach, which resulted in the airplane exceeding its critical angle of attack and entering an inadvertent aerodynamic stall/spin at a low altitude over mountainous terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV4
Amateur built
true
Engines
1 Reciprocating
Registration number
N87LW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1115
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2020-11-27T09:39:00Z guid: 102340 uri: 102340 title: WPR21LA078 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102485/pdf description:
Unique identifier
102485
NTSB case number
WPR21LA078
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-02T16:30:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-01-28T21:09:35.794Z
Event type
Accident
Location
Moab, Utah
Airport
CANYONLANDS FLD (CNY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 2, 2021, about 1430 mountain standard time, a Cessna P210N airplane, N833RT, was substantially damaged when it was involved in an accident near Moab, Utah. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the airplane was brought into a hangar for a few hours to melt ice that had accumulated on the airframe. When the engine would not start after several attempts, the airplane was brought back into the hangar for a few more hours to warm the engine. After the initial engine startup, the oil pressure and oil temperature indications were confirmed, and the pilot taxied the airplane to the runup area. The engine runup revealed no anomalies. Shortly after takeoff, about 100 to 200 ft above ground level (agl), the engine began to run rough and lost partial power. The pilot retracted the landing gear but soon felt additional loss of engine power followed by a loss of altitude and maneuverability. The pilot extended the landing gear and performed a forced landing onto the remaining runway. The airplane landed on the left side of the runway before veering right and exiting into the snow-covered runway safety area. The right main landing gear collapsed, and the airplane came to rest on the right-wing tip and right horizontal stabilizer. The pilot reported that the landing gear was possibly not in the fully extended position upon landing. The front passenger reported to the pilot that the fuel flow gauge indicated about 42 gallons of fuel per hour (gph) during the takeoff. At 1453, the recorded weather at Canyonlands Field Airport (CNY), Moab, Utah, included wind from 330° at 8 knots, and a temperature of -6 C°. The airplane was installed with a Continental IO-550 engine that was converted from a normally aspirated engine to a turbo-normalized engine on November 9th, 2020. This was also the date of the last annual inspection with an engine total time of 0.0 hours. The engine had about 40 hours of operation at the time of the accident. Vitatoe Aviation owns the Supplemental Type Certificate (STC) SA02918CH that was installed. Recovered engine data revealed a loss of rpm, manifold pressure, and fuel pressure during the takeoff. These values were restored shortly before dropping again. Manifold pressure and fuel flow values reached a maximum of 33.7 inHg and 47.9 gph, respectively. During a postaccident test run, the engine hesitated; however, manifold pressure indicated 34.2 in Hg and the fuel flow was 44 gph, at 2,720 rpm. After the engine was at normal operating temperature, the manifold pressure and fuel flow displayed nominal values when the engine was operated at 2,700 rpm. Following the engine test run, a test flight was performed with no anomalies noted through multiple power settings. No component adjustments were made to the engine during the test run. The Vitatoe Pilot Operating Handbook (POH) Supplement Rev. B issued on July 24, 2014, stated: On the first flight of the day, when the throttle is advanced for takeoff, manifold pressure will normally exceed 31.0 inches Hg and fuel flows will exceed 37 GPH if the throttle is opened fully. Momentary manifold pressures up to 33.0 inches Hg are acceptable. If manifold pressure consistently exceeds 31.0 inches of Hg, mechanical adjustment may be necessary. On any takeoff, the manifold pressure should be monitored, and the throttle set to provide 31.0 inches Hg; then, for maximum engine power, a full rich mixture should provide at least 35 GPH (36-37 GPH preferred). -
Analysis
The pilot was departing on the first flight of the day in cold weather conditions after the airplane had spent several hours inside a hangar to melt ice from the airframe and warm the engine. About 100-200 ft above ground level (agl) shortly after takeoff, the engine began to run rough and lost partial power. He retracted the landing gear, and the engine subsequently lost additional power. The pilot decided to land on the remaining runway and extended the landing gear. The airplane landed on the left side of the runway before veering right and exiting into the snow-covered runway safety area. The right main landing gear collapsed, and the airplane came to rest on the right wingtip and right horizontal stabilizer. The front passenger reported to the pilot that the fuel flow gauge read about 42 gallons of fuel per hour (gph) during the takeoff. Recovered engine data indicated that fuel flow values exceeded 47 gph before the second loss of engine power. During an engine test run, the engine hesitated when the throttle was advanced, and the manifold pressure indicated 34.2 inHg, fuel flow 44 gph, at 2,720 rpm. After the engine reached a normal operating temperature, the engine ran normally. No component adjustments were made to the engine during the test run. According to the engine operating handbook, during the first flight of the day, the manifold pressure will normally exceed 31 inHg and fuel flows will exceed 37 gph if the throttle is opened fully. The handbook advised that manifold pressure be monitored and that the throttle be set to provide 31 inches of manifold pressure. It is likely that, during takeoff, the pilot fully advanced the throttle, which resulted in a high manifold pressure and high fuel flow, an excessively rich fuel/air mixture, and a subsequent loss of engine power.
Probable cause
The pilot’s improper application of full throttle during takeoff, which resulted in loss of engine power due to an excessive fuel flow and overly rich fuel mixture.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
P210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N833RT
Operator
NASH LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
P21000809
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-01-28T21:09:35Z guid: 102485 uri: 102485 title: CEN21LA104 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102480/pdf description:
Unique identifier
102480
NTSB case number
CEN21LA104
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-02T17:41:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-01-06T21:36:42.442Z
Event type
Accident
Location
New Hudson, Michigan
Airport
Oakland Southwest (Y47)
Weather conditions
Instrument Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
On January 2, 2021, about 1541 eastern standard time, a Piper PA-24-250 airplane, N8347P, was destroyed when it was involved in an accident near New Hudson, Michigan. The pilot and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and his passengers flew from Oakland Southwest Airport (Y47), New Hudson, Michigan, to Cherokee County Airport (CNI), Canton, Georgia, on December 29, 2020. The accident occurred on the return flight to Y47. There was no record that the pilot obtained a weather briefing or filed a flight plan on the day of the accident. The pilot and his passengers departed CNI at 1221 for the return trip and flew Global Positioning System (GPS) direct at 7,500 ft. The pilot was not instrument rated. The following is based on Federal Aviation Administration Form 8020-6, Report of Aircraft Accident. At 1238, the pilot contacted Knoxville Air Route Traffic Control Center (ARTCC) and requested VFR (visual flight rules) flight following to Y47 at 7,500 ft. He was issued a discrete beacon code. The pilot was subsequently handed off to Atlanta and Indianapolis ARTCC; Lexington, Cincinnati, Columbus, and Toledo Air Traffic Control Towers (ATCT). At 1452, while talking to Toledo ATCT, the pilot advised he would have to “convert to IFR (instrument flight rules)” to descend to Y47. At 1456, air traffic control asked the pilot if he was ready to “go IFR” and the pilot responded that he was ready. The pilot was cleared direct to Y47 at 7,000 ft and later was told to contact Detroit (DTW) approach control. At 1513, the pilot contacted DTW approach and was issued the DTW altimeter setting. The pilot asked if there were any pilot reports (PIREPs) for icing in the area. He was told there had not been any in the last hour. The pilot then asked for the VOR-A approach into Y47. He further stated that if he made a missed approach, he would proceed to Oakland County International Airport (PTK), Pontiac, Michigan. The pilot was cleared to descend to 4,000 ft, then to 3,000 ft. At 1533, he was instructed to fly a heading of 020° to intercept the VOR final approach course to Y47. He was also given a PIREP from a Learjet pilot who had landed at Willow Run Airport (YIP), Ypsilanti, Michigan, located about 16 miles south of Y47. That pilot had reported the cloud base to be 300 ft with no ice descending through the layers. The pilot of N8347P responded that 300 ft “would not work for Y47.” He was then asked what his intentions were, and he replied that he would “give it [the approach] a shot.” At 1535, the pilot was cleared for the VOR -A approach to Y47. [Although the pilot was cleared for the VOR-A approach, the VOR portion of the approach had been NOTAMed (Notice to Air Missions) unavailable. This notice was displayed on the Information Display System (IDS) at the radar position]. The controller told the pilot to change to the airport advisory frequency and to report back to him if he executed a missed approach or cancelled his IFR clearance after landing. This was the last radio contact with the airplane. According to the Automatic Dependent Surveillance-Broadcast (ADS-B) data the airplane approached Y47 at an altitude of about 2,000 ft and an airspeed of 100 knots (kts). It passed over the airport and decelerated in a left descending turn to 1,475 ft and 85 kts. The airplane entered a second tighter turn and descended to 1,150 ft and 60 kts. Track data was lost at 1541:20. The last recorded altitude and airspeed were 975 ft and 71 kts near the accident location. A video taken from a home security camera, located at a dwelling across the street from the accident site, captured the accident sequence. The sound of an aircraft engine could be heard on the recording at the video time stamp of about 4:39:28. The sound goes away and returns, but louder, about 4:40:23. Once again, the sound disappears and then can be heard again with the airplane coming into view at 4:41:24 in a left wing low, nose low attitude. The wings leveled off and the nose was raised just before the airplane impacted the ground in a flat attitude. It slid across the ground and collided with a house. The airplane immediately caught fire and the house was set ablaze. No occupants in the house were injured, but a cat perished. A pilot who was in his hangar at the airport and heard but did not see the airplane reported that it sounded like it was “quite high for landing.” He then heard the engine power increase as if the pilot were performing a go-around. He then heard the airplane make a second approach and once again he heard the engine power increase to “full throttle.” He reported that he assumed the pilot was performing another go-around, but the airplane did not return. - An autopsy on the pilot was performed by the Oakland Country Medical Examiner’s Office. The cause of death was listed as Multiple Blunt Force Trauma. Toxicological testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. - A pilot who was at Y47 when the accident occurred reported the weather conditions “…. were not favorable for flying – fairly low ceiling, heavy clouds, light mist and rain with low temperatures.” - Copies of the pilot’s two logbooks were made available for review. Logbook 1 began on January 20, 2007, and ended on July 3, 2020. Logbook 2 began of July 2, 2020, and ended on November 26, 2020. According to these logbooks, the pilot started taking instrument instruction on April 3, 2007, and flew with an instructor under simulated conditions, logging 10.9 hours. The pilot continued logging simulated instrument time between September 19, 2007, and November 7, 2010, but there were no instructor signatures and no mention of a safety pilot. The simulated time totaled 8.3 hours. The pilot flew three more times with an instructor between July 6 and August 27, 2011, totaling 3.7 hours. Between October 14, 2011, and June 19, 2020, the pilot logged 38 flights under actual instrument conditions totaling 40.6 hours. None of those flights bore an instructor’s signature. His last recorded flight review was dated January 25, 2018. The pilot then switched flight schools. Between July 2, 2020, and November 26, 2020, he flew 13.9 hours under simulated instrument conditions, 0.6 hours of which were with a flight instructor. Additionally, the pilot logged 2.8 hours under actual instrument conditions, none of which were with an instructor. In summary, the pilot had logged 41.5 hours under simulated instrument conditions, 15.2 of those hours were with an instructor. Additionally, he had logged 99.6 hours under actual instrument conditions, 4.8 hour of which were with an instructor, for a total of 141.1 instrument hours. The last logbook entry indicates the pilot had logged 1,278.8 hours total time. Adding the 3.5 hours for the flight to CNI and the 3.6 hours for the accident flight, the pilot’s total flight time was no less than 1,278.8 hours. - The wreckage was later examined by investigators from Piper Aircraft and Lycoming Engines under the supervision of an FAA inspector. The fuel selector was on the right auxiliary tank, the flaps were retracted, and the stabilator trim was between neutral and a slightly nose-up position. There were no preimpact mechanical anomalies that would have precluded normal operations. -
Analysis
As the airplane approached the destination, the pilot requested VFR (visual flight rules) flight following and was issued a discrete beacon code. He asked if there were any pilot reports (PIREPs) for icing in the area and was told there had not been any in the last hour. The pilot then requested the VOR-A approach into Y47. The pilot stated that if he missed the approach, he would divert to another airport. The pilot was vectored to intercept the VOR-A final approach course and was given a pilot report from a pilot who landed at a nearby airport who reported the cloud base to be 300 ft with no ice descending through the layers. The accident pilot said he would “give it (the approach) a shot.” Automatic Dependent Surveillance-Broadcast (ADS-B) data showed the airplane approach the airport at an altitude of about 2,000 ft and 100 knots (kts). It passed over the airport and began to decelerate in a left descending turn to 1,475 ft and 85 kts. The airplane entered a second tighter turn and descended to 1,150 ft and 60 kts. Track data was lost at 1541:20. The last recorded altitude and airspeed were 975 ft and 71 kts. near the accident location. A residential security camera captured the accident. The sound of an aircraft engine is audible on the recording. The sound goes away and returns, but is louder. Once again, the sound disappears and is heard again with the airplane coming into view in a left wing low, nose low descent. The wings and nose level off just before the airplane impacts the ground in a flat attitude. The airplane slides across the ground, impacts a house, and a fire erupts. The airplane was destroyed during the postimpact fire. A pilot who was in a hangar at the airport reported hearing the airplane fly over the airport twice. He thought the airplane was trying to land and he reported hearing the engine power increase both times as if the pilot was performing a go-around. This pilot reported that the weather conditions at the time consisted of a low ceiling, “heavy clouds”, light mist, and rain. A NOTAM (Notice to Air Missions) was issued for the VOR-A approach at the destination airport. Although the NOTAM stated the VOR portion of the approach was unavailable it is unlikely that this played a role in the accident as the pilot had overflown the airport on the approximate approach course and was circling the area when the accident occurred. There was no record that the non-instrument rated pilot obtained a weather briefing or filed a flight plan for his flight. The pilot had logged 41.5 hours of simulated instrument flight time, 15.2 of those hours were with an instructor. Additionally, he had logged 99.6 hours under actual instrument conditions, 4.8 hour of which were with an instructor, for a total of 141.1 instrument hours. The pilot was not instrument rated and was not trained to fly in the weather conditions that existed during the accident flight. An examination of the airplane, engine, and related systems revealed no mechanical anomalies that would have precluded normal operations. It is likely that while maneuvering in instrument meteorological conditions while trying to locate the runway, the non-instrument rated pilot failed to maintain the proper airspeed, which resulted in the exceedance of the airplane’s critical angle of attack and the airplane experiencing an aerodynamic stall.
Probable cause
The pilot’s failure to maintain proper airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall. Contributing to the accident was the pilot’s lack of an instrument rating and the low visibility at the time of the accident.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N8347P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-3604
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-01-06T21:36:42Z guid: 102480 uri: 102480 title: ERA21LA102 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102525/pdf description:
Unique identifier
102525
NTSB case number
ERA21LA102
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-11T14:30:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-02-22T21:30:54.485Z
Event type
Accident
Location
Vineland, New Jersey
Airport
VINELAND-DOWNSTOWN (28N)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On January 11, 2021, at 1230 eastern standard time, an unregistered Kolb Firestar KXP was substantially damaged when it was involved in an accident near Vineland, New Jersey. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to a witness, he and the accident pilot flew, in separate airplanes, from the witness’ residence to Vineland-Downstown Airport (28N), Vineland, New Jersey, about 7 miles away. After landing, the accident pilot told the witness that he wanted to fly over a friend’s house in the local area. The accident pilot boarded the airplane, took off from runway 20, and flew a traffic pattern around the airport. The airplane remained in view the entire flight. The airplane turned from a base leg to final at an altitude of 400 to 500 ft, and “seemed to be at normal cruising speed of 80 mph.” While on final, the airplane appeared to be “significantly” to the right of the runway 20 extended centerline, with the wings straight and level. The airplane began a gradual descent, followed by a “steep 45° nose down pitch into the trees.” The airplane appeared to be at “cruising speed” and did not appear to stall. The engine was “operating normally and no indication of sputtering or engine failure of any kind.” Another witness stated that he watched the two airplanes land, and the accident airplane take off shortly thereafter. He stated that the accident airplane flew a “wider than normal” traffic pattern around the airport, but that everything seemed normal until the airplane pitched to about 45° nose-down from a wings-level attitude while on approach. He did not believe that the airplane stalled and stated that the engine sounded like it was running. The first witness, who was the custodian of the airplane reported that he and the pilot had flown their respective airplanes on the previous day, and the witness had flown the accident airplane 3 to 4 times in the previous 6 months. The witness believed that the pilot had a total of 3 to 4 hours of flight experience in the accident airplane. The pilot had inquired about purchasing the accident airplane, which had been in storage for about 20 years. The witness had aided the pilot with repairing the airplane and provided operational instruction over the previous year. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate, his most recent 3rd class medical certificate was issued February 4, 2004. At that time, he reported 300 hours of total flight experience. No pilot logbooks were available for review. The accident airplane was equipped with two seats, a 50-horsepower engine with a 10-gallon fuel capacity, and an empty weight of 325 lbs. The airplane did not meet the requirements of Title 14 CFR Part 103.1 to be operated as an ultralight aircraft. No maintenance logbooks for the airplane were available for review. The airplane came to rest in a near-vertical, nose-down attitude in a wooded area. All major components were present and located within a 60-ft diameter area. Both wings were damaged and separated from the fuselage. The ailerons remained attached to the wings. The fuselage tube was fractured just aft of the cockpit. The control cables to the rudder and elevator remained intact and were continuous from the cockpit controls to their respective control surfaces. The engine was separated from the fuselage and located 10 ft from the main wreckage. Both carburetors were separated from the engine. The fuel shutoff valves for both fuel tanks were open. Fuel was leaking from both tanks, and each tank contained about 2 gallons of green-colored fuel. When the fuel bulb was squeezed, fuel flowed from the carburetor supply fuel lines. According to the Office of Gloucester-Camden-Salem Medical Examiner, Sewell, New Jersey autopsy report, the cause of the pilot’s death was multiple injuries, and the manner of death was accident. Toxicology testing performed for the medical examiner’s office on the pilot’s heart blood detected the primary psychoactive compound in cannabis, delta-9-tetrahydrocannabinol (THC), at 5.4 nanograms per milliliter (ng/mL); THC’s inactive metabolite, carboxy-delta-9-tetrahydrocannabinol (THC-COOH), at 60 ng/mL; methamphetamine at 830 ng/mL; amphetamine at 90 ng/mL; and hydrocodone at 25 ng/mL. FAA Forensic Sciences Laboratory toxicology testing detected THC at 3.1 ng/mL, THC’s active metabolite, 11-hydroxy-delta-9-THC, at 0.9 ng/mL; THC-COOH at 31.1 ng/mL; methamphetamine at 708 ng/mL; amphetamine at 73 ng/mL; hydrocodone at 27 ng/mL; hydrocodone’s active metabolite, dihydrocodeine; and zolpidem at 9 ng/mL. These compounds were also detected in the pilot’s lung, muscle, or liver tissue. -
Analysis
The pilot was interested in purchasing the accident airplane, which had been abandoned and in storage for about 20 years. In the year preceding the accident, the pilot had worked on repairing the airplane and received some instruction from the airplane’s custodian. The pilot had accrued a total of 3 to 4 hours of flight time in the airplane and had flown it most recently the day before the accident. On the day of the accident, he flew it to a nearby airport along with the accident airplane’s custodian, who flew in a separate airplane. After landing, the pilot advised that he wanted to fly over a friend’s house. The pilot took off and flew a traffic pattern at the airport. Witnesses described that while on final approach to the runway, in a wings-level attitude, with the engine sounding normal, the airplane suddenly entered a steep, nose-down attitude until it impacted trees. The witnesses stated that the airplane was flying at a normal speed and did not stall. Examination of the airplane revealed no pre-impact anomalies that would have precluded normal operation. Although the wings were found separated from the fuselage, the control cables from the cockpit to the rudder and elevator remained intact and continuous from the cockpit to their respective control surfaces, suggesting that the airplane’s pitch control remained intact. The pilot’s autopsy did not reveal any indications of incapacitation. Toxicology was positive for hydrocodone, zolpidem (a sleep aid), methamphetamine, and cannabis. The hydrocodone level detected was within the therapeutic range, the level of zolpidem was subtherapeutic. Both compounds can impair mental and physical performance. The level of methamphetamine was over four times the therapeutic level, which is suggestive of abuse. At higher doses of methamphetamine, risk-taking increases, as does inattention, increased reaction time, and incoordination. The levels of delta-9-tetrahydrocannabinol (THC) and its metabolites suggest that either the usage occurred several hours before the accident or that the pilot was a chronic user. THC blood concentrations do not correlate well with levels of impairment. Most behavioral and physiological effects of cannabis use are diminished within 3 to 5 hours after use though some effects can last as long as 24 hours. Usage can lead to slow reaction time, impaired cognitive performance, and increased risk-taking. The pilot was likely impaired by his use of one or more of these drugs; however, his level of impairment and how it may have contributed to the accident could not be determined. Witnesses did not report any unusual behavior by the pilot on the day of the accident, and both flights appeared normal except for the final pattern leg on the accident flight. The toxicology results were not indicative of when the pilot may have used each of the detected drugs, which could have been at different times before or between the flights on the accident day. Depending on when the usage occurred, it is possible that the pilot’s level of impairment significantly affected his ability to control the airplane during the final pattern leg; however, whether the steep descent was a result of the pilot’s impairment, his limited experience in the same make/model, or other reason, could not be determined based on the available information.
Probable cause
A steep descent and impact with terrain during final approach for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KOLB
Model
FIRESTAR
Amateur built
false
Engines
1 Reciprocating
Registration number
UNREG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-02-22T21:30:54Z guid: 102525 uri: 102525 title: ERA21LA101 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102522/pdf description:
Unique identifier
102522
NTSB case number
ERA21LA101
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-13T12:33:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-01-22T02:15:32.282Z
Event type
Accident
Location
Columbia, South Carolina
Airport
JIM HAMILTON L B OWENS (CUB)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA's Pilot's Handbook of Aeronautical Knowledge contained the following guidance: Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome. The handbook also advised, "unless a pilot has many hours of training in instrument flight, flight in reduced visibility or at night when the horizon is not visible should be avoided." The FAA’s Airplane Flying Handbook (FAA-H-8083-3) described hazards associated with flying when visual references, such as the ground or horizon, are obscured. The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. The FAA’s publication "Spatial Disorientation Visual Illusions" (OK-11-1550), stated in part the following: False visual reference illusions may cause you to orient your aircraft in relation to a false horizon; these illusions are caused by flying over a banked cloud, night flying over featureless terrain with ground lights that are indistinguishable from a dark sky with stars, or night flying over a featureless terrain with a clearly defined pattern of ground lights and a dark starless sky. The publication provided further guidance on the prevention of spatial disorientation. One of the preventive measures was "when flying at night or in reduced visibility, use and rely on your flight instruments." The publication also stated the following: If you experience a visual illusion during flight (most pilots do at one time or another), have confidence in your instruments and ignore all conflicting signals your body gives you. Accidents usually happen as a result of a pilot's indecision to rely on the instruments. The FAA publication “Medical Facts for Pilots” (AM-400-03/1) described several vestibular illusions associated with the operation of aircraft in low-visibility conditions. The somatogravic illusion, which involves the semicircular canals of the vestibular system, was generally placed into the "graveyard spiral" Category. According to the publication text, the graveyard spiral is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude. Pilot Reports A review of the audio from the CAE Radar North control position revealed that, between 0945 and 1015 on the day of the accident, the controller provided air traffic control services to at least five aircraft that were either departing from or arriving at CUB or CAE and one aircraft overflight. During that time, no PIREPs were solicited by the controller, and one was received unsolicited. This PIREP was not entered into the Aeronautical Information System – Replacement system (one of the FAA-approved electronic systems for PIREP dissemination) and was disseminated to only one aircraft when a pilot asked (about 1016) if aircraft were landing at CAE. FAA Order JO 7110.65Y, Air Traffic Control, paragraph 2-6-2,. PIREP Solicitation and Dissemination, noted that “every phase of flight has the potential to be impacted by weather, and emphasis must be placed on gathering, reporting, and disseminating weather information.” The paragraph also stated in part the following: Emphasis must be placed on the solicitation and dissemination of Urgent (UUA) and Routine (UA) PIREPs. Timely dissemination of PIREPs alerts pilots to weather conditions and provides information useful to forecasters in the development of aviation forecasts. PIREPs also provide information required by ATC in the provision of safe and efficient use of airspace… Controllers must provide the information in sufficient detail to assist pilots in making decisions pertinent to flight safety. The order states that controllers should solicit PIREPs when requested, deemed necessary, or when ceilings are at or below 5,000 ft or visibility (surface or aloft) is at or less than 5 miles (or if these conditions are forecast). In addition, the order states that pertinent PIREP information should be relayed to “concerned aircraft in a timely manner.” Approach Information Paragraph 4-7-10 of FAA Order JO 7110.65Y addressed approach information and stated in part the following: Both en route and terminal approach control sectors must provide current approach information to aircraft destined to airports for which they provide approach control services. This information must be provided on initial contact or as soon as possible thereafter. Approach information contained in the ATIS [automatic terminal information system] broadcast may be omitted if the pilot states the appropriate ATIS code. The paragraph also stated that, for pilots destined to an airport without an ATIS broadcast, the controller should issue the following approach information · surface wind; · ceiling and visibility if the reported ceiling at the airport of intended landing is below 1,000 ft or below the highest circling minimum, whichever is greater, or the visibility is less than 3 miles; and · 5. altimeter setting for the airport of intended landing. - CUB was located 2 miles south of Columbia, South Carolina. It had one runway designated as 13/31, which was 5,011 ft long by 75 ft wide. The instrument approach procedure being flown just prior to the accident was the RNAV (GPS) RWY 13, effective December 31, 2020, to January 28, 2021. Localizer Performance without Vertical Guidance (LP) were non-precision approaches with Wide Area Augmentation System (WAAS) lateral guidance. They were added in locations where terrain or obstructions did not allow publication of vertically guided LPV procedures. While conducting such an approach, lateral sensitivity would increase as an aircraft gets closer to the runway. LP minimums would not be published with lines of minima that contained approved vertical guidance (LNAV/VNAV or LPV). Lateral Navigation (LNAV) were non-precision approaches that provide lateral guidance. The pilot must check RAIM (Receiver Autonomous Integrity Monitoring) prior to the approach when not using WAAS equipment. Both LP and LNAV lines of minima were Minimum Descent Altitudes (MDAs) rather than Decision Altitudes (DAs). It was possible to have LP and LNAV published on the same approach procedures chart. An LP was published if it provides lower minima than the LNAV. Each standard instrument approach procedure has associated weather minimums of visibility and sky conditions that determine how low an aircraft can travel while flying the final approach course. If the pilot flying the instrument approach procedure reaches the published minimums for that approach and the pilot has the runway environment in sight, the pilot can continue to land visually. Conversely, if the airplane reaches the published minimums without the runway in sight, the pilot should execute the published missed approach. The published minimum descent altitude for the CUB RNAV runway 13 approach was 780 ft msl and 1 statute mile flight visibility. - On January 13, 2021, about 1033 eastern standard time, a Beech F33A, N266DC, was destroyed when it was involved in an accident near Columbia, South Carolina. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Radar and air traffic control voice communication data provided by the Federal Aviation Administration (FAA) indicated that the airplane departed runway 19 at Greenville Downtown Airport (GMU), Greenville, South Carolina, about 0959 under visual flight rules and that the pilot was cleared to climb the airplane to 5,500 ft mean sea level (msl). About 1006, while the airplane was airborne, the pilot requested an instrument flight rules clearance and continued southeast toward Jim Hamilton – L B Owens Airport (CUB), Columbia, South Carolina. The controller provided the clearance, and the pilot descended the airplane to 5,000 ft. Soon afterward, the pilot requested clearance to descend to 3,000 ft, which the controller provided. About 1015, the controller asked the pilot to advise the receipt of weather information for CUB and advise the type of approach to the airport. The pilot requested the area navigation (RNAV) runway 13 approach and asked the controller to provide a pilot report (PIREP) and the weather minimums for CUB (the pilot did not state that he had received the current weather conditions at CUB, nor did the controller provide that weather information to him). The controller stated that a PIREP was received about 45 minutes earlier (about 0930) and that the pilot was trying to land there but was not able to “make it.” The controller cleared the pilot for the RNAV approach, and the pilot continued the flight. About 1030, the controller advised the pilot of the alternate missed approach instructions, which consisted of entering controlled airspace on a heading of 050° and climbing and maintaining 2,500 ft. Soon afterward, the pilot announced that he was performing a missed approach, and the controller instructed him to fly a heading of 360° when able and climb and maintain 2,500 ft. The pilot acknowledged the information and asked if a left turn was required for the 360° heading, which the controller confirmed. The pilot acknowledged the information and requested the weather conditions at Columbia Metropolitan Airport (CAE), Columbia, South Carolina, which was about 6.5 nautical miles west of CUB. About 1033, the controller provided the weather conditions at CAE. The pilot did not acknowledge this transmission, and the controller advised the pilot that radar contact was lost. The controller made additional attempts to establish communication with the pilot, which were unsuccessful. Review of ADS-B data showed that during the instrument approach, the airplane remained about 3/4-mile left of course until the airplane was about 1 1/4 miles from the approach end of the runway. At that time, the airplane made a right turn, descended to 325 ft msl, and made a climbing left turn to 800 ft msl before descending into a residential neighborhood (see figures 1 and 2). Figure 1. Airplane flight track during the approach (in red) and extended runway centerline at CUB (in magenta). Note: JSSTN is the initial approach fix for the RNAV runway 13 approach, and PEPHR is the final approach fix for the approach. Figure 2. Three-dimensional view of the airplane’s flight track (in red) with the minimum descent altitude overlay of the flight track (semi-transparent gray layer). Note: The lowest minimum descent altitude for the RNAV runway 13 approach was 780 ft mean sea level. The airplane descended below the MDA three times before the accident occurred. Witnesses who heard the airplane during the final moments of the flight stated that the engine sounded normal. One eyewitness saw the airplane emerge from the fog in a left-wing-low attitude and then impact the roof of a residence. The airplane came to rest in the backyard of the residence against a wooden fence. A postimpact fire ensued. - Professional Pathology Services in Columbia, South Carolina, performed an autopsy on the pilot. His cause of death was massive blunt force injuries. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected no drugs, carboxyhemoglobin, or ethanol in the pilot’s specimens. - The 0953 recorded weather observation at CUB included calm wind, visibility 1/4-mile in fog, vertical visibility of 200 ft above ground level (agl), temperature of 2°C, dew point of 2°C, and altimeter setting of 30.20 inches of mercury. The 1053 recorded weather observation at CUB, included wind from 240° at 5 knots, visibility 1/4-mile in fog, a vertical visibility of 200 ft agl, a temperature of 3°C, a dew point of 3°C, and an altimeter setting of 30.20 inches of mercury. The 1029 recorded weather observation at CAE, which was about 6 miles southwest of the accident site, included wind from 240° at 3 knots, visibility 1/2-mile, fog, vertical visibility of 200 ft agl, temperature 3°C, dew point 2°C, and altimeter setting of 30.18 inches of mercury. The observations from CUB and CAE surrounding the accident time indicated low instrument flight rules (IFR) conditions with light and variable wind at or below 5 knots over the area. AIRMET advisory Sierra, which was issued at 0945, was valid for the accident site at the accident time. AIRMET Sierra indicated IFR conditions in the area due to fog and mist. The pilot did not request or receive weather information from Leidos Flight Service. A search of archived ForeFlight information indicated that the pilot did not request weather information via ForeFlight. The investigation found no other record of the pilot receiving or retrieving any weather information before or during the flight. - The pilot’s logbook was not recovered. - The airplane impacted a tree in a residential area before impacting the ground at an elevation of 270 ft msl. The postimpact fire consumed most of the fuselage. All major components of the airplane were located near the main wreckage. Sections of left wing and the pitot tube were observed near the initial tree impact. The right wing separated from the fuselage and exhibited thermal damage. The vertical stabilizer separated from the empennage, and the rudder separated from the vertical stabilizer. The cabin and seats were consumed by fire. The instrument panel was fragmented, and the avionics exhibited thermal damage. The landing gear and the flaps were in the retracted position. The flight control cables were examined, but flight control continuity could not be confirmed as a result of fragmentation and thermal damage. The gyro and gyro housing exhibited rotational scoring. The engine remained partially attached to the airframe. Both magnetos had separated from the accessory housing due to impact. The ignition leads were consumed by fire. The No. 5 cylinder head rocker assembly had separated from the cylinder head due to impact. The Nos. 1, 3, and 4 rocker covers exhibited impact damage. The fuel injection mixture control was separated from the engine. The throttle butterfly housing was fragmented, and the butterfly valve remained attached to the throttle linkage. The propeller had separated from the engine due to impact, but all three propeller blades remained attached to their hub. All three blades exhibited tip curling and chordwise scratching. -
Analysis
The instrument-rated commercial pilot departed on a visual flight rules flight plan but requested and received an instrument flight rules clearance while en route to the destination airport. During the flight, the air traffic controller instructed the pilot to advise when he had obtained the reported weather conditions at the destination airport and asked the pilot about the type of instrument approach he was requesting to the destination. The pilot requested an area navigation (RNAV) approach, and the controller acknowledged; however, the controller did not confirm if the pilot had the weather conditions at the destination airport, nor did he provide that information to him. The pilot then asked the controller for the approach minimums at the destination airport and if any pilot reports (PIREPs) had been received. The controller responded that he received an unsolicited PIREP 45 minutes earlier from a pilot who had attempted to land at the same destination airport, but was unable to do so. About that time, and continuing through the time of the accident, the reported weather conditions at the airport included 1/4-mile visibility in fog and 200 ft vertical visibility. The accident pilot continued the approach, subsequently declared a missed approach, and the controller responded with heading and climb instructions. The pilot asked if the change in heading involved a left turn, and the controller confirmed that it did. The pilot read back the instructions correctly and then asked about the weather at a nearby airport. The controller provided the pilot with the weather conditions; however, the pilot did not respond, and radar contact was lost shortly thereafter. Flight track data indicate that, throughout the approach, the airplane remained about 3/4 mile left of course until the airplane was about 1 1/4 mile from the approach end of the runway. At that time, the airplane made a right turn, descended to an altitude of 325 ft mean sea level, then made a climbing left turn to 800 ft mean sea level before descending and impacting terrain in a residential neighborhood. A postcrash fire ensued. The witness descriptions of the engine sounds as the airplane maneuvered during the final moments of the flight, as well as the tip curling and chordwise scratching observed on the propeller blades after the accident, indicated that the engine was producing power at the time of the accident. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. Given the instrument meteorological conditions at the time of the accident, which included restricted visibility, and the pilot’s maneuvering off of the instrument approach course both laterally and vertically, it is likely that the pilot became spatially disoriented during the approach, which led to a loss of airplane control and a subsequent spiraling descent.
Probable cause
The pilot's in-flight loss of airplane control due to spatial disorientation during a missed approach in instrument meteorological conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
F33
Amateur built
false
Engines
1 Reciprocating
Registration number
N266DC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7335393
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-01-22T02:15:32Z guid: 102522 uri: 102522 title: ERA21LA106 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102531/pdf description:
Unique identifier
102531
NTSB case number
ERA21LA106
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-19T12:55:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-01-30T02:15:22.273Z
Event type
Accident
Location
Leesburg, Virginia
Airport
Leesburg Executive Airport (JYO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The airplane was equipped with two Garmin G5’s each without an externally removable microSD card. The devices were shipped to the NTSB’s Vehicle Recorder Division; however, since no microSD cards were installed, no flight data was recovered from either of the devices. The AA-5 Traveler airplane has horizontal stabilizers, elevators, and anti-servo tabs which are constructed using a metal-to-metal bonding process. The elevator assembly consists of the elevator, and an anti-servo tab which extends the full length of the elevator and is attached to the trailing edge by a piano hinge. The elevator is composed of a torque tube bonded to honeycomb ribs, which are bonded to a one-piece aluminum skin formed around the elevator leading edge and bonded to the rear spar. The elevator was attached/supported at the inboard and outboard ends. The inboard end of each elevator torque tube was supported by a bearing support bracket attached to the aft side of the horizontal stabilizer spar connector, and the torque tube was mechanically connected to a bellcrank by a bolt, washers, and a nut. The outboard end of each elevator torque tube was supported by a bearing support bracket attached to the outboard face of the outboard rib on the horizontal stabilizer assembly. As assembled, each outboard elevator bearing support bracket was attached with two threaded fasteners that are threaded into nut plates riveted to the interior surface of each outboard rib. According to the airplane maintenance manual (AMM), at each annual or 100-hour inspection, an inspection of the bond lines for any indication of damage, peeling, or cracks should be performed. The AMM also indicated to inspect the horizontal stabilizers for damage and secure mounting. In over 45 years, 7 months of airframe maintenance records, there was no entry associated with repairs to the left horizontal stabilizer or outer rib of the left horizontal stabilizer. The airplane’s last 100-hour inspection in accordance with the AMM was completed on December 15, 2020, at a tachometer time of 2,879.3 hours. At the time of the accident, the airplane had accrued about 51 hours since the most recent inspection. Airworthiness Directive (AD) 76-17-03, associated with delaminations in bonded skin with an effective date of August 30, 1976, was a one-time inspection that was completed on July 15, 1977. - On January 19, 2021, about 1055 eastern standard time, an American AA-5, N5880L, was substantially damaged when it was involved in an accident near Leesburg, Virginia. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that, while flying direct to Leesburg Executive Airport (JYO), Leesburg, Virginia, in smooth air in a slight descent at 1,500 to 1,700 ft mean sea level while below the yellow arc indicated airspeed, the airplane began shaking and buffeting violently and loudly. The control yoke was also shaking violently, left and right, fore and aft, and the airplane was pitching up and down. He took control of the airplane from the student and initially thought there was an engine issue. He applied carburetor heat, reduced the throttle to idle and slowed to the airplane’s best glide speed, which was 80 mph, and completed the engine failure checklist from memory. He circled left looking for a suitable field in which to perform an emergency landing and declared an emergency to the JYO tower controller. As the instructor proceeded to JYO, the pilot of another airplane flew alongside and reported that the accident airplane’s elevator was “flapping in the wind.” The flight was cleared to land on runway 17. As the airplane approached the runway, the instructor reduced power to idle and attempted to flare normally. The nose pitched down quickly, impacting the runway, and the airplane skidded on the nose landing gear and propeller. After coming to rest, the airplane was secured and both occupants egressed. - The airplane came to rest upright on the runway with the nose landing gear collapsed. The left elevator remained attached at the inboard bellcrank and supported at the inboard support bearing assembly, but was separated at the outboard attach point. The elevator was displaced down from its normal position hinging on the bellcrank and inboard support bearing assembly. Movement of the control yoke produced movement of each elevator control surface. Postaccident examination of the airplane following recovery from the runway was performed by representatives of the Federal Aviation Administration (FAA), as well as representatives of the airplane type certificate holder. Examination of the left horizontal stabilizer revealed that the upper skin at the juncture of the surface and outboard rib showed evidence of upper surface debonding from the rib. The debonding measured approximately 9 1/2”, as measured from the upper horizontal surface training edge forward to the visible termination of the debonding. The end rib displayed an approximate 7/8” vertical crack emanating from the upper edge of the rib at the 7 1/2” location, as measured from the upper horizontal surface trailing edge forward. Corrosion was noted throughout the interior of the left horizontal stabilizer and under the bond lines where debonding occurred and also on the outboard surface of the left horizontal stabilizer outboard rib, just below and just aft of the forward lightening hole. The bearing support assembly, part number (P/N) 301030-501, was missing from the left horizontal stabilizer end rib. A section of the outboard rib was missing from the aft end of the lightening hole to the aft spar of the horizontal stabilizer. The aft spar was structurally damaged. Examination of the elevator control system revealed no discrepancies with the elevator stops, mass balance weights, or four “idler” pulleys. Control cable tension checks of the upper and lower elevator control cables revealed that the upper and lower cables were less than the minimum specified. The upper and lower cables were a maximum of 12.5 pounds and 18.5 pounds, respectively, less than the lower specified limit. Although there was no maintenance manual requirement for a “Free Play” check of the elevator trim tab for the accident make and model airplane, an inspection of the accident airplane using the procedures for an AA5A or AA5B was performed for the right side and the free play measured 0.031 inch, while the maximum specified for the AA5A or AA5B was 0.27 inch. Rigging check of the elevator using the right elevator revealed the nose-up was 3.0° greater than the maximum limit, while the nose down was 5.8° less than the minimum limit. It was noted that the damage could have affected the measurements. The right elevator remained attached at the bellcrank and both the inboard and outboard attach points; however, the associated trim tab had disconnected from its inboard control arm and was only attached to the elevator by its hinge attachment. The horizontal stabilizer assembly, both elevators with trim tabs from the accident airplane, as well as the horizontal stabilizer assembly from another AA5 were sent to the NTSB Materials Laboratory for examination. According to the NTSB Materials Laboratory Factual Report of the accident airplane components, the aft spars on the horizontal stabilizers were fractured at approximately left station 19 to 20 and right station 14. On the left horizontal stabilizer aft spar, the upper flange was fractured at left station 19 and buckled and cracked at left station 14.75, and the lower flange was buckled and fractured at left station 20. On the right horizontal stabilizer aft spar, the lower flange was buckled and the upper flange was slightly buckled near the fracture at right station 14. The lower flange was also buckled and cracked at right station 17. The upper and lower skins around each aft spar damage area also showed buckling deformation. Bondline separations were observed between the ribs and the skins on both horizontal stabilizers. On the fractures intersecting the aft lightening hole of the left outboard rib, rough fracture features with out-of-plane bending deformation were observed. Scanning electron microscope (SEM) imaging of the fracture surfaces of the left outboard rib showed dimple features consistent with ductile overstress fracture. On the right horizontal stabilizer, bondline separations were observed between the inboard rib and the upper skin extending 2.5 inches aft from the leading edge and 14 inches forward from the trailing edge. Additional separations were observed between the inboard rib and the lower skin extending 0.75 inches aft from the leading edge and along a 2.5-inch-long segment in a damaged area near the forward fuselage attachment flange. At the outboard rib for the right horizontal stabilizer, bonds with the upper and lower skins were separated extending 4.5 inches and 2.75 inches forward from the aft spar, respectively. The leading edge was deformed aft, and the lower skin was buckled and separated from the outboard rib extending 1.25 inches aft from the rib leading edge. Examination of the exemplar airplane horizontal stabilizer revealed multiple cracks at the upper and lower bondlines as well as bondline separation on the left and right sides. Following this accident, the airplane type certificate holder issued Service Bulletin (SB) 195 on May 24, 2021 (followed by revision A issued June 1, 2021). The SB required bondline inspections of the wings, stabilizers, and fuselage to detect bondline separations. Following issuance of the SB, the Federal Aviation Administration issued Airworthiness Directive 2021-14-12, effective July 27, 2021, requiring inspection of horizontal stabilizers within 25 hours time-in-service or at the next scheduled 100-hour or annual inspection, whichever occurs first, with particular attention paid to the bondlines. -
Analysis
The flight instructor reported that, during a local instructional flight, while descending in smooth air at an airspeed below the yellow arc, the airplane began shaking and buffeting violently and loudly. The control yoke was also shaking violently (left, right, fore, and aft), and the airplane was pitching up and down. The instructor took control of the airplane from the student pilot, declared an emergency, then returned for landing after being informed by the pilot of a chase airplane that their left elevator was “flapping in the wind.” With reduced elevator authority due to the displaced position of the left elevator, the airplane landed hard, and the nose landing gear collapsed. Postaccident examination of the airplane revealed that the left elevator remained attached to the bellcrank and supported at the inboard support bearing assembly, but the outboard support bearing assembly was separated from the outer rib of the left horizontal stabilizer, leaving the elevator displaced down from its normal position. The outboard support bearing assembly and a separated aft section of the outboard rib of the left stabilizer were not located or recovered. Relatively coarse striations intermixed with dimple features, consistent with cyclic overstress loading, were noted on the fractured outer rib of the left horizontal stabilizer. Additionally, the aft spar for the left horizontal stabilizer was buckled on the upper and lower flanges, consistent with upward and downward overstress loading during a flutter event. The cracks and fractures on the right outboard rib had coarse striations intermixed with dimple features, consistent with cyclic overstress loading, providing further evidence of loading associated with elevator flutter. The elevator flutter likely occurred due to separations at the bondlines of the left horizontal stabilizer that reduced the overall stiffness of the structure. Bondline separations in the horizontal stabilizer, such as those observed on an exemplar horizontal stabilizer, may have been present at the outboard rib-to-skin bondlines, which could have weakened the area around the outboard bearing support bracket and made the elevator more susceptible to flutter. Since a separation of the left outboard elevator bearing support bracket would tend to relieve loads on the aft spar, this indicated the failure of the left horizontal stabilizer outboard rib likely occurred after the aft spar buckled due to overstress loading. Although both elevator trim tabs were disbonded along most of the length of the trailing edge, which would have made them more susceptible to flutter due to their reduced structural stiffness, a representative from the current type certificate holder reported that the overall damage pattern was not consistent with a trim tab flutter event. While the airplane maintenance manual (AMM) contained a specific instruction to inspect the bondlines, and a 100-hour inspection was performed in accordance with the AMM about 51 flight hours before the accident, it is likely that internal corrosion on the interior of the upper skin of the left horizontal stabilizer and bondline separation at the outboard rib of the left horizontal stabilizer existed at the time of the inspection; therefore, the failure of maintenance personnel to detect the disbonding at the outer rib of the left horizontal stabilizer likely contributed to the accident. Following this accident, a service bulletin and Federal Aviation Administration airworthiness directive were issued regarding bondline inspections.
Probable cause
The weakened structure of the left horizontal stabilizer, which resulted in elevator flutter and subsequent partial separation of the left elevator in flight. Contributing to the accident were the lack of elevator authority while landing due to the damaged left elevator and the inadequate inspection of the airplane, which failed to detect the disbonding of the left horizontal stabilizer.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
American
Model
AA5
Amateur built
false
Engines
1 Reciprocating
Registration number
N5880L
Operator
Aero Elite Flight Training LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA5-0080
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-01-30T02:15:22Z guid: 102531 uri: 102531 title: WPR21LA097 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102572/pdf description:
Unique identifier
102572
NTSB case number
WPR21LA097
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-26T18:40:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-02-03T01:34:56.011Z
Event type
Accident
Location
Port Angeles, Washington
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
A National Transportation Safety Board investigator reviewed the radio and telephone audio recorded by the US Coast Guard (USCG) Sector Puget Sound (SPS) Command Center. SPS was initially notified of the accident at 1635. The caller relayed that the aircraft was near a tug and barge. Internal calls between SPS watchstanders discuss what tugs are in the area and that Canadian Coast Guard Ship (CCGS) Sir Wilfred Laurier was near Race Rocks. At 1642, SPS issued an Urgent Marine Information Broadcast (UMIB) that was rebroadcast many times over 20 hours requesting assistance for an “airplane that has crashed north of Port Angeles in the Straits of Juan de Fuca.” Several vessels in the area report not seeing anything in the area. Although phone calls were not time stamped, SPS talked to every tug and barge underway in the Straits including the east bound Seapan King. None of these vessels reported seeing the airplane. At 1720 the first USCG helicopter launched from Air Station Port Angeles and ten minutes later the SPS directed them to search a trackline from Pillar Point to Whidbey Island. At 1738, the Coast Guard relayed a latitude/longitude position from the Air Force and Federal Aviation Administration. Over the next 22 hours, this datum corrected as needed for drift, was used to generate multiple search patterns for surface and air search and rescue units. At 2006, the USCG helicopter pilot and a Canadian fixed-wing airplane pilot discussed that a GPS position put the Cessna by Race Rocks, one of several tugs was seen in that area, and that the fixed-wing airplane pilot should search by Race Rocks. Search patterns continued through the night with additional morning searches the following day. At 0937, the Coast Guard relayed a new a position derived from radar. At 1558, the following day, the active search was suspended. - The fuel system was comprised of two wing fuel tanks and the pilot had modified the airplane with a tank in the fuselage. The main left and right tanks each held 20 gallons and the fuselage tank held between 10-15 gallons. The airplane was not recovered and is presumably on the sea floor. According to the Flight Owner’s Manual, with the engine operating at 2,100 rpm, at 6,000 ft mean sea level, the total fuel burn for the time the airplane was inflight, would be between 28.83 gallons and 37.15 gallons based on the leaning procedure used by the pilot. - On January 26, 2021 about 1640 Pacific standard time, a Cessna 170A airplane, N9114A, sustained substantial damage when it was involved in an accident near Port Angeles, Washington. The pilot, the sole occupant, was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot initially departed from Kodiak, Alaska the day before the accident with a final destination of Lake Havasu City, Arizona. The day of the accident, the pilot refueled the airplane and departed from Ketchikan, Alaska, about 1000. During the flight, the pilot was in contact with his mother sending numerous text messages. Around 1525 the pilot sent a text stating that there was a severe headwind and expressed concern about having enough fuel to complete the flight. About 15 minutes later, the pilot stated that his GPS indicated he had been airborne for 5.7 hours and had another 1.1 hours of flight time until reaching his destination (equating to a landing time of 1647). He estimated that with a fuel burn between 6 to 10 gallons per hour that the airplane could make it to Port Angeles, but that the headwinds were slowing the airspeed and it was taking him longer than expected to navigate around numerous clouds. Around 1615, the pilot stated that his estimated time of arrival kept changing on his GPS because of the fluctuating wind, turbulence, and maneuvering to avoid clouds. A review of the radar data revealed that the airplane was on a southerly track, reaching the edge of the northern land mass at 1634. The radar data continued south for about 5.4 nautical miles (nm) at an altitude of about 1,200 ft. At 1638:06 the data deviated from the southerly direction and were consistent with the airplane reversing course and heading north-northeast. The data from the turn to the last data point indicated a decreasing airspeed and a gradual decent from 1,200 to 400 ft (see figure 1). Figure 1: Last Radar Returns The radar data the furthest south were about 6 nm from land to the south and 4 nm from land to the north. The last radar return was 2.9 nm from the closet land (see figure 2). The pilot sent a picture to his mother about 1637 that showed a marine vessel towing a barge in the water below his location. The pilot broadcast a mayday call over the Port Angeles UNICOM frequency at 1638:47. He stated that he was out in the middle of the water and was ditching by a boat that was towing a barge. Figure 2: Radar Track in Reference to Land. -
Analysis
The pilot had departed on a long cross-country flight and stopped to refuel at which point he filled up both wing tanks and the pilot had modified the airplane with a tank in the fuselage. During the flight, the pilot sent text messages to a family member expressing concerns about having enough fuel to complete the flight. The pilot texted that the headwinds were stronger than he expected, he was encountering turbulence, and he was having to maneuver around clouds. Radar data showed that the airplane was over a 10 nautical mile wide body of water when the pilot made a mayday call stating that he was going into the water. The airplane ditched in the sea and was never recovered. The search and rescue efforts did not locate the airplane.
Probable cause
The total loss of engine power due to fuel exhaustion, which resulted from the pilot's inadequate in-flight fuel planning.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170A
Amateur built
false
Engines
1 Reciprocating
Registration number
N9114A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18873
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-02-03T01:34:56Z guid: 102572 uri: 102572 title: WPR21LA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102581/pdf description:
Unique identifier
102581
NTSB case number
WPR21LA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-01-31T13:44:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-02-16T22:00:24.678Z
Event type
Accident
Location
Crescent City, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On January 31, 2021, about 1144 Pacific standard time, a Cessna T182T airplane, N291FR, was substantially damaged when it was involved in an accident near Crescent City, California. The flight instructor and pilot rated student received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. During the flight, the flight instructor noticed a flashing red turbine inlet temperature (TIT) warning light. He enrichened the fuel mixture resulting in the TIT indication returning to normal. Shortly after, the engine began to run rough. The flight instructor switched to the left magneto and the engine lost power. He then switched to the right magneto and the engine continued to run rough. He switched back to both magnetos and the engine continued to run rough. The flight instructor then adjusted the mixture and turned on the auxiliary fuel pump. Despite his actions he was unable to get the engine to operate sufficiently to maintain altitude. The flight instructor located an open field and initiated a forced landing. The airplane landed in marshland and during the landing roll the airplane nosed over. Postaccident examination of the engine revealed that the magnetos would not produce a spark and had corrosion on their internal components. It was also noted that the pressurized magnetos did not have a moisture trap or filter installed. The magnetos were disassembled, and corrosion and rust were noted on the interior surfaces and interior components. The points were removed from the magnetos, and corrosion was noted on the contact surfaces. Sandpaper was used to remove the corrosion from both sets of points. Deformities such as deterioration and buildup of the contact surfaces were visible. The points were reinstalled on the magnetos and the magnetos were installed on the test bench. No spark was produced from either magneto. The magneto’s capacitors were bench tested and both failed under normal testing. An ohmmeter was used on the each of the (4) point assemblies and revealed inconsistent resistance on the surface areas (high points) of each point. A used set of points and capacitors were installed on the magnetos. The magnetos were installed on a bench and a normal amount of spark was observed. The used set of points had about 500 hours of operation during the test. The maintenance records revealed that, on February 1, 2019, at an airplane total time of 1,248.8 hours of operation, both magnetos were replaced with newly overhauled units. On November 10, 2020, the last annual was performed with an aircraft total time of 1,704.5 hours of operation. The accident occurred 82 hours of operation after the last annual inspection. At the time of the accident, the magnetos had 537 hours of operation since they were installed. -
Analysis
The flight instructor noticed a flashing red turbine inlet temperature (TIT) warning light during the flight. He enrichened the fuel mixture, which returned the TIT to normal. Shortly after, the engine began to run rough. The flight instructor switched to the left magneto and the engine lost power. He then switched to the right magneto and the engine continued to run rough. He switched back to both magnetos and the engine continued to run rough. The flight instructor then adjusted the mixture and turned on the auxiliary fuel pump. Despite his actions, he was unable to get the engine to operate at a power setting sufficient to maintain altitude. The flight instructor located an open field and initiated a forced landing. The airplane landed in marshland and nosed over during the landing. The postaccident examination of the engine revealed excessive gap on all sparkplugs and two of the sparkplug electrodes were fouled. The magnetos would not produce spark and had corrosion on their internal components. It was also noted that the pressurized magnetos did not have a moisture trap or filter installed. The magnetos were sent to a facility for further examination, which revealed deformities on both magneto point assembly contact areas and the failure of both magneto capacitors during testing. The failure of the capacitors likely resulted in the deformities on the points surface contact areas resulting in the magnetos not producing sufficient spark for normal operation.
Probable cause
The partial loss of engine power due to the failure of both magneto capacitors.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T182T
Amateur built
false
Engines
1 Reciprocating
Registration number
N291FR
Operator
Morey's West Coast Adventures, Inc
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
T18209082
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-02-16T22:00:24Z guid: 102581 uri: 102581 title: ERA21LA124 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102609/pdf description:
Unique identifier
102609
NTSB case number
ERA21LA124
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-07T18:47:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-02-26T02:48:23.137Z
Event type
Accident
Location
Belvidere, Tennessee
Airport
Winchester Muni (BGF)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On February 7, 2021, about 1647 central standard time, a Cessna 441, N44776, was destroyed when it was involved in an accident near Belvidere, Tennessee. The airline transport pilot and the commercial pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) data, radar, and voice communications obtained from the Federal Aviation Administration (FAA), the flight departed from Thomasville Regional Airport (TVI), Thomasville, Georgia, about 1527 with a destination of Winchester Municipal Airport (BGF), Winchester, Tennessee. The flight was cleared to flight level 220 after departing TVI. About 1616, the flight was cleared to begin the descent into BGF. About 1640, as the airplane was descending to 4,000 ft mean sea level (msl), the pilot established contact with the Bowling Green, Kentucky, radar controller. The flight was then cleared for the area navigation (RNAV) GPS runway 36 approach into BGF. The airplane crossed the intermediate fix at an altitude of about 4,000 ft. The approach procedure allowed the pilot to cross the intermediate fix at or above 4,000 ft and then descend to cross the final approach fix at or above 3,000 ft. The airplane was observed descending slowly from 3,000 ft when the airplane was about 4 nautical miles (nm) south of the final approach fix. As the airplane descended through 2,300 ft, its radar target disappeared, which was expected due to the limited radar coverage in the area. The last ADS-B target for the airplane showed that it was about 0.6 nm south of the final approach fix and at an altitude of 2,100 ft on a northerly heading. Shortly thereafter, the controller attempted to contact the pilot but received no response. The airplane subsequently impacted trees and terrain about 0.25 nm north-northeast of the final approach fix, which was about 5 nm south of the runway 36 threshold. A postcrash fire ensued. No distress calls were received. - A dissipating cold frontal boundary stretched eastward from Arkansas to Georgia and then northeastward into the mid-Atlantic states. A trough stretched from northeastern Arkansas to northern Tennessee and West Virginia. The accident site was located to the north of the dissipating cold front on the cold side of the front. The station models surrounding the accident site depicted air temperatures in the low 30s (°F), dew point temperatures in the upper 20s (°F), temperature-dew point spreads of 2°F or less, an easterly wind at 5 knots, and overcast sky cover. The weather at BGF at 1635, about 12 minutes before the accident, included a ceiling of 800 ft overcast. The BGF weather at 1655, 8 minutes after the accident, included a ceiling of 1,000 ft overcast. The tops of the clouds were about 4,000 ft, and light rime icing conditions prevailed in the clouds. The pilot received a weather briefing before the flight. The briefing revealed that the pilot was comfortable with ceilings above 500 ft and that he was aware of the icing conditions at the destination. The pilot reported that he had deicing equipment and “onboard weather” on the accident airplane. - The logbooks for the pilot and the pilot-rated passenger were not located after the accident. All flight times were obtained from FAA sources. - The airplane impacted elevated, wooded terrain at an elevation of about 1,880 ft. The debris path was about 260 ft long. The first piece of wreckage found along the debris path was the left-wing tip lens. The farthest piece of wreckage was a light housing. The debris path was on a magnetic heading of about 342°. The fuselage was found inverted on a heading of 260°. Tree strikes indicated that the airplane impacted trees in a left-wing, nose-low attitude before rolling inverted and colliding with terrain. The postaccident fire consumed most of the cockpit, fuselage, inboard left wing, and outboard left horizontal stabilizer. All structural components of the airplane were found within the wreckage debris field. Flight control continuity was established from the control surfaces to the cockpit controls except in areas with tension overload failures. The preaccident position of the main landing gear and the wing flaps could not be determined due to impact and postaccident fire damage. The nose landing gear was in the extended position. The fuel system components were damaged during the postimpact fire. The left fuel cap was securely installed; the right fuel cap separated during the impact sequence. Postaccident examination of the airframe revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Teardown and examination of both engines found no evidence of a pre-existing malfunction or failure was found that would have precluded normal operation. Both engines exhibited internal signatures consistent with normal operation at impact, including rotational scoring and metal spray on internal components and compressor blades bent opposite the direction of engine rotation. Teardown and examination of both propeller assemblies also found no evidence of a preexisting malfunction or failure that would have precluded normal operation. -
Analysis
The pilot was conducting a cross-country flight and was beginning an instrument flight rules approach from the south. Weather conditions at the destination airport included a ceiling between 800 and 1,000 ft and light rime icing conditions in clouds; the pilot was aware of these conditions. Elevated, wooded terrain existed along the final approach course. Radar and automatic dependent surveillance-broadcast data revealed that the airplane crossed the intermediate approach fix at the correct altitude; however, the pilot descended the airplane below the final approach fix altitude about 4 miles before the fix. The airplane continued in a gradual descent until radar contact was lost. No distress calls were received from the airplane before the accident. The airplane crashed on a north-northwesterly heading about 5 miles south of the runway threshold. The elevation at the accident site was about 1,880 ft, which was about 900 ft higher than the airport elevation. Postaccident examination of the airframe, engines, and propellers revealed no evidence of a pre-existing mechanical failure or anomaly that would have precluded normal operation. Because of the weather conditions at the time of the final approach, the pilot likely attempted to fly the airplane under the weather to visually acquire the runway. The terrain along the final approach course would have been obscured in low clouds at the time, resulting in controlled flight into terrain.
Probable cause
The pilot’s failure to follow the published instrument approach procedure by prematurely descending the airplane below the final approach fix altitude to fly under the low ceiling conditions, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
441
Amateur built
false
Engines
2 Turbo prop
Registration number
N44776
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4410121
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-02-26T02:48:23Z guid: 102609 uri: 102609 title: HWY21FH005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102638/pdf description:
Unique identifier
102638
NTSB case number
HWY21FH005
Transportation mode
Highway
Investigation agency
Other
Completion status
Completed
Occurrence date
2021-02-11T08:00:00Z
Publication date
2023-04-11T04:00:00Z
Report type
Final
Last updated
2023-02-27T05:00:00Z
Event type
Accident
Location
Fort Worth, Texas
Injuries
6 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the multivehicle crash in Fort Worth, Texas, was ice accumulation on the surface of the elevated roadway, which made drivers lose control of their vehicles, which then slid into road barriers and other vehicles. Contributing to the unsafe roadway condition was the failure of North Tarrant Express Mobility Partners Segments 3 to effectively monitor and address roadway conditions along Interstate 35 West during and after periods of freezing rain and mist. Contributing to the severity of the crash outcome was drivers traveling at speeds too fast for the winter weather conditions.
Has safety recommendations
true

Vehicle 1

Traffic unit name
Ford F-250 Pick-up Truck (1)
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
Ford F-250 Pick-up Truck (2)
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 3

Traffic unit name
Ford F-350 Pick-up Truck
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 4

Traffic unit name
Honda Accord
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 5

Traffic unit name
Pedestrian (1)
Traffic unit type
Pedestrian
Findings

Vehicle 6

Traffic unit name
Pedestrian (2)
Traffic unit type
Pedestrian
Findings
creator: Other last-modified: 2023-02-27T05:00:00Z guid: 102638 uri: 102638 title: WPR21LA110 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102629/pdf description:
Unique identifier
102629
NTSB case number
WPR21LA110
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-13T13:50:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-03-02T03:32:58.86Z
Event type
Accident
Location
San Diego, California
Airport
MONTGOMERY-GIBBS EXEC (MYF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The Crew Operational Documentation for Dassault EASy aircraft (CODDE2) directs the pilot to set the trim indicator in the green band for takeoff and includes the following two notes: NOTE Appropriate position within this green band depends on location of airplane CG: - Nose Up (NU) if airplane is balanced towards forward limits of CG envelope (i.e., if fuel tanks are fully loaded), - Nose Down (ND) if airplane balanced aft. NOTE During take-off with heavy gross weight and forward CG, and if aircraft has not been trimmed toward nose-up limit of green take-off range, rotation may require full aft control yoke and a delay may be noticed between reaching full aft control and actual rotation.” According to the FAA’s Aircraft Weight and Balance Handbook (FAA-H-8083-1-A), Chapter 10: Weight and Balance: Loading in a nose-heavy condition causes problems in controlling and raising the nose, especially during takeoff and landing. - The airplane was manufactured in 2008, and its most recent annual inspection was completed June 18, 2020, at 2,977 total hours. The airplane was modified after delivery by a Supplemental Type Certificate (STC) No.ST02188SE held by Aviation Partners which consists of the addition of winglets. Such a modification changes the aircraft weight, balance, and trim settings according to the data provided by the STC holder in an AFM Supplement. Honeywell conducted a review of the central maintenance computer and found no anomalies with the engines or airplane systems that would have precluded normal operation. Similarly, a review of the DFDR and maintenance data recorder (MDR) revealed no mechanical anomalies. The airplane was equipped with an FMS interfaced with the aircraft communications addressing and reporting system (ACARS), which sends information from the ground to the FMS for performance, weather, and flight planning. According to the ACARS manufacturer, Collins Aerospace, data transmissions for the takeoff and landing data (TOLD) were available but were not utilized on the day of the accident. They reported that the same city pairing, KMYF – PHKO was entered into the FMS several days before. The investigation did not recover a paper copy of a TOLD card and was not able to retrieve performance data from the FMS at the accident site because power could not safely be applied to the airplane due to the fuel spill from the ruptured tanks. With the airplane configured at slats/flaps 20° (SF2) and the available takeoff run of 4,598 ft, the maximum takeoff weight (MTOW) limit to depart was 45,064 lbs. According to the DFDR and data provided by the pilots, 20,500 lbs. of fuel was onboard. Therefore, based on aircraft loading, the actual takeoff weight was 48,039 lbs. Takeoff performance data showed the balance field length required at this weight was 5,173 ft. The forward center of gravity (CG) limit per the STC Aircraft Flight Manual (AFM) was 15% for takeoff with SF2. The calculated CG for the accident flight, based on the seating location of the occupants, was 15.2%. According to the STC AFM supplement, the recommended pitch trim position for a heavy gross weight takeoff with a forward CG is -7.5°. The pilots would visually see a configuration alert or a “NO TAKEOFF” warning if the stabilizer trim was outside of the green band (-4.5° to 7.5°). The DFDR indicated that the stabilizer trim was set at -5.73° and SF2 was selected. This was confirmed by physical examination after the accident. According to the airplane manufacturer, an amber “FIELD LIMITED” message would illuminate on the TOLD page of the FMS if the MTOW is exceeded, and it would not compute takeoff speeds; therefore, no takeoff card would have been displayed for the crew. Under this condition, the crew would be unable to acknowledge the TOLD performance calculations, thus preventing the correct airspeed bugs (V1, Vr) from appearing on the airspeed tape. According to the airplane manufacturer, it is possible for the pilots to change FMS-suggested runway length or takeoff weight for the computation of takeoff speeds. The DFDR data indicated that the captain attempted takeoff at a rotation speed (Vr) of 110 knots indicated airspeed (KIAS). At the airplane’s MTOW, Vr was calculated to be 133 KIAS. The data further indicated that rejected takeoff was initiated once the speed had reached 123 KIAS, and the maximum airspeed recorded was 127 KIAS. After the airplane decelerated to 102 KIAS and traveled 3,770 ft down the runway, the thrust reversers were fully deployed. The airplane exited the departure end of the runway at 75 KIAS and impacted a berm at 59 KIAS. The CVR, DFDR, and MDR showed that the engines, flight controls, and brakes were functioning. - The airplane was equipped with an L3 SRVIVR series CVR that could record a minimum of 6 hours of digital data stored on solid-state modules. The CVR contained four channels of audio input: one channel for each flight crew, one spare channel (for an observer), and one channel for the cockpit area microphone (CAM). Upon arrival at the laboratory, it was evident that the CVR had not sustained any heat or structural damage and the audio information was extracted from the recorder normally without difficulty. The NTSB Vehicle Recorders Laboratory completed a summary report of the recorded audio. The airplane was also equipped with a Honeywell ARFDR, 256wps DFDR that recorded about 27 hours of digital data stored using solid-state flash memory. The NTSB Vehicle Recorders Laboratory completed a specialist’s report and found the recorder was in good condition and the data were extracted normally. - On February 13, 2021, about 1150 Pacific daylight time, a Dassault Falcon 900EX EASy, N823RC, was substantially damaged when it was involved in an accident in San Diego, California. The two pilots, flight attendant and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to the flight crew, the accident flight was their third flight in the airplane. They planned to depart from runway 28R at Montgomery-Gibbs Executive Airport (MYF), San Diego, California, with a destination of Ellison Onizuke Kona International at Keahole (PHKO), Kailua/Kona, Hawaii. The captain was the pilot flying (PF), and the first officer was the pilot monitoring (PM). Both crewmembers reported that before departure, the airplane had no preflight anomalies, and all pre-takeoff checks, the engine start, taxi, and engine run-ups were normal. The first officer reported they planned for a maximum performance takeoff. A review of the cockpit voice recorder (CVR) confirmed there were no anomalies with the airplane announced by the pilots during preflight or while taxiing to the runway. The automatic terminal information service was obtained at 1115:21 and the crew briefed the departure and general routing. The crew discussed fuel, stating, “19.5 required” and that they we’re going to burn “11.5,” but they had an extra “6 to 7 onboard.” At 1136:58 the crew performed the after-start/before-taxi checklist, which included a brief discussion on what the preferred trim setting should be and a comment stating, “we’re pretty far aft.” The airspeeds were acknowledged with the comment “green, 112.” The crew reviewed their departure plan and discussed their takeoff reject plan, including their intention not to reject the takeoff after reaching 80 kts. The crew then called the air traffic control tower at 1142:16 to request a momentary takeoff delay for a short field takeoff. The takeoff was initiated at 1146:13. The crew noted the airspeed was alive, they cross-checked 80 kts, and the first officer stated they were committed to takeoff. The crew then called out, “V1”, and at 1146:52 the first officer called “rotate.” However, 7 seconds later, the captain responded that they “couldn’t take off.” The first officer called for “thrust reversers,” and the captain stated that “he couldn’t,” followed by repeated exclamations of “we can’t.” Sounds consistent with the airplane departing the paved runway surface were recorded, followed by several master caution aural alerts, and the captain stating, “kill it” just before the recording ended. The airplane overran the departure end of the runway by about 315 ft and struck a berm, which sheared off all three-landing gear. The airplane slid an additional 230 ft and came to rest on a gravel overrun pad. The airplane sustained substantial damage to the wings and fuselage, and the fuel tanks were ruptured (see figure). Continuity was confirmed from the flight controls to the control surfaces, and significant fuel leakage was present, but no fire ensued. Due to COVID restrictions, the National Transportation Safety Board (NTSB) did not travel to this accident, and data were gathered by responding representatives from the Federal Aviation Administration (FAA) and the airplane manufacturer, Dassault Aviation. Figure - View of Airplane Damage (Source: FAA) - Captain The captain stated he was employed directly by the owner of the airplane and had previously flown another airplane for the same owner. He reported having multiple type ratings in corporate jets. FAA safety inspectors, who arrived on scene the day of the accident, stated that when the captain was asked for his pilot certificate, he was not able to locate it but eventually produced a certificate later in the day after continued requests. The airplane type rating for the accident airplane was not listed, and a review of airmen records revealed that the FAA had issued an emergency revocation of all his certificates 2 years earlier on February 13, 2019. FAA records indicated that the reason for the emergency revocation was because he had violated 14 CFR §61.59(a)(2) while employed as a check pilot for a Part 135 operator by falsifying logbook entries and records for pilot proficiency checks, competency checks, and training events on 15 separate occasions. The captain stated that he used his tablet and Aircraft Performance Group (APG) performance data software to calculate performance and file the flight plan for the accident flight. When NTSB investigators asked the pilot for his tablet, he reported it was destroyed. He reported he could not recall any weight and balance or performance information from the accident flight and did not respond to any further correspondence. The captain was enrolled for the DA-900EX EASy initial training on October 1, 2020, at Flight Safety International. He was not issued a type rating because he never finished the ground or flight simulator training although he attended the ground school portion of training. First Officer The first officer stated he was also employed directly by the owner of the accident airplane. Two years before the accident, he was hired as the owner’s helicopter pilot and security specialist. When the accident airplane was purchased, he was offered the first officer position. At the time of the accident, he reported a total of 568 hours flight experience, which included 380 flight hours in helicopters. According to Flight Safety International, the first officer was also enrolled for the DA-900EX EASy initial training on August 31, 2020. He completed training on September 28, 2020, and received his type rating with pilot-in-command limitations on his second checkride attempt. At the time of the accident, he had logged 16 hours in the Falcon 900EX EASy. In an interview with NTSB investigators, the pilot stated that he confirmed the FMS inputs that were made by the captain but later revealed that he was not proficient regarding the FMS. -
Analysis
The flight crew was conducting a flight with two passengers and one flight attendant onboard the multiengine jet airplane. The flight crew later stated that at rotation speed, the captain applied back pressure to the control yoke; however, the nose did not rotate to a takeoff attitude. The captain attempted to rotate the airplane once more by relaxing the yoke then pulling it back again, and, with no change in the airplane’s attitude, he made the decision to reject the takeoff by retarding the thrust levers and applying maximum braking. The airplane overran the end of the runway onto a gravel pad where the landing gear collapsed. Continuity was confirmed from the flight controls to the control surfaces. No mechanical anomalies with the engines or airplane systems were noted during the investigation that would have precluded normal operation. A review of performance data indicated that the flight crew attempted to takeoff with the airplane 2,975 lbs over the maximum takeoff weight (MTOW), a center of gravity (CG) close to the most forward limit, and an incorrect stabilizer trim setting. The digital flight data recorder (DFDR) data indicated that the captain attempted takeoff at a rotation speed 23 knots (kts) slower than the calculated rotation speed for the airplane at maximum weight. Takeoff performance showed the departure runway was 575 ft shorter than the distance required for takeoff at the airplane’s weight. The captain, who was the pilot flying, did not hold any valid pilot certificates at the time of the accident because they had been revoked 2 years prior due to his falsification of logbook entries and records. Additionally, he had never held a type rating for the accident airplane and had started, but not completed, training in the accident airplane model before the accident. The first officer had accumulated about 16 hours of flight experience in the make and model of the airplane and was not authorized to operate as pilot-in-command. The airplane’s flight management system (FMS) data were not recovered; therefore, it could not be determined what data the flight crew entered into the FMS that allowed the airspeed numbers to be generated. The investigation revealed that had the actual performance numbers been entered, a “FIELD LIMITED” amber message would have illuminated warning the crew that the MTOW was exceeded, and airspeed numbers would not have been generated. Therefore, it is likely that the crew entered incorrect data into the FMS either by manually entering a longer runway length and/or decreased the weight of the fuel, passengers, and/or cargo.
Probable cause
The flight crew’s operation of the airplane outside of the manufacturer’s specified weight and balance limitations and with an improper trim setting, which resulted in the airplane’s inability to rotate during the attempted takeoff. Contributing to the accident, was the captain’s lack of proper certification and the crew’s lack of flight experience in the airplane make and model.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DASSAULT
Model
FALCON900EX
Amateur built
false
Engines
3 Turbo fan
Registration number
N823RC
Operator
Aerospike Iron Aero, LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
201
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-02T03:32:58Z guid: 102629 uri: 102629 title: WPR21LA111 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102630/pdf description:
Unique identifier
102630
NTSB case number
WPR21LA111
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-13T18:27:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-03-02T03:14:03.688Z
Event type
Accident
Location
Tehachapi, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 13, 2021, about 1627 Pacific standard time, a Piper PA46R-350T airplane, N40TS, was destroyed when it was involved in an accident near Tehachapi, California. The non-instrument-rated pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Flight track data revealed that, the airplane departed from Camarillo Airport (CMA), Camarillo, California, and flew an outbound heading of about 61° true for about 7 minutes before turning to a heading of about 32° true. The airplane remained on this heading and climbed to the track’s maximum altitude of 10,650 ft mean sea level (msl), 9 minutes later. The altitude remained about 10,500 ft for about 10 minutes then made a slow descent over the next 5 minutes before dropping off radar. Near the end of the flight track data, the flight track showed a tight left turn follow by a steep descending spiral left turn. The last flight track data was over the accident site. Concerned family members contacted the Federal Aviation Administration (FAA) the following day and an alert notice (ALNOT) was issued for the missing airplane. The airplane was found on the morning of February 15 in rugged steep terrain. According to a family member, the pilot regularly flew from CMA to Mammoth Yosemite Airport (MMH), Mammoth Lakes, California, where he had a home. The family member also stated that the pilot had flown his helicopter for about an hour with his flight instructor on the day of the accident before departing on the accident flight. An FAA accident coordinator interviewed the pilot’s flight instructor who reported that the pilot appeared to be in good spirits. The flight instructor stated that the pilot was "very physically capable of flying the accident airplane on that day." A search of the FAA automated flight service station contract provider Leidos indicated that they had no contact with the accident pilot for any weather briefing on the day of the accident and no third-party vendors that utilized their system made any requests for weather data or to file any flight plans for the pilot. Accident site photos revealed that the airplane impacted a steep north-facing slope. The airplane was found in several sections and postcrash fire damage was concentrated to the cabin section and inboard wings. All the airplane’s flight controls were identified at the accident site. The accident site was at an elevation of about 4,900 ft msl. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunction or failures that would have precluded normal operation. The backup attitude indicator instrument was disassembled, and the rotor and case were removed. The vacuum-powered rotor and housing revealed rotational scoring damage to both the rotor and interior of the housing. The last entry in the aircraft maintenance logbook indicated an annual inspection that was performed on November 20, 2020, at a tachometer reading of 877.7 hours. The engine was overhauled and installed on August 1, 2019, at a tachometer time of 798.2. Airframe total time was not obtained during the investigation. PILOT INFORMATION At his most recent FAA medical certification examination on June 5, 2020, the pilot reported no medication use or medical conditions. He reported a back injury from a car accident in 2014. No personal flight records were located for the non-instrument rated pilot. MEDICAL AND PATHOLOGICAL INFORMATION According to the autopsy report from the Sheriff-Coroner-Public Administration Office, Bakersfield, California, the pilot’s death was caused by multiple injuries and the manner of death was accident. Toxicology testing detected diazepam and its metabolites nordiazepam, oxazepam, and temazepam; butorphanol; carisoprodol and its active metabolite meprobamate; and citalopram and its metabolite n-desmethylcitalopram in muscle and lung tissue. No blood was available for toxicological testing. Diazepam, commonly marketed as Valium, is a sedating benzodiazepine available by prescription as a controlled substance and used to treat anxiety; it is also useful to help treat muscle spasms, alcohol withdrawal, and seizures. It is metabolized to the active metabolites nordiazepam or temazepam. These compounds are further metabolized to the active metabolite oxazepam. Diazepam and its metabolites carry the warning that they may impair the mental and physical ability to perform hazardous tasks. Butorphanol is a synthetic opioid prescribed for severe pain management. It is an impairing medication and carries the warning that patients should not drive or operate dangerous machinery until they know how they will react to the medication. Concomitant use of opioids with benzodiazepines and other central nervous system depressants such as muscle relaxants and alcohol can result in profound sedation. Carisoprodol, commonly marketed as Soma, is a muscle relaxant prescribed to relieve acute, painful musculoskeletal conditions and muscle spasms. It is metabolized to its active metabolite meprobamate. Both have sedative properties and can impair the mental and physical abilities required for performing hazardous tasks such as driving. Citalopram is a prescription antidepressant medication marketed under the trade name Celexa. N-desmethylcitalopram is the active metabolite of citalopram. Both carry the warning that their use may impair mental of physical ability for performing hazardous tasks. The therapeutic range for citalopram is 50 to 110 ng/mL and its half-life is 25 to 35 hours. The FAA will consider a special issuance of a medical certificate for depression after six months of treatment if the applicant is clinically stable and using only one approved treatment medication. Citalopram is one of the FAA approved antidepressant medications. METEOROLOGICAL INFORMATION Weather around the accident site was reported as marginal visual flight rules (MVFR) conditions due to low ceilings and visibility in light rain and mist before the accident with peak winds reported to 40 knots. The National Weather Service had advisories current for turbulence over the region and included G-AIRMET Tango and Center Weather Advisory, which bordered the area for severe turbulence below 15,000 ft. The closest weather reporting station to the accident site was at Tehachapi Municipal Airport (TSP), Tehachapi, California, located approximately 7 ½ miles north of the accident site at an elevation 4,001 ft. The airport had an automated weather observation system (AWOS) and issued observations every 20 minutes. The following conditions were reported at the approximate time of the accident. TSP weather observation at 1615 PST, automated, wind from 310° at 19 knots gusting to 26 knots, visibility 10 miles or more, ceilingbroken at 1,200 ft agl, broken at 1,700 ft, overcast at 2,500 ft, temperature 5° C, dew point 4° C, altimeter 29.92 inches of mercury (inHg). The next closest weather reporting station was located approximately 12 miles east of the accident site at Mojave Air and Space Port (MHV), Mojave, California, with an elevation of 2,801 ft. The airport also had an AWOS and issued observations every 20-minutes. The following conditions were reported at the approximate time of the accident. MHV weather observation at 1620 PST, automated, wind from 300° at 33 knots gusting to 47 knots, visibility 10 miles or more, sky clear below 12,000 ft agl, temperature 10° C, dew point temperature 0° C, altimeter 29.75 inHg. Remarks; automated station without a precipitation discriminator. -
Analysis
The non-instrument-rated pilot departed on a cross-country flight. Radar track data revealed the airplane traveled on a relatively straight course to the northeast for about 32 minutes. Near the end of the flight track data, the track showed an increasingly tight left spiraling turn near the accident site. The airplane impacted steep sloping terrain, and a postimpact fire ensued. As a result of the impact, the airplane was segmented into several sections. Examination of the wreckage revealed no evidence of mechanical malfunction or failures that would have precluded normal operation. The attitude indicator instrument was disassembled, and the vacuum-powered rotor and housing revealed rotational scoring damage, indicating the instrument vacuum system was operational at the time of the accident. The investigation found no evidence indicating the pilot checked the weather or received weather information before departure. The surrounding weather reporting stations near the accident site reported wind conditions with peak gusts up to 47 knots around the time of the accident. The pilot likely encountered mountain wave activity with severe turbulence, which resulted in loss of control of the airplane and impact with terrain. Contributing to the accident was the pilot’s failure to obtain a preflight weather briefing, which would have alerted him to the presence of hazardous strong winds and turbulent conditions. Postmortem toxicology testing of the pilot’s lung and muscle tissue samples detected several substances that are mentally and physically impairing individually and even more so in combination for performing hazardous and complex tasks. However, blood concentrations are needed to determine the level of impairment, and no blood samples for the pilot were available. While the pilot was taking potentially impairing medications and likely had conditions that would influence decision making and reduce performance, without blood concentrations, it was not possible to determine whether the potentially impairing combination of medications degraded his ability to safely operate the airplane.
Probable cause
The pilot’s encounter with mountain wave activity with severe turbulence, which resulted in a loss of airplane control. Contributing to the accident was the pilot’s failure to obtain a preflight weather briefing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA46R-350T
Amateur built
false
Engines
1 Reciprocating
Registration number
N40TS
Operator
IST SOLUTIONS INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4692156
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-03-02T03:14:03Z guid: 102630 uri: 102630 title: WPR21FA114 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102651/pdf description:
Unique identifier
102651
NTSB case number
WPR21FA114
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-19T13:58:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-03-05T04:50:01.494Z
Event type
Accident
Location
Los Angeles, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
According to the Lycoming Overhaul manual at each 400-hour inspection, the following valve inspection must be completed: Remove rocker box covers and check for freedom of valve rockers when valves are closed. Look for evidence of abnormal wear or broken parts in the area of the valve tips, valve keeper, springs and spring seats. If any indications are found, the cylinder and all of its components should be removed (including the piston and connecting rod assembly) and inspected for further damage. Replace any parts that do not conform with limits shown in the latest revision of Special Service Publication No. SSP-1776 - The Lycoming O-540-E4B5, was the original engine installed on the airplane at manufacture and was overhauled in October 2010, 495 operating hours before the accident. The airplane’s last annual inspectionwas in August 2020, about 7 hours before the accident; all compressions were noted to be within operating limits. The engine was rebuilt in 2018, about 35 operational hours before the accident. The invoices from the rebuild showed the mechanic purchased 4 (2 sets) exhaust valve keepers; 12 thrust buttons (fitted at the ends of the rocker shafts); and a seal and gasket overhaul set. Despite numerous attempts, the Safety Board investigator was unable to interview the mechanic that performed that maintenance so it is unknown the reason for purchasing the keepers and which cylinders they were installed on. - On February 19, 2021, about 1158, a Piper PA-32-260 Cherokee Six airplane, N57014, was substantially damaged when it was involved in an accident in Los Angeles, California. The pilot was fatally injured and a person on the ground sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Investigators reviewed flight track data covering the area of the accident during the time surrounding the accident using Federal Aviation Administration (FAA) provided Automatic dependent surveillance-broadcast (ADS-B) data. The airplane had been assigned a discrete transponder code of 0242 by the FAA’s Southern California Terminal Radar Approach Control (SCT). The data was consistent with the airplane departing Zamperini Field in Torrance at 1146 and proceeding south-southeast along the coastline while climbing, reaching an altitude of about 3,400 ft mean sea level (msl). The pilot was in communication with SCT air traffic controllers during the flight receiving visual flight rules (VFR) flight following. At 1155:29, the pilot reported to the SCT Harbor radar controller that he was experiencing engine problems. After the controller queried about the nature of the problem, at 1156:30 the pilot stated, “I have an engine wobble; no rpm’s.” About 20 seconds later, the pilot added, “I think I have to make an off-airport landing.” Several seconds later he transmitted his final communication that the Long Beach harbor appeared to be the best place to land and that “I am going to see if I can make it.” The ADS-B data indicated that the airplane proceeded toward Terminal Island and aligned for an emergency landing to a paved area (see figure 1). Figure 1: Accident Flight Path (showing where pertinent communications were made) Video footage was obtained from numerous security cameras at the terminal. A review of the footage revealed that the airplane descended in a relatively flat pitch attitude (see figure 2). The left wing collided with a semi-truck followed by the airplane impacting a concrete barrier in a left-wing low attitude. The airplane rotated over itself in a cartwheel type motion and came to rest upright (see figure 3). Figure 2: Security Camera Footage (compilation prior to impact) Figure 3: Security Camera Footage (by frame) - The accident site was located in a container shipping yards about 6.5 nautical miles southeast of Torrance. The wreckage was found distributed over about 200 ft on a median magnetic bearing of about 79°. Figure 4: Accident Site The first identified piece of debris was the outboard left wing that had come to rest in the truck cab. The hood of the truck, about 6 ft above ground level, had paint transfers, consistent with the tip of the left wing contacting cab in a left-wing low attitude. Adjacent to the truck was a 120 ft tall light post, which is where security cameras were located. Figure 5: First Identified Point of Impact There was an approximate 3-ft high concrete barrier 40 ft east of the truck; a 15-ft section was laying on its side with numerous paint transfers visible. About 40 ft from the barrier was the mid portion of the left wing with a majority of the aileron attached. The inboard wing was about 80 ft east of the barrier, which included the flap and left main landing gear. The fuselage had come to rest upright and was impact damaged the majority of which was near the pilots’ seats. The left forward cabin area was fragmented, and the floor skin was deformed aft. Control continuity was established by manipulating a cockpit control and observing the respective control surface move in response. The electric fuel pump remained mounted within the cabin floor and the external examination revealed no evidence of mechanical anomalies. The inlet line remained installed on the pump; however, the copper outlet line was pulled from the “B” nut. About one ounce of liquid consistent in appearance and odor with that of avgas remained in the pump. In the fuel was also a substantial amount of sediment and a submersing water-detecting paste indicated that water was present in the sample. Removal of the fuel screen revealed that it was brittle and covered in similar sediment and rust. Figure 6: Electric Fuel Pump The copper fuel line between the electric fuel pump and the firewall was fragmented and entangled in the deformed fuselage skin folds. The line was fractured from the firewall fitting. The hoses installed on the firewall forward in the engine compartment had bright orange torque stripes that were consistent with a recent installation. The engine driven fuel pump was removed and disassembled. The diaphragms were pliable, and no anomalies were noted. The fuel line was removed at the carburetor and it contained liquid that was clean and consistent in appearance and odor with that of avgas. The water detecting paste did not reveal evidence of water. Engine An external examination of the engine revealed that there were no holes in the crankcase and there was about 9 quarts of oil, as measured with the dipstick. Continuity from the throttle and mixture control in the cockpit to the arms on the carburetor was established. The controls were located in the full forward position and after moving the friction arm (relieving the tension), manipulation of the controls moved the respective arms from stop to stop. The oil sump drain had penetrated the cabin air scat tube. Oil was draining in the scat tubing to the carburetor airbox. Disassembly of the carburetor airbox revealed that the filter had sustained burn damage consistent with a carburetor fire. The lower cowling had corresponding soot marks at the vent. The carburetor was dissembled, revealing intact plastic floats and liquid resembling Avgas in the bowl. All of the upper spark plugs contained an oily film and were dark. The Nos. 1, 3, and 4 cylinder spark plugs did not have a gap between the electrodes. The No. 3 cylinder spark plugs were not damaged. Removal of the bottom spark plugs disclosed that the Nos. 3, 4, and 6 cylinders were damaged. The magneto timing was tested and found to be within the Lycoming recommendations A spark was visible on each lead when the propeller was rotated. Removal of the rocker box valve covers revealed that the exhaust rotator cap on the No. 2 cylinder was laying in the cover. The exhaust valve springs on the No. 6 cylinder were displaced and protruded out at an angle with the rocker arm contacting the upper valve spring seat (retainer) and the No. 6 exhaust pushrod was bent. Removal of the No. 2 cylinder revealed that there were numerous pieces of metal in the engine crankcase. Removal of the No. 4 cylinder revealed that the piston face had numerous gouges consistent with metal consumption in the barrel. There were pieces of worn metal found in the intake and exhaust pipes. Removal of the No. 6 cylinder revealed that the upper portion of the piston was trapped inside the barrel and dislodged from the wrist pin. Further examination of the No. 6 piston revealed it was fractured into multiple pieces, and impact marks were observed on the crown and the interior surface of the cylinder head. The exhaust valve guide had been extruded outward, and the cam follower on the No. 6 exhaust tappet body had been worn. The No. 6 exhaust valve was fractured through the stem, and the valve seat face exhibited a shiny metallic appearance. The No. 6 exhaust valve spring seats exhibited wear and fracture features. The upper spring seat flange at the base of the No. 6 exhaust valve spring seat had fractured along an approximate 225° arc segment, and the compression-spring-facing side of the seat exhibited striated features, consistent with fatigue crack progression. Figure 7: Cylinder No. 6 Figure 8: No. 6 Piston Head and Spring Seats Separation of the crankcase halves revealed numerous lifter (tappet) heads were broken and large pieces were found in the crankcase. The camshaft lobes and heels appeared to have normal wear with no spalling noted. The No. 6 and No. 5 cylinders and their respective components were taken to an engine overhaul facility to evaluate the wear on each component. The intake and exhaust guides on both cylinders over the new tolerance, but within the service limit. The intake valves on the No. 5 and No. 6 had 0.0007 and 0.0009 stem wear, respectively and were within the service limit. The exhaust valve on the No. 5 cylinder had 0.0011 stem wear and was within the service limit. The No. 5 And No. 6 inner and outer exhaust springs were compression tested and both were out of limits. A magnaflux inspection of the intake valve spring seats revealed cracks in both the upper and lower seats for the No.6 cylinder. The lower exhaust valve spring seat had cracks in the No. 5 cylinder. The No. 6 and No. 5 cylinders and their respective components were then sent to the Safety Board Materials Laboratory for analysis. A fatigue crack had formed in the exhaust valve upper spring seat of the No. 6 cylinder assembly, which is consistent with it eventually leading to the release of the exhaust valve. The crack formed at the base of the cup that housed the valve stem keys. Under typical operation, the exhaust valve is either on the valve seat or off the valve seat. When the valve is on the valve seat, the compression in the valve springs push against the underside of the spring seat, and the keys are compressed between the stem and the support flange. In the valve open condition, the rocker arm pushes against the rotator cap, which sits on top of the keys, keeping the compressive load path on the keys. The examination findings were consistent with the No. 6 exhaust valve floating, which likely would have decoupled the motion of the exhaust valve and the spring seat, removing the compressive load on the keys and allowing them to move and rub against the support flange and sidewall of the spring seat cup. A compression test of the No. 6 exhaust valve springs indicated that they did not pass, suggesting that a floating valve would have been possible. The No. 5 exhaust valve springs also did not pass, and wear features around the key cup were not observed in that instance. Because the keys and valve stem were not found (likely destroyed during the continual operation with the failed valve), they were not able to be examined to determine if there was some issue with either component that could have contributed to the failure. -
Analysis
Shortly after takeoff, the pilot reported to air traffic control that the airplane was experiencing engine problems and he was going to make an off-airport landing. The airplane contacted a semi-truck and a concrete barrier during the landing in a shipping harbor. Postaccident examination of the engine revealed that the No. 6 cylinder exhaust valve head was separated from the stem. A fatigue crack was found in the exhaust valve upper spring seat of the No. 6 cylinder assembly that likely led to the release of the exhaust valve. The crack formed at the base of the cup that housed the valve stem keys, causing a portion of the flange that supported the keys to separate. This could have allowed the exhaust valve to drop into the cylinder, impacting the piston, the cylinder head, and the exposed end of the valve guide before being sheared through the stem near the stem-to-fillet transition. The findings suggest that the No. 6 exhaust valve may have been floating, which would have removed the compressive load on the keys and allowed them to move and rub against the support flange and sidewall of the spring seat cup. The compression test of the exhaust valve springs indicated that they did not pass, suggesting that a floating valve is a possibility. However, the No. 5 exhaust valve springs also did not pass, and similar wear features around the key cup were not observed in that instance. Because the keys and valve stem were not found (likely destroyed during the continual operation with the failed valve), it could not be determine if there was some issue with either component that could have contributed to the failure.
Probable cause
The total loss of engine power due to the failure of the No. 6 exhaust valve for reasons that could not be determined based on available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N57014
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-7400014
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-05T04:50:01Z guid: 102651 uri: 102651 title: DCA21FA085 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102652/pdf description:
Unique identifier
102652
NTSB case number
DCA21FA085
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-20T15:09:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-02-21T06:42:00.852Z
Event type
Incident
Location
Broomfield, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
Maintenance History and Inspection Process The UAL maintenance program for the fan blades was governed by UAL’s Federal Aviation Administration (FAA) approved engine maintenance program, based on P&W’s PW4000 112-inch maintenance planning document. The installed set of fan blades, including the fractured blade, had undergone two overhauls at the manufacturer’s overhaul facility; once in 2014 and again in 2016. The overhaul included removal of the outer protective coating and a fluorescent penetrant inspection (FPI) to detect surface cracks, a visual inspection, and a thermal acoustic imaging (TAI) inspection. At the time of the accident, overhaul inspection of the blades was required every 6,500 cycles. Blades were permitted to continue in service as long as they passed the required inspections. During the TAI process, the fan blade’s airfoil is coated with heat conductive and radiating paint, after which sonic transducers that vibrate the entire blade structure are attached to the blade root. The vibrational excitation causes a high-frequency movement between faying sides of any contacting discontinuity (or crack), causing frictional heating of the crack, which can then be detected on the surface of the fan blade with a thermal camera. These thermal camera images are then processed via computer, which amplifies and interprets the temperature signatures and displays them for evaluation by an inspector. The inspectors occasionally encounter extraneous or questionable indications in the TAI results, which must be evaluated to determine if the indication is a true crack or caused by other benign conditions, such as a loss of thermal paint adhesion on the outer surface or grit particles that have accumulated in the internal cavities of the airfoil, neither of which are reasons for removing the blade from service. If the inspector is not able to clearly evaluate an indication, they are instructed to forward the images and the blade itself to a process engineer, who can use other non-destructive inspection methods. In response to a similar in-flight fan blade failure event on February 13, 2018, involving a UAL PW4077-powered Boeing 777-222 airplane while over the Pacific Ocean (NTSB report ID DCA18IA092), Non-Destructive Inspection Procedure (NDIP) 1065 Revisions B, C, and D were issued to introduce process improvements and additional controls, as well as more detailed examples of acceptable and rejectable TAI inspection indications. Following the 2018 event, the digital data of the thermal images captured in April 2016 of the incident fan blades were reviewed; the reviewers accepted the previous interpretations and the blade continued in service. In 2021, the data from the April 2016 TAI inspection of the incident fan blades were again retrieved and reviewed by P&W. Although the software identified two low-level indications on the convex side of the blade near the center of the airfoil chord in the flow path region, the inspector categorized the findings as “extraneous” and concluded that they were likely generated by either camera sensor noise or loose grit in the cavity. A review of the NDIP procedure that was in effect at the time of the 2016 inspection indicated that, given the low-level indications observed, the blade should have been either stripped and re-painted for a second TAI inspection, or the ambiguous indications should have been elevated to a team review for further inspections; however, there is no evidence to suggest that either of these additional reviews occurred. The anomalous indications were located very close to the origin of the fatigue crack that led to the fracture of blade No. 19 and were likely associated with the initiating fatigue fracture in this event. Boeing Failure Analysis Following the February 2018 FBO event, Boeing produced a dynamic simulation model to examine failure scenarios of the inlet and fan cowl structures using data collected during certification FBO tests along with physical evidence collected during previous FBO events, which included the February 2018 event as well as an incident in 2010. During an FBO event, the released fan blade has a significant amount of centrifugal and circumferential energy. The fan case and Kevlar containment belt were designed to absorb the energy and prevent fan blade fragments from exiting radially through the fan case. Although the fan case and Kevlar containment belt will deflect outward as they absorb this energy, significant A-flange deflections were not anticipated. Certification test simulation studies of an FBO event with an aluminum aft bulkhead predicted a bulkhead displacement of 0.47 inch with localized yielding, but without a failure of the inlet structure or the inlet-to-fan-case interface. Analysis of the 2018 event predicted a displacement of 0.55 inch and delamination of the installed CFRP bulkhead face sheets, which exceeded the face sheet laminate rupture strain in compression, leading to the failure of the inlet aft bulkhead. Analysis of the 2010 event predicted a displacement of 0.46 inch and compression buckling of the CFRP aft bulkhead, but no failure. The aluminum structure in the certification inlet had the ability to yield and absorb the same amount of energy and redistribute the FBO loads between the fan case and the inlet without causing failure of the inlet aft bulkhead. Boeing records also indicated that evidence of moisture ingression had been found on multiple other 777 fan cowls, and although varied in extent and location, was reported in the area of the latches on the lower fan cowl panels and the area of the hinge attachments on the upper fan cowl panels. Such moisture ingression would degrade the strength of the cowls. Safety Actions Following this event, the FAA issued Emergency AD 2021-05-51, effectively grounding all PW4000 112”-powered 777-200 and -300 airplanes so that a one-time TAI inspection of the 1st stage LPC blades could be completed. On October 21, 2021, P&W issued Alert Service Bulletin (SB) PW4G-112-A72-361, Engine – Blade Assembly, 1st Stage, Low Pressure Compressor (LPC) – Ultrasonic Testing (UT) Inspection and Thermal Acoustic Image (TAI) Inspection of 1st Stage LPC Blade Assemblies to Find Airfoil Cracks. The SB included both immediate and repetitive UT inspections for three specific high-risk areas on the PW4000 112-inch hollow fan blades. It also added a required TAI inspection every 1,000 cycles for all 1st stage LPC blades. The inspections included in this SB were subsequently made mandatory on April 15, 2022, when the FAA issued Airworthiness Directive (AD) 2022-06-09. As of January 31, 2023, seventeen confirmed cracked fan blades have been found, the first of which was identified in December 2004. These do not include the three fan blades that sustained full-blade separation in service. Prior to release of the UT inspection, seven cracked fan blades were identified via TAI and one visually. Nine cracked blades were identified following the introduction of the new UT inspection process. UT indications have been identified in 102 fan blades, of which fifteen have been destructively examined, with nine being confirmed cracks. The selection of blades for destructive evaluation is based on Pratt & Whitney’s evaluation of the UT inspection results and prioritizing those whose indication characteristics are more likely to be cracks. All confirmed cracks greater than 0.016-inch deep exhibited evidence of low-cycle fatigue progression, with contributing crack accelerating factors that included discontinuities and molten metal deposits introduced during machining processes, surface damage, microtexture regions, and surface contamination. Also in response to this event, Boeing developed an interim design solution incorporating engine nacelle modifications, and Boeing subsequently issued multiple alert SBs for fan cowl inspections; modifications to the inlet cowls and thrust reversers on 777-200 and -300 airplanes equipped with PW4000 series engines; and inspection/repair of fan cowls for moisture ingression. These SBs were subsequently mandated via FAA ADs 2022-06-10 and 2022-06-11. - Overview The Boeing 777-222 is a long range, twin-engine, transport category airplane. The primary wing and fuselage structure is of all metal construction, primarily aluminum alloys. The control surfaces and engine cowlings are of composite construction, which comprises graphite epoxy carbon fiber reinforced plastic (CFRP), fiberglass, or honeycomb sandwich. The incident airplane was manufactured in September 1995. Engines The airplane was powered by two Pratt & Whitney (P&W) PW4077 turbofan engines. The right engine was manufactured in 1995 and installed on the accident airplane in August 2016. At the time of the event, the engine had accumulated 12,384 hours and 2,979 cycles since overhaul and 81,768 hours and 15,262 cycles since new. The PW4077 is a dual-spool, axial flow, high-bypass turbofan engine that features a single-stage, 112-inch diameter fan (low pressure compressor [LPC] 1st stage), a 6-stage LPC, 11-stage high pressure compressor (HPC), annular combustor, a 2-stage high pressure turbine (HPT) that drives the HPC, and a 7-stage low pressure turbine (LPT) that drives the fan and LPC. Each engine is attached to a pylon on its respective wing. The engine inlet is attached to the forward end of the engine, the fan cowls are attached around the center portion of the engine, and the thrust reversers are attached around the aft portion of the engine. (see figure 2.) Engine flanges are identified alphabetically from the front of the engine aft, with the A-flange located where the inlet attaches to the fan case and the T-flange at the aft end of the exhaust case. (see figure 3.) Figure 2. Engine installation drawing for 777-200 (Source: Boeing). Figure 3. PW4000 112-inch significant engine flanges (Source: Pratt & Whitney) Inlet The engine inlet is a cantilevered structure attached to the forward flange of the engine fan case through the inlet attach ring with 52 bolts. The inlet consists of two concentric cylindrical structures joined together by forward and aft bulkheads (see figure 4). The hollow aluminum lip skin is attached to the forward bulkhead and provides an aerodynamic surface for the leading edge of the inlet and a passage for engine anti-ice air. The inlet aft bulkhead consists of the aluminum inlet attach ring and aluminum outer ring chord with a CFRP honeycomb sandwich composite web. The inlet forward bulkhead consists of the aluminum inner and outer ring chords with a stiffened aluminum web. The inlet outer barrel comprises three CFRP honeycomb sandwich panels. A section of the outer barrel in the lower right quadrant is comprised of a titanium skin, where the anti-ice exhaust duct is located. The inlet inner barrel is comprised of two CFRP honeycomb sandwich panels. The inner face sheet of the inner barrel is perforated for noise suppression and the outer face sheet is solid. Figure 4. Inlet cross-section drawing for 777-200 (Source: Boeing). Fan Cowl The fan cowl provides an aerodynamic closure around the engine fan cases and the doors open to allow maintenance access to the engine. The CFRP honeycomb sandwich construction cowls are semi-cylindrical doors fastened to four hinges at the upper ends; two on the cowl support beam, one floating hinge, and one hinge on the engine. The fan cowl support beam is a CFRP honeycomb sandwich panel attached at the forward end to the inlet attach ring and to the fan case at the aft end through aluminum fittings. The fan cowls interface with the inlet at the forward edge through a v-blade on the fan cowls that seats in a v-groove on the inlet aft bulkhead. The fan cowls interface with the thrust reversers at the aft edge through a sliding contact seal. Thrust Reversers The thrust reversers (TRs) provide an aerodynamic enclosure around the core of the engine, direct the fan exhaust, and actuate to provide reverse thrust during landing. The two semi-cylindrical TR halves comprise three main components; the translating sleeve, the fan duct cowl, and the aft cowl. The CFRP honeycomb sandwich inner wall of the fan duct cowl and the titanium aft cowl enclose the engine core and comprise the fire zone in the TR. The TRs are hinged at the upper end to the pylon and open to provide maintenance access. The main structural skeleton of the TR consists of the aluminum hinge beam at the upper end, the aluminum torque box at the forward end, the aluminum latch beam at the lower end, and the aluminum aft support ring and titanium aft cowl at the aft end. The CFRP honeycomb sandwich inner wall is connected to the TR at the upper and lower bifurcations. The CFRP honeycomb sandwich translating sleeve forms the outer surface of the TR and the outer wall of the fan duct cowl in the closed position. The translating sleeve slides aft along a mechanism attached to the torque box when actuated for reverse thrust. Rubber fire seals are installed in each TR half to help contain an undercowl fire within the interior of the fan duct inner wall and aft cowl. The fabric-reinforced silicone rubber seals are installed along the upper and lower bifurcation walls and down the upper aft edge of the aft cowl. Kapton-faced thermal insulation blankets are installed on the upper and lower bifurcations and on the inside of the inner wall in the fire zone to protect the composite structure from radiant engine heat and fire. Engine Fire Protection and Extinguishing Systems The B-777 engine fire protection comprised two systems: an engine fire and overheat detection system, and an engine fire extinguishing system. The engine fire and overheat detection system comprised two detector loops in each engine nacelle. Normally, both loops must detect a fire or overheat condition to cause an engine fire warning or overheat caution message to display on the EICAS. If a fault was detected in one loop, the system automatically switched to single-loop operation. If there were faults in both detector loops, no fire or overheat detection would be provided. The EICAS advisory message DET FIRE ENG (L or R) would be displayed if the engine fire detection system failed. An engine fire warning would be accompanied by several indications, including an aural fire bell, the illumination of master WARNING lights, an EICAS warning message (FIRE ENG [L or R]), the illumination of the affected engine fire switch, unlocking of the engine fire switch, and the illumination of the engine FUEL CONTROL (L or R) switch fire warning light. Each engine was equipped with two fire extinguisher bottles, which were located inside the engine nacelle and cowling and activated by engine fire switches in the flight deck. When the switch is pulled out and rotated in either direction, a single extinguisher bottle is discharged into the associated nacelle cavity. When the switch is rotated in the other direction, the remaining extinguisher bottle is discharged into the same engine. Activation of the fire switch is also designed to isolate the engine by closing the fuel spar valve, de-energizing the engine fuel metering unit cutoff solenoid, closing and depressurizing the engine driven hydraulic pump supply shutoff valve, closing the pressure regulator and shutoff valve, removing power from the thrust reverser isolation valve, and tripping the generator and backup generator fields. - On February 20, 2021, about 1309 mountain standard time, a Boeing 777-222, N772UA, operated by United Airlines (UAL) as flight 328, experienced a right engine fan blade separation and subsequent engine fire shortly after takeoff from Denver International Airport (DEN), Denver, Colorado. The two pilots, eight crew members, and 229 passengers onboard were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 121 scheduled passenger flight. The airplane departed DEN about 1304 enroute to Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii. The captain was the pilot flying, and the first officer was the pilot monitoring. The pilots reported that preflight weather forecasts indicated moderate turbulence from about 13,000 ft mean sea level (msl) to 23,000 ft msl, and as the airplane climbed through about 12,500 ft msl at an airspeed about 280 knots (kts), they increased engine power in order to minimize the time spent climbing through the altitudes where turbulence was forecast. About 5 to 7 seconds after advancing the throttles, the cockpit voice recorder (CVR) captured a loud “bang,” and the flight data recorder (FDR) showed an uncommanded shutdown of the No. 2 (right) engine. Shortly thereafter, an engine fire warning activated on the engine indicating and crew alerting system (EICAS). The flight crew declared an emergency with air traffic control (ATC) and completed multiple checklists, including the engine fire checklist. As part of the engine fire checklist, the crew discharged both right engine fire extinguishing bottles; however, the engine fire warning continued to display on the EICAS until shortly before landing. The crew landed the airplane on runway 26 at DEN at 1328 and the airplane was met by aircraft rescue and firefighting (ARFF), which applied water and foaming agent to the right engine for about 40 minutes. The airplane was then towed off the runway, where the passengers disembarked via air stairs and were bussed to the terminal. Figure 1 below, a still image captured from in-flight video recorded by a passenger, shows the damage to the engine nacelle as well as the under-cowl fire about 11 minutes after the fan blade separation. Figure 1. Still image from passenger in-flight video showing engine nacelle damage and under-cowl fire about 11 minutes after fan blade separation (Courtesy Boeing via YouTube). At the time of the event, the airplane was over Broomfield, Colorado; multiple pieces of the engine inlet, fan cowls, and thrust reversers separated from the airplane and were found scattered over an area of about 40 acres, including a public park and residential areas. There were no ground injuries reported. - Captain The captain, age 60, held an airline transport pilot certificate with a rating for airplane multiengine land and multiple type ratings, including the B-777. His most recent first-class Federal Aviation Administration (FAA) medical certificate was issued on February 23, 2021. Operator records indicated that the captain had 28,062 total hours of flight experience, including 414 hours on the B-777 in the previous 12 months. His most recent proficiency check was completed on February 5, 2021. First Officer The first officer, age 54, held an airline transport pilot certificate with a rating for airplane multiengine land and multiple type ratings, including the B-777. Operator records indicated that the first officer had 18,612 total hours of flight experience, including 355 hours on the B-777 in the previous 12 months. His most recent proficiency check was completed on November 27, 2020. - Fan Blade Description The PW4000 112-inch engine fan blade is a hollow core airfoil made of a titanium alloy. The blades are manufactured with a waffle-style core structure; the interior of the blade comprises a pattern of cavities separated by spanwise and chordwise ribs. The blades are manufactured from two titanium alloy plates from which the internal and external features of the blade are machined. The two halves are then diffusion bonded, inspected, and machined before being formed into the final airfoil shape. During the hot final forming process, pressurized argon is introduced into most of the blade cavities to prevent skin deformation. Fan Blade Failure Analysis Metallurgical examination of the fractured blade was performed at the P&W Materials Laboratory under NTSB supervision. The examination revealed a fatigue crack that initiated internally about 6.6 inches above the root on the surface of an internal radius in a cavity of the hollow core fan blade. (see figure 6.) The fracture surface showed evidence of an estimated 3,150 cycles of stable low-cycle fatigue growth between 0.063 inch to 0.199 inch from the fatigue origin. In addition to the primary fracture, multiple fatigue cracks were identified in the flowpath and midspan of the fractured blade. These secondary fatigue cracks had origins at the internal cavity surfaces, and many of the cracks exhibited multiple origins, consistent with the primary fracture. The largest of the secondary cracks had a maximum crack depth of 0.065 inch. Figure 6. Closeup of fan blade No. 19 fracture surface and fatigue evidence. Examination of the crack that led to the failure of the blade revealed a discontinuity in a local tight radius in the internal blade geometry that had been introduced during the machining and manufacturing process. A P&W technical review of the discontinuity estimated a local steady stress increase of 30% at the location, reducing the fatigue life by 50%. Metallurgical and chemical characterization revealed that the surfaces of the internal cavities were contaminated with carbon that had diffused into the parent material. According to P&W engineers, carbon contamination of titanium can cause decreased fatigue resistance capability. It was observed that the carbon surface contamination was not present in the cavities of the blade that are sealed off during the diffusion bonding process, indicating that the contamination was introduced after the diffusion bonding process. Review of the manufacturing process revealed that the most likely source of the carbon contamination was the shop argon system used during the hot final forming process. Before 1997, P&W’s high-pressure argon was supplied through the regular shop lines, which are not cleaned and can contain various contaminants. In 1997, P&W began using a clean dedicated argon system. The hot final forming of the event blade occurred in 1994. - Examination of the airplane revealed that the right engine inlet and fan cowls had separated from the engine and the right engine thrust reversers were thermally damaged. Fan Blades Examination of the right engine revealed that one fan blade, identified as No. 19, was fractured transversely across the chord of the airfoil at the plane of the fan hub fairing, known as a full-span blade separation, or fan blade out (FBO). A piece of fan blade, which measured about 13 inches long by 6 inches wide, was recovered with the debris that had fallen from the airplane during flight and was identified with the last five digits of the fractured blade serial number. The adjacent fan blade (No. 18) was fractured across the airfoil about 25 inches above the fairing and displayed evidence of overload failure. All of the other fan blades were intact, but displayed varying degrees of impact damage to the airfoils, with the tips bent and curled opposite the direction of rotation. (see figure 5.) Figure 5. Fan blades as viewed from front, showing the two fractured blades and damage to the remaining intact blades. Main Gearbox and “K” Flange The main gearbox (MGB), normally supported by the “J” and “K” flanges via three brackets, was separated from the two flanges and fractured. The left MGB mount bracket, upper clevis, mount link, and MGB clevis were intact and still connected to the MGB; however, the left MGB link bracket was detached from the “J” and “K” flanges due to the fractures of all of the flanges’ bolts. The MGB housing was deformed in the area of the left clevis, consistent with multiple impacts against the upper clevis in an orientation where the MGB had rotated counterclockwise as viewed from the top. The MGB sustained significant thermal damage, and most of its housing was melted away. The servo fuel heater, which is mounted on the MGB, was found fractured at a high-pressure fuel cavity location. The fracture texture was sharp and jagged, consistent with contact against the fuel oil cooler, and the lack of thermal distress on the impact marks suggested that this may have been the initiating fracture of the fire event. The “K” flange joins the HPC rear case with the diffuser case, which contains the internal hot gases of the operating engine (refer to Figure 3 for location of the “K” flange). Examination revealed that the “K” flange was separated, and all the fastening bolts had failed. Most of the bolt holes were empty; in the locations where bolt remnants were found, the bolts were sheared in the plane of the aft face of the forward flange. Some of the fractured bolts or nut ends were retained by case features. At the location of the “K” flange near the HPC discharge plane, the compressed air temperature exceeds 1,000°F. In the event of a “K” flange separation, the leaking high temperature HPC discharge gas could provide an ignition source of any fuel present in the nacelle. Fan Case The front fan case comprises a cylindrical aluminum isogrid structure wrapped externally with multiple layers of continuously wound Kevlar fabric strip, then covered with an epoxy resin environmental wrap, the purpose of which is to prevent penetration of the engine case in the event of a fan blade failure or separation. A honeycomb acoustic structure is bonded to the entire inner surface, upon which a fan blade rub strip is bonded in the plane of the fan. The clock positions referenced in the following paragraph are as viewed from aft of the engine looking forward. The 12:00 position is the upper center line of the engine as installed on the wing. The outer two layers of the Kevlar containment belt, inclusive of the environmental wrap, were torn with split and frayed fibers along the edges. The tear near the 11:30 position extended aft about 34 inches axially starting about 1 inch aft of the forward edge. There was a hole in the third layer of Kevlar from the outside that measured about 5 inches axially and 3.5 inches circumferentially. All of the remaining Kevlar layers were penetrated by an embedded piece of fan blade that was centered about 15 inches aft of the A-flange near the 11:30 position. The hole through the layers measured 1 inch axially and 1.5 inches circumferentially. The Kevlar containment belt layers were displaced outward about 3 inches from their nominal position with the blade fragment still in place. The forward edge of the containment belt was displaced aft between 11:15 and 12:00 with a maximum displacement of about 0.5 inch centered near 11:30 that cracked the sealant. The sealant bead on the aft edge of the containment belt was cracked and displaced forward from 9:00 to 1:30. The maximum displacement was about 1.75 inches between 11:15 and 11:45. The inner three layers of the containment belt remained in place, while the rest were displaced forward. There was red sealant on the aft edge between 1:45 and 7:00 and between 8:00 and 9:45. The fan blade rub strip and its honeycomb substrate material were completely missing; the underlying fan case material was circumferentially scored and gouged around the full circumference. The interior surface of the fan case displayed significant damage, including an area of heavy scoring and gouging of the case aluminum isogrid material around nearly the entire circumference in the fan blade plane of rotation. A rectangular puncture of the aluminum isogrid was located near the 11:00 position. A section of fan blade about 18 inches by 16 inches was lodged in the aluminum isogrid between 11:15 and 12:05. Multiple witness marks corresponding to fan blade fragment trajectories were identified on the inner surface of the fan case; the witness marks were consistent with blade fragments moving forward, aft, and circumferentially. Six distinct witness marks consistent with fan blade fragment paths were identified during reconstruction of the inlet inner barrel; four of these paths aligned with those identified on the fan case inner surface. Most of the composite outer barrel was recovered and identified. A two-dimensional reconstruction revealed several axial fractures and an arc-shaped mechanical cut. Two pieces of metallic debris were found embedded in the outer barrel panel near 6:00. One piece had coloration and composition consistent with the aluminum fan case isogrid, and the other was consistent with the titanium alloy used in construction of the fan blades. Additionally, two areas of the outer barrel exhibited evidence of fluid ingression into the honeycomb. Engine Driven Pump (EDP) Supply Shutoff Valve Examination of the right engine fire suppression system revealed that the EDP supply shutoff valve, which stops hydraulic supply from the reservoir to the EDP when the fire switch is pulled, was in the OPEN position. Fire switch and wire continuity was confirmed with no shorts or anomalies found, and the circuit breaker associated with the valve was found closed. Additionally, a maintenance message stating, “Supply shutoff valve (EDP R) is not in the commanded position” was active in the central maintenance computer existing faults. The unit was removed for further examination and testing. Disassembly and examination of the unit’s DC motor revealed silicone contamination of the brushes and commutators consistent with the silicone-based lubricant used in the unit’s motor bearings, as well as fretting debris from the commutators, which increased the electrical contact resistance between these components. -
Analysis
United Airlines flight 328 was climbing through 12,500 ft mean sea level about 5 minutes after departure from Denver International Airport (DEN), Denver, Colorado, when the right engine, a Pratt & Whitney PW4077, sustained a full-length fan blade separation, or fan blade out (FBO) event. This resulted in the subsequent separation of the engine inlet lip skin, fan cowl support beam, and components of the inlet, fan cowls, and thrust reversers (TRs), as well as an engine fire. The flight crew declared an emergency and landed the airplane without incident at the departure airport about 24 minutes after takeoff. There were no injuries to the passengers or crew, and no ground injuries due to debris; however, a vehicle and a residence sustained damage when impacted by the inlet lip skin and fan cowl support beam, respectively. Fan Blade Impact Damage Examination of the engine revealed that the separated fan blade and other fan debris impacted the fan case, which successfully contained the fan blade fragments. Damage to the nacelle inner and outer barrels was observed, and a postaccident evaluation indicated that the displacement wave of the impact resulted in a deflection of the fan case and contact with the nacelle doors and hinges, which subsequently resulted in the failure of the inlet aft bulkhead and the fan cowl support beam. The failure of the bulkhead, along with the damage to the inner and outer barrels, allowed these structures, as well as the inlet lip skin, to separate from the engine. Following the separation of the inlet, air loads resulted in the separation of the fan cowls and the fan cowl support beam. Simulation studies indicated that the carbon fiber reinforced plastic (CFRP) honeycomb structure of the event engine inlet and inlet aft bulkhead was unable to dissipate and redistribute the energy of the loads imposed by the FBO event in the same manner as the aluminum structure inlet that was used during certification tests. Separation of the inlet and fan cowls due to an FBO event is not allowed under certification standards, and following this event, Boeing developed modifications to the inlet to ensure that inlets and fan cowls remain in place during an FBO event that may damage the aft bulkhead, inner barrel, or outer barrel and modifications to add strength and ductility to the inlet by incorporating additional metallic structure. Boeing also developed procedures for inspection and repair for moisture ingression damage to the fan cowls, which can degrade the strength of the cowls. These modifications were subsequently mandated by Federal Aviation Administration (FAA) Airworthiness Directives (AD) 2022-06-10 and 2022-06-11, effective April 15, 2022. Additional modifications are expected to the fan cowl. This event was the fourth in-service FBO event due to fatigue cracking recorded for PW4000-powered 777 airplanes and resulted in the most nacelle damage of the four events. In the first event in 2010, approximately 50 percent of the blade airfoil was released. Full-span separations occurred in 2018, 2021, and during this event. Engine Fire Propagation Seconds after the FBO event, the flight crew received a right engine fire warning. The crew completed the engine fire checklist, which included activating the fire switch and discharging both engine fire extinguishing bottles; however, the fire was not arrested and continued to propagate through the engine for the remainder of the flight due to damage the engine sustained during the fan blade out event. Although the cockpit fire warning light extinguished shortly before landing, this was likely the result of thermal damage to the engine fire detection system. The engine fire propagated as the result of several cascading failures following the FBO event. The engine core was subjected to high dynamic loads due to the energy of the initial blade release; the fan blade rubbing against the case, which created rotating torsion loads through the engine core structure; and the continued fan shaft imbalance during the engine run-down, which created rotating bending loads through the core structure. The loading associated with the high dynamic activity of the attached main gearbox (MGB) ultimately resulted in the failure of the “K” flange bolts that attached the MGB to the engine. The remaining “K” flange bolts then fractured, resulting in the total separation of the “K” flange, which allowed hot, compressed gases to escape the engine core and provided an ignition source in the engine nacelle. As the “K” flange was part of the MGB support structure, the failure of the flange also allowed the MGB to rotate and the MGB-mounted servo fuel heater to contact the engine core-mounted fuel oil cooler. As a result of this contact, a high-pressure fuel cavity within the servo fuel heater was fractured open, releasing high-pressure fuel into the nacelle, where it was ignited by the hot, compressed gases that escaped through the “K” flange separation. Pratt & Whitney is evaluating actions to improve the strength of the “K” flange and expects hardware to be available in 2025. The fire spread to the TR lower bifurcation area, burned away the support structure for the nacelle drain access door, and exited the lower aft TR area. The undercowl fire melted the aluminum latch beams at the lower end of each TR and through the TR inner wall and translating sleeves. One of the last components to separate from the airplane was a section of the outboard TR translating sleeve, which was located about 30 miles southeast of the debris associated with the initial FBO event. The burn-through of the TR lower bifurcation area likely occurred within about six to nine minutes of the initial FBO event, though certification standards required that materials in this area withstand fire for a minimum of 15 minutes. Examination of the engine’s fire suppression system revealed that the engine driven hydraulic pump supply shutoff valve failed to close as designed upon the crew’s activation of the engine fire handle due to silicone lubricant contamination of electrical contact components in the valve’s DC motor. The failure of the valve to close allowed a limited amount of hydraulic fluid to leak into the engine compartment and feed the undercowl fire. FAA AD 2022-06-10 and 2022-06-11 required installation of debris shields on the TR inner wall lower bifurcation area, as well as repeated functional checks of the engine driven hydraulic pump supply shutoff valves to ensure proper operation in response to fire switch activation. Fan Blade Fatigue Failure and Inspection Process The separated fan blade was fractured transversely across the chord of the airfoil near the fan hub fairing as the result of a fatigue crack, which originated at the surface of an internal radius in a hollow cavity within the blade. The event blade had accumulated 2,979 cycles since overhaul; at the time of the event, overhaul inspection was required every 6,500 cycles. As part of the overhaul, blades were inspected for both external and internal cracks using a proprietary thermal acoustic imaging (TAI) process. The most recent TAI inspection of the event fan blade occurred about five years before the event, in 2016. Inspection imagery revealed multiple low-level indications, two of which were in the fatigue crack origin area, that were reviewed further and interpreted as being generated by camera sensor noise or loose contamination within the cavity. Given the observed indications and the inspection criteria in place at the time, the blade should have received a second TAI inspection, or the images should have undergone a team review; however, there was no record that either of these occurred, and the blade was approved for continued service. Following an FBO event in 2018 involving another PW4077 engine, the data from the 2016 inspection of the blade involved in this event were reviewed again; once more, the indications were not identified as anomalous and the blade continued in service. Two of the low-level indications identified during the 2016 TAI inspection were likely associated with the fatigue crack that grew to result in the blade failure. The accident blade had accumulated 15,262 cycles since new, which was less than one quarter of the expected life for a nominal blade, and only 2,979 cycles since its last overhaul, less than half the prescribed inspection interval at the time. Metallurgical examination identified two conditions which contributed to the reduced fatigue life of the accident blade: a surface carbon contamination; and a geometric discontinuity that occurred during manufacturing. In assessing fatigue life of this blade relative to the nominal expectation, the reduced fatigue capability from the surface carbon contamination accounted for approximately 2/3 of the difference, and the increased stress from the geometric discontinuity accounted for approximately 1/3 of the difference. Following this event, Pratt & Whitney performed an immediate TAI inspection of the entire fleet before the next flight and issued a service bulletin introducing ultrasonic testing (UT) blade inspections to occur both immediately and at regular intervals. Additionally, the frequency of required TAI inspections was increased from every 6,500 cycles to every 1,000 cycles. The increased inspection interval and the immediate TAI inspection were made mandatory on April 15, 2022, when the FAA issued AD 2022-06-09. Additionally, the new UT inspection that was developed by Pratt & Whitney for the flowpath and midspan areas has shown a capability to detect small cracks that are below the threshold of detectability for the TAI inspection. The blades are now inspected by UT every 275 cycles. Examination of the crack in this event and previous fan blades failure events have shown the growth rates of the fatigue crack, from detectable size to full-wall penetration, are relatively stable and predictable in each case, since the sources for premature fatigue initiation are surface related and do not have a significant impact on growth through the thickness of the blade. The increased TAI inspection interval and the new UT inspections should provide multiple opportunities to detect cracks in the high-stress areas.
Probable cause
The fatigue failure of the right engine fan blade. Contributing to the fan blade failure was the inadequate inspection of the blades, which failed to identify low-level indications of cracking, and the insufficient frequency of the manufacturer’s inspection intervals, which permitted the low-level crack indications to propagate undetected and ultimately resulted in the fatigue failure. Contributing to the severity of the engine damage following the fan blade failure was the design and testing of the engine inlet, which failed to ensure that the inlet could adequately dissipate the energy of, and therefore limit further damage from, an in-flight fan blade out event. Contributing to the severity of the engine fire was the failure of the “K” flange following the fan blade out, which allowed hot ignition gases to enter the nacelle and imparted damage to several components that fed flammable fluids to the nacelle, which allowed the fire to propagate past the undercowl area and into the thrust reversers, where it could not be extinguished.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
777-222
Amateur built
false
Engines
2 Turbo fan
Registration number
N772UA
Operator
United Airlines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
26930
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2021-02-21T06:42:00Z guid: 102652 uri: 102652 title: ERA21FA135 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102659/pdf description:
Unique identifier
102659
NTSB case number
ERA21FA135
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-22T19:56:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-03-04T23:54:27.849Z
Event type
Accident
Location
Mayfield, Kentucky
Airport
MAYFIELD GRAVES COUNTY (M25)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 22, 2021, about 1756 central standard time, an experimental, amateur-built Vans RV-7A airplane, N383DB, was substantially damaged when it was involved in an accident near Mayfield Graves County Airport (M25), Mayfield, Kentucky. The private pilot was fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. A witness at M25 stated the airplane was conducting touch-and-go landings on runway 1. Another witness traveling eastbound on a nearby interstate saw the airplane climbing and reported that, “as the airplane went higher…the tail dropped, and the plane went into a back flip. This witness then observed the airplane come out of the “flip” and descend “nose first” toward the ground. The airplane subsequently impacted an open field located about 1,011 ft north of the airport. Another witness reported that he observed the airplane takeoff and noted that it was climbing at a high angle of attack. The wreckage was confined to a small area. All airplane components were accounted for at the accident site, and flight control continuity was confirmed for all control surfaces. The wings exhibited symmetrical accordion-type crushing damage and remained attached to the fuselage. Both wing fuel tanks were breached, and both fuel main caps were found in place. The empennage, main landing gear, and all control surfaces also remained attached to the fuselage. The engine and nose landing gear separated from the forward fuselage. The engine was rotated by hand at the accessory gear section, and crankshaft continuity was confirmed. Thumb compression was attained on all cylinders. The engine-driven fuel pump contained 100 low-lead aviation fuel and produced suction and pressure when activated by hand. The left magneto was impact damaged and was not able to be rotated. The right magneto produced spark on all towers. The two-bladed propeller was found fractured from the engine due to impact forces. One blade exhibited rearward bending and leading-edge gouges, and the other blade exhibited Sbending. Examination of the airframe and engine revealed no preimpact mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The private pilot was conducting touch-and-go landings in the experimental, amateur-built airplane. A witness stated that, during the departure climb, “as the airplane went higher…the tail dropped, and the plane went into a back flip.” The witness then observed the airplane come out of the “flip” and descend “nose first” toward the ground. The airplane subsequently impacted terrain north of the departure airport. Another witness reported that he observed the airplane climbing at a high angle of attack during the takeoff. Postaccident examination of the accident site revealed that the wreckage was confined to a small area, which was consistent with a near-vertical impact. The wings showed symmetrical accordion-like crushing damage. Examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or anomalies. According to the available evidence for this accident, the pilot likely exceeded the airplane’s critical angle of attack and entered an aerodynamic stall, resulting in the pilot’s loss of airplane control and the airplane’s subsequent impact with terrain.
Probable cause
The pilot's exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall, loss of airplane control, and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV7
Amateur built
true
Engines
1 Reciprocating
Registration number
N383DB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
72319
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-04T23:54:27Z guid: 102659 uri: 102659 title: ERA21LA141 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102682/pdf description:
Unique identifier
102682
NTSB case number
ERA21LA141
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-24T13:04:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-03-24T05:01:01.132Z
Event type
Accident
Location
Atlantic Ocean, Atlantic Ocean
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 24, 2021, about 1104 eastern standard time, radar contact was lost with an experimental amateurbuilt Lancair 320, N670BS, while the airplane was over the Atlantic Ocean about 16 nautical miles southeast of Boca Raton, Florida. The airplane wreckage and the pilot were not subsequently located. As a result, the airplane was presumed to have impacted the Atlantic Ocean and sustained substantial damage, and the pilot was presumed to be fatally injured. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to Federal Aviation Administration (FAA) radar tracking data, the airplane departed DeLand Municipal Airport (DED), DeLand, Florida, about 0949 and flew southeast toward Boca Raton Airport (BCT), Boca Raton, Florida. A review of FAA audio recordings revealed that the pilot contacted the BCT air traffic control tower at 1054:00 when the airplane was about 10 miles northwest of the airport. The pilot reported that the airplane was at an altitude of 2,400 ft mean sea level (msl) and was descending, and the pilot stated his intention to land at BCT. The controller instructed the pilot to report when he had entered a left downwind for runway 5; at 1054:30, the pilot replied, “report left downwind for runway five, bravo sierra.” No further communications were recorded from the pilot or the controller. Shortly after the pilot’s radio transmission, the airplane made a gradual turn to the right (turning about 12° during a 10- to 15-second period) followed by gradual turn to the left (turning about 10° during a period of about 10 seconds). The turn stopped at 1054:58, after which the airplane flew straight for the remainder of the flight on a true heading of about 136°. The airplane entered the BCT class D airspace from the northwest while descending through 1,700 ft msl. The airplane continued to track toward the southeast and, at 1057:53, was abeam BCT 1 nautical mile to the northeast and at 1,400 ft msl. The airplane exited the class D airspace about 1 nautical mile east of Boca Raton at an altitude of about 1,100 ft msl. The airplane continued to descend on a southeast heading until 1104:02, when track data were lost. At that time, the airplane was about 16 nautical miles southeast of BCT at an altitude of about 100 ft msl and a groundspeed of about 155 knots. The figure below shows the airplane’s flight track through presumed water impact. Figure - The airplane’s ground track (in red) as the airplane flew southeast past BCT toward the Atlantic Ocean. During a postaccident interview, the local controller at BCT did not recall the details of the accident. Based on information provided during the interview, he surmised that he did not observe the airplane as it transitioned through the BCT airspace. The BCT air traffic control tower staff were not aware of the event until family members reported the airplane overdue. On February 26 (2 days after the accident flight), family members of the pilot reported that the airplane was overdue. In response, the FAA issued an alert notification about 1022 that day and coordinated with the US Air Force Rescue Coordination Center and the US Coast Guard for search and rescue efforts. Surface vessels and aircraft began searching about 1240, and the search effort was suspended about 1937 on March 1 with “no findings” regarding the airplane and pilot. According to the FAA’s flight plan service provider, no flight plans from the pilot were on file or activated on the day of the accident. According to FAA airman records, the 87-year-old male pilot’s last aviation medical examination was in July 2010. At that time, he reported a history of high blood pressure treated with medication, and he was issued a third-class medical certificate limited by a requirement to wear corrective lenses. However, in September 2010, the FAA sent the pilot a letter requesting information regarding a history of heart pain, coronary artery disease requiring an angioplasty procedure, and high blood pressure requiring medication; the pilot had not reported a history of heart pain or coronary artery disease at his last aviation medical examination, nor had he disclosed that he had previously had an authorization for Special Issuance medical certification that had expired in 2001. The pilot responded to the FAA's September 2010 letter but declined to provide the requested information. As a result, the FAA revoked the pilot's medical certificate on March 30, 2011. Generally, revocation of a pilot’s most recently issued medical certificate disqualifies that pilot from exercising privileges requiring medical certification, as well as from exercising sport pilot privileges. The pilot’s airman certificates (commercial and private pilot) were subsequently revoked in February 2015 after the FAA determined that he had previously operated an airplane without a valid medical certificate. According to friend of the pilot, he had been visiting in the DeLand area for a couple of days. She had flown with the pilot several times. He did not mention any recent problems with the airplane but noted that a navigation system had been “checked out” about 1 month before the accident flight and that one of the wingtip lights had been replaced a few months before the flight. The pilot’s friend reported that the pilot had fueled the airplane at DED. (Fuel records indicated that the pilot purchased 14 gallons on the day before the accident flight.) She reported that the pilot seemed healthy and had undergone a heart procedure about 3 years before the accident. Weather radar records showed an area of precipitation along the airplane’s track about 1057:00; however, ceilings likely remained at or above 1,500 ft msl and the flight was below 1,500 ft msl during the last 7 minutes of the flight. There was no evidence of wind shear, outflow boundaries, or other convective wind phenomena near the accident site at the accident time. -
Analysis
The pilot was operating a cross-country flight in visual flight rules (VFR) weather conditions. About 10 miles from the destination airport, the pilot contacted the air traffic control tower and reported the airplane’s location and altitude and his intention to land. The controller advised the pilot to report entering a left downwind for the active runway, which the pilot acknowledged. No further communications were received from the pilot or, nor were any made by the controller. Shortly after the pilot’s last transmission, the airplane made a gradual turn to the right and then back to the left, and the airplane then continued on a constant heading with a gradual descent. About 4 minutes later, the airplane passed the destination airport, which the controller did not notice, and the airplane continued in a gradual descent until tracking data ended. At that time, the airplane was over the Atlantic Ocean about 16 miles southeast of the destination airport. Family members reported the airplane overdue 2 days later, after which the Federal Aviation Administration (FAA) issued an alert notification. Search and rescue operations, which were coordinated by the US Coast Guard, ensued. The airplane and pilot were not located despite a 3.5-day search. Search and rescue operations might have been initiated sooner if the controller at the destination airport had followed the track of the airplane as it transitioned through the controlled airspace. If the controller had followed the airplane’s track, he would likely have attempted to contact the pilot and initiated procedures for search and rescue operations after losing contact with the airplane over the ocean. Further, the pilot had not filed a VFR flight plan, which is the primary tool the FAA uses to initiate search and rescue operations for an overdue airplane operating under VFR. Such flight plans are not required by the FAA. However, for those VFR flight plans that are filed, the FAA will initiate action if the flight plan is not closed or the airplane is not confirmed to have successfully landed beginning 30 minutes after the estimated time of arrival indicated on the flight plan. Because the airplane could not be examined and no pilot autopsy or toxicology could be performed, the investigation was unable to determine the events that led to the airplane’s impact with water.
Probable cause
The airplane’s impact with water for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STEINMAN MARK E
Model
LANCAIR 320
Amateur built
true
Engines
1 Reciprocating
Registration number
N670BS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
09-320-QB
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-24T05:01:01Z guid: 102682 uri: 102682 title: ERA21LA138 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102675/pdf description:
Unique identifier
102675
NTSB case number
ERA21LA138
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-02-25T13:26:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-03-09T00:11:54.436Z
Event type
Accident
Location
Panama City, Florida
Airport
Tyndall AFB (PAM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
Previous Similar Event According to the operator of the accident airplane, in May 2020 an industry competitor flying a similar make and model airplane experienced a loss of directional control during takeoff that was attributed to having traveled over a raised aircraft arresting system. The National Transportation Safety Board did not investigate the event. As a result of the event the operator of that aircraft prohibited crossing raised arresting gear systems with the nosewheels at high speed. The operator of the accident airplane was not aware of that event and that company’s policy change until after the accident. After Accident Safety Changes After the accident, the owner/operator incorporated numerous safety changes, which included an updated policy prohibiting crossing a raised aircraft arresting system at high speed, a one-time inspection of the NWS and ejection seats for their fleet of aircraft, a safety sharing information agreement with an industry competitor operating similar aircraft, and the hiring of a subject matter expert familiar with the airplane to provide operational consulting. They also modified their flight manual for ejection decisions in the event of a runway excursion, developed immediate action procedures for runway excursion, and developed procedures for a loss of directional control on landing. In addition, they made the results of the accident available to all pilots and mechanics and to all pilots during their initial training. - According to ATAC’s Mirage F1 flight manual, the airplane was equipped with electro-hydraulic nosewheel steering (NWS) that was commanded by the rudder pedals and available whenever a microswitch on the nose strut (weight-on-wheels switch) was compressed. The flight manual had a procedure for the symptom, “Aircraft Swerves During Taxi.” The action items directed the pilot to verify that the NWS caution light was out. If it was out, it specified to check the rudder trim, and if required, turn off the anti-slip switch. If that was unsuccessful, the pilot was to turn off the NWS switch. The airplane was equipped with ejection seats at both positions, capable of ejection at all altitudes and at all speeds between 0 and 620 knots. A sequence selector in the front cockpit was used to select the ejection sequence for either solo or dual flight operations In the DUAL position, both seats were connected for ejection by the ballistic manifold to the disconnecting block/disconnect unit to the airframe connection (Command Selector valve) at the front seat or Connector Unit (rear seat). If the rear cockpit initiated the ejection sequence, the rear seat ejected immediately, and the gas from the rear connector unit flowed to the front seat disconnect unit to begin the ejection sequence. A built-in 0.5 second delay occurred before the front seat ejection was initiated. Seat ejection was controlled by pulling the firing handle on the front of the seat bucket between the occupant’s thighs. At the time of the accident, neither the flight manual nor the operator had any limitation preventing operation of the airplane from a runway equipped with an aircraft arresting system. - The departure runway, 14R, was equipped with two standard United States Air Force operational aircraft arresting systems. They were located about 1,440 ft and 6,580 ft, respectively, from the approach end of runway 14R. The arresting system included a pendant cable suspended slightly above the runway by pendant support disks or donuts. The aircraft arresting system closest to the approach end of the runway 14R was in place and raised at the time of departure. Examination of the arresting system closest to the approach end of runway 14R revealed the pendant support disk or donut centered on the left side of the runway appeared to have an abrasion, but it could not be determined if the abrasion was from the accident airplane. Correlation of the suspended pendant cable with the nose and main landing gear of an exemplar airplane revealed the upper edge of a pendant support disk or donut was about the height of the lowest portion of the nose and main landing gear and also in proximity to the main landing gear anti-skid electrical connector. - On February 25, 2021, about 1126 central standard time, a Dassault Aviation Mirage F1B, N601AX, was substantially damaged when it was involved in an accident at Tyndall Air Force Base (PAM), Panama City, Florida. Both pilots sustained serious injuries. The airplane was operated as a public aircraft under the provisions of Title 49 of the United States Code Sections 40102 and 40125. The planned flight of the dual-seat, turbojet-powered fighter airplane was conducted under the provisions of a contract between by Airborne Tactical Advantage Company (ATAC) and the United States Air Force to provide ATAC owned and operated aircraft to support adversary training for U.S. military forces. The accident airplane was the lead of a two-airplane formation departure from runway 14R at PAM. As the lead, the accident airplane was lined up on the left side of the runway and the second airplane was lined up on the right side of the runway. The accident pilot reported that he initiated the takeoff roll with the nose gear steering selected to low. A line speed check was performed at 100 knots indicated airspeed (KIAS) and before the airplane had reached the arresting cable, located about 1,440 ft from the approach end of runway 14R. Everything was acceptable at that time. The takeoff roll continued and at about 125 KIAS, which was just after the airplane had crossed the arresting cable, the pilot reported, “there was this huge swerve to the left and it was an instantaneous swerve.” He applied full right rudder input and tapped the right brake, but without effect. The airplane drifted towards the left edge of the runway and the pilot applied aft elevator input, became airborne and flew in ground effect. The airplane accelerated and climbed while remaining in the same configuration (flaps and slats full, gear down). The pilot flew south over the water where he orbited numerous times to burn fuel and determine the condition of the airplane. The second airplane had aborted its flight during the takeoff roll. While orbiting over the water, the front- and rear-seat pilots reviewed the applicable emergency procedure checklists and discussed possible system failures, such as blown tires, brake and anti-skid failures, NWS failures, and loss of control. Nearby pilots provided a visual check of the landing gear and tires. The accident pilots’ operations base also provided input into the most likely cause of the problem. After considering all the possibilities, the consensus was that there was an issue with the left main landing gear. The pilot also stated that he was prepared to turn off the NWS if the airplane started veering after touchdown. After burning fuel and coordinating with air traffic control, the pilot returned to PAM to land on the right side of runway 14L. He touched down near the right edge of the runway. When the main landing gear contacted the runway, the rear-seat pilot deployed the airframe drag chute. The pilot put the nose down as soon as he landed and felt a significant pull to the left occurring soon after he relaxed left-wing-up control input. He applied full right rudder and brake but without effect. He did not turn off the NWS because of the rapid sequence of events. The airplane departed the runway onto the grass infield and the nosewheel landing gear collapsed. The rear-seat pilot initiated an unannounced ejection; the rear seat ejected successfully, but the front seat did not. The airplane continued to skid across the grass infield and then impacted a taxiway. When the airplane came to rest, the pilot secured the engine but was unable to get out of the airplane. Both occupants were rescued by responding emergency personnel and both had incurred serious injuries. - Examination of runway 14R was performed by representatives of the Federal Aviation Administration (FAA), the operator of the airplane, and the ejection seat manufacturer. Markings from the main and nose landing gear tires were first identified about 580 ft past the arresting system closest to the approach end of the runway. The markings were initially centered on the left side of the runway consistent with the takeoff position and appeared to swerve to the left. The marks from the main landing gear tires continued to the point where the airplane became airborne. At that location the left main landing gear was off the left side of the paved surface and the right main landing gear was left of the runway edge marking but still on paved surface. Further examination of the runway revealed damage to one runway edge light associated with the tire track from the right main landing gear. Following the accident, runway 14R was swept and the sweeper truck contained a component that was determined to be the missing anti-skid connector from the right main landing gear of the accident airplane. Examination of the landing runway, 14L, and the ground path revealed it could not be determined by physical evidence where the airplane touched down; however, based on video evidence the airplane appeared to touch down near the intersection of taxiway Delta, or about 7,000 ft before the departure end of the runway. Inspection of the runway revealed light residue from the nose landing gear tires and the marks from the nose landing gear tires showed a veer to the left. The marks from the nose and then main landing gear tires continued off the left side of the runway with the marks from the nose tires closer to the left main consistent with the airplane being yawed to the left. The marks from the tires continued onto the grass that was relatively flat except one area described as a “ramp,” or about an 18-inch rise in terrain. Immediately before the “ramp” marks in the grass were noted but no marks were noted for about 29 ft after the ramp. Either on the “ramp” or about 10 ft after the “ramp,” a section of the airplane’s floorboard or pressure bulkhead was found, while about 282 ft after the “ramp” large pieces of rear canopy were noted. The marks then continue across grass adjacent to the runway and also across taxiway Foxtrot then onto grass, where the airplane came to rest upright with the nose landing gear collapsed about 5,857 ft and 122° from the approach end of runway 14L. Examination of the airplane where it came to rest revealed the nose landing gear was collapsed aft and the anti-skid connector of the right main landing gear was separated. The drag chute was deployed and the air brakes, flaps, and slats were fully extended. The drag chute did not display any signs of scorching or damage. The cockpit rear canopy was shattered consistent with the ejection sequence, while the front cockpit canopy had a small section broken out on the rear left side. The main and nose landing gear tires were checked and all were satisfactory except the left nose tire, which registered 0 psi and exhibited tears in multiple areas. The rudder trim was set at, “0 or 30 minutes.” Examination of the front cockpit revealed the anti-skid switch was in the off position and the NWS disconnect switch was on with the guard covering the switch. The sequence unit selector valve in the front cockpit was selected to “Dual.” The front ejection seat, which did not deploy, was made safe before the airplane was recovered. Postaccident examination of the airplane following recovery was performed by representatives from the FAA, aircraft operator, and ejection seat manufacturer. Examination of the airframe revealed damage to the airframe attachment of the nose landing gear actuator, structural separation of pieces of the pressure bulkhead adjacent to the front seat lower ejection gun seat mount, and structural damage to fuselage forward of the forward edge of the forward windshield or canopy. Examination of the nose gear steering system revealed that the annular ball bearing outer race was fractured consistent with a static load, with no evidence of preimpact failure or malfunction. Testing of the NWS distribution block revealed that the nose landing gear went uncommanded “immediately” to the left 45°, which was inconsistent with switch position, rudder pedal position, and system design. According to a report from the ejection seat manufacturer representative and the operator, the airplane was travelling about 55 knots when the ejection was initiated by the rear seat occupant; the ejection was not verbalized or commanded. At that time the airplane was in a 10° nose-low attitude due to the collapsed nose landing gear. Inspection of the rear ejection seat revealed no issues. Inspection of front ejection seat by the ejection seat manufacturer representative revealed that the lower seat attachment bolt was broken and the upper seat attachment bolt was deformed; thus the seat was only secured by the upper attachment. Damage to the ejection gun window top latch was consistent with seat movement in the up direction. Further examination of the seat revealed the ballistic time release unit “sear” was dislodged from its housing and activated. That activation also released all of the pilot harness locks and the scissor link on top of the seat to release the main parachute. The disconnecting unit, which routes gas from the rear to front ejection seats to initiate ejection sequence, was disconnected from the front seat ballistic manifold. As a result of the separation, gas was discharged into the cockpit consistent with a report from the front-seat pilot. A pull test of the connections of the disconnect unit revealed no discrepancies. No other discrepancies were reported for the front ejection seat. -
Analysis
During takeoff roll from a runway equipped with a raised aircraft arresting system, the pilot of the turbojet-powered fighter airplane noted no discrepancies upon reaching 100 knots, and before the airplane had reached a raised aircraft arresting system that was present across the runway. The takeoff roll continued and at about 125 knots, which was just after the airplane had crossed the arresting system, the airplane suddenly swerved left. As the airplane neared the left edge of the runway it became airborne. While airborne and orbiting near the airport, the front- and rear-seat pilots reviewed the applicable emergency procedure checklists, discussed possible system failures, and had pilots from another airplane provide a visual check of the accident airplane’s landing gear. Based on the information provided and the lack of an annunciation of any problem with the nosewheel steering (NWS) system, the pilots attributed the sudden swerve to an issue with the left main landing gear. Although there was some discussion about a hard over of the NWS system, the pilot left it on but planned to turn it off if the airplane veered during the emergency landing. The pilot burned fuel and returned for landing on the right side of a 200-ft-wide runway. After touchdown the airplane veered to the left, travelled off the runway and onto the grass infield, and the nose landing gear to collapsed. The rear-seat pilot initiated an unannounced ejection, which should have resulted in the front seat also ejecting; however, the rear seat ejected successfully, but the front seat did not. The airplane came to rest and both pilots sustained serious injuries. A postaccident examination of the NWS system revealed that the annular bearing of the distribution block fractured in overload, with no evidence of preimpact failure or malfunction. The fracture likely resulted from travelling over the raised aircraft arresting system at a high speed, the shock from which traveled from the nose landing gear into the distribution block and resulted in a fracture of the bearing race. Because of the fractured bearing race, the distribution block commanded a left turn consistent with the condition reported by the pilot during takeoff and landing. Although the airplane checklist for failure of the NWS did not include a loss of control during takeoff, it is likely that had the NWS been disconnected upon landing when the nosewheel touched down, directional control would have been possible using differential braking for directional control authority and the airplane likely could have been stopped safely on the runway. The postaccident examination of the front seat pilot’s ejection seat determined that it did not eject from the airplane because of impact damage to aircraft structure that secured the lower ejection seat gun mount, which resulted in movement of the seat and subsequent separation of a gas line from the rear seat to the front seat, which made ejection of the front seat impossible.
Probable cause
Nose landing gear contact with a raised aircraft arresting system during takeoff, which damaged components of the nose wheel steering system and resulted in an uncommanded left turn and loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DASSAULT AVIATION
Model
MIRAGE F1 B
Amateur built
false
Engines
1 Turbo jet
Registration number
N601AX
Operator
AIRBORNE TACTICAL ADVANTAGE COMPANY
Second pilot present
true
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Commercial sightseeing flight
false
Serial number
502
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-09T00:11:54Z guid: 102675 uri: 102675 title: CEN21LA156 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102750/pdf description:
Unique identifier
102750
NTSB case number
CEN21LA156
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-09T14:15:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-03-18T02:37:07.781Z
Event type
Accident
Location
Poplar Bluff, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 9, 2021, about 1215 central standard time, a Cessna 170A, N9515A, was substantially damaged when it was involved in an accident near Poplar Bluff, Missouri. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he departed Shawnee Regional Airport (SNL), Shawnee, Oklahoma, about 0900, for the cross-country flight to Poplar Bluff Regional Business Airport (POF), Poplar Bluff, Missouri. The airplane was equipped with a communication radio, but it was not equipped with very high frequency omni-directional range (VOR) equipment or a transponder. Although he had access to a handheld Garmin GPSmap 396 device, the pilot did not use it to navigate during the flight. The pilot stated that he navigated via dead-reckoning and following roads. He occasionally referenced a mobile phone application to verify the airplane’s position on a digitized visual flight rules (VFR) sectional chart. The pilot acknowledged that he did not have traditional paper VFR sectional charts to navigate with if his mobile phone’s battery became depleted during the flight. About 15-20 minutes before reaching Poplar Bluff, Missouri, the pilot’s mobile phone powered off after its battery became depleted. The pilot stated that he then inserted the Garmin adapter into the airplane’s cigarette-lighter socket, but the GPS device did not power on. The pilot continued flying his current heading, which took him directly over the city of Poplar Bluff, Missouri. The pilot did not see the airport to the east of the city, so he turned and flew a couple miles south of the city before he made a 180° course reversal and flew over the city northbound. After flying several miles north of the city, he decided to locate a suitable field for a precautionary landing due to the airplane’s low fuel status. The left fuel tank gauge indicated “empty” and he estimated that the airplane had about 10 minutes of fuel remaining in the right fuel tank. He turned the airplane into the wind and landed in what he believed to be a suitable field. The pilot stated that the engine was still running throughout the precautionary landing. After touchdown, the airplane rolled about 200-300 ft before the main landing gear dug into the soft terrain and the airplane nosed over. The airplane sustained substantial damage to the vertical stabilizer and the engine mounts. During a telephone interview, the National Transportation Safety Board investigator asked the pilot to connect the Garmin GPSmap 396 device to his vehicle’s 12-volt direct current (DC) cigarette-lighter socket by means of the Garmin cigarette-lighter adapter. The GPS device automatically powered-on when connected to the power source, with and without the device’s battery installed. When disconnected from the power source, the GPS device did not power-on with battery installed. The last known position displayed on the GPS device was from a flight completed two days before the accident. The airplane wreckage was recovered to a secured location where it was examined by two Federal Aviation Administration (FAA) airworthiness inspectors. The airframe battery was removed from the airplane during wreckage recovery. The 12-volt battery was not an aviation-certified battery and was consistent with a motorcycle battery. Without any electrical load, the battery had 12.45 volts when tested with a digital multimeter. The battery had 11.8 volts when it was connected to an automotive battery tester that subjected the battery to a 5-second electrical load. The battery was then reconnected to the airplane and, when the master switch was turned on, the communication radios powered on and the cigarette-lighter socket had 12.45 volts when measured with a digital multimeter. The FAA inspector inserted his personal USB charger adapter into the cigarette-lighter socket and confirmed that there was sufficient power to charge his mobile phone. Additional bench testing of the alternator, voltage regulator, and battery did not reveal any anomalies that would have prevented normal operation of the airplane’s electrical system. -
Analysis
The pilot was conducting a cross-country flight and became lost as he neared his intended destination. During the flight, the pilot navigated via dead-reckoning and following roads. He occasionally referenced a mobile phone application to verify the airplane’s position on a digitized visual flight rules (VFR) sectional chart. The pilot did not have traditional paper VFR sectional charts to navigate with, if his mobile phone’s battery became depleted during the flight. Although he had access to a handheld GPS device, he did not use the device to navigate during the flight. About 15-20 minutes before reaching the intended destination, the pilot’s mobile phone powered off after its battery became depleted. The pilot then inserted the GPS power adapter into the airplane’s cigarette-lighter socket, but the GPS device did not power-on. The pilot continued on the current heading that took the airplane over his intended destination, but he could not locate the airport and subsequently decided to make an off-airport precautionary landing before the airplane ran out of fuel. The pilot landed the airplane in what he believed to be a suitable field; however, after touchdown, the airplane’s main landing gear dug into soft terrain and the airplane nosed over. The airplane sustained substantial damage to the vertical stabilizer and the engine mounts. Postaccident examination and testing did not reveal any electrical system anomalies that would have prevented the pilot from using the airplane’s cigarette-lighter socket as a power source for his mobile phone and handheld GPS during the flight. Additional bench testing of the alternator, voltage regulator, and battery did not reveal any anomalies that would have prevented normal operation of the airplane’s electrical charging system.
Probable cause
The pilot’s decision to make a precautionary landing in a field that contained soft terrain, which resulted in the airplane nosing over. Contributing to the accident was the pilot’s decision to fly without a printed VFR sectional chart to identify the location of the destination airport.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170
Amateur built
false
Engines
1 Reciprocating
Registration number
N9515A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
19383
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-18T02:37:07Z guid: 102750 uri: 102750 title: WPR21LA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102758/pdf description:
Unique identifier
102758
NTSB case number
WPR21LA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-15T11:30:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-03-26T05:09:31.771Z
Event type
Accident
Location
Leadore, Idaho
Airport
LEADORE (U00)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 15, 2021, about 1030 mountain daylight time, a Cessna T210M airplane, N886KH, was substantially damaged when it was involved in an accident near Leadore, Idaho. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.  In a written statement, the pilot described the flight to Leadore Airport (U00), Leadore, Idaho, as smooth and uneventful. After arriving over the airport, the pilot circled runway to determine the wind direction for landing and examine the airport runway surface conditions. After the airplane landed on runway 29, the pilot applied brake pressure. According to local law enforcement, the pilot reportedly landed about 1/3 of the length down the runway at an airspeed of about 80 knots. Shortly after the pilot’s application of brake pressure, he realized the “brakes were not effective” and that he needed to apply more pressure during the landing roll. The airplane subsequently veered to the right, exiting the runway near the departure end. The airplane continued across the airport property impacting a small berm and came to rest near a building. The elevation at U00 is 6,029 ft mean sea level (msl) and runway 29 is a 3,500 ft long “rough”-surfaced runway. Accident site photos revealed that the approach end of runway had freshly mowed bunchgrass, while the remaining runway was covered in deteriorated asphalt and gravel. The first identifiable contact with the runway surface was a set of marks consistent with skidding tires, about 2,600 ft from the approach end of the runway, with about 900 ft of runway remaining. The skid marks continued off the runway and traveled through low sagebrush, impacting a small berm, through a barbed wire fence with metal poles, and ended near the main wreckage. The main wreckage was found about 420 ft from the departure end of the runway. The right main landing gear brake line near the wheel brake assembly was bent downward and separated from the caliper’s B-nut fitting. The horizontal stabilizers and elevators had substantial damage and the left main landing gear collapsed. The flaps were set to about 30°. A postaccident examination of the airplane’s brake system was conducted. The brake pedals were activated and showed no pressure and some residual brake fluid in the system. The right main landing gear brake hydraulic line was separated near the caliper and line fitting. Examination of the separated hydraulic line fracture surfaces were consistent with an overstress fracture. No other anomalies were noted. The Pilot’s Operating Handbook contained landing distance information for a dry, paved surface runway. Investigators calculated the airplane’s landing performance based on ambient temperature, calm wind, zero runway slope, an airplane maximum weight, 6,000 ft msl and flaps at 30°. Estimated landing distance over a 50 ft obstacle and ground roll were 1,710 and 905 ft, respectively. -
Analysis
The pilot circled the runway to determine the wind direction and examine the runway surface conditions. The runway surface consisted of deteriorated asphalt and gravel. The pilot reportedly touched down 1/3 the way down the runway and experienced a lack of braking effectiveness. He then pushed the brake pedal to the floor as he neared the end of the runway. The airplane exited the runway near the departure end, continued across the airport property, and impacted a small berm before coming to rest near a building. The first identifiable marks on the runway were skid marks that began 2,600 ft down the 3,500 ft long runway and continued off the runway. Tire marks continued over the rough terrain, over the berm and through a barbed wire fence before where the airplane came to rest. It is likely that the airplane’s brakes were not effective due to the deteriorated asphalt and gravel on the runway surface. Also, it is likely that the pilot applied an abundance of pressure due to the lack of runway remaining, preventing the proper braking for the runway surface condition. During the postaccident examination the right main landing gear brake line was separated near the caliper and line fitting. The line was examined and determined that the fracture surfaces were consistent with an overstress fracture. It likely that the line was damaged during the accident sequence. The pilot’s decision to land long on a gravel runway likely resulted in an inability to maintain control of the airplane during the landing roll.
Probable cause
The pilot’s failure to attain the proper touchdown point on a graveled surfaced runway with insufficient landing performance and subsequent loss of control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210M
Amateur built
false
Engines
1 Reciprocating
Registration number
N886KH
Operator
Lexi Air LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21061727
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-03-26T05:09:31Z guid: 102758 uri: 102758 title: ERA21LA155 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102766/pdf description:
Unique identifier
102766
NTSB case number
ERA21LA155
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-15T16:14:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-04-02T21:13:11.281Z
Event type
Accident
Location
Monroe, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 15, 2021, about 1514 eastern daylight time, a Socata MS894A airplane, N42BF, was substantially damaged when it was involved in an accident in Monroe, Georgia. The pilot sustained minor injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to the pilot, about 1400 on the day of the accident, he obtained weather and notice of air mission information for a roundtrip flight from Gwinnett County Airport – Briscoe Field (LZU), Lawrenceville, Georgia, to Cy Nunnelly Memorial Airport (D73), Monroe, Georgia, to perform practice landings. The wind was reported to be from 110° at 10 knots gusting to 15 knots at LZU and from 070° at 10 knots gusting to 15 knots at D73. The pilot reported that he had performed a preflight insepction, which included checking the cowling latches, and that the results were “normal.” The pilot also reported that taxi, takeoff, and departure were normal and that he elected not to have flight following for the short local flight. The airplane departed LZU about 1450 and flew to D73 at 3,500 ft mean sea level (msl), and the pilot received the latest automated weather observing system report for D73, which indicated that the wind was from 080° at 10 knots gusting to 15 knots with occasional gusts to 20 knots. The pilot delayed his traffic pattern entry to allow a Cessna to enter the left downwind leg of the traffic pattern for runway 2, and then the accident airplane entered a standard left downwind from a 45° entry once the pilot had the Cessna in sight. The Cessna landed uneventfully, and the accident airplane turned onto the final approach leg once the Cessna cleared the runway. The pilot performed a normal crosswind touch-and-go landing but noticed that the wind was increasing and decided to return to LZU earlier than planned. The airplane climbed straight out to pattern altitude, turned westbound toward LZU, and leveled off at 2,500 ft msl. The pilot received the automatic terminal information service information report, which indicated unchanged conditions since the time of the airplane’s departure. When the airplane was 16 miles from LZU, the cowling “suddenly” departed the airplane and struck the right side of the windscreen, puncturing a large hole from just left of the center post to about 10 inches from the right canopy bow. The pilot “was blasted with wind,” the airplane’s nose dropped sharply, and the airplane started to yaw sharply left and right. The pilot stated that he struggled to regain control and was not certain that the airplane was flyable. The pilot was eventually able to regain control, but the airplane would not turn right as easily as it turned left, so the pilot started a left descending turn. He hoped to fly to D73 and land. The pilot determined the airplane responded better at lower speeds, but the airplane was not able to maintain level flight, even with full power; at that point, the pilot realized that he needed to select an off-field landing site. The pilot continued to turn the airplane left while in a continuous descent. The airplane was unable to level off or climb. The pilot could look only to the left because of the intensity of the wind blast from the hole on the right portion of the windscreen, which also caused his prescription eyeglasses and headset to blow off. The pilot selected a large field running east-west that looked “fairly unobstructed” and would give him “a short run-out area.” The pilot was maintaining around 60 knots, and the leading-edge slats deployed normally. The pilot elected to not use flaps because he was concerned about changing the airplane’s configuration given the damage that the airplane had already sustained. The airplane touched down hard on the main gear about one-third of the way down the field, bounced, and touched down again at a point where the terrain started sloping uphill. The pilot started braking, and the airplane slowed but continued rolling until it struck a large tree and a free-standing swing on an Aframe on residential property, causing substantial damage to the horizontal stabilizer and right wing. The pilot reported that, according to the sheriff’s department, the cowling was located near the point where the airplane touched down. The pilot believed that “the cowling had been lodged on the empennage and only dislodged when [he] landed.” Wreckage and Impact Information Postaccident examination of the cowling latching mechanism revealed that all four lower catches were intact. Examination of the upper levers revealed that the left forward upper lever displayed wear and corrosion and appeared to be broken. Further examination of the left forward upper lever and the right forward upper lever (used as an exemplar) revealed that both consisted of an outer housing that could be actuated over the latch assembly, affixed by two separate rivets. On the intact latch, a hook (the upper catch) was affixed to the latch through a riveted U-shaped clasp (the spring) that was inserted into a T- shaped shaft (the trunnion) and held in place via a cotter pin. This shaft was joined to the latch body by a shear pin. The hook and shaft subassembly appeared to be missing in the broken latch. On the right forward upper lever (the exemplar lever), just outside of the hook and clasp, randomly oriented scratch marks were located on the inside face. These scratches were also on the inside surface of the latch body on the broken latch. The number of scratches, as well as their depth and location, were comparable on both latch interiors. Further examination of the broken latch revealed that the pin was missing from the pinhole on its right side, the riveted connection was still intact, and the damage around the pin hole was consistent with smearing of material from an adjacent component sliding along the surfaces. The smearing direction was generally outward and parallel to the sliding and impact damage on the adjacent rivet head. In addition, material was deformed outward from the pin hole, including outward smearing on the hole edge. This deformation was parallel to and consistent with the other smearing features on the latch body interior. The opposite interior sides of the broken latch also exhibited a riveted connection with the outer housing adjacent to the pinhole, but the amount of damage was confined to circular wear marks around the pin hole. These wear marks were about 0.03 inches in width and were located around the opposite sides of the pin. These marks were consistent with interaction of the latch body surface with the sidewall of the T-shaped shaft. No other indications of damage were found on the broken cowling latch. The witness marks and the absence of the hook and shaft subassembly were consistent with the loss of the pin. Additional Information The pilot advised that he performed the cowling latch check (during the preflight inspection before the accident flight) according to Socata Rallye Service Bulletin 107. The pilot also advised that the airplane complied with Federal Aviation Administration (FAA) Airworthiness Directive (AD) 76-11-02. Review of Socata Rallye Service Bulletin 107 and AD 76-11-02 indicated that they were issued to prevent the possible loss of an engine cowling on Socata airplanes due to improper latching of locks and cowl lock wear. Further, AD 76-11-02 required the following: For airplanes incorporating Socata-type engine cowl locks, within the next 25 hours time in service after the effective date of this AD, and thereafter at intervals not to exceed 100 hours time in service from the last inspection – (1) Visually inspect the engine lower cowling metal centering tabs and the upper cowling centering pins, for wear of the metal tab receiving holes and wear of the centering pins to assure proper mating of the upper and lower cowling. Replace the metal centering tabs and cowling centering pins, found to be worn; and (2) Inspect the engine cowling locking mechanism and if deterioration in locking push force is evident as demonstrated by a lack of snap action on the latch locking lever, adjust the Socata type engine cowl lock by removing the cotter pin in the upper catch, threading the latch trunnion into the upper catch a distance of one or more turns, and reinserting the cotter pin in accordance with the procedure described in paragraphs 1 .2 and 3.1 of Socata Service Bulletin No. 107 Gr. 71-06, dated November 1972, or an FAAapproved equivalent. The accident airplane’s maintenance records showed the following: - On March 22, 1977, at an unknown time in service, AD-76-11-02 was first accomplished. The entry indicated that the cowl was inspected and “needed no adjustment.” - On June 2, 1981, at 371 hours in service, the “cowling latch” was inspected. The entry stated, “no adjustment needed.” - On October 1, 1989, at 464 hours in service, an entry stated, “76-11-02 No adjustment required.” - On August 21, 2006, at 580 hours in service (116 hours since the last entry), AD-76-11-02 was accomplished. - On September 1, 2011, at 799 hours in service (219 hours since the last entry), the inspection was accomplished “with no defects noted.” - On January 1, 2013, at 836 hours in service, the inspection was accomplished with “no defects noted.” - On May 22, 2014, at 873 hours in service, the inspection was accomplished with “no defects noted.” - On October 1, 2015, at 901 hours in service, the inspection was accomplished with “no defects noted.” No other entries regarding compliance with the AD were noted after the October 1, 2015, inspection. At the time of the accident, the airplane had accrued 1,105 hours of service (about 204 hours since the October 2015 inspection). Additionally, the maintenance records contained an AD compliance report for the airplane, dated January 5, 2021, which listed the AD as “PCW” (previously complied with), even though the AD was considered to be a recurring AD. -
Analysis
After takeoff from his home airport, the pilot flew his airplane to a nearby airport to practice landings. After arrival at the nearby airport, the pilot performed a touchandgo landing but decided to return to his home airport because the wind was increasing. When the airplane was in level flight at 2,500 ft mean sea level and was about 16 nautical miles from the destination airport, the upper portion of the engine cowling departed the airplane, punctured the windscreen, and became lodged against the empennage; as a result, the pilot had difficulty controlling the airplane, which was no longer able to maintain level flight. The pilot elected to make a landing in a field, and the airplane struck a large tree and a swing on residential property. During the separation of the cowling and the subsequent forced landing, the airplane sustained substantial damage. Postaccident examination of the cowling latching mechanism revealed that all four lower catches were intact, but the left forward upper lever was worn and corroded and had broken, causing the upper engine cowling to depart the airplane. Further examination of the broken latch also revealed that the latching mechanism, which had been attached to the handle, was missing along with the shear pin, which kept the latching mechanism attached to the handle. The hook and shaft subassembly appeared to be missing in the broken latch. Also, the pinhole where the mechanism’s right side would have been attached, displayed damage around the pinhole, consistent with the smearing of material from an adjacent component sliding along the surfaces. The smearing direction was generally outward and parallel to the sliding and impact damage on the adjacent rivet head. In addition, material was deformed outward from the pinhole, including outward smearing on the hole edge. This deformation was parallel to and consistent with the other smearing features on the latch body interior. Witness marks and the absence of the hook and shaft subassembly were consistent with the loss of the pin. Thus, when the shear pin, which was not recovered, fractured, the pin remnant likely came out of one of the holes and then tore out of the other hole in a bending direction, damaging the adjacent housing rivet head. The pilot had performed, as part of his pre-flight inspection before the accident flight, a check of the cowling latches in accordance with a manufacturer service bulletin and a Federal Aviation Administration airworthiness directive (AD), both of which had been issued to prevent the possible loss of an engine cowling due to improper latching of locks and cowl lock wear. The pilot reported that the preflight inspection was “normal.” The AD required in part that, maintenance personnel visually inspect the engine lower cowling metal centering tabs and the upper cowling centering pins for wear of the metal tab receiving holes and wear of the centering pins to ensure proper mating of the upper and lower cowling. The metal centering tabs and cowling centering pins were to be replaced if found to be worn. The AD also required maintenance personnel to inspect the engine cowling locking mechanism and, if deterioration in locking push force is evident, adjust the engine cowl lock by removing the cotter pin in the upper catch, threading the latch trunnion into the upper catch a distance of one or more turns, and reinserting the cotter pin. These inspections were to occur within 25 hours after the AD was issued and then within 100 hours of time in service from the last inspection. Review of the airplane’s maintenance records found logbook entries from 1977 to 2015 that indicated that the recurring AD had been accomplished and that no adjustments were needed, and no defects were noted. However, the AD was not consistently performed according to the specified time requirement. Additionally, between the time of the last inspection and the accident, the airplane had been operated for about 204 hours, but maintenance records showed no other entries indicating compliance with the AD. The most recent document in the logbook, an AD compliance report for the airplane, showed that the AD was previously complied with, even though it was a recurring AD. Therefore, the upper engine cowling likely separated from the airplane due to maintenance personnel’s failure to perform the required inspection of the engine cowling latches.
Probable cause
Maintenance personnel’s failure to properly inspect and maintain the airplane’s engine cowling latches, which resulted in the in-flight separation of the engine cowling and a subsequent forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SOCATA
Model
MS894A
Amateur built
false
Engines
1 Reciprocating
Registration number
N42BF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11930
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-02T21:13:11Z guid: 102766 uri: 102766 title: ERA21LA156 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102767/pdf description:
Unique identifier
102767
NTSB case number
ERA21LA156
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-16T13:52:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-04-12T18:14:03.618Z
Event type
Accident
Location
Groveland, Florida
Airport
Seminole Lake Gliderport (6FL0)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On March 16, 2020, at 1252 eastern daylight time, an experimental Schempp-Hirth K G Mini Nimbus C glider, N16MG, was substantially damaged during a glider competition held at the Seminole Lake Gliderport in Groveland, Florida. The pilot sustained serious injuries. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness described that the glider was on the takeoff roll on runway 18 under aerotow when the left wing dipped and struck the ground, and the glider began to swerve to the left. The pilot released from the towplane and the glider departed the left side of the turf runway. The glider crossed over a paved airport road oriented parallel to the runway, and impacted an unoccupied parked pickup truck, located about 500 ft from the north end of runway 18 and about 150 ft left of the runway centerline. The pilot reported that his glider was lined up on the left side of the runway with the left wingtip about 1 ft from the edge of the runway. Immediately after the towplane began to roll, the glider yawed to the left as the left wing dropped to the ground. As the glider approached the access road, he attempted to release from the tow plane; however, his hand slipped off the release handle. He was subsequently able to release and then attempted to turn and stop before colliding with the truck, but he was unsuccessful. He reported that there were no mechanical malfunctions with the glider that would have precluded normal operation. The towplane pilot reported that the takeoff was performed on the east side of runway 18, and that the line up, rope hookup, and rope tensioning were normal. The wind was from the south at 12 to 15 knots. The tow pilot aborted the takeoff after he observed the glider’s release from the tow rope. Examination of the accident site by a Federal Aviation Administration inspector revealed that the glider sustained substantial damage to the forward fuselage, which was crushed and separated forward of the pilot’s seat. The right wing sustained leading edge impact damage that extended aft of the wing spar, between 1 and 4 ft outboard of the wing root. Flight control continuity was established from the cockpit controls to the control surfaces. The pilot reported that the truck was parked in an area where the event organizers had asked participants to not park. The truck was parked perpendicular to the runway, about 30 ft (to the east, or left) from the single-lane access road that ran parallel to the runway at the runway’s left edge. A review of the guidance materials provided to the event participants revealed a diagram (see figure) that depicted hashed areas on either side of the runway which were denoted as “landing rolloff areas” that were to be clear of personnel and vehicles during landing operations. The width of the hashed areas was not specified. The text portion of the parking guidance indicated that parking was permitted “before the launch” on either side of the runway “at the north end.” An approved trailer parking area was located about 50 ft directly east of the truck against a tree line. Approximate location of Collision with Truck Figure - Diagram of Facility -
Analysis
On the day of the accident, the pilot was participating in a glider competition event. During the takeoff roll under aerotow, the glider yawed to the left as the left wingtip dropped to the ground. As the glider approached an access road east of the runway, the pilot attempted to release from the tow plane; however, his hand slipped off the release handle. He was subsequently able to release from the tow plane and attempted to turn and stop but was unsuccessful. The glider struck an unoccupied parked pickup truck. The pilot was seriously injured, and the glider sustained substantial damage to the forward fuselage and right wing. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation. If the pilot’s initial attempt to release from the tow plane had been successful, it likely would have allowed him more time to reduce speed or change course before the collision. The reason for the left yaw was not identified. The truck was parked in or near a strip along the left side of the runway that was to remain clear of personal vehicles during landing operations. Had the truck instead been parked in the designated parking area, the collision may have been prevented or its severity may have been reduced.
Probable cause
The pilot’s unsuccessful initial attempt to release from the tow plane at the start of an unstable takeoff roll, which resulted in a runway excursion and collision with a parked vehicle. Contributing to the severity of the accident was the vehicle’s proximity to the active runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHEMPP-HIRTH K G
Model
MINI-NIMBUS C
Amateur built
false
Registration number
N16MG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
104
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-12T18:14:03Z guid: 102767 uri: 102767 title: WPR21LA141 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102801/pdf description:
Unique identifier
102801
NTSB case number
WPR21LA141
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-24T01:21:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-04-08T02:20:09.81Z
Event type
Accident
Location
Animas, New Mexico
Airport
FORT STOCKTON-PECOS COUNTY (FST)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On March 24, 2021, 0021 mountain daylight time, a Mooney M20B, N74786, was substantially damaged when it was involved in an accident near Animas, New Mexico. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while on an instrument flight rules (IFR) flight plan from Fort Stockton-Pecos County Airport (FST), Fort Stockton, Texas, to Tucson International Airport (TUS), Tucson, Arizona, the airplane was accumulating light rime ice at 8,000 ft mean sea level (msl). He contacted Albuquerque Air Route Traffic Control and was instructed to climb to 14,000 ft msl. During the climb to 14,000 ft, the pilot reported climbing into clouds; the engine began to run rough and lost partial power. He applied carburetor heat and checked both magnetos. The pilot believed that he had lost both magnetos. The airplane became the subject of an alert notice (ALNOT) after radio communication and radar contact was lost. According to responding law enforcement, the airplane came to rest in mountainous terrain at an elevation about 5,010 ft msl about one mile northwest of Pinkey Wright Mountains. A postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. The magnetos remained secured and attached to their respective mounting pads on the engine. Both magnetos were removed and manually rotated with spark observed at each P-lead. Flight control continuity was established from the cockpit to all the flight control surfaces via their respective cables and hardware. METEOROLOGICAL INFORMATION The closest recorded aviation weather station was Grant County Airport (KSVC), Silver City, New Mexico, about 44 miles northeast of the accident site at an elevation of 5,446 ft msl. Recorded weather at 0015 included wind from 300° at 9 knots, 10 miles visibility in light rain, a broken ceiling 1,300 ft above ground level (agl), an overcast cloud layer at 2,200 ft agl, temperature 35° F, dew point 33°F, altimeter 29.79 inches of mercury (inHg). AIRMET advisories for mountain obscuration conditions, moderate turbulence below 16,000 ft, and moderate icing between the freezing level and 20,000 ft msl were valid for the area of the accident site at the time of the accident. The atmospheric sounding supported an overcast layer of clouds with bases near 200 ft agl and tops to 16,000 ft msl, rain showers, and a freezing level of 1,400 ft agl (6,400 ft msl). The sounding also supported the potential for light to moderate turbulence between 5,800 and 17,000 ft. Light rime to clear type icing in the clouds was identified between 6,400 ft and 16,000 ft. The Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, stated the following: Pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. The special airworthiness information bulletin included a chart that showed the probability of carburetor icing for various temperature and relative humidity conditions. According to that chart, the weather conditions at the time of the accident were conducive to serious carburetor icing at cruise power. -
Analysis
During a night instrument flight rules cross-country flight, the airplane encountered weather that included clouds and icing conditions. Shortly thereafter, the engine began to run rough and lose power; radar contact was lost, and the airplane was located in mountainous terrain. Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. Weather conditions reported at the time of the accident were conducive to the formation of serious carburetor icing at cruise power settings. The pilot reported that, during a climb into clouds, with the carburetor heat off, the engine began to run rough and was losing rpms before he applied carburetor heat. Therefore, it is likely that carburetor ice accumulated during the climb, which resulted in a partial loss of engine power.
Probable cause
The pilot’s delayed use in the operation of carburetor heat which resulted in a loss of engine power due to carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20B
Amateur built
false
Engines
1 Reciprocating
Registration number
N74786
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1786
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-08T02:20:09Z guid: 102801 uri: 102801 title: WPR21FA143 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102813/pdf description:
Unique identifier
102813
NTSB case number
WPR21FA143
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-27T19:36:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-04-08T05:30:24.741Z
Event type
Accident
Location
Palmer, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
5 fatal, 1 serious, 0 minor
Factual narrative
Heli-Ski Guides Two passengers aboard the accident flight were heli-ski guides who TML contracted for the accident flight. Guides provide a critical safety role during a flight, and their responsibilities can include loading and unloading passengers, understanding surface snow conditions, and coordinating with pilots about landing and pickup zones. The HSUS operating guidelines specify duties for guides during the approach and landing, which include assisting the pilot with hazard and pickup zone identification, confirming clearances to terrain features on short final, and ensuring passenger safety after landing. TML offered annual training to heli-ski guides working at its operation each season, which the accident guides attended in January 2021. TML was listed on the HSUS website as a member at the time of the accident. HSUS designated the accident guides as lead guides. According to HSUS, a lead guide is “an individual designated by an Outfitter to supervise the activities of one or more Groups and who meets the recommended qualifications for that position as established in the Guide Qualification Guidelines.” One of the accident guides was designated as the senior lead guide for the flight. Flight-Locating Information Soloy Helicopters had delegated flight-locating responsibilities to TML. The NTSB requested that the FAA provide a definition or clarification for the term “flight locating” given that the Federal Aviation Regulations did not define that term. The FAA acknowledged that “flight locating” is not defined but stated that 14 CFR 135.79, Flight Locating Requirements, stated that procedures were required to be established for locating each flight for which an FAA flight plan is not filed. The regulation specified the following procedures: 1. Provide the certificate holder with at least the information required to be included in a VFR flight plan. 2. Provide for timely notification of an FAA facility or search and rescue facility, if an aircraft is overdue or missing. 3. Provide the certificate holder with the location, date, and estimated time for reestablishing communications, if the flight will operate in an area where communications cannot be maintained. The regulation also required that flight-locating information be retained at the certificate holder's principal place of business, or at another place designated by the certificate holder in its flight-locating procedures, until the completion of each flight. Flight-following was not defined for Part 135 operations and was not required for aircraft operating under Part 135. The term “flight follower” generally refers to personnel who perform various flight support duties. - The accident helicopter was equipped with a Garmin Aera 660 GPS, which was certified for visual flight rules (VFR) flight but had the capability to display IFR procedures and maps. The helicopter was also equipped with a Kannad 406-MHz AF Compact emergency locator transmitter (ELT) that was installed on the upper right side of the right baggage compartment. - On March 27, 2021, about 1836 Alaska daylight time, an Airbus Helicopters AS350-B3, N351SH, was substantially damaged when it was involved in an accident near Palmer, Alaska. The pilot and four passengers were fatally injured, and one passenger was seriously injured. The helicopter was operated under Title 14 Code of Federal Regulations (CFR) Part 135 as an on-demand air charter flight. Representatives from the operator, Soloy Helicopters, reported that the helicopter was under contract to Tordrillo Mountain Lodge (TML) to transport passengers from a private residence on Wasilla Lake, Wasilla, Alaska, to the Chugach Mountains to conduct heli-ski operations. (The Organizational and Management section of this report provides additional information about Soloy Helicopters and TML.) According to Heli Ski US (HSUS), which is a trade association that promotes helicopter skiing safety and provides support, heli-ski operations involve a “helicopter [that] is utilized to provide up-hill transportation for participants” of “guided winter recreation activities including, but not limited to skiing.” GPS data showed that the helicopter arrived at the Wasilla Lake residence about 1450. About 53 minutes later, the helicopter departed the residence and flew toward the Chugach Mountains. The surviving passenger recalled “nice” but “kind of creepy weather” in the mountains, which delayed the departure for the ski trip. The helicopter arrived at the intended operating area about 19 minutes later and subsequently flew multiple runs between about 1612 and 1807. GPS data showed that the helicopter departed for the last run of the day at 1827:05 on a northwest heading and climbed to about 5,900 ft mean sea level (msl). The helicopter's final movements began about 1833 over a ridgeline at an altitude of 6,266 ft msl (about 14 ft above ground level) and at a groundspeed of 1 knot. The helicopter maintained its low altitude and groundspeed as it maneuvered over the ridgeline. The data track ceased at 1836:42 near the location of the accident site, which is shown in figure 1. Figure 1. Location of departure point, previous operating areas, and the accident site. The surviving passenger stated that the passengers had completed five or six runs and that the accident occurred while the helicopter was relocating for the last run of the day. The surviving passenger also stated that the pilot first attempted to land the helicopter normally on the ridgeline but that the helicopter subsequently “went up to try to get into the right position.” The surviving passenger further stated that the snow was “real light” and that, while the pilot was attempting to land a second time, the helicopter was “engulfed in a fog, which made it appear like a little white room.” The passenger recalled that another passenger yelled “don’t do it” three times just before the helicopter “began going backward real fast and impacted the rocky mountainside several times.” - Pilot The State of Alaska Medical Examiner’s Office in Anchorage performed an autopsy of the pilot. His cause of death was multiple blunt force injuries. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory detected no tested for substances. Ski Guides According to the autopsy inspection report (which comprised an external examination only) issued by the State of Alaska Medical Examiner’s Office, the senior lead guide’s cause of death was blunt force head injury. Toxicology tests performed by NMS Labs identified the following in the senior lead guide’s blood specimen: amphetamine at 96 ng/ml, cocaine at 52 ng/ml, and the inactive cocaine metabolite benzoylecgonine at 1,000 ng/ml. The autopsy inspection report for the other lead guide showed that his cause of death was multiple blunt force injuries. Toxicology tests of the lead guide’s blood specimen performed by NMS Labs identified delta 9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, at 1.1 ng/ml. Amphetamine is a central nervous system stimulant drug that is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, a prescription drug is metabolized to amphetamine; commonly marketed names include Adderall, Dexedrine, and Vyvanse. Amphetamine may also be produced and used illicitly. Cocaine is another central nervous system stimulant drug. Initial effects of cocaine use include euphoria, excitation, general arousal, dizziness, increased focus, and alertness. At higher doses, effects can include psychosis, confusion, delusions, hallucinations, fear, antisocial behavior, and aggressiveness. Late effects, beginning within 1 to 2 hours after use, include depression, agitation, nervousness, drug craving, fatigue, and insomnia. Additional performance effects would be expected after higher doses, with chronic ingestion, and during drug withdrawal, including agitation, anxiety, distress, inability to focus on divided-attention tasks, inability to follow directions, confusion, hostility, time distortion, and poor balance and coordination. THC's mood-altering effects include euphoria and relaxation. Also, THC can cause alterations in motor behavior, perception, cognition, memory, learning, endocrine function, food intake, and body temperature regulation. Specific performance effects may include a decreased ability to concentrate and maintain attention. In addition, impairment in retention time and tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided-attention tasks have been reported. Significant performance impairments are usually observed for at least 1 to 2 hours after marijuana use, and residual effects can occur for up to 24 hours. THC may be detected at low levels in the blood for days or weeks after use. - At 1600, the Anchorage, Alaska, upper air sounding wind profile indicated light surface wind from the north above the surface with little directional variation with height and increasing wind speed. At an altitude of about 6,000 ft, the wind was from 350° at 21 knots with a temperature of -17°C. The sounding was characterized as conditionally unstable below 6,000 ft and stable above that level. The Universal Rawinsonde Observation analysis program sounding supported light turbulence below 8,000 ft and mountain wave activity. The northerly wind south of the ridgeline (the accident location) would have resulted in a general downslope wind flow near the accident site. A pilot operating on Knik Glacier (near the accident site) a few hours before the accident reported light surface wind with stronger wind at altitude. This pilot indicated that it “was windy as heck at altitude but dead calm on the valley floor.” A snowmobile tour operator at Knik Glacier reported that, during the morning and afternoon tours on the day of the accident, he noticed large plumes of snow blowing off the nearby mountain peaks, and he estimated the wind to be between 30 to 40 miles per hour from the west. - Soloy Helicopters Soloy Helicopters is a Part 135 air carrier that conducted rotorcraft on-demand operations. At the time of the accident, Soloy Helicopters operated 17 helicopters and employed about 20 pilots, some of whom were seasonal. In addition, Soloy Helicopters conducted operations under Parts 133 (rotorcraft external-load operations) and 137 (agricultural aircraft operations). Pilot Training Program Soloy’s CFIT-A training manual, dated December 12, 2016, outlined the company’s CFITA policies, procedures, and training requirements and stated that CFIT-A training was required as part of initial and recurrent training. Training topics included whiteout conditions, flat-light conditions, deteriorating visibility, IIMC, advanced aircraft systems, and normal and abnormal/emergency procedures. Some of the training was conducted with a desktop computer. The CFIT-A training manual also stated the following: If inadvertent white out conditions are encountered it is important to rely on instrument indications and carefully attempt to fly away from obstacles and terrain until visible references can be re-established. If visible references cannot be reestablished then proceed as inadvertent IMC. According to Soloy Helicopters’ chief pilot, as part of CFIT-A training, the company administered a test to newly hired pilots to ensure mastery of the subject matter, but subsequent training was discussion-based only. The director of operations stated that the company did not accomplish flight training for CFIT-A (which was not required). Further, other than the instruction included in the CFIT-A training manual, Soloy Helicopters’ training program contained no specific IIMC training module. The company’s training program contained a module titled “Abnormal and Emergency Procedures.” This module comprised the following elements: maneuvering by instruments (for aircraft equipped with navigational radios), controlled flight by reference to instruments, intercepting and tracking a course, and recovery from unusual attitudes. In addition, the AS350 maneuvers guide, which was also part of the company’s training program, had a module titled “Maneuvering by Reference to Instruments.” The objective of the module was “to provide practice in the methods and procedures of maneuvering the aircraft by instruments and to recognize and recover from unusual attitudes.” The training applied to cruise flight, straight-and-level flight, standard rate turns, navigation, and unusual attitudes. The company’s director of operations stated that IIMC flight training consisted only of unusual attitude training. Soloy Helicopter’s pilot training program for the AS350 and Hughes 500 (the two helicopters for which the accident pilot was qualified) did not include training in unprepared site operations involving ridgelines. The pilot’s records also did not show any documented training specifically for ridgeline operations. Flight Checks The Soloy Helicopters director of operations indicated that the only IIMC training that was typically part of the competency check involved recognition of and recovery from unusual attitudes. The chief pilot stated that only unusual attitudes were assessed as part of the flight check required by 14 CFR 135.293(b) because the company did not have any IFR aircraft capable of IFR approaches. Title 14 CFR 135.293(b) stated in part the following: The competency check may include any of the maneuvers and procedures currently required for the original issuance of the particular pilot certificate required for the operations authorized and appropriate to the category, class and type of aircraft involved…. For the purposes of this paragraph, type, as to a helicopter, means a basic make and model. Paragraph (c) of 14 CFR 135.293 states the following: Each competency check given in a rotorcraft must include a demonstration of the pilot's ability to maneuver the rotorcraft solely by reference to instruments. The check must determine the pilot's ability to safely maneuver the rotorcraft into visual meteorological conditions following an inadvertent encounter with instrument meteorological conditions. For competency checks in non-IFR-certified rotorcraft, the pilot must perform such maneuvers as are appropriate to the rotorcraft's installed equipment, the certificate holder's operations specifications, and the operating environment. According to postaccident interviews and operator documentation, Soloy Helicopters used FAA form 8410-3 (issued in 1981) to conduct pilot competency checks. The form did not include all training requirements, so flight instructors documented those requirements within the remarks section of the form. Heli-Skiing Guidance Soloy Helicopters provided pilots with Standard Operating Guidelines for heli-skiing operations. These guidelines, dated March 1, 2012, stated the following: Whenever possible the guidelines outlined within this document should be followed. Deviations from these guidelines should only be considered when operational circumstances occur that necessitate changes due to safety, unforeseen circumstances or the impracticality of any written procedure. Section 600 of the guidelines, Operational Concerns, stated, in part, the following: Operations will not be conducted unless the pilot has positive visual reference during all phases of flight [emphasis in original]…. All landings should be to previously staked areas or areas that have adequate visual reference to determine slope, surface, snow conditions, hazards, touchdown spot, abort flight path, etc. Considerations should be paid to: 1) Approaches and departures; 2) Proximity to hazards, avalanche chutes, cornice build-up, down flowing etc. 3) Prevailing wind. Section 800, Passenger Briefing discussed, in part, the following: It is the responsibility of the pilot-in-command to ensure every guest is given a comprehensive briefing prior to initial flight. Briefings may be given by another designated and trained person (i.e. guides) or a combination video/practical method, provided all aspects of a briefing are covered. The section also stated that “guides are essential to the briefings,” and the guidelines discussed the topics that were required to be provided during an initial safety briefing, including the operation of all doors and emergency exits, use of seat belts at all times, procedures in case of accident, and location and use of the ELT and first aid kit. Operational Control for Flight Operations According to 14 CFR Part 1, operational control regarding a flight refers to the exercise of authority over initiating, conducting, or terminating a flight. The certificate holder is required to have an operational control system that includes all the elements of operational control. In addition, 14 CFR Part 135 requires operators to have a system and/or procedures for the control of flight movements. Review of Soloy Helicopters’ Operations Specifications, paragraph A008, Operational Control, which was valid at the time of the accident, showed that the specifications had been digitally signed by the FAA POI and issued to the operator on February 8, 2019. The intent of paragraph A008 was to ensure a mutual understanding between an operator and the FAA concerning the operational control system and/or procedures used by the operator. Paragraph A stated the following: The [operational control] system described or referenced below in this subparagraph must be used by the certificate holder that conducts operations under 14 CFR Part 135 to provide operational control for its flight operations. The essential elements of operational control…must be included or described in that system. Soloy Helicopters’ operational control system was not described or referenced in the operations specifications. Title 14 CFR 119.7 states, in part, that each certificate holder’s operations specifications must contain the authorizations, limitations, and procedures under which operations are to be conducted. Title 14 CFR 135.77, Responsibility for Operational Control states, in part, the following: “each certificate holder is responsible for operational control and shall list…the name and title of each person authorized by it to exercise operational control.” Review of Soloy’s GOM revealed that, in section 1, management personnel were listed by name and included the director of operations, chief pilot, and director of maintenance. Only the director of operations had operational control as a listed duty, responsibility, or authority. Section 2 showed that only the director of operations had operational control. No chain of command or other list of authorized personnel appeared in section 2. During a postaccident interview, the director of operations stated that he was the only company individual with operational control. The director of operations added that he could delegate that responsibility to the chief executive officer, even though this transfer was not listed in the GOM or operations specifications. Soloy Helicopters’ operations specifications did not indicate that the company had delegated the responsibility for flight-locating to TML. The company’s GOM stated, under the Flight Assignment Procedures heading, that “a qualified Flight Locator may accomplish…flight assignment tasks either by delegation from the DO [director of operations] or in the temporary absence of the DO.” The term “flight locator” was not defined in the GOM, and no personnel names were associated with this position. Overdue Aircraft Procedures The Soloy Helicopters GOM stated that an aircraft would be considered overdue when it was 60 minutes beyond the latest estimated time of arrival. The Soloy Helicopters emergency response plan stated that an aircraft would be considered overdue “30 minutes Beyond Camp or FAA flight plan.” The Soloy Helicopters safety management system manual stated that the emergency response plan should be initiated due to, among other things, “an overdue or missing Soloy Helicopters aircraft.” The manual continued, “a Soloy Helicopters aircraft is considered overdue if it is more than 60 minutes” beyond its estimated time of arrival or agreed-upon reporting time and that “personnel in the field should use 30 minutes as a guide to begin referencing” the plan. Federal Aviation Administration Oversight Principal Operations Inspector for Operator The POI for Soloy Helicopters at the time of the accident had been employed with the Anchorage Flight Standards District Office since 2016 and became the POI for Soloy Helicopters in 2018. She was also responsible for the oversight of six other Part 135 certificates. Before her employment with the FAA, she was the chief pilot at Soloy (between 2011 and 2013), and she worked at another helicopter operator (from 2001 to 2011) with the person who would later become the president of the Soloy Helicopters. The POI stated that she visited Soloy Helicopters about 1 year before the accident, possibly for a check airman observation. The POI also stated that she conducted a flight operations observation in December 2020 and an operational control inspection, which included flight-locating, during the third quarter of 2020. Review of FAA safety assurance system records beginning March 2018 (3 years before the accident) revealed that, from September 11, 2018, to June 16, 2021, 13 surveillance assessments of Soloy Helicopters were completed, 12 of which had been closed with no issues or findings. The record of the other assessment indicated a minor nonregulatory issue and had a status of “closed pending action.” During the same timeframe, six surveillance assessments had been automatically closed because they were overdue and not in an “ready status.” Additional records showed that the POI visited Soloy on November 14, 2019, and October 30, 2020, to conduct check airman surveillance and line checks. During a postaccident interview, the POI stated that she had not observed any heli-ski operations in her current position. (The POI stated that she had observed those operations while she was employed by Soloy Helicopters.) In addition, the POI did not recall making any recommendations to Soloy for changes to its manuals or procedures (in her capacity as the POI for Soloy certificate). The POI further stated that she had asked other FAA inspectors to conduct checkrides at Soloy on her behalf because she was not medically qualified for that responsibility. According to the POI, flight-locating was a part of operational control, and the list of company personnel with operational control was in the company’s GOM. The POI also stated that the lodge personnel who would be performing flight-locating tasks did not need to be named in the company’s Operations Specifications paragraph A008 or its GOM. Regarding CFIT-A training, the POI stated that the training was conducted “in the mountains, in bad weather” and that she did not normally observe that training. The POI also stated that she had observed some ground training “probably” in 2019. The POI thought that IIMC recovery was not a required training item. Federal Aviation Administration Order 8900.1 FAA Order 8900.1, Flight Standards Information Management System, is “the repository of all Flight Standards policy and guidance concerning aviation safety inspector job tasks.” The order was primarily intended for “Flight Standards aviation safety inspectors, their managers and supervisors, and other operational and administrative employees.” Operators can use the order as a reference. Paragraph 3 1255 of the order, Part 135 Pilot-in-Command/Second-in-Command Flight Training (All Training Categories) – Helicopters, listed certain maneuvers that “must be conducted for satisfactory completion of each category of flight training.” The order stated that pilots in command must complete each training event listed in the paragraph, which included “unprepared site operations: ridgelines.” The paragraph stated that a POI should ensure that the certificate holder’s flight training emphasized operations in various environments, including mountainous areas. Paragraph 3-1256, IIMC Training, stated that all pilots operating helicopters under Part 135 must be trained on procedures for avoiding and recovering from IIMC and that inspectors would evaluate the certificate holder’s operational procedures for this training and ensure that these procedures were incorporated into the certificate holder’s initial, transition, upgrade, and recurrent training curriculums. The order further stated that “training should emphasize the identification of circumstances likely to lead to IIMC encounters and encourage the pilot to abandon a planned flightpath or route to avoid continued VFR flight into deteriorating conditions.” Paragraph 3-1256 also stated the following: Recovery from IIMC is an emergency maneuver since the pilot would be operating under VFR prior to the IIMC. The recovery from IIMC must include attitude instrument flying, recovery from unusual attitudes, navigation, ATC [air traffic control] communications, and at least one instrument approach, if the helicopter is appropriately equipped…. IIMC training should include visual cues and unusual conditions, which should prompt pilot action to avoid an IIMC encounter and pilot reaction plans to divert, land, or initiate an emergency transition to IFR as appropriate to the situation. Table 3-71 in the order showed the requirement for helicopter IIMC recovery. A note to the table stated, “this event must include attitude instrument flying, recovery from unusual attitudes, navigation, air traffic control (ATC) communications, and at least 1 instrument (if aircraft is so equipped) approach appropriate to circumstances.” Soloy Helicopters had not incorporated each training subject into its training program, and no record was found that showed that either Soloy Helicopters or the FAA had requested a deviation or waiver from this requirement for approval of Soloy’s training program. FAA Order 8900.1 also contained guidance for determining the acceptability of a certificate holder’s flight-locating procedures. The order required the operator’s notification of an overdue or missing aircraft to be at least as prompt as notifications provided by FAA procedures and facilities (30 minutes). Further, paragraph 3-2023 of the order stated that, when operations were conducted in an area where radio contact cannot be maintained with ATC, the individual authorized to exercise operational control must be provided with the location, date, and estimated time at which the pilot-in-command would re-establish radio or telephone communications. The order indicated that operators should maintain sufficient records to show compliance with these requirements. In addition, paragraph 3-2023 of the order stated that Part 135 operators could contract with other operators or organizations to perform direct operational control functions but that the operator would remain fully responsible for ensuring compliance with applicable regulations, the GOM, and safe operating practices. The name of each contractor employee authorized to perform these functions for the operator must be listed in the operator’s GOM. The order also stated that operators were responsible for ensuring that individuals authorized to exercise operational control are adequately trained to perform their assigned duties and are knowledgeable of, and have access to, appropriate sections of the operator’s GOM while performing their assigned duties. Soloy Helicopters had not incorporated these requirements into its flight-locating procedures. No record was located during the investigation that showed that either Soloy Helicopters or the FAA had requested a deviation or waiver from these requirements for acceptance of the GOM. Tordrillo Mountain Lodge TML‘s emergency response plan stated that a search and rescue facility (specifically, the 210th Rescue Squadron of the Alaska ANG located at Joint Base Elmendorf Richardson in Anchorage) should be contacted “if communication with the helicopter is not established by the end of the prearranged or 30 minute grace period.” In September 2021, TML provided the NTSB with a written summary about its drug and alcohol policy for its pilots and guides, which was included in the TML employee handbook, dated July 2020. TML’s summary stated the following: Pilots must follow the policies of Soloy Helicopters. Guides are not permitted to be under the influence of recreational drugs or alcohol while heli-ski guiding. Although there is not an employee handbook that specifically states how a breaking of this or any other rule will be handled, offences [sic] are not taken lightly and infractions of any rule, especially serious ones, will be dealt with individually and can result in termination. - A review of the pilot’s training records indicated that he completed recurrent training on January 21, 2021, including a pilot competency check and a line check, as required by 14 CFR 135.293 and 135.299, respectively. In addition, the pilot completed CFIT-A ground training in January 2021 and IIMC flight training in January 2020. Records showed that the IIMC flight training lasted 1 hour and covered “T/R [tail rotor] failures, autorotations, emergency ops.” The records did not indicate the specific IIMC training that the pilot received, and no other record was found showing IIMC flight training for the pilot. The IIMC flight training also included pinnacle landings and slopes and heli-ski and snow operations. - The helicopter was configured with the pilot’s seat in the front right seat position. Passenger seats were located in the front left seat position and a bench in the cabin with four seating positions. Figure 3 shows the helicopter seating configuration. The senior lead guide was in the left front seat; the other lead guide was in aft seat No. 1. The deceased passengers were in aft seat Nos. 2 and 4; the surviving passenger was in aft seat No. 3. Figure 3. Simplified drawing of the accident helicopter showing seating positions with rear bench seat position numbers annotated. Surviving Passenger Account According to the surviving passenger, when the helicopter came to rest, he was still inside the helicopter with his body stuck in snow and lodged between two other occupants. He observed one of the other passengers (later identified as the occupant in aft seat No. 4) sitting in the snow outside the helicopter and heard thumping sounds from the bottom of the helicopter. The surviving passenger and the passenger who had been in aft seat No. 4 verbally communicated with each other using short messages. The surviving passenger noted that the passenger then began to move downslope in a seated position (the surviving passenger was unsure what that passenger was doing) and that he (the passenger who had been in aft seat No. 4) eventually stopped responding. The surviving passenger recalled that he eventually saw the light of a helicopter, which appeared to have left the area before coming back and hovering over the accident site. The passenger did not recall anything else until he woke up in a hospital. Upon arrival at the hospital, the passenger had a recorded internal temperature of 82°F along with extensive frostbite damage to both hands. Flight-Following and Search and Rescue Efforts A TML heli-ski guide (who was not aboard the accident helicopter) reported, during a postaccident interview, that he was “on radio communications and flight following” for the lodge on the day of the accident, and the TML radio/event log for that day showed that the flight-follower was in communication with a guide aboard the accident helicopter during the flight. The flight-follower stated that his “main source of communication” with the helicopter would be “via inReach, which is a Garmin satellite device.” The flight-follower also reported that the ski guide “was checking in every hour via inReach with a written message” and that inReach had an automated tracking system that sent a “ping” that the flight-follower tracked on his computer. The flight-follower further reported that he also used a flight-following website that depicted where the helicopter was operating. The TML flight-follower’s last communication with the ski guide (acknowledging that an inReach interval was received) occurred about 1824. About 10 minutes later, the last flight-following ping from the helicopter was received. About 1915, TML’s flight-follower notified a TML supervisor that there had been “no positive comms” with the ski guide within the last 1.5 hours and that “flight following indicates no movement” of the helicopter in the last 40 minutes. The supervisor contacted another heli-ski operator in the area, Third Edge Heli, to find out the status of the accident helicopter (Third Edge Heli’s operation base was closer to the helicopter’s last known location than TML’s operations base). During a conversation between representatives from TML and Third Edge Heli, the Third Edge Heli representative considered the flight to be “ops normal” and expected that the last lift would occur about 1940. The TML supervisor then instructed the flight-follower to “keep an eye on” the accident helicopter. The TML radio/event log showed that the flight-follower continued attempting to reach the helicopter through 1949 with no success. About 2004, Third Edge Heli mistakenly reported to TML that the accident helicopter was “inbound” for the Wasilla Lake residence. About 2025, Third Edge Heli notified Soloy Helicopters that the helicopter was overdue. About 2030, TML notified Soloy that it was activating its emergency plan. About 2032, Soloy Helicopters activated its emergency response plan. About 2034, Third Edge Heli requested that one of its helicopters attempt to locate the accident helicopter. About 2052, the Soloy Helicopters director of operations arrived at the company office and notified the Alaska Rescue Coordination Center (AKRCC) about the overdue helicopter. (The AKRCC, which logged this notification about 2110, was responsible for coordinating on-land and aviation federal search and rescue activities in Alaska.) About 2112, Third Edge Heli contacted the AKRCC about the overdue helicopter. About 2136, the wreckage was located by an Alpha Aviation Helicopter, which was under contract with Third Edge Heli. About 2202, Third Edge Heli called the AKRCC to relay that the wreckage was located on the “Knik [Glacier] side of the ridge.” The AKRCC responded that a helicopter would be en route to the coordinates where the wreckage was located. While the helicopter crew prepared to launch, AKRCC updated Soloy Helicopters, Third Edge Heli, and the Alaska State Troopers. About 2258, the AKRCC told the Alaska State Troopers that the crew was about to take off. About 2325, an Alaska Air National Guard (ANG) helicopter was on scene searching for the wreckage, which the crew located about 2333. According to the Alaska ANG helicopter pilot, it was a clear night, but the wind was at least 20 knots or more at the top of the mountains. It took about 30 minutes for the helicopter to dump the amount of fuel that would allow it to descend to a hover over the accident site and hoist down two pararescue personnel. They arrived at the wreckage site about 0015, about 5 hours 40 minutes after the accident and about 2 hours after TML and Soloy Helicopters activated their emergency response plans. The cause of death for the passengers in aft seats No. 2 and 4 was blunt force injuries. (The causes of death for the pilot and ski guides were discussed in the Medical and Pathological Information section of this report.) According to information from the first on-scene responders, the passenger who had been in aft seat No. 4 was ejected from the helicopter, and the other five occupants were found in the cabin wreckage. The surviving passenger was still wearing his seatbelt, which had to be cut before he could be extricated. About 0115, the Alaska ANG helicopter pilot reported to the AKRCC that the helicopter was en route to a hospital in Anchorage with one passenger, who was in critical condition. The Alaska ANG helicopter arrived at the hospital about 0136. During postaccident interviews, the Soloy Helicopters director of operations was asked what time the accident flight was due back to the principal operations base; he stated that he did not have that information but that TML was providing the flight-locating. The director of operations was then asked how Soloy was able to conduct flight-locating if the company did not know when the accident flight was due back. The director of operations responded that TML was responsible for determining if the helicopter was overdue. When the Soloy Helicopters’ director of operations was asked about the delay between being informed that the helicopter was overdue (about 2025) and notifying the AKRCC (about 2052), he stated that he was “still working through the information that was provided” about the helicopter. - Aerial assessment of the accident site on the day after the accident revealed that the helicopter impacted terrain about 15 to 20 ft below the top of the ridgeline. The main wreckage came to rest on its right side about 500 ft downslope from the initial impact area, as shown in figure 2. The debris field extended about 900 ft downslope from the top of the ridgeline. Figure 2. Accident site (Source: Alaska State Troopers). Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. The ELT’s installed location (the upper right side of the right baggage compartment) was found packed with snow. The ELT remained secured to its airframe mount via a velcro strap. The ELT’s antenna coaxial cable and remote cockpit control wiring remained connected. The ELT switch was found in the ARM position. The external antenna had been fractured from its mount and was not located. Postaccident testing of the ELT found that it was working properly and that the ELT had transmitted during and after the accident sequence for 178 hours (12,884 bursts at 50-second intervals). -
Analysis
A local lodge had contracted with the helicopter operator to transport passengers from a private residence to a heli-ski area at a nearby mountain. The surviving passenger stated that, before the last ski run of the day, the pilot attempted to land on a ridgeline but that the helicopter lifted off for an attempted second landing. The passenger also stated that, during the second landing attempt, the snow was “real light” but that the helicopter became “engulfed in a fog which made it appear like a little white room.” The helicopter subsequently began “going backward real fast” and impacted the ridgeline and rolled backward down the mountain. Postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. The passenger’s recollection of the conditions just before the accident was consistent with whiteout conditions caused by rotor wash while the helicopter was hovering near the ridgeline. Thus, the pilot likely experienced whiteout conditions during the second landing attempt, which caused him to lose visual reference with the ridgeline and resulted in the helicopter impacting terrain. Title 14 Code of Federal Regulations Part 135 required flight-locating for the helicopter in case it was overdue so that information about the helicopter’s location could be reported to a Federal Aviation Administration (FAA) or a search and rescue facility. The helicopter operator stated that it had delegated the responsibility for flight-locating to the local lodge. However, this delegation was not documented in the company’s FAA operations specifications or general operations manual, as required by Part 135. On the day of the accident, the local lodge was providing flight-following for the accident helicopter, which, unlike flight-locating, was not required by Part 135. The helicopter was expected to depart the heli-ski area for the principal operations base once all the ski runs had been completed. The flight-follower informed his supervisor that 40 minutes had elapsed since the helicopter moved from its last recorded position and that there had been “no positive comms” with the ski guide during the last 1.5 hours; this notification was made 41 minutes after the last “ping” from the helicopter. However, the remote area in which the accident flight was operating had limited communication capabilities, and no clear evidence indicated that an accident had occurred. The flight-follower’s supervisor contacted another heli-ski company to help determine the status of the helicopter. The heli-ski company considered the flight to be “ops normal” and expected that the last lift would occur shortly. The supervisor instructed the flight-follower to “keep an eye on” the accident helicopter; however, the lodge’s emergency response plan stated that a search and rescue facility should be contacted “if communication with the helicopter is not established by the end of the prearranged [time] or 30-minute grace period.” Therefore, it would have been reasonable for the lodge to activate its emergency response plan at this point given that the helicopter’s location was unknown at the time. The flight-follower continued to try to reach the helicopter but was unsuccessful. About 90 minutes after the last flight-following “ping” for the helicopter, the lodge received erroneous information from the heli-ski operator that the accident helicopter was “inbound” for the private residence; however, lodge personnel did not realize that this information was not accurate and that the accident had occurred immediately after the last ping. This incorrect information likely played a role in the lodge’s further delay in activating its emergency response plan. About 1 hour and 50 minutes after the accident (and the last flight-following ping), the heli-ski operator notified the accident helicopter operator about the overdue aircraft. Five minutes later, the lodge notified the helicopter operator that it was activating its emergency response plan. About 2 hours after the accident occurred, the helicopter operator activated its emergency response plan. About 17 minutes later, the helicopter operator notified the Alaska Rescue Coordination Center. The director of operations for the helicopter operator stated that the search and rescue notification did not occur before that time because he had been “working through the information that was provided” about the helicopter. The helicopter wreckage was located about 3.5 hours after the accident. Rescue personnel launched within 1 hour of notification and arrived on scene less than 30 minutes later (about 5 hours 40 minutes after the accident). The surviving passenger was transported via helicopter to a local hospital. Upon arrival at the hospital, the surviving passenger had hypothermia and severe frostbite. A shorter exposure to the cold would likely have decreased the severity of the surviving passenger’s injuries. However, a faster emergency response time (and thus shorter exposure to the cold) could only have occurred if the notification to search and rescue personnel had been timelier. Thus, because the lodge and the helicopter operator did not activate their emergency response plans sooner, the initiation of search and rescue operations was delayed. Given the circumstances of this accident, the investigation considered three types of training that the pilot should have received: inadvertent instrument meteorological conditions (IIMC) training; controlled flight into terrain-avoidance (CFIT-A) training, during which instruction in whiteout conditions would be conducted; and ridgeline training. Review of the operator’s pilot training program showed that ridgeline training was not provided for the make and model of the accident helicopter (or the previous helicopter in which the accident pilot had been trained). Further, IIMC training was a part of CFIT-A training, and the CFIT-A manual stated that pilots were required to complete IIMC training annually. However, the chief pilot for the helicopter operator stated that the related test for pilots (to demonstrate understanding of the subject) was only administered when a pilot was first hired, and the director of operations stated that the company’s only IIMC flight training involved recovery from unusual attitudes. In addition, review of the accident pilot’s flight training records found that he completed IIMC training 14 months before the accident (which was about 1 year after he began working for the operator), but the records did not reflect the specific IIMC training that the pilot received. Based upon the information provided by the operator, it could not be determined if the accident pilot had fulfilled the training requirement. The director of operations reported that the helicopter operator did not accomplish flight training as part of its CFIT-A training; however, flight training was not required for that subject, and the pilot received CFIT-A ground training. The CFIT-A manual stated that, if inadvertent whiteout conditions were encountered, the pilot was to rely on flight instruments and carefully attempt to maneuver the helicopter away from obstacles and terrain. Additional review of training records revealed that, during competency checks, the helicopter operator was not evaluating several requirements of 14 CFR 135.293, including recovery from IIMC, navigation, air traffic control communication, and instrument approach flying. Paragraph (c) of the regulation required a pilot to demonstrate the ability to maneuver the helicopter into visual meteorological conditions after a simulated encounter with IIMC, a skill that was needed during the accident flight. The operator stated that it did not have any instrument-flight-rules (IFR) aircraft capable of IFR approaches, but the GPS model installed on the accident helicopter had IFR capabilities with instrument approach procedures in its database. Thus, given the deficiencies in the operator’s pilot training program and Part 135 checkrides, particularly regarding IIMC, it is likely that the pilot did not meet the qualification standards to be the pilot in-command of the accident flight. The FAA principal operations inspector (POI) for the operator failed to ensure that the company’s operations specifications (specifically, paragraph A008) contained the operational control information required by 14 CFR 119.7 and 135.77. (Flight-locating was part of operational control.) The company’s operations specifications did not describe who would be responsible for the safe operation of company flights and how those flights would be operated to meet requirements; thus, the operations specifications were incomplete. Although the company should have noticed this omission before the operational specifications were signed, the POI was ultimately responsible for ensuring that the operations specifications contained all the required information. FAA Order 8900.1, paragraph 3-1255, discusses helicopter flight training maneuvers that “must be conducted for satisfactory completion of each category of flight training.” The order also stated that all helicopter pilots operating under Part 135 “must be trained on procedures for the avoidance and recovery from IIMC” and that inspectors were required to ensure that operational procedures for recovery from IIMC are incorporated into the certificate holder’s training curriculums. Thus, the POI failed to ensure that the operator’s training program contained all required elements, which also included ridgeline training, before approving the training program. In addition, the POI was also unaware that the operator was not conducting competency checks in accordance with section 135.293(c) and that its checkrides were only assessing a pilot’s recovery from unusual attitudes. From 2011 to 2013, the POI was the chief pilot for the accident operator; from 2001 to 2011, she worked at another helicopter company with the person who later became the president of the accident operator. The POI started her employment with the FAA in 2016 and, 2 years later, became the POI for the accident operator. The available evidence for this investigation was insufficient to determine whether the POI’s previous employment history was a factor in the inadequate oversight of the accident operator. Toxicology testing of specimens from the senior lead ski guide identified two central nervous system stimulant drugs: amphetamine and cocaine. Given the drug levels measured in his blood, the senior lead ski guide was likely impaired by drug effects at the time of the accident. Toxicology testing of specimens from the other lead ski guide identified delta-9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis. The low THC level measured in his blood indicates that he was not likely experiencing significant impairment from THC effects at the time of the accident. Although ski guides are not considered crewmembers according to the Federal Aviation Regulations, they have safety-related responsibilities during heli-ski flights such as coordinating with pilots about landing and pickup zones and assisting pilots with hazard and pickup zone identification. However, the investigation was unable to determine whether the senior lead guide’s illicit drug use played a role in the accident.
Probable cause
The pilot’s failure to adequately respond to an encounter with whiteout conditions, which resulted in the helicopter’s collision with terrain. Contributing to the accident was the (1) operator’s inadequate pilot training program and pilot competency checks, which failed to evaluate pilot skill during an encounter with inadvertent instrument meteorological conditions, and (2) the Federal Aviation Administration principal operations inspector’s insufficient oversight of the operator, including their approval of the operator’s pilot training program without ensuring that it met requirements. Contributing to the severity of the surviving passenger’s injuries was the delayed notification of search and rescue organizations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Airbus Helicopters
Model
AS350-B3
Amateur built
false
Engines
1 Turbo shaft
Registration number
N351SH
Operator
Soloy Helicopters LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Other work use
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
4598
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-08T05:30:24Z guid: 102813 uri: 102813 title: WPR21LA145 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102822/pdf description:
Unique identifier
102822
NTSB case number
WPR21LA145
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-28T15:28:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-04-05T23:08:02.806Z
Event type
Accident
Location
Marana, Arizona
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 28, 2021, at 1428 Pacific daylight time, a Cirrus SR22 GTS, N644SR, was substantially damaged when it was involved in an accident near Marana, Arizona. The pilot and passenger were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated from Tucson, Arizona, and the pilot reported the takeoff and climb were normal until reaching 10,000 ft mean sea level when the engine shuttered, lost all power, and began to shake the airplane violently. The pilot shut down the engine controls; however, the propeller continued to windmill which resulted in the engine continuing to shudder. Air traffic control provided a heading to the Marana Regional Airport. When the pilot realized he was not going to make it to the airport, the controller issued a heading to a nearby glider port. The pilot reported he was “confident” that he could make it but instead he elected to deploy the airplane’s Cirrus Airframe Parachute System (CAPS) upon reaching 2,000 ft above ground level. The pilot reported he pulled the parachute deployment handle three times, but the parachute did not deploy. He subsequently landed the airplane on a dirt road. The left wing contacted tall brush and spun the airplane 180° resulting in substantial damage to the underside of the wings and fuselage. Wreckage and Impact Information The empennage, upper fuselage, engine, and propeller were intact and received very little damage. The landing gear was bent and collapsed, and the left flap was deformed. The compartment for the ballistic parachute was intact and unopened. A postaccident examination revealed that about 5 quarts of dark oil were drained from the oil sump. The oil sump was removed, and it contained broken aluminum and steel engine components. The Nos. 1 and 3 cylinders through bolt and deck stud nuts had torque seal. The remaining cylinders did not have torque seal applied. The 8-through bolts nuts were retorqued to the manufacturer’s specified torque setting and none of the nuts tightened before the specified torque was reached. The Nos. 2 and 4 cylinders could not be removed from the crankcase due to internal mechanical damage to their cylinder skirts. Figure 1. – Crankcase damage and view of interior engine components. The No. 2 connecting rod and piston were separated from the crankshaft. The left half of the No. 2 main bearing was found rotated about 15° within the saddle area and overlapping the right half of No. 2 bearing. The left bearing half was shifted forward about 1/8 of an inch from its original position. The corresponding main bearing seal was not positioned properly in the saddle bearing support, which resulted in a lack of oil lubrication and the discoloration of the connecting rod journal. The last annual inspection was performed on April 20, 2020, at recorded Hobbs time of 2130.0 hours. The No. 1 cylinder and piston assembly was removed, repaired, and reinstalled during the inspection due to low compression. Figure 2. No. 2 connecting rod, piston, crankcase pieces, and piston material. Cirrus Airplane Parachute System A postaccident examination of the Cirrus Airplane Parachute System revealed the chute had been packed properly but the rocket motor initiating device (squib) was inoperative. It was determined that the squib circuit was “open”, and not “closed” as it should have been had the system not been fired. No other anomalies were initially identified that would have contributed to the system not firing. Figure 3. CAPS Igniter Assembly (Exemplar), courtesy Cirrus Aircraft The squib utilizes an internal bridge wire that heats up and ignites a primer charge, a Boron-Barium Chromate mixture (B1), within the squib. Activation of the B1 then ignites the output charge (B3) which subsequently ignites the BKNO3 pellets. The flame from the burning pellets exits the igniter through holes drilled in its sides and ignites the rocket propellent grains. Figure 4. CT Scan of squib showing B1 and B3 powder and void in cap. CT scans of the squib revealed the bridge wire was broken/activated (fused); however, the B1 did not ignite properly which subsequently prevented the BKNO3 from igniting. The specific reason for the failure of the B1 to properly ignite was not determined during this investigation; however, several possible factors were identified. 1) The ration of boron versus barium chromate used in squib manufactured in 2015 was different and provided a different fuel/oxygen ratio. 2) It was noted that pieces of boron were larger in the B1 produced in 2015 which could have provided for a less homogenized mixture. 3) The accident squib recorded high moisture levels, although this may have resulted from when the squib was opened. Additional Information On June 9, 2021, Cirrus issued SB2X-95-27, “SNS SUBJECT SPECIAL PURPOSE EQUIPMENT – Replacement of CAPS Rocket Igniter.” This service bulletin called for the removal of 25 squib assemblies produced from the same lot as the accident squib. Testing of the returned parts demonstrated additional “no-ignition” squibs from the same lot. On December 10. 2021, SB2X-95-27R2 was subsequently issued, which expanded the number of recalled squibs to 347. These squibs had been installed in SR20 and SR22 airplanes and were manufactured with the same batch of B1 as the accident squib. The suspect batch of B1 was tracked from the manufacturer and it was determined that 27 SF50 airplanes would have received squibs with potentially the same issue. SF50-0010 was included in the original (27) but it has since been removed from service due to a ground fire. SB SB5X-90-13 defined removal of the remaining (26) suspect igniter assemblies from fielded SF50 airplanes. All squibs removed as a result of SB2X-95-27 and FRA000017186 (additional random sample size of 90 that included 30 new, 30 mid-age, and 30 old), were returned to either Cirrus or Vulcan Systems for further testing. In August 2022, testing on returned squibs resulted in another no-fire squib (SN 0416-3617). This serial number was outside the previously understood scope of suspect parts. As a result, SB20X-95-27R3 was issued on October 14, 2022, which expanded the scope of the previous SB by an additional 925 igniters. As a result of this accident, Cirrus also issued Service Advisory SA21-16, “SUBJECT: Verification of CAPS Electric Ignition Checkout Procedure at Annual Inspection.” The Service Advisory states, “… the Inspection/Check – Cirrus Airplane Parachute System in AMM 95-00 must be completed in its entirety and can be completed by technicians performing the scheduled maintenance checks listed in AMM 5-20. Cirrus training and authorization (CAPS re-pack certified) is not required to perform the tasks in this section of the AMM.” -
Analysis
The pilot reported that after a normal takeoff and upon reaching 10,000 ft, the engine shuddered, stopped producing power, and began violently shaking the airplane. The pilot turned toward the closest airport and shut down the engine controls; however, the propeller continued to windmill, which resulted in the engine continuing to shudder. Air traffic control issued a heading to the closest airport, but the pilot realized he was not going to be able to reach the airport, so the controller issued a heading to a nearby glider port. The pilot reported that he was able to reach the glider port but instead elected to activate the airplane’s parachute system upon reaching an altitude of 2,000 ft above the ground. The pilot pulled the activation handle several times, but the parachute did not deploy so he turned his attention to landing the airplane. The pilot made a forced landing on a dirt road and the left wing contacted brush alongside the road, spinning the airplane 180° before it came to rest. The airplane sustained substantial damage to the underside of the wings and fuselage A postaccident examination of the engine revealed the No. 2 main bearing had rotated and the corresponding main bearing seal was not positioned properly in the saddle bearing support, which resulted in oil starvation and subsequent catastrophic failure of the engine. The reason for the bearing and bearing seal shift could not be determined due to the extent of the engine damage. Postaccident examination and testing of the airplane’s parachute system found that the firing process was initiated, as indicated by the open circuit and broken bridge wire. However, undetermined inconsistencies within the ignition primer charge material prevented the subsequent ignition of the rocket propellent, which in turn prevented the activation of the parachute.
Probable cause
A total loss of engine power resulting from a catastrophic engine failure caused by a shift of the No. 2 main bearing and bearing seal, which resulted in oil starvation to the crankshaft; the reason for the bearing and bearing seal shift could not be determined due to the extent of the engine damage. Contributing to the accident was the failure of the airframe parachute system to deploy due to undetermined inconsistencies within ignition material in the rocket igniter assembly/squib.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N644SR
Operator
OC AVIATION LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2070
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-05T23:08:02Z guid: 102822 uri: 102822 title: ERA21FA165 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102831/pdf description:
Unique identifier
102831
NTSB case number
ERA21FA165
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-29T19:00:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-04-19T18:11:08.28Z
Event type
Accident
Location
Cave Spring, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On March 29, 2021, about 1800 eastern daylight time, a Aviat Husky A-1, N800MH, was substantially damaged when it was involved in an accident near Cave Springs, Georgia. The commercial pilot was fatally injured. The airplane was owned by the pilot, who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a witness in the area, the pilot was circling low over his house and waving at him. He said that after circling for about 5 minutes, the airplane departed the area. As he watched the airplane head north, it collided with a power line. The airplane pitched down abruptly and descended into a ravine, where it collided with the ground. He said the broken power line “knocked out” the power, and a brush fire started because of the power line contacting the dry brush. The witness said he rushed down the ravine to assist the pilot and contacted the local authorities. WRECKAGE AND IMPACT INFORMATION Assessment of the wreckage site revealed that a power line was struck above the ravine where the airplane came to rest. The power line was broken and was about 500 ft aft of the airplane wreckage. All flight control components were located at the wreckage site. The airplane sustained substantial damage to the airframe, and both wing assemblies. Postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Georgia Bureau of Investigation, Georgia, performed an autopsy on the pilot. His cause of death was multiple blunt force injuries. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory was negative for carbon monoxide and drugs. -
Analysis
A witness reported the pilot was circling low over his house and waving at him. The pilot circled for about 5 minutes then departed the area. As he watched the airplane head north, it collided with a power line, resulting in a loss of electrical power to nearby residences and a brush fire. The airplane pitched down abruptly and descended into a ravine where it collided with the ground about 500 ft from the location of the power line. Postaccident examination of the airplane did not reveal any anomalies that would have precluded normal operation.
Probable cause
The pilot's inadequate visual lookout and failure to maintain clearance from a power line.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT INC
Model
A-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N800MH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1210
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-19T18:11:08Z guid: 102831 uri: 102831 title: ERA21LA166 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102845/pdf description:
Unique identifier
102845
NTSB case number
ERA21LA166
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-03-30T11:57:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-04-14T17:55:25.096Z
Event type
Accident
Location
Fort Pierce, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On March 30, 2021, about 1057 eastern daylight time, a Jabiru USA Sport Aircraft J250-SP, N236X, was substantially damaged when it was involved in an accident near Fort Pierce, Florida. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, about 10 minutes after takeoff, while in cruise flight at 2,500 ft mean sea level, the engine “got rough, then smoothed right out.” He made a 180° turn to return to the airport and the engine “got very rough.” He turned the carburetor heat ON and checked the magnetos. When he switched from BOTH to the right magneto, there was no change. When he switched from BOTH to the left magneto the engine stopped, but then started again when he switched back to BOTH. The airplane was shaking and he was unable to maintain altitude so he elected to make a precautionary landing on a dirt road alongside a canal. As the airplane approached the road, the pilot maneuvered to avoid large trees; however, during the landing the left wing struck tree branches and the airplane spun around coming to rest in the tidal canal. According to the Federal Aviation Administration (FAA) inspector who responded to the accident site, the airplane’s left wing was mostly separated, and the entire airplane was submerged. A detailed engine examination supervised by the FAA inspector revealed no anomalies. The engine’s crankshaft was rotated by hand, and internal and valve train continuity was established. Fuel was present throughout the fuel system, carburetor, and fuel filters, and the fuel was absent of debris. A small amount of water was present in the carburetor. Both magnetos produced spark. At 1053, the weather reported at St. Lucie County International Airport, about 9 miles east of the accident site, included a temperature of 28°C and a dew point of 19°C. The calculated relative humidity at this temperature and dewpoint was 94%. Review of the icing probability chart contained in Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin CE-09-35 revealed that the weather conditions at the time of the accident were "conducive to serious icing at glide [idle] power." -
Analysis
The pilot reported that while in cruise flight, the engine ran rough then smoothed right out. The pilot elected to return to the airport and the engine roughness increased. He applied carburetor heat and cycled the magnetos. When operating on the left magneto the engine stopped, then it started again when the selector was placed back to the BOTH position. The airplane was shaking, and the pilot was unable to maintain altitude so he elected to perform a precautionary landing on a dirt road. The left wing stuck tree branches, and the airplane spun around and came to rest submerged in a canal adjacent to the road. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Although the weather conditions at the time of the accident were conducive to the accumulation of carburetor icing at glide power, the pilot reported that he used carburetor heat, which would have prevented the accumulation of ice. The reason for the total loss of engine power could not be determined based on available information.
Probable cause
A total loss of engine power for reasons that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JABIRU USA SPORT AIRCRAFT
Model
J250-SP
Amateur built
false
Engines
1 Reciprocating
Registration number
N236X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
363
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-14T17:55:25Z guid: 102845 uri: 102845 title: CEN21LA176 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102858/pdf description:
Unique identifier
102858
NTSB case number
CEN21LA176
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-03T08:30:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-04-16T00:19:30.845Z
Event type
Accident
Location
Pearland, Texas
Airport
Skyway Manor (T79)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 3, 2021, about 0730 central daylight time, a Beech B35 airplane, N5240C, was substantially damaged when it was involved in an accident near Pearland, Texas. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he conducted a thorough preflight and runup with no anomalies noted. The pilot performed a short-field takeoff from a grass runway and lowered the nose of the airplane to gain airspeed while in ground effect. The pilot reported that there was a difference in the engine sound, and the engine did not have the power it normally had. The engine speed was at “2,100 rpm and dropping.” The pilot was unable to climb the airplane above the powerlines in his flight path and he decided to fly under them. While maneuvering the airplane to land in a field, the right wing struck a tree, separating the wing from the fuselage. The pilot landed the airplane on its belly, and it skidded across the grass before it came to rest. The airplane sustained substantial damage to both wings and the fuselage. The pilot stated that he purchased the airplane in October 2020 and that the airplane had undergone extensive maintenance to troubleshoot excessive engine rpm issues. The pilot noted that the airplane flew uneventfully for the first time on the day before the accident. A mechanic had examined the airplane just before the accident flight and found no anomalies. An examination of the engine after the accident revealed a crack between the No. 1 cylinder head and bore. According to the maintenance records, on October 1, 2016, all 6 cylinders were removed and replaced with serviceable cylinders and new piston rings. The cylinders had 324.3 hours since overhaul at the time of installation. It is estimated the cylinders accumulated about 60 hours between the time of installation and the accident. -
Analysis
The pilot reported that immediately after takeoff he noted a difference in the sound of the engine and that the engine speed started to decrease. The airplane was unable to climb above obstacles along the flight path, and the pilot elected to conduct a forced landing. During the forced landing the right wing struck a tree, and the airplane came to rest in a field. The airplane sustained substantial damage to both wings and the fuselage. A postaccident engine examination revealed a crack between the No. 1cylinder head and bore. The engine likely lost power due to this crack; however, the origin of the crack was not identified.
Probable cause
The partial loss of engine power due to a crack in the No. 1 cylinder for unknown reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B35
Amateur built
false
Engines
1 Reciprocating
Registration number
N5240C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-2631
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-16T00:19:30Z guid: 102858 uri: 102858 title: ERA21LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102861/pdf description:
Unique identifier
102861
NTSB case number
ERA21LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-03T17:30:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-04-23T22:55:42.335Z
Event type
Accident
Location
Palmyra, Pennsylvania
Airport
REIGLE FLD (58N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On April 3, 2021, about 1630 eastern daylight time, a Robinson R66 helicopter, N577DD, was substantially damaged when it was involved in an accident in Palmyra, Pennsylvania. The pilot was seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On the day of the accident, the pilot had picked up the helicopter at Fredrick Municipal Airport (FDK), Fredrick, Maryland where an annual inspection had just been completed on the helicopter. The pilot then flew it to Double D Ranch Heliport (70PA), Mechanicsburg, Pennsylvania, to pick up a package that he wanted to deliver in the Hershey, Pennsylvania, area. He then flew direct to Reigle Field Airport (58N), Palmyra, Pennsylvania. While en route he “picked up” the weather, and upon arriving at 58N, entered the traffic pattern for runway 31. His intended landing point was the grass area just to the east of runway 31. According to the pilot, on touchdown, the helicopter was on a slight downhill slope. He felt a dynamic rollover starting, so he pulled up on the collective control stick and his right foot slipped off the right tail rotor control pedal and got stuck behind it. The helicopter entered a left turn from the low hover and impacted the ground. According to a neighbor who lived in a subdivision near 70PA, before the accident flight, while working in his yard, the pilot “buzzed our rooftop and could not have been more than 20 feet above our house.” He also stated that the pilot then landed quite quickly in his (the pilot’s) back yard and was there for a short while before taking off towards the east. The neighbor further stated “to my knowledge he has never done this before. Something wasn’t right with him or the helicopter on Saturday given his landing maneuvers.” According to a witness, who worked at 58N, during the helicopter’s approach for landing, the helicopter flew toward her office from the runway, closer than the witness had ever seen happen at the airport, and it was right next to the picnic table (which was close to the building she was in.). She stated that the helicopter was “really wobbly.” Then when it came down, it bounced gently off the ground, flew up rather quickly, and did a tailspin in the other direction away from the office and crashed. According to another witness, who was riding in a vehicle at the time, he observed the nose of the helicopter go down, then the main rotor hit the ground and the helicopter instantly crash into the ground. His wife then pulled over the vehicle he was riding in, and he ran to the helicopter. When he arrived at the helicopter, he pulled open the door to the helicopter and started to assist the pilot in getting out. The pilot was disoriented and seemed to be in shock from the crash. He had to reach over him to unbuckle the seat belt that was holding him in, and then pulled him out of the cockpit and started to assess his wounds and asked him if he could stand. At this time, he noticed a gash on the pilot’s forehead and a laceration on his right arm. He was able to help him to his feet and helped him reach into the cockpit to shut off parts of the running helicopter. The pilot seemed adamant about getting things out of the cockpit such as his cell phone, but the witness was concerned about getting everyone away from the helicopter, as there was smoke coming out of the engine compartment and he saw fuel leaking to the ground from the tail. The witness continued to talk to the pilot and explained that they needed to get away from the helicopter for safety reasons. After they got some distance away from the helicopter, he noticed that the pilot had a pill bottle in his hand which he opened, and then poured two pills into his hand, the witness did not see him take them. The witness and a police officer were able to walk him over to an ambulance that had arrived. Two other witnesses also described the accident with similar details with one reporting that the pilot had pulled a bottle out and tossed the pills into the field and the other witness stating that he saw pills falling out of a pill bottle and he was not sure if the pilot meant to dump them or the lid came off. An additional witness also observed the pilot throwing pills on the ground and picked up two of them and gave them to a police officer. These pills bore the inscription “n352” and were later identified as acetaminophen and hydrocodone bitartrate 300mg/7.5mg. Examination of the track log downloaded from a portable GPS unit that was onboard the helicopter showed a number of tracklog points which confirmed the route of flight of the helicopter. The last portion of the track data showed the helicopter’s approach to 58N and the descent and turn toward the grass area. The data ended in the immediate vicinity of the accident location. Engine monitoring data in the timing region associated with the accident event, also showed marked increases in engine speed parameters for N1 (the low-speed spool) and N2 (the high-speed spool). Examination of the wreckage revealed that it was substantially damaged but no preimpact failures or malfunctions of the helicopter or engine that would have precluded normal operation were discovered. The 68-year-old male pilot had last applied for a medical certificate on May 9, 2015. At that time, he reported having had surgery for a broken pelvis, high cholesterol, and low testosterone. He reported using fenofibrate for his cholesterol and topical testosterone. These medications are not considered impairing. He also reported the intermittent use of an over-the-counter analgesic and methylprednisolone (an oral steroid medication) for reasons that were not specified. No significant abnormalities were identified, and he was issued a third-class medical certificate without limitations. This medical certificate had expired for all classes of operation as of May 31, 2017. The pilot had applied for and completed the requirement of BasicMed as of November 15, 2019. Records from the pilot’s admission to a trauma center following the accident were reviewed. During his hospitalization, the pilot reported having arthritis with chronic low back pain, obstructive sleep apnea treated with use of a continuous positive airway pressure device, high blood pressure, high cholesterol, a previous pulmonary embolism (2017), and chronic kidney disease. The pilot reported using the following medications: Vicodin (a combination of acetaminophen and hydrocodone), apixaban, fenofibrate, nasal fluticasone, and hydrochlorothiazide. A clinical urine drug screen identified opiates. A search of the Pennsylvania Prescription Drug Monitoring Program database, which contained information on all controlled substance prescriptions filled at a dispensary within the state, did not reveal a record of him having a prescription for Vicodin. Toxicology tests performed by the FAA’s Forensic Sciences Laboratory on leftover blood and urine specimens obtained by the hospital when the pilot arrived, identified hydrocodone (38 ng/ml in blood) and its active metabolites dihydrocodeine and hydromorphone in blood and urine; cyclobenzaprine (24 ng/ml in blood) and its metabolite norcyclobenzaprine in blood and urine; as well as metoprolol, naproxen, ibuprofen, and acetaminophen in blood and urine. Vicodin, which is a combination of acetaminophen and hydrocodone, is a Schedule II controlled substance. Hydrocodone is an opioid and carries a significant risk of addiction, abuse, or misuse. It also carries this warning, “may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to its effects and know how they will react to the medication.” Blood levels where novice users would expect to have effects are between 10 and 50 ng/ml. The pilot’s hydrocodone blood level when tested was 38 ng/ml. Acetaminophen is an analgesic, often marketed by itself with the name Tylenol. Alone, it is not considered impairing. Cyclobenzaprine is a prescription medication that acts in the brain to relieve muscle spasm. It is well known to cause significant drowsiness and carries this warning, “especially when used with alcohol or other central nervous system depressants, may impair mental and/or physical abilities required for performance of hazardous tasks, such as operating machinery or driving a motor vehicle.” Effects are expected when blood levels are between 5 and 40 ng/ml. The pilot’s cyclobenzaprine blood level when tested was 24 ng/ml. -
Analysis
The pilot picked up the helicopter at a maintenance facility, flew it to a private heliport at his residence, where he landed briefly to pick up a package, then flew to his destination airport. Upon arriving in the area of the destination airport, the pilot entered the traffic pattern with an intended landing point of a grassy area just east of the runway. According to the pilot, on touchdown, the helicopter was on a slight downhill slope. He felt a dynamic rollover starting, so he pulled up on the collective control stick and his right foot slipped off the right tail rotor control pedal and got stuck behind it. The helicopter then impacted the ground in a left turn from a low hover. A postaccident examination of the helicopter did not reveal any failures or malfunctions that would have prevented normal operations, and the terrain where the accident occurred was flat. A neighbor who lived near the pilot reported that the pilot “buzzed” his home, flying about 20 ft above his roof when the pilot was landing at his private heliport. The neighbor stated this was uncharacteristic for the pilot and “something wasn’t right with him or the helicopter…given his landing maneuvers.” A witness, who worked at the destination airport stated the helicopter flew toward her office from the runway, coming close to the picnic tables that were near the building where she worked. She stated that the helicopter was “real wobbly,” bounced off the ground, flew up quickly, made a tailspin in the opposite direction away from the office, and crashed. Several witnesses reported seeing the pilot with a pill bottle in his hands following the accident. One of the witnesses reported seeing the pilot with two pills in his hand, but he did not see the pilot take them. One of the witnesses reported seeing the pilot toss the pills into the field, and another witness reported seeing pills falling out of the bottle. A witness who saw the pilot throwing pills on the ground picked up two of the pills and gave them to law enforcement. The pills were later identified as acetaminophen and hydrocodone bitartrate 300mg/7.5mg. Toxicology tests performed on blood and urine samples taken from the pilot at the hospital following the accident identified hydrocodone, acetaminophen, cyclobenzaprine, as well as several other drugs. Vicodin, which the pilot reported using, is a Schedule II controlled substance made from a combination of acetaminophen and hydrocodone. Hydrocodone may impair ones mental or physical abilities to perform activities such as driving a car or operating machinery. The level of hydrocodone in the pilot’s blood when tested was within the range that novice users could expect to have side effects. Cyclobenzaprine is known to cause drowsiness and may also impair mental and/or physical abilities required to perform tasks such as operating machinery or driving a motor vehicle. The level of cyclobenzaprine in the pilot’s blood was within the range that impairing effects are expected. The pilot reported having obstructive sleep apnea and told healthcare providers he used a continuous positive airway pressure device for treatment. However, no information was available concerning his usage in the days before the accident. As a result, whether fatigue from inadequately treated sleep apnea contributed to the pilot’s performance could not be determined. The pilot had effective levels of two potentially impairing medications in his system when the accident occurred. When used in combination, the effects of such medications are greater than when each is used alone, although the exact effects have not been studied. In this case, the pilot’s performance during the flight was not consistent with his level of skill and experience in the helicopter; it is likely effects from his use of a combination of impairing medications contributed to his degraded performance and his inability to safely land the helicopter.
Probable cause
The pilot’s improper judgment to attempt a flight while impaired by medications, which resulted in the helicopter’s abnormal ground contact, loss of control, and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER CO
Model
R66
Amateur built
false
Engines
1 Turbo shaft
Registration number
N577DD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0675
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-23T22:55:42Z guid: 102861 uri: 102861 title: ERA21LA174 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102884/pdf description:
Unique identifier
102884
NTSB case number
ERA21LA174
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-06T12:30:00Z
Publication date
2023-05-24T04:00:00Z
Report type
Final
Last updated
2021-04-19T16:40:38.568Z
Event type
Accident
Location
Arcadia, Florida
Airport
ARCADIA MUNI (X06)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On April 6, 2021, about 1130 eastern daylight time, a Beech A36, N18394, was substantially damaged when it was involved in an accident near Arcadia, Florida. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after takeoff he reduced engine speed to 2,300 rpm at an altitude about 800 ft mean sea level (msl). Several minutes later, he noticed that the engine rpm had risen to 2,500 and the oil pressure was zero. The pilot attempted to return to the airport; however, the engine “locked and the propeller stopped turning.” The airplane was at an altitude of 1,700 ft msl and the pilot subsequently performed a forced landing to a field. According to the Federal Aviation Administration inspector who responded to the accident site, the airplane’s right wing and cowling were substantially damaged. There was oil streaking present on the left side of the fuselage. According to the engine logbook, all six cylinders were replaced about 8 months before the accident. The airplane accumulated about 61 hours between the maintenance performed and the accident. Examination of the engine revealed the engine was seized; no holes were found in the crankcase and the oil filter remained attached to the engine. The No. 4 spark plug was oily, the others were in normal wear condition when compared to a Champion Spark Aviation Check-A-Plug chart AV-27. Both magnetos were removed, actuated with an electric drill, and spark was produced at all terminal leads. The valve covers were removed, and valve movement was not observed on Nos. 2, 3, and 6. The propeller movement was limited. The Nos. 5 and 6 cylinders would not move. The engine was not made available for an additional, follow up examination. -
Analysis
Shortly after takeoff, the pilot noticed the engine rpm had increased and oil pressure was zero. While returning to the airport the engine lost all power and the pilot performed a forced landing to a field. About 8 months prior to the accident, all six cylinders were replaced. Examination of the engine revealed the engine was seized and would not rotate. The reason for the loss of power was not determined. The engine was not made available for an NTSB postaccident examination.
Probable cause
A total loss of engine power for underdetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N18394
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-1121
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-19T16:40:38Z guid: 102884 uri: 102884 title: ERA21LA177 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102890/pdf description:
Unique identifier
102890
NTSB case number
ERA21LA177
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-06T16:00:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-04-26T23:38:00.68Z
Event type
Accident
Location
Worcester, Massachusetts
Airport
WORCESTER RGNL (ORH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 6, 2021, about 1500 eastern daylight time, an experimental, amateur-built Bushby Mustang M II, N61EF, was substantially damaged when it was involved in an accident near Worcester, Massachusetts. The flight instructor and the pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The commercial pilot, who was the new owner of the airplane, stated that he hired the flight instructor to ferry the airplane from Fresno, California to Worcester Regional Airport (ORH), Worcester, Massachusetts. Then the flight instructor was to provide him with 3 hours of dual flight instruction before his insurance coverage would be effective. He further stated that on the day of the accident, the flight instructor had him perform three high-speed taxis to demonstrate directional control. The flight instructor was pleased with the control shown and cleared him for flight. During takeoff, about 6 feet above ground level, the airplane began a roll to the right. The pilot stated he attempted to apply left aileron control but was unable to move the control stick to the left. He told the flight instructor about the problem and they both tried to move the control stick to the left, but it would not move. At this point, the pilot aborted the takeoff and landed the airplane in the grass to the right side of the runway. Both main landing gears collapsed, and the airplane slid to a stop. They shut down the electrical system, shut off the fuel, and egressed the airplane. The flight instructor’s description of the accident flight was consistent with that provided by the pilot. The wreckage was examined by a Federal Aviation Administration inspector. An attempt to cycle the control stick was unsuccessful with binding in movement to the left. Examination of the left aileron bellcrank and push/pull rod revealed that the rod was contacting the access hole in the aft spar. The rivets that hold the threaded insert into the rod were contacting the edge of the spar and binding. After disconnecting the left aileron push/pull rod from the bellcrank, the control stick moved freely in the full range of motion. -
Analysis
According to the pilot, he recently purchased the airplane and needed 3 hours of dual instruction before his insurance would be effective. He and a flight instructor were taking off and the airplane was about 6 feet above ground level when it began to roll to the right. The pilot attempted to apply left aileron control but was unable to move the control stick to the left. He told the flight instructor about the problem and they both tried to move the control stick to the left, but it would not move. The pilot rejected the takeoff and landed in the grass to the right side of the runway. Both main landing gear collapsed, and the airplane slid to a stop. Examination of the left aileron bellcrank and push/pull rod revealed that the rod was contacting the access hole in the aft spar. The rivets that hold the threaded insert into the rod were contacting the edge of the spar and binding. This condition would have resulted in the uncommanded right turn experienced during the accident flight. After disconnecting the left aileron push/pull rod from the bellcrank, the control stick moved freely in the full range of motion.
Probable cause
Binding of the left aileron bellcrank push/pull rod, which resulted in an uncommanded right turn.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FORISCH EDWARD
Model
BUSHBY MUSTANG M II
Amateur built
true
Engines
1 Reciprocating
Registration number
N61EF
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
M-II-1019
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-26T23:38:00Z guid: 102890 uri: 102890 title: CEN21LA187 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102902/pdf description:
Unique identifier
102902
NTSB case number
CEN21LA187
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-09T11:12:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-04-27T16:31:47.079Z
Event type
Accident
Location
LeRoy, Kansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
A few months before the accident, the passenger, who also was an aviation mechanic specialized in helicopter maintenance, was contracted by the helicopter’s maintainer to replace the helicopter’s windshields. The passenger purchased the replacement windows and, on the day before the accident, the helicopter’s maintainer flew a Pilatus PC12 to Dallas, Texas, to retrieve the passenger and the replacement windows. They flew to GCM where the replacement windows were offloaded into the maintainer’s hangar where the work would be completed. However, due to inclement weather the helicopter was delayed in Topeka, Kansas, so the decision was made to continue to TOP where the passenger overnighted at the pilot’s residence. The passenger stated that he traveled to Topeka so he could examine the helicopter’s windshields and discuss their removal process with the helicopter present. The decision was made that the passenger would accompany the pilot the following morning during the flight from TOP to GCM. The passenger then intended to return to Dallas for unrelated work on the afternoon of the accident. When interviewed by the NTSB Investigator-In-Charge (IIC), the passenger stated that he was unaware of any unresolved maintenance concerns on the helicopter, believing that if there were any the helicopter’s maintainer and/or the pilot would have asked him for his opinion/assistance. Additionally, the helicopter’s maintainer did not mention any recent maintenance concerns in the days and weeks before the accident. However, according to an engine manufacturer field representative, the passenger contacted him the day before the accident to discuss a trip to Kansas that he was making to investigate a reported fuel filter bypass indication and illuminated fuel filter light on the helicopter. The passenger previously told the helicopter’s maintainer to inspect and replace the fuel filter and he shipped a new fuel filter to be installed. The helicopter’s maintainer reportedly did not observe any evidence of fuel system contamination in the aircraft fuel cell or in the engine’s main fuel filter. In a subsequent conversation after the accident, the passenger told the engine manufacturer field representative that the helicopter’s maintainer told him that the fuel system issues were resolved and, as such, the passenger did not troubleshoot any fuel system components before the flight. When interviewed by the NTSB IIC, the helicopter’s maintainer was asked if he was troubleshooting an ongoing fuel system issue before the accident flight. The helicopter’s maintainer replied that there were no fuel system related issues with the helicopter, and that he routinely replaced fuel filters because of their minimal cost. Additionally, he stated that they never fueled from a non-standard source, such as a steel barrel, or had to transport fuel to an off-airport location to refuel the helicopter. - Based on logbook documentation, the helicopter accumulated 52.4 hours during the 14-month period before the accident, during which the engine’s injection manifolds were replaced once, and the oil, main fuel, and FCU filters were replaced twice. The helicopter accumulated 2.9 hours since the oil, main fuel, and FCU filters were last changed about 6 weeks before the accident. - On April 9, 2021, about 1012 central daylight time, a Eurocopter EC120B helicopter, N421PB, was substantially damaged when it was involved in an accident near LeRoy, Kansas. The pilot and his passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed on the cross-country flight from Philip Billard Municipal Airport (TOP), Topeka, Kansas, to Claremore Regional Airport (GCM), Claremore, Oklahoma, with about 90 gallons of fuel. He reported that about 35 minutes after departure, while in cruise flight at 2,000 ft, he heard the low rotor speed warning horn but no cockpit caution/warning lights illuminated. The pilot stated that the engine’s free turbine speed and the main rotor speed were “drooped”, and he reduced collective and moved the cyclic control aft to stabilize the main rotor speed. He was able to maintain main rotor speed with about “70%” collective input as indicated on the first limit indicator (FLI). The pilot stated that the main rotor speed continued to decrease as he flew toward an open field for a landing, but he eventually entered an autorotation before reaching the intended field because of the decreasing main rotor speed. The passenger, who also was a helicopter-rated pilot, stated that during cruise flight between 1,700 ft and 2,000 ft, at 100 knots, the main rotor low speed warning horn briefly sounded. The engine’s free turbine speed and main rotor speed were “drooped” but there were no cockpit caution/warning lights illuminated. The pilot used the collective to maintain main rotor rpm at “70%” as indicated on the FLI. The helicopter decelerated from 100 knots to 85 knots while the pilot maintained the helicopter’s altitude. The pilot and the passenger began looking for suitable fields to land in, but about 2-3 minutes after the initial main rotor low speed warning horn, the horn resumed a sustained tone for the remainder of the flight. The passenger did not recall seeing any caution/warning lights, but his attention was outside the helicopter trying to locate a suitable landing area. The passenger recalled that the pilot entered a right turn and made an immediate landing in a residential backyard. He was unsure if the pilot made an autorotation or if the helicopter landed hard, but the helicopter had a high descent rate when it touched down. After the hard landing, the engine continued to run, and the pilot twisted the throttle to OFF before he selected the fuel shutoff to OFF. - The helicopter came to rest upright in a residential backyard. The landing gear skids were deformed outward from the hard landing. The aft tailboom exhibited evidence of buckling/crushing near the fenestron. The lower portion of the fenestron also exhibited buckling/crushing consistent with the tailboom impacting the ground during landing. Postaccident examination of the helicopter revealed proper flight control continuity and engine control continuity. The engine’s main fuel filter delta-p bypass indicator was in the popped position. Fuel samples were taken after the accident from the fuel service truck used to refuel the helicopter before the flight. The samples were free of contamination and exhibited a light straw color consistent with Jet-A aviation fuel. The engine was removed from the airframe and mounted in a test cell for operational testing. All the original filters remained installed for the initial test, and the main fuel filter delta-p bypass indicator was reset before the initial engine start. Upon the first engine start, the fuel filter pre-clogging indication illuminated on the test bench control display, and the engine’s physical delta-p bypass indicator popped. Applying a load to the engine caused the free turbine speed to droop and the gas generator could not accelerate above 83%. The engine was shut down and the main fuel filter examined. The main fuel filter showed significant discoloration when compared to a new filter, but there was no physical contamination visible on the filter’s paper pleats. A new main fuel filter was installed on the engine, and the engine restarted without any pre-clogging indication or bypass indication. A load was applied to the engine, and again the free turbine speed drooped, the gas generator could not accelerate above 83%, and the engine’s gas generator began to oscillate. The engine was shut down to further troubleshoot the issue. During subsequent engine test runs, the gas generator could not maintain the free turbine at a constant 100% when the load was increased on the system. After multiple tests and several component swaps, the fuel injection manifolds were determined to be the cause of the drooping power condition. When bench tested, the left fuel injection manifold flowed within the design limits with an average flow of 21.3 liters/hour (limits 21.2 ± 0.8 liters/hour) and max deviation of 0.6 liters/hour (limits = 1.6 liters/hour). When bench tested, the right fuel injection manifold flowed significantly less than the design limits with an average flow of 4.3 liters/hour. The right fuel injection manifold houses a filter at the entrance to the manifold that protects both right and left injection manifolds where they connect inline to the adjusted valve. The original filter was removed, a new filter installed, and the right fuel injection manifold tested within the design limits with an average flow of 20.9 liters/hour and max deviation of 1.0 liters/hour. A microscope examination revealed contamination that obscured about 75% of the filter screen, as shown in figure 1. The fuel injection manifold filter was sent to the National Transportation Safety Board Materials Laboratory for additional examination using Fourier Transform Infrared (FTIR) spectrometry. The FTIR spectrum for the unknown sample had signatures consistent with cellulose. Cellulose is found in natural plant fibers like paper and cotton. The spectra of known samples of white paper and white cotton were also compared to the unknown sample and exhibited strong matches. The engine fuel control unit (FCU) was removed and dissembled. The fuel drained from the FCU was contaminated. During FCU disassembly, the same contamination was found throughout the device. The engine’s main fuel filter, previously removed during the engine testing, was placed in a clear glass jar and agitated. The main fuel filter contained particles similar in appearance to those found in the FCU. Additional laboratory testing of the contamination determined the elemental composition but was unable to identify the material as a whole or to its origin. The contamination was characterized as flakes and spheres measuring up to 0.5 mm and 0.2 mm, respectively. Figure 1 – (A) Exemplar fuel injection manifold filter; (B) Accident fuel injection manifold filter, wet; (C) Accident fuel injection manifold filter, dry; (D) Filter contamination at 200X magnification -
Analysis
The pilot and passenger were conducting a personal cross-country flight when the helicopter had a partial loss of engine power while in cruise flight at 2,000 ft. The pilot reported that the engine’s free turbine speed and the helicopter’s main rotor speed “drooped” and he was unable to maintain the main rotor speed with the collective and cyclic controls. An off-airport landing was made to a residential backyard, during which the tailboom struck the ground when the helicopter landed hard resulting in substantial damage to the tailboom. Postaccident engine testing confirmed the pilot’s report of being unable to maintain the engine’s free turbine speed at 100% while under increased loads. Further examination and testing revealed a contaminated fuel injection manifold fuel filter, which restricted the amount of fuel that could be delivered to the engine’s gas generator. A laboratory examination determined the contamination was consistent with a cellulose material, and its spectra closely matched that of white paper and white cotton. The engine’s main fuel filter also was found to be contaminated and similar contamination was found throughout the engine’s fuel control unit (FCU) during disassembly. Laboratory testing of the contamination recovered from the FCU was unable to identify the material as a whole or to its origin. Based on logbook documentation, the helicopter accumulated 52.4 hours during the 14-month period before the accident, during which the engine’s injection manifolds were replaced once, and the oil, main fuel, and FCU filters were replaced twice. The helicopter accumulated 2.9 hours since the oil, main fuel, and FCU filters were last changed about 6 weeks before the accident. When asked if he was troubleshooting an ongoing fuel system issue, the helicopter’s maintainer replied that there were no fuel system issues with the helicopter, and that he routinely replaced fuel filters because of their minimal cost. Additionally, he stated that they never fueled from a non-standard source, such as a steel barrel, or had to transport fuel to an off-airport location to refuel the helicopter. According to a field representative of the engine manufacturer, the passenger contacted him the day before the accident to discuss a trip that he was making to investigate a reported fuel filter bypass indication and illuminated fuel filter light on the helicopter. The passenger previously told the helicopter’s maintainer to inspect and replace the fuel filter and shipped a new fuel filter to be installed. The helicopter’s maintainer reportedly did not observe any evidence of fuel system contamination in the aircraft fuel cell or in the engine’s main fuel filter. In a subsequent conversation after the accident, the passenger told the engine manufacturer field representative that the helicopter’s maintainer told him that the fuel system issues were resolved and, as such, the passenger did not troubleshoot any fuel system components before the flight. Based on the known information, the cellulose contamination found in the fuel injector manifold filter was likely introduced during associated fuel system maintenance at an undetermined date. The contaminated fuel injection manifold filter restricted fuel flow to the gas generator, which resulted in the partial loss of engine power during the flight. Additionally, the pilot likely delayed entering an autorotation after the partial loss of engine power, which resulted in insufficient main rotor speed and an excessive descent rate at touchdown.
Probable cause
The contamination of the fuel injection manifold filter due to improper maintenance, resulting in a partial loss of engine power during cruise flight. Contributing to the accident was the pilot’s delayed autorotation, which resulted in insufficient main rotor speed and an excessive descent rate at touchdown.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
EC120
Amateur built
false
Engines
1 Turbo shaft
Registration number
N421PB
Operator
Black Wolf Air, LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1403
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-27T16:31:47Z guid: 102902 uri: 102902 title: ERA21LA183 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102905/pdf description:
Unique identifier
102905
NTSB case number
ERA21LA183
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-12T20:20:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-05-05T21:44:02.228Z
Event type
Accident
Location
Weyers Cave, Virginia
Airport
SHENANDOAH VALLEY RGNL (SHD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On April 12, 2021, about 1920 eastern daylight time, a Piper PA-28-140 airplane, N7242F, was substantially damaged when it was involved in an accident in Weyers Cave, Virginia. The pilot was seriously injured, and the passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, on the evening of the accident, he planned to fly to Shenandoah Valley Regional Airport (SHD), Weyers Cave, Virginia, perform a touch-and-go landing, then return to the area of the departure airport, do maneuvers until dark, and then land. Before departing, he conducted his normal preflight inspection and filled both fuel tanks. The flight was uneventful, and he entered the traffic pattern for runway 23 at SHD. Upon turning onto the final leg of the traffic pattern, he opted to land with only two notches of flaps because of an 8-knot crosswind. He reported that, around 100 ft above the runway at an airspeed about 90 mph, he decided to go around, since the airplane was fast and it felt like the approach was unstable. He smoothly applied full power, but the airplane did not gain any altitude, and started banking hard to the left. By this time, the airplane was about 50 ft above ground level, left of the runway, and the pilot was applying right aileron and right rudder in an attempt to level the wings. He had no further memory of the accident sequence. The engine remained attached to the engine mounts and firewall. The propeller remained attached to the engine with a slight bend to the crankshaft flange face. Except for the alternator, the accessories and base engine appeared to be undamaged condition. The Nos. 1 and 3 cylinders had markings consistent with chrome barrels, the Nos. 2 and 4 cylinders had markings consistent with nitride barrels. The propeller was rotated by hand and thumb compression and suction was established on all four cylinders via the top spark plug holes. Valve train movement was observed, and continuity was confirmed throughout the engine. The exhaust stacks for all four cylinders displayed crush damage from the impact forces. The exhaust stack studs on cylinder Nos. 2 and 4 had pulled slightly away during the impact sequence. No evidence of any preimpact malfunction or failure of the engine was discovered. Flight control continuity was established from the control wheels in the cockpit to the breaks in the system, and from the breaks in the system to the left and right ailerons and the stabilator. Flight control continuity could not be established from the rudder pedals to the rudder, and during examination of the rudder pedal assembly, it was discovered that the rudder bar arm (Part No. 63448-000) and rudder pedal tube (Part No. 65165-053), which were part of the rudder control assembly (Part No.66661-000), had separated. Visual examination of the separated rudder bar arm and rudder pedal tube revealed that they had separated near a weld, which displayed a crack where extensive corrosion was visible on the fracture surface. Examination of the fractured surface under magnification revealed a peak in the fracture surface which was indicative of where an initial overload sometime in the past had occurred that caused a crack to begin. To the left of the peak along the fracture surface, corrosion products could be seen all along the fracture surface. This indicated that the crack had been open for a while and the fracture surface was allowed to react with oxygen to create iron oxide and other corrosion products as well as capture debris. To the right of the peak along the fracture surface, pockets of corrosion as well as fresh substrate were visible, which was indicative of gnashing of the right fracture surface against the opposite surface through cyclic movements (such as the actuation of the control cable) which would continuously remove corrosion products and expose fresh substrate. Down along either side of the arm, two fresh substrate areas could also be observed. The right fracture surface at the base of the weld also exhibited porosity which was indicative of a cup-and-cone failure (tensile failure in a ductile material). Voids or contamination in the weld were also visible. Review of Federal Aviation Administration (FAA) and airplane maintenance records indicated that the airplane had been manufactured 53 years prior to the accident and had accrued about 11,406 hours as of its last 100-Hour inspection, which was completed on January 19, 2021. A review of Piper Aircraft published guidance revealed multiple documents that included inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly, which included: The Piper Aircraft Corporation Inspection Report Form for the Cherokee Series Airplanes (PA-28-140/150/160/180/235), which at intervals of 100-hours required under Item No. 8 to “Inspect condition and operation of rudder pedals and rudder bar assembly (See Note 28).” Note 28 stated, “In airplanes with a rudder pedal and bar assembly or with a rudder bar support assembly, that has1,200 hours or more time-in-service each 100 hours perform Rudder Pedal and Bar Assembly Inspection and/or Rudder Bar Support Assembly inspection on page III-90. As appropriate.” The Piper Cherokee Service Manual, Section III-Inspection (Page III-90), required “In airplanes with rudder pedal and bar assembly or, for fixed gear airplanes only, with a rudder bar support assembly, that has 1,200 hours or more time-in-service each 100 hours inspect the rudder pedal and bar assembly and/or the rudder bar support assembly for cracks as follows:” It then goes on to say in part, to use a 10X magnifier, a mirror, and a suitable light source to visually inspect all welds, and that any cracked components must be replaced before next flight. Additionally, it also stated, “If no cracks are detected (or upon appropriate replacement of cracked or damaged parts), make proper logbook entry documenting completion of this inspection.” Piper Service Letter (SL) No.671(Rudder Bar Assembly Inspection and Modification), dated October 5, 1973, was issued to bring to the attention of field maintenance facilities the necessity of a visual inspection of the rudder bar assembly to detect evidence of cracks, and to provide material and instructions to fabricate and install reinforcement doublers to the affected area. Initial inspection was to be accomplished at the next regularly scheduled inspection interval, and to be repeated within each subsequent 100 hours of operation until the modification (the addition of doublers was accomplished). Piper Service Bulletin (SB) No. 1242 (Rudder Pedal Assembly Inspection), dated January 30, 2015, was issued as a review of the service history on the affected airplanes revealed that, over time, cracks may develop in specific locations on the pedal and bar assembly and the rudder bar support assembly. This service bulletin provided a schedule and instructions for the inspection of these critical components for cracks, and for modification or replacement, on condition. SB1242 superseded SL 671 in its entirety, and airplanes that were in compliance with SL 671 were still required to comply with SB1242. Piper Service Bulletin (SB) 1242A (Rudder Pedal Assembly Inspection), dated May 12, 2020, added additional inspection locations, and SB 1242A superseded SB 1242 and SL 671 in their entirety. Airplanes that have previously complied with SL 671 were still required to comply with SB 1242A. Airplanes that had previously complied with SB 1242 were in compliance with SB 1242A until the next inspection interval was reached. Review of the rudder bar assembly drawing revealed that the rudder control assembly was readily accessible by maintenance personnel for visual inspection. Further review of the airplane maintenance records also did not reveal any entries that referenced any of the published inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly. According to FAA and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. His most recent application for a FAA third-class medical certificate was dated June 22, 2020. The pilot reported about 138 total hours of flight experience, of which 84 hours were in the accident airplane make and model. Review of weather conditions that existed around the time of the accident indicated that the airplane while on final approach to landing, would have been subjected to an approximate 2 knot headwind, and a crosswind from the right of approximately 6 knots. Review of the flight characteristics of the PA-28-140 indicated that, even without rudder, the vertical tail would provide enough directional control to counter the “left-turning tendencies” during take-off or go-around, though the rolling moment due to the sideslip would have tried to roll the airplane left without any right rudder input. Roll could be compensated by adding right aileron inputs. -
Analysis
The pilot reported that, while landing, less than 100 ft above ground level, he felt that the approach was unstable and decided to go around. He smoothly applied full engine power, but the airplane did not gain any altitude and started banking hard to the left. He stated that the airplane was to the left of the runway and that he was applying right aileron and right rudder to level the wings with no effect. The airplane subsequently impacted a fence and trees. The pilot was seriously injured, his passenger received minor injuries, and the airplane was substantially damaged. Examination of the airplane revealed that the rudder bar arm and rudder pedal tube, which were part of the rudder control assembly, had separated near a weld, which displayed a crack where extensive corrosion was visible on the fracture surface. Examination under magnification revealed that the fracture of the rudder arm began with an unknown overload event, and crack growth had occurred slowly. As the crack developed, the fracture surfaces fretted against each other until the crack grew enough to cause the left and right fracture surfaces at the base of the weld to the rudder tube to fail as a hinge point, causing a cup-and-cone failure with fresh substrate at the base of the fracture surface. The airplane had accrued about 11,406 hours as of its most recent 100-hour inspection, which was completed about 3 months before the accident. A review of manufacturer’s published guidance revealed multiple documents that included inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly, which were readily accessible by maintenance personnel for visual inspection. Review of the airplane maintenance records did not reveal any entries that referenced any of the published inspection requirements for the rudder pedals, rudder bar, and rudder bar support assembly. Even without rudder control, the airplane likely remained controllable; however, given the 6-knot right crosswind that existed at the time of the accident, and the airplane’s proximity to the ground when the failure occurred, it is likely that the failure of the rudder control assembly resulted in the pilot’s loss of control.
Probable cause
Maintenance personnel’s inadequate inspection of the rudder control system, which resulted in failure of the rudder control assembly and the pilot’s loss of control during a go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N7242F
Operator
DJAIR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-25155
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-05T21:44:02Z guid: 102905 uri: 102905 title: ERA21LA188 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102935/pdf description:
Unique identifier
102935
NTSB case number
ERA21LA188
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-15T17:05:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-05-04T00:18:47.369Z
Event type
Accident
Location
Dover, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 15, 2021, at 1605 eastern daylight time, a Cessna A188B, N731TB, was substantially damaged when it was involved in an accident near Dover, North Carolina. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he fueled the airplane before the flight at a private airport. The purpose of the accident flight was for the pilot to familiarize himself with the airplane and to practice maneuvers in advance of the spraying season. A few minutes after takeoff, at an altitude of about 300 ft, he heard a “loud pop,” and the engine lost all power. He looked at the engine gauges and noticed that there was “no fuel flow.” As the propeller windmilled, he unsuccessfully attempted to restart the engine, then elected to perform a forced landing to a nearby corn field. He stated that the landing was “hard.” Examination of the airplane at the accident site by a Federal Aviation Administration inspector revealed leading edge damage and compression buckling of the top of the left wing outboard of the wing strut, that extended aft of the wing spar. The left side of the empennage was buckled just forward of the vertical stabilizer. The right horizontal stabilizer was bent upward slightly about 12 inches from its root. The upper surface of the right elevator was buckled forward of the trim tab. When the inspector attempted to rotate the propeller by hand, she heard a “clink” sound, and the propeller would not rotate. A follow-up examination and disassembly of the engine revealed that the No. 2 main bearing had spun, smearing metal into the oil ports on the bearing bore and deforming the bore. Numerous fragments of bearing material were found in the oil sump and inside the case, adjacent to the Nos. 1 and 2 cylinders. The remaining main bearings were well lubricated and were normal in appearance. The crankshaft was fractured between main journal No. 2 and rod journal No. 2. There were visible signatures of heat distress near the fracture surfaces. All connecting rods remained attached to their journals on the crankshaft and they rotated freely. A review of the airplane’s maintenance records revealed that the most recent annual inspection was performed 9 days (11 flight hours) before the accident. The previous annual inspection was performed in September 2019, 73 flight hours before the accident. -
Analysis
The pilot departed to familiarize himself with the airplane and to practice maneuvers. A few minutes after takeoff, at an altitude of about 300 ft, he heard a “loud pop,” and the engine lost total power. He looked at the engine gauges and noticed that there was “no fuel flow.” As the propeller windmilled, he unsuccessfully attempted to restart the engine, then elected to perform a forced landing to a nearby corn field. He stated that the landing was “hard.” The airplane sustained substantial damage to the left wing, right horizontal stabilizer, and elevator. Examination of the engine revealed that the crankshaft No. 2 main bearing had spun, smearing metal into the oil ports on the bearing bore and deforming the bore. Numerous fragments of bearing material were found in the oil sump and inside the case adjacent to the Nos. 1 and 2 cylinders. Based on the available information, it is likely that the shift of the No. 2 main bearing resulted in a lack of lubrication and subsequent failure of the engine crankshaft. The reason for the bearing shift was not determined.
Probable cause
A total loss of engine power due to a shift of a crankshaft main bearing, which resulted in a lack of lubrication and subsequent overheating and failure of the engine crankshaft. Contributing to the accident was the hard touchdown during the forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188
Amateur built
false
Engines
1 Reciprocating
Registration number
N731TB
Operator
Eastern Flying Services
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18803133
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-04T00:18:47Z guid: 102935 uri: 102935 title: CEN21FA195 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102942/pdf description:
Unique identifier
102942
NTSB case number
CEN21FA195
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-19T14:46:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-04-28T08:38:15.999Z
Event type
Accident
Location
Tatum, Texas
Airport
East Regional (GGG)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On April 19, 2021, about 1346 central daylight time, a Cessna 340A airplane, N801EC, was destroyed when it was involved in an accident near Tatum, Texas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. According to information provided by a fixed-base operator (FBO) at the East Texas Regional Airport (GGG), Longview, Texas, the pilot intended to perform a functional test of a newly upgraded autopilot system. On the day of the accident, a mechanic at the FBO reported that he pulled out the airplane from the hangar, and that the pilot planned to get fuel and have the propellers balanced before the flight. According to the mechanic, he explained to the pilot that the autopilot should not be engaged until the airplane was at an altitude of at least 5,000 ft above ground level or higher, which was a standard procedure that the mechanic provided to all pilots who were testing an autopilot. The pilot started the engines, and the airplane sat on the ramp for about 15 minutes. The pilot then shut down the engines and told the mechanic that he could not get the autopilot to work. The mechanic showed the pilot where the main autopilot and trim master switches were located and showed him that the autopilot passed a self-test. The mechanic then told the pilot to try another autopilot self-test with engines running and, if the autopilot did not pass another self-test, to shut down. The pilot ran the engines for about 5 to 10 minutes and then departed. According to air traffic control (ATC) information, the controller cleared the pilot to operate under visual flight rules to the east of the airport. Communications between ground control, tower control, and the pilot were normal during the taxi, takeoff, and climb. Automatic dependent surveillance–broadcast (ADS-B) data showed that the airplane took off from runway 13 at GGG about 1340. The data also showed that, after takeoff, the airplane was in a steady climb to the east of GGG. The airplane climbed to an altitude of 2,750 ft mean sea level (msl) and then descended to 2,675 ft msl. The last recorded data point, at 1346, showed that the airplane was heading east at an altitude of 2,675 ft msl and a groundspeed of 152 knots. The airplane impacted wooded terrain about 3/4 mile east of the last recorded data point. Groundspeeds and headings were consistent throughout the flight with no abrupt deviations (see figures 1, 2, and 3). Radio and radar communications were lost 6 minutes after takeoff. No radio distress calls were received from the pilot. Figure 1. Airplane flightpath. Figure 2. Flightpath elevation view. Figure 3. Flight track with final data points. A local resident about 1 mile from the accident site reported that, while inside his residence, he heard and felt a “boom” that shook the windows. His wife then saw black smoke rising immediately. - The accident site was located at an elevation of 361 ft msl. The airplane impacted wooded terrain in a nose-down, near-vertical flight attitude. The forward fuselage and cabin were embedded into the ground and were mostly consumed from a postimpact fire. The empennage and aft fuselage were folded forward over the cabin area and were charred and consumed by fire. Both left and right wings showed leading-edge aft crushing along their respective spans. Portions of both wings were charred, melted, and consumed by the fire (see figure 4). Figure 4. Airplane wreckage. Both the left and right engine nacelles were separated from the wings, and the engine and propeller assemblies were embedded in 3-ft-deep craters forward of the main airplane wreckage. The engines sustained heavy impact damage, and the propellers were fractured and separated at their crankshafts immediately aft of the flanges. All three blades on the left and right propellers were bent aft and showed leading-edge polishing and chordwise rubs and scratches. Flight control continuity was confirmed. The elevator trim cables stop blocks were secured to the cables and undamaged. They were found against the forward stop meaning the trim tab was at full down travel (elevator leading edge full down) which indicated that the airplane was trimmed full nose up at impact. The airplane’s instrument panel, avionics, autopilot, and engine controls were broken out, fragmented, melted, and consumed by the postimpact fire. Avionics and instrument tubing and wiring behind the panel were melted and consumed by the fire. A functional test of the autopilot system could not be performed due to the damage that it sustained in the accident. Examination of the engines revealed no preaccident failures or malfunctions that would have precluded normal operation. -
Analysis
The pilot was planning to perform a functional test of the airplane’s newly upgraded autopilot system. Automatic dependent surveillancebroadcast data showed that, after takeoff, the airplane turned east and climbed to 2,750 ft. Air traffic control information indicated that the controller cleared the pilot to operate under visual flight rules to the east of the airport. Communications between ground control, tower control, and the pilot were normal during the ground taxi, takeoff, and climb. Radio and radar communications were lost 6 minutes after takeoff, and no radio distress calls were received from the pilot. The airplane impacted wooded terrain about 3/4 mile to the east of the last recorded radar data point. Groundspeeds and headings were consistent throughout the flight with no abrupt deviations. The airplane impacted the wooded terrain in a nose-down, near-vertical flight attitude. Most of the airplane, including the fuselage, wings, and empennage, were consumed by a postimpact fire. Both engines and propellers separated from the airplane at impact with the ground. Examination of the engines revealed no preaccident failures or malfunctions that would have precluded normal operations. Both propellers showed signs of normal operation. Flight control continuity was confirmed. The elevator trim cables stop blocks were secured to the cables and undamaged. They were found against the forward stop meaning the trim tab was at full down travel (elevator leading edge full down) which indicated that the airplane was trimmed full nose up at impact. The airplane’s cabin sustained fragmentation from impact and was consumed by fire; as a result, the autopilot system could not be examined. The investigation was unable to determine why the pilot lost control of the airplane.
Probable cause
The pilot’s loss of airplane control for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
340A
Amateur built
false
Engines
2 Reciprocating
Registration number
N801EC
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
340A0312
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-04-28T08:38:15Z guid: 102942 uri: 102942 title: WPR21LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102960/pdf description:
Unique identifier
102960
NTSB case number
WPR21LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-21T15:10:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-04-23T04:25:31.308Z
Event type
Accident
Location
Twentynine Palms, California
Airport
TWENTYNINE PALMS (TNP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
History of Flight On April 21, 2021, about 1410 Pacific daylight time, a Consolidated Aeronautics Lake LA-4-200, N2989P, sustained substantial damage when it was involved in an accident near Twentynine Palms, California. The pilot, the sole occupant, sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he had recently purchased the airplane and had undergone training in the airplane make and model. The purpose of the flight was for the pilot to transport the airplane from the seller’s location in Novato, California, to his home airport in Texas. On the morning of the accident, the pilot departed about 0800, made a fuel stop, and departed again before landing in Twentynine Palms about 1330. He filled the fuel tanks to their maximum capacity and began the departure from runway 26. The airplane climbed to about 200 ft above ground level (agl), at which point the engine lost partial power and was unable to maintain altitude. The engine began to vibrate, and the pilot could hear a “loud chatter noise” from the engine area. He noted that the manifold pressure gauge appeared normal and that the digital tachometer displayed fluctuating rpm. The pilot verified that the auxiliary boost pump was selected to the “on” position and retracted the flaps to maximize the time that the airplane would be able to stay airborne. The pilot further stated that he was unable to maintain altitude and that, after determining that the airplane would not be able to return to the departure airport, he elected to make an emergency landing on a road. As the airplane approached the road, the pilot observed power lines and decided to have the airplane touch down on the adjacent desert terrain. During the landing, the airplane collided with a sign, and the airplane nosed over, coming to rest inverted. Aircraft Information The Lake LA-4-200 is a mid-wing single-engine amphibian airplane powered by a fuel-injected four-cylinder piston engine. The engine, which is mounted on a vertical pylon above the fuselage, drives the two-bladed constant-speed pusher propeller. In 1983, the accident airplane was outfitted with a Rayjay turbocharger under a supplemental type certificate. The pilot stated that, during the day before the accident, he flight tested the airplane, and the manual turbocharger went into overboost for “a second” before he pulled the power back. The airplane’s logbooks indicated that the engine was the original engine installed at the time of manufacture. The last annual inspection, which was also a pre-buy inspection, occurred on March 1, 2021, at a total time of 1,727 hours and about 10 hours before the accident. Records indicated that the last 500-hour magneto inspection was in May 2002 at a total aircraft time of 1,339 hours; the capacitor on the right magneto was replaced at a total time of 1,493 hours. Wreckage and Impact Information A postaccident examination of the engine found that the crankshaft could be rotated by hand using the propeller. The crankshaft was easy to rotate in both directions. A “thumb” compression test was performed on all cylinders and strong pressure was felt trying to escape at the upper spark plug bores. The entire valve train operated properly. Mechanical continuity was established throughout the rotating group, valve train, and accessory section during hand rotation of the crankshaft. Clean, uncontaminated oil was observed at all four rocker box areas. Removal of the spark plugs revealed that they were oily and that several had cracked ceramic cores. The cylinders were removed, and the pistons were free from deposits. The magnetos did not produce a consistent spark; as a result, their timing could not be determined. The magnetos were then tested at Kelly Aero in Montgomery, Alabama. Both magnetos were in good condition with no oil or dust contamination beyond normal wear. The distributor gears of both magnetos were free from damage. The right magneto was functionally tested, and it operated within test parameters, producing consistent spark at different rpm. The left magneto failed to produce a spark at different rpm; the impulse coupling engaged between 75 and150 rpm and then disengaged above 450 rpm. Disassembly of the left magneto revealed that capacitor lead insulation had previously been cut, which exposed the center conductor wire. The contact point tungsten faces were corroded and exhibited an oxide crust on the external surfaces of the tungsten (see the figure below). When the operational capacitor of the right magneto was replaced with the left magneto’s capacitor, consistent spark was produced at different rpm. Additionally, after replacing the corroded contact points of the left magneto with those from the right magneto, the left magneto also produced consistent spark at different rpm. Figure 1. Magneto points. Additional Information Lycoming Engines issued Mandatory Service Bulletin (SB) 592 regarding the corrective actions to be taken after an overboost event. For engines configured similarly to the accident engine, the SB states, in pertinent part, to inspect spark plugs for a ceramic core nose with a cracked or crazed surface. It is unknown if the overboost event that the pilot described made the accident airplane engine subject to the actions in the SB (because no information was available regarding the pressure exceedance and exact duration of the event). -
Analysis
The pilot had recently purchased the airplane and was transporting it to his home airport. During the cross-country flight, the pilot stopped to refuel the airplane. During departure, the airplane climbed to an altitude of about 200 ft above ground level, at which point the engine lost partial power and was unable to maintain altitude. The pilot elected to perform an emergency off-airport landing, and the airplane touched down on desert terrain. During the landing, the airplane collided with a sign and nosed over, coming to rest inverted. The airplane had undergone a pre-buy and an annual inspection about 10 flight hours before the accident. The pilot stated that, on the day before the accident, he flight tested the airplane, during which time the manual turbocharger went into overboost for “a second” before he pulled the power back. A postaccident examination revealed that several ceramic cores of the spark plugs were cracked. The combustion chambers were free from deposits, consistent with a preignition or detonation event. It is unknown if the overboost event that the pilot described resulted in this damage. The magnetos, while still installed on the engine, did not produce a consistent spark, and their timing could not be determined. The magnetos were then removed from the engine. The right magneto was functionally tested and operated normally. The left magneto capacitor lead insulation had previously been cut, exposing the center conductor wire, consistent with improper assembly. The contact point tungsten faces were both corroded and exhibited an oxide crust on the external surfaces of the tungsten. A functional test, revealed the left magneto would not produce spark at different rpms. The left magneto was likely not operating during the accident takeoff, which, along with the cracked spark plugs, would have resulted in a partial loss of engine power.
Probable cause
A partial loss of engine power due to inadequate ignition from cracked spark plugs and a failed magneto.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CONSOLIDATED AERONAUTICS INC.
Model
LAKE LA-4-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N2989P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
954
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-04-23T04:25:31Z guid: 102960 uri: 102960 title: WPR21FA175 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102972/pdf description:
Unique identifier
102972
NTSB case number
WPR21FA175
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-23T16:19:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-05-20T22:50:18.112Z
Event type
Accident
Location
Winslow, Arizona
Airport
WINSLOW-LINDBERGH RGNL (INW)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
History of Flight On April 24, 2021, about 1519 mountain standard time, a Swearingen SA226-T(B) twinengine airplane, N59EZ, was destroyed when it was involved in an accident near Winslow-Lindbergh Regional Airport (INW), Winslow, Arizona. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed from Scottsdale Airport (SDL), Scottsdale, Arizona, about 1409 with an intended destination of INW. No flight plan was filed, and no contact was attempted between the pilot and air traffic control during the flight. Recorded ADS-B data showed that, after takeoff, the airplane proceeded north with some deviations, climbing to about 12,000 ft above mean sea level (msl) by about 1430. Between about 1430 and 1440, the airplane climbed to an altitude above 17,000 ft msl and performed two 360° turns. About 1452, the airplane began a descent into the Winslow area. The airplane circled over INW for about 15 minutes at altitudes between 6,000 and 9,500 ft msl while the airplane’s calibrated airspeed varied between 140 and 220 knots. About 1511, the airplane turned away from INW on a north-northeast heading before turning back toward the airport after about 1514. At 1516:30, the airplane began a right descending turn with a corresponding deceleration in airspeed. During the final 2 minutes of flight, the airplane descended steadily while slowing from 200 to about 125 knots. The airplane continued to slow while aligning with Interstate 40 (I-40). At 1519:15, the airplane began a turn to the right and away from I-40. The final ADS-B reported altitude for the airplane was 4,950 ft msl (about 80 ft above ground level). Figure 1 shows the airplane’s track. Figure 1. ADS-B track for the accident flight. Witnesses driving eastbound on I-40 saw a low-flying airplane that appeared to bank “hard” to the north and then veer toward the ground. The witnesses subsequently observed a fireball and black smoke. The airplane came to rest about 4 miles east of INW. The accident site was about 70 ft from the last ADS-B target. Aircraft Information The airplane was equipped with a singleredline (SRL) autostart computer, which controlled three functions: engine speed switching functions, automatic start fuel enrichment, and exhaust gas temperature (EGT) computation. According to the Honeywell TPE331 Pilot Tips manual, the SRL system computer automatically switches on at 80% RPM or higher, is used with the Exhaust Gas Temperature (EGT) indicating system and provides a constant temperature indication, which equates to maximum Turbine Inlet Temperature (TIT) under varying atmospheric conditions. The manual also stated that the SRL light would normally extinguish above 80% rpm. Wreckage and Impact Information The airplane came to rest inverted in a rock quarry and was contained within a flat portion of the quarry. The postcrash fire consumed the wreckage. The first identified point of impact was a ground mark about 10 ft from a barbed-wire fence. Two metal fence posts, about 12 ft apart from each other, were not damaged or disturbed (see figure 2). Figure 2. Barbed wire fence and fence posts. The debris path was oriented on a 028° heading that extended to the main wreckage (see figure 3), which was about 410 ft from the first identified point of impact. All major structural components of the airplane were located within the wreckage debris path. Both wings were separated from the fuselage, and both engines had separated from their respective wings. Both propeller assemblies had separated from their respective engines and were found in the debris field. Flight control continuity was established throughout the airframe. There was no evidence that indicated any preexisting mechanical malfunction with the airframe. Figure 3. Main wreckage (Source: Navajo County Sheriff Department). Fuel System The right-side fuel system had sustained impact and thermal damage from the collector tank outboard. The fuel outlet lines for both fuel pumps were separated from their associated fittings and sustained thermal damage. The fuel fittings and fuel lines from the fuel pumps to the engine were not located. The right-side fuel vent line sustained impact and thermal damage; when compressed air was applied to the fuel vent line, no air flow was noted. Movement of the fuel line expelled debris consistent with the internal portions of the fuel line. The fuel tank had been breached. The associated check valves remained intact; when compressed air was applied to the system, air flowed freely through it. The left-side fuel system was intact from the wing root to the fuel shutoff valve, and all fuel lines were secure at their fittings. The outlet fuel lines from the primary and auxiliary fuel pumps were disconnected; when compressed air was applied to the lines, air was expelled from the fuel line that attached to the fuel shutoff valve. The fuel shutoff valve was removed and found to be in the open position. The associated check valves were intact; when compressed air was applied to the system, air flowed freely through it. The cross-feed tube was intact. It was removed and found to be in the closed position. Each engine’s two fuel boost pumps were removed and examined. No mechanical anomalies were identified that would have precluded all four fuel boost pumps from operating normally before the thermal exposure. Left (No. 1) Engine Visual examination of the left engine revealed thermal damage to the accessory gearbox housing and various external fluid lines. The high-speed coupling shaft was fractured, and hand rotation of the low-pressure turbine did not produce a corresponding rotation of the propeller shaft. Evidence indicating that the left engine was operating at the time of impact included circumferential scoring on rotating components, torsional fracture of the coupling shaft, elongation of the propeller shaft locating dowel hole, dirt debris within the combustor section, and metal spray on turbine components. There was no evidence that indicated any pre-existing mechanical malfunction with the left engine. Right (No. 2) Engine Visual examination of the right engine revealed no signs of an uncontained failure or fire damage. Engine continuity was confirmed using hand rotation of the low-pressure turbine, which produced a corresponding rotation of the propeller. Localized contact marks were observed along the outer diameter of the propeller shaft; these marks were consistent with contact marks observed on the sun gear inner diameter. The compressor section remained intact and had no impact or mechanical damage. No metal spray was observed on the turbine blades or nozzle airfoils. The local contact marks, intact compressor section, and lack of metal spray on the turbine blades and nozzle airfoils were consistent with the No. 2 engine having low or no rotation at the time of the accident. A functional test and teardown of the fuel control unit and propeller governor were performed. Both units operated within the manufacturer’s specifications. The fuel control unit was disassembled; no significant damage was observed to any of the internal components that would have precluded normal operation. Propeller Assemblies Both the left and right propeller assemblies separated from their respective engines during the accident sequence. The left propeller blades were bent forward in the thrust direction, with twisting toward high pitch, face-side chordwise scoring, bending opposite the direction of rotation tip fractures and leading-edge gouging. There was no evidence of any preexisting mechanical malfunction with the airframe, No 1 (left) engine and propeller. The manufacturer determined the impact signatures on the left propeller were consistent with a high-power setting. The right propeller blades were bent aft and twisted toward low pitch with some rotation scoring found predominately on the camber side without tip fractures. The manufacturer determined the impact signatures on the right propeller were consistent with a low-to-zero power setting. Annunciator Panel The annunciator panel was submitted to the National Transportation Safety Board’s Materials Laboratory in Washington, DC, for examination. The panel contained 48 individual annunciators, and each annunciator contained two bulbs. One annunciator light, R-SRL OFF (right single redline off), displayed hot filament stretch in both bulbs. -
Analysis
The pilot was conducting a personal flight and was descending the airplane to the destination airport. Automatic dependent surveillance-broadcast (ADS-B) data showed that the airplane accomplished several turning maneuvers near the airport. These turns occurred from an elevation of 6,000 to 4,950 ft mean sea level, at which time the data ended. The airplane was 80 ft above ground level at the time. Witnesses reported seeing a low-flying airplane perform a turn and then veer toward the ground. The airplane came to rest about 4 miles east of the destination airport and 70 ft from the last data target. A postcrash fire ensued. Postaccident examination of the airframe and engines found no mechanical anomalies that would have precluded normal operation. Examination of the left engine revealed that the engine was likely producing power. The right engine examination revealed damage consistent with low or no rotation at the time of the accident, including distinct, localized contact marks on the rotating propeller shaft. In addition, no metal spray was found in the turbine section, and no dirt was found within the combustor section. The examination of the right propeller blades showed chordwise scoring with the blades bent aft and twisted toward a low-pitch setting. Examination of the fuel system noted no anomalies. The airplane was equipped with a single redline (SRL) autostart computer. Examination of the right (R) SRL-OFF annunciator panel light bulb showed signatures of hot filament stretch, which was consistent with illumination of the light at the time of the accident. The SRL light normally extinguishes above an engine speed of 80% rpm. Given the low rotational signatures on the right engine and the illuminated “R SRLOFF” warning light, it is likely that the right engine lost engine power during the flight for reasons that could not be determined.
Probable cause
The loss of engine power to the right engine for reasons that could not be determined. Contributing to the accident was the pilot’s failure to maintain control of the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SWEARINGEN
Model
SA226-T(B)
Amateur built
false
Engines
2 Turbo prop
Registration number
N59EZ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
394
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-20T22:50:18Z guid: 102972 uri: 102972 title: ERA21FA195 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102994/pdf description:
Unique identifier
102994
NTSB case number
ERA21FA195
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-28T14:24:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-05-05T21:03:16.964Z
Event type
Accident
Location
Eden, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 2 serious, 0 minor
Factual narrative
On April 28, 2021, about 1324 eastern standard time, a Bell 429 helicopter, N53DE, was destroyed when it was involved in an accident near Eden, North Carolina. The commercial pilot was fatally injured, and two passengers were seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. The helicopter was equipped with a GPMS Foresight MX Health and Usage Monitoring System (HUMS), which captured data for the accident flight. The HUMS device recorded position, attitude, acceleration, rotor speed (Nr), and engine data. The HUMS data showed the helicopter departed Danville, Virginia, about 1233 and flew cross-country south-west into North Carolina. By 1245, the helicopter was flying a powerline patrol around Eden, North Carolina. The powerline inspection was accomplished at an altitude of about 100 ft above the terrain with the helicopter gaining altitude during turns and when flying between line inspections. During the final minutes of flight, the helicopter was traveling at an airspeed between 50 and 60 kts parallel to powerlines at an altitude between 700 and 775 ft msl (Figure 1). Nr was near 100%, torque varied between 15% and 25%, and the engine gas generator (N1) speeds were between 84 and 88%. Figure 1- Combined map of flight track with corresponding flight parameters. A utility lineman seated in the front left seat recalled that the pilot was reversing course and the helicopter was in a banking turn to the right when he heard a very loud noise, “almost cannon-like, very deep, [and] within a second or two we were heading into the trees.” Several ground witnesses nearby observed the accident flight. One witness driving westbound observed the helicopter cross the road heading southbound, flying low over the trees along the powerlines. The helicopter made a right turn before it disappeared behind trees. Two other witnesses observed the helicopter flying from east to west over the trees before making a steep “left turn” as seen from their vantage point; however, as the helicopter pointed toward the witnesses, it was in a right turn. The witnesses stated they could see the underside of the helicopter and skids before it “slid at an angle downward and disappeared into the woods.” The Bell 429 is a light, twin-engine helicopter. It was maintained by the operator under the manufacturer’s recommended inspection program. Log sheet 1071, which was found at the accident site and, although undated, was presumably from the day of the accident, showed that at the start of the day the helicopter had an airframe total time of 283.5 hours and both engines had an engine total time of 283.5 hours. There were abnormalities in the recovered HUMS data that led to the attitude and acceleration data being unreliable for use in this investigation. The accident helicopter was not equipped with, nor was it required to be equipped with a cockpit voice/flight data recorder (CV/FDR), which is an available option offered by Bell. The flight was also recorded by Automatic Dependent Surveillance-Broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA). ADS-B broadcasts an aircraft’s Global Positioning System (GPS) position and other data to the ground where it is recorded. The helicopter impacted wooded terrain at an elevation of 570 ft and came to rest on a heading of about 251° magnetic and about 393 ft from the powerlines the crew was observing. All major components of the helicopter were accounted for at the accident site. A post-crash fire occurred and damaged the majority of the fuselage. The overall concentrated debris path was about 200 ft long on a 245° heading with several pieces scattered in multiple directions outside the main debris path. Remnant carbon fiber layup was present in the area of the upper cowlings, fuselage skin, and doors. The cockpit, cabin floor, and the transmission and engine deck were present but sustained heavy thermal damage. The avionics and wiring were strewn outside the nose section, with pieces of wood branches embedded within the wiring. The main rotor hub remained attached to the main rotor mast. The two yoke assemblies remained installed with the mast nut intact. The main rotor blades remained installed to their respective grips via blade pins. All blade attachment hardware was present and secured. All four blade tips exhibited impact damage and their spars exhibited a “broom straw” appearance. Three separated leading edge pieces near the tip end, including the tip cap lap joint, were found in the debris field (surrounding the main wreckage). All four main rotor blade pitch horns remained intact, and all four pitch change links were connected to their respective pitch horns and the rotating swashplate. The main rotor transmission was partially separated from the airframe. The tail boom had fractured into multiple pieces, the majority of which were found adjacent to and behind the fuselage. The tail rotor was hanging to one side of the gearbox due to fracturing of the output shaft and bending of the pitch control rod. The two tail rotor yokes remained installed on the tail rotor output shaft and were whole. All four tail rotor blades remained installed on the yokes. None of the tail rotor drive shaft covers remained installed on the tail boom. The horizontal stabilizer remained attached to a separated portion of the tail boom. The left horizontal stabilizer was generally whole with a puncture near the inboard side of its lower surface as well as a puncture near the outboard side of its upper surface. The left finlet remained attached with the lower portion intact and the upper portion fractured and partially separated. The right horizontal stabilizer was generally whole on its inboard end but was fractured at its outboard end. The lower portion of the right finlet was fractured and partially separated, remaining attached only by wiring. The upper portion of the right finlet was fractured and completely separated. The leading edge slats were present on the inboard portions of both left and right horizontal stabilizers but were fractured and separated on their outboard sections. Pieces of blue-colored composite fairing consistent with the tail rotor drive shaft cover were found in the flight path leading up to the main wreckage. The leading edge of the upper vertical fin showed evidence of impact deformation and separation above its attachment point. The four main rotor blades were reconstructed in their respective positions and laid out by their designated colors, Green, Red, Orange, and Blue (Figure 2). Three separated leading edge pieces near the tip end, including the tip cap lap joint, were found in the debris field surrounding the main wreckage. Two swept tip ends, which were fractured and separated, were reconstructed by the investigation team to the ‘blue’ and ‘orange’ main rotor blades. Two additional swept tip ends, also fractured and separated, exhibited impact damage with a width consistent with contact with the tail rotor drive system aft snubber and belonged to the ‘red’ and ‘green’ main rotor blades (Figure 3). All four swept tip ends were found in the debris field leading up to and around the main wreckage. Figure 2- A reconstruction of the four main rotor blades; From top to bottom, Green, Red, Orange, and Blue. Figure 3- An approximate reconstruction of rotor blade impact damage on the blade tip that is consistent with the dimensions of the snubber housing. The yaw hydraulic actuator remained attached to both the airframe and its control bell crank within the tail boom. The lower portion of the right finlet was fractured and partially separated, remaining attached only by wiring. The upper portion of the right finlet was fractured and completely separated. The leading edge slats were present on the inboard portions of both left and right horizontal stabilizers but were fractured and separated on their outboard sections. Pieces of blue-colored composite fairing consistent with the tail rotor drive shaft cover were found along flight path leading up to the main wreckage. The steel tail rotor drive shaft was continuous to the fan blower shaft. The fan blower shaft and oil cooler blower remained installed on the airframe but were crushed from impact forces. The drive shaft was attached at its forward end to the shaft segment running through the oil cooler blower assembly, one of the lobes (or “ears”) on the adapter assembly was fractured. The forward segmented drive shaft was fractured about 25 inches aft of its forward attachment flange. Two additional pieces from the forward segmented drive shaft were recovered: 1) the midsection of the forward segmented drive shaft, containing the stainless steel snubber sleeve, was found in the wreckage adjacent to the tail boom and 2) the aft section of the forward segmented drive shaft, about 40 inches in length, remained attached to a separated section of the tail boom and remained connected to a forward portion of the aft segmented drive shaft, about 23 inches in length, and the hanger bearing between them. The segmented drive shaft hanger bearing and its mount remained attached to the tail boom. A 34-inch -long section of the aft segmented drive shaft was found embedded near-vertically into the ground, with about 18 inches buried. The aft portion of the 34-inch section of the aft segmented drive shaft exhibited an angled cut (Figure 4). Figure 4 - The 34-inch section of the aft segmented drive shaft, the aft end of which exhibited the angular cut. A piece of a tail rotor drive shaft, semi-circular in its cross-section, was found about 172 ft from the main wreckage. Additional multiple smaller fragments of composite tail rotor drive shaft were found in the debris field along the flight path leading up to the main wreckage. The helicopter was configured with only the pilot flight controls installed in the right cockpit seat. Various thermally degraded control clevis connections and bell cranks were found in the main wreckage site, but the majority of the cockpit flight control system was consumed by the post-crash fire. None of the connection points between linkages and bell cranks exhibited evidence of fastener disconnection or separation. The three main rotor servo actuators were found separated on the ground near the forward end of the main transmission. All three main rotor servo actuators exhibited thermal damage. The hydraulic lines remained connected to the three servo actuators, allowing for identification of their positions. The tail rotor servo actuator was found in the tail boom wreckage and its hydraulic lines remained connected. The right integrated hydraulic module (IHM) was found on the ground in front of the main transmission and was partially melted. The left IHM was found within the transmission deck wreckage, closer to the swashplate assembly, and was whole but covered in soot and otherwise exhibited no anomalies or debris in the reservoir. The right hydraulic pump was partially melted but the splines and springs, although deformed due to thermal stress, did not show any anomalies. The left hydraulic pump was whole, and its exterior was thermally damaged but remained whole and showed no evidence of anomalous wear. The lateral, longitudinal, and collective flight control servos exhibited thermal damage. The tail rotor servo actuator sustained no thermal damage. The flight control servo actuators were imaged and examined under the direction of the NTSB, and subsequently shipped to Woodward, Inc. for additional teardown examination. Examination of the four servo actuators revealed no preimpact or anomalous damage. All components within the valves were present and all O-rings and backup rings exhibited thermal degradation but were present and no scoring was noted. The helicopter was equipped with two Pratt and Whitney PW207D1 engines, both of which remained installed on the engine deck. The No. 1 engine exhibited thermal damage, and the No. 2 engine exhibited thermal and impact damage. Both electronic engine controls (EECs) and data collection units (DCUs) for the Nos. 1 and 2 engines were removed for download but usable data could not be retrieved from either of the units due to thermal and impact damage. Postaccident examination of both engines and their respective components revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded their normal operation. The North Carolina Department of Health and Human Services, Office of the Chief Medical Examiner performed the pilot’s autopsy. According to the autopsy report, the cause of death was smoke inhalation and thermal injuries with blunt forces contributing. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. There were no findings of a contributory nature. A performance study was accomplished utilizing the HUMS data along with ADS-B data, weather data, and published Bell performance data. The HUMS data did not record flight control inputs, so the pilot inputs during the final climb and maneuver at the time of the accident were unknown. The helicopter was not near the edge of its operating performance envelope for speed, altitude or temperature and reported weather at the time of the accident was clear with 10 statute miles visibility. A LIDAR (“light detection and ranging” or “laser imaging, detecting, and ranging”) scan was conducted in the area of the accident by Duke Energy to record the location of powerlines and surrounding terrain, including the trees. Analysis of the accident flight path using the HUMS data and the LIDAR scan showed the accident helicopter’s distance from the treetops increasing near the end of recorded data. -
Analysis
The helicopter departed and flew cross-country to begin a powerline patrol, which included flying adjacent to powerlines at an altitude of about 100 ft above ground level and with the helicopter gaining altitude during turns and when flying between line inspections. During the final minutes of flight, the helicopter was traveling at an airspeed between 50 and 60 kts along powerlines at an altitude between 700 and 775 ft above mean sea level (msl). As the helicopter flew south, near the end of the north-south powerline’s right of way, the helicopter began a climbing right turn towards the west. A utility lineman in the helicopter’s front left seat recalled that the pilot was reversing course and the helicopter was in a banking turn to the right when he heard a very loud noise, “almost cannon-like, very deep, within a second or two we were heading into the trees.” Onboard data recovered from the helicopter showed rotor speed suddenly increased to 107% about 1.5 seconds before the end of recorded data. Examination of the wreckage showed evidence the main rotor blades impacted the tail rotor drive system. Therefore, it is likely the loud noise heard by the onboard lineman was caused by the main rotor blades impacting the tail rotor drive system, resulting in a severance of the tail rotor drive shaft and subsequently a loss of directional control. Successful recovery of the helicopter after the loss directional control at a low altitude was unlikely and resulted in impact with terrain. Based on analysis of flight data and a scan of the local terrain, it is unlikely the helicopter impacted powerlines or nearby trees at the time the main rotor blades impacted the tail rotor drive system. The loss of clearance between the main rotor and the tail of the helicopter can be caused by sudden aft cyclic control inputs, usually in conjunction with a reduction in collective pitch that would reduce main rotor thrust and increase downward flapping of the blade. The lack of flight control parametric data precluded analysis of flight control inputs at the time the main rotor blade contacted the tail boom. However, it is likely the pilot was not maneuvering to avoid trees based on the increasing distance between the accident helicopter and treetops near the end of the accident flight. Examinations of the helicopter wreckage found no evidence of any preimpact anomalies or malfunctions that would have precluded normal operation of the helicopter.
Probable cause
The impact of the main rotor blades with the tail boom during low-altitude maneuvers, which severed the tail rotor drive shaft and resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
429
Amateur built
false
Engines
2 Turbo shaft
Registration number
N53DE
Operator
DUKE ENERGY BUSINESS SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
57380
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-05T21:03:16Z guid: 102994 uri: 102994 title: ERA21LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103045/pdf description:
Unique identifier
103045
NTSB case number
ERA21LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-29T11:52:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-05-11T21:58:37.918Z
Event type
Accident
Location
Okeechobee, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On April 29, 2021, about 1052 eastern daylight time, a Piper PA-28-161, N271SG, was substantially damaged when it was involved in an accident near Okeechobee, Florida. The private pilot was seriously injured, and the student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the private pilot, the purpose of the cross-country flight was for both pilots to build flight time. Shortly after departing on the second leg of their flight, at an altitude about 5,500 ft mean sea level (msl), the engine began running rough. The private pilot applied carburetor heat, but the engine continued to lose power, followed by a sudden drop in rpm. She noticed a drop in fuel pressure and turned on the fuel pump, but engine power was not restored. When the airplane was about 2,000 ft msl, the student pilot, who had previous experience performing a forced landing, assumed control of the airplane and landed the airplane in a field. According to the Federal Aviation Administration inspector who responded to the accident site, the airplane came to rest in a muddy ditch and sustained substantial damage to the fuselage. The engine air box, exhaust, and nose gear assembly were pushed upward into the engine compartment. Fuel was present throughout the fuel system, carburetor, and fuel filters, and the fuel was absent of water and debris. The fuel gauges indicated that the left and right wing tanks each contained 12 gallons of fuel. The throttle, mixture, and carburetor heat controls operated normally. The fuel selector was found in the left wing tank position; the fuel selector operated normally. All flight control cables were continuous from the cockpit controls to the control surfaces. Manual manipulation of the aileron, stabilator, and rudder cables operated their respective control surfaces. A detailed examination of the engine revealed no evidence of preimpact malfunctions or anomalies. The engine was subsequently test run, during which it performed normally through all power settings. Disassembly of the carburetor found no contamination inside the bowl. -
Analysis
About 5,500 ft mean sea level during cruise flight, the engine began running rough and eventually lost all power. The pilot applied carburetor heat and turned on the fuel pump, but engine power was not restored. The airplane sustained substantial damage during the subsequent forced landing to a field. Postaccident examination and test run of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The reason for the loss of power could not be determined based on the available information.
Probable cause
A total loss of engine power for reasons that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-161
Amateur built
false
Engines
1 Reciprocating
Registration number
N271SG
Operator
Airborne Systems Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-42071
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-11T21:58:37Z guid: 103045 uri: 103045 title: OPS21LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103049/pdf description:
Unique identifier
103049
NTSB case number
OPS21LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-04-29T16:07:00Z
Publication date
2023-09-22T04:00:00Z
Report type
Final
Last updated
2021-08-24T01:18:12.753Z
Event type
Incident
Location
St Petersburg-Clearwater, Florida
Airport
ST PETE-CLEARWATER INTL (PIE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 29, 2021, about 1507 EDT, a near midair collision occurred at the St. Pete-Clearwater International Airport (PIE), St Petersburg-Clearwater, Florida, when AAY803, while on initial climb from runway 18, took evasive action to avoid a midair collision with N370SD that was crossing over head of the runway about midfield, while on the right downwind for runway 22. AAY803 was being operated under Title 14 Code of Federal Regulations (CFR) Part 121 and N370SD was operated under Title 14 CFR Part 91. There were no injuries reported to the crew or passengers of either flight, and no damage to the aircraft. Daytime visual meteorological conditions prevailed at the time of the incident. About 1457, N370SD departed Albert Whitted Airport (SPG), St. Petersburg, Florida and flew to the west and then northwest along the intercoastal waterway about 1,100 ft above mean sea level (msl). The flight made a 270 degree turn and then flew to the northeast towards PIE. Figure 1 is the PIE airport diagram and shows the locations of runway 22 and runway 18 circled in red. Figure 1. PIE airport diagram showing locations of runway 18 and runway 22. About 1501, the pilot of N370SD checked in with the PIE LC controller and said they had Automatic Terminal Information Service (ATIS) information November. The LC controller asked the pilot to “say again.” The pilot of N370SD responded with his call sign. About 1502, the LC controller instructed the pilot of N370SD to squawk 0163 and requested the pilot to say his intentions. The pilot readback the squawk and informed the controller that he wanted to make a full stop landing. The LC controller instructed the pilot to fly eastbound and then enter a left downwind for runway 22. The pilot readback, “eastbound left downwind runway 22.” The LC controller asked the pilot of N370SD if he had ATIS information November. The pilot acknowledged “affirmative, November.” About 1504, the LC controller instructed AAY803 to line up and wait (LUAW) on runway 18 and told the crew they had traffic on a 7-mile final. The crew of AAY803 responded, “line up and wait.” About 1505, the LC controller informed the pilot of N370SD that he had to change plans and instructed the pilot to turn 20 degrees to the left and enter a right downwind to runway 22. The pilot readback, “right downwind runway 22.” About 1506, the LC controller cleared AAY803 for takeoff from runway 18. The crew responded, “cleared for takeoff 18, Allegiant 803.” About 1507, the crew of AAY803 stated, “tower, Allegiant 803 what’s with the aircraft that we almost just hit.” The pilot of N370SD transmitted, “I have the aircraft in sight, sir, right downwind 22.” The LC controller instructed N370SD to continue to the right downwind. The LC controller advised the crew of AAY803 that, “there’s traffic at 10 o’clock but they’re turning northeast bound and they’re no factor, and there was traffic that flew over the runway at 1,000 feet towards the approach end and they’re in a right downwind for runway 22, is that who you are talking about.” The crew of AAY803 stated, “yeah, we had to level off we were climbing right into them.” The pilot of N370SD stated, “I had the traffic in sight at all times sir.” According to the AAY803 Captain’s statement, they were light and rotated about five hundred feet before the old runway 9/27. He called positive climb and the pilot flying (PF) called for the gear up. Since they were light the aircraft was climbing very fast. He reached over for the gear handle and saw an aircraft coming right at them about 200 feet higher at our one-thirty [clock] position. He immediately called for the PF to level off, pointed out the traffic and he left the gear down. When clear of traffic they continued the climb. He contacted the tower to report the near midair and the controller responded the aircraft was at 1,000 feet. The LC controller then instructed AAY803 to contact Tampa departure control. The crew of AAY803 responded “contact departure.” FAA radar data showed that at 1507:02 N370SD was on a right downwind for runway 22, at an altitude of 300 feet and a lateral distance of about 800 feet from the centerline of runway 22, when it overflew runway 18. At the same time AAY803 was at 200 feet departing runway 18. The closest proximity was 100 feet vertically and 369 feet laterally. Figure 2 is satellite imagery overlaid with FAA radar data showing the closest proximity between N370SD and AAY803. The figure provides a close-up overhead view of the location. A legend of pertinent information is located in the bottom right corner of this figure. Figure 2. FAA Radar data overlaid on satellite imagery illustrating the flights routes of N370SD and AAY803, and the location of the closest proximity to each other. Figure 3 is satellite imagery overlaid with FAA radar data illustrating flight paths of N370SD and AAY803 from a side view. A legend of pertinent information is located in the bottom right corner of this figure. Figure 3. FAA Radar data overlaid satellite imagery illustrating the flight paths of N370SD and AAY803, from a side view perspective. About 1508, the LC controller advised the pilot of N370SD that he would call his base turn. Then the LC controller instructed the pilot to turn his base and asked what his altitude was. The first part of the pilot’s transmission was indiscernible, and although the last part of the transmission was intermittently distorted, the pilot was heard stating, “turn base.” The LC controller asked the pilot again what his altitude was. The pilot responded, “700 feet at the moment.” The LC informed the pilot that he could not understand him. The first part of the pilot’s transmission was indiscernible, and although the last part of the transmission was intermittently distorted, the pilot of N370SD was heard stating, “700 feet at this time.” The LC controller said, “understand 700 feet” and informed the pilot that he was not receiving his mode C at that point. About 1509, the LC controller cleared N370SD to land on runway 22. The pilot read back “cleared to land.” Two minutes later N370SD landed on runway 22. According to the pilot of N370SD, “My recollection of the flight into KPIE on the day in question is very clear, the air traffic controller cleared me to "left downwind 22" whilst established left downwind 22 I was instructed "change of plan RIGHT downwind 22." At all times I had the Allegiant jet in view. On approaching [runways] 36-18 I saw the jet start to climb then heard the pilot of the jet comment about my position to which the air-traffic controller replied, "you have sufficient clear airspace the aircraft is at 1000 ft mid field. " My assumption was the controller moved me to right downwind to give sufficient clearance so that the airbus could pass safely under me.” -
Analysis
Review of the radar data showed that N370SD, a Cessna 337, was on a right downwind for runway 22 at 300 feet when it overflew runway 18, and at the same time Allegiant Air flight 803 (AAY803), an Airbus A319, was at 200 feet departing runway 18. The closest proximity was 100 feet vertically and 369 feet laterally. The crew of AAY803 saw the Cessna 337 and took evasive action by stopping their takeoff climb and maintaining 200 feet, and flew underneath the Cessna 337, which was at 300 feet as the airplane’s paths intersected over the runways. The local controller did not visually scan all runways and airspace when he instructed the Cessna 337 pilot to enter a right downwind, and again, when he issued a takeoff clearance to the Allegiant Air flight; the lack of fully scanning all runways and airspace resulted in the local controller losing situational awareness of the Cessna 337, and ultimately not ensuring positive control and separation between the Allegiant Air flight and the Cessna 337. The Cessna 337 pilot’s downwind leg for runway 22 was significantly less than the standard 1/2 to 1 mile defined downwind leg distance from the runway, which placed the Cessna 337 in a closer vicinity to the runway intersections than what was expected. Additionally, the Cessna 337 pilot did not fly a standard traffic pattern altitude, and the local controller did not instruct or advise the pilot that the traffic pattern altitude was 1,000 feet. PIE airport did not have a charted traffic pattern altitude.
Probable cause
The air traffic controller’s failure to properly scan the runway and local area, and their general loss of situational awareness, resulting in a near midair collision. Contributing to the incident was the Cessna 337 pilot's poor decision making when he failed to fly the standard downwind leg distance from the runway and to maintain the standard traffic pattern altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A319-112
Amateur built
false
Engines
2 Turbo fan
Registration number
N306NV
Operator
Allegiant Air
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
2420
Damage level
None
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
CESSNA
Model
M337B
Amateur built
false
Engines
2 Reciprocating
Registration number
N370SD
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
69-7659
Damage level
None
Events
Findings
creator: NTSB last-modified: 2021-08-24T01:18:12Z guid: 103049 uri: 103049 title: ERA21LA201 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103010/pdf description:
Unique identifier
103010
NTSB case number
ERA21LA201
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-01T15:28:00Z
Publication date
2023-05-10T04:00:00Z
Report type
Final
Last updated
2021-05-13T23:26:50.159Z
Event type
Accident
Location
Lakeland, Florida
Airport
Lakeland Linder International (LAL)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
The flight time for the four legs that the accident airplane flew totaled about 1 hour 17 minutes. The estimated maximum total fuel consumption for all four legs including fuel for engine start, run-up, taxi, and takeoff was about 28 gallons. The left and right main wing fuel tanks each had a total capacity of 74 gallons. The airplane was equipped with dual control yokes. The engine was modified in 2001 with the addition of a “turbonormalizing system” in accordance with FAA supplemental type certificates. The airplane manufacturer’s Engine Failure emergency checklist states the following for an engine failure after liftoff and in flight: Landing straight ahead is usually advisable. If sufficient altitude is available for maneuvering, accomplish the following: 1. Fuel Selector Valve – SELECT OTHER TANK (Check to feel detent) 2. Auxiliary Fuel Pump – ON 3. Mixture – FUEL RICH, then LEAN as required 4. Magnetos – CHECK LEFT and RIGHT, then BOTH 5. Alternate Air T-handle – PULL AND RELEASE Note The most probable cause of engine failure would be loss of fuel flow, improper functioning of the ignition system or blockage of the induction system. Recovered records included an airplane flight manual supplement, aircraft registration, Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual, a Basic Empty Weight and Balance form, and a transponder installation entry. No other maintenance records were located. - On May 1, 2021, about 1428 eastern daylight time, a Beech A36, N125WC, was destroyed when it was involved in an accident near Lakeland Linder International Airport (LAL), Lakeland, Florida. The flight instructor was fatally injured, and the pilot under instruction was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot under instruction, who was the owner of the airplane, stated that, after arriving at the airport, he checked the engine oil, walked around the airplane, and performed a preflight inspection. After the airplane was fueled, the pilot under instruction waited for the flight instructor to arrive, and he checked the fuel drains, the tip tank fuel drains, and the lower part of the fuel strainer (near the engine compartment) for water; no water was detected. According to Federal Aviation Administration (FAA) automatic dependent surveillancebroadcast (ADS-B) data, the airplane flew four legs on the day of the accident, including the accident leg. The pilot under instruction stated that the first flight departed with full fuel tanks and the fuel selector positioned to the left tank. About 30 minutes into the flight, he moved the fuel selector to the right tank. The flight continued to Sebring Regional Airport (SEF), Sebring, Florida, where the pilot under instruction performed a full-stop landing and secured the airplane. Before the second flight leg, the pilot under instruction performed a walkaround, started the engine, and taxied to the runway. He reported departing with the fuel selector positioned to the right tank. ADS-B data showed that the airplane flew to Arcadia Municipal Airport (X06), Arcadia, Florida. While the pilot under instruction recalled the second flight leg destination was different then the ADS-B data, he stated that he moved the fuel selector to the left tank position while en route to the destination, where it remained for landing. Although the pilot under instruction had no recollection of a third flight leg, ADS-B data showed that the airplane departed X06 and proceeded to Bartow Executive Airport (BOW). The position of the fuel selector during the third leg could not be determined. The pilot under instruction recalled departing from BOW on what he thought was the third flight leg but was actually the fourth flight leg based on ADS-B data. The flight departed with the fuel selector positioned to the left tank and climbed to 2,600 ft mean sea level (msl). The pilot under instruction planned to perform an instrument approach to LAL while the flight instructor handled radio communications. The flight instructor called the tower, gave a position report, and advised the controller that the airplane was inbound for a planned fullstop landing. The controller instructed them to call back when the airplane was 2 miles out from LAL. According to ADS-B data, between 1423:38 and 1425:37, the flight was about 4 nautical miles east-southeast of the approach end of runway 27 at LAL. The airplane flew to the west, consistent with entering the downwind leg of the airport traffic pattern for runway 9. After 1425:37, the airplane turned slightly to the right and then proceeded briefly to the west. The pilot under instruction reported that, when the airplane was 2 miles away and descending with the fuel selector positioned to the left tank (about 30 minutes after placing the selector in that position), the engine “absolutely quit.” He then told the flight instructor, “your aircraft.” While the flight instructor flew the airplane, the pilot under instruction moved the fuel selector to the other position (the right tank position), checked both magnetos, and turned on the auxiliary fuel pump to prime the engine. Those actions were part of the procedures in the airplane manufacturers’ Engine Failure emergency checklist (after liftoff and in flight), but the actions did not restore engine power. The pilot under instruction then moved the fuel selector back to the left tank position and tried to start the engine, noting that it “turned over” but did not start. The pilots notified the controller that the airplane had lost engine power. The controller cleared the airplane to land on runway 5 and then provided a clearance to runway 27. The pilots advised that the airplane could not reach the runway. ADS-B data showed that, at 1426:25, the airplane turned to the right and flew westnorthwest toward the approach end of runway 27. At 1427:53, when the flight was about 0.8 nautical miles and 101° from the approach end of the runway, the airplane turned right and flew north-northwest toward a forced landing area. The airplane’s last ADS-B target, at 1427:59, was located about 0.7 nautical miles east of the approach end of runway 27. While the airplane was descending, the left wing impacted a palm tree and the ground, and a postimpact fire ensued. The flight instructor initially survived his injuries but succumbed to them 11 days later. A 13-second video taken by a pilot-rated witness, who was located about 540 ft northnortheast of the airplane’s position, depicted the airplane descending with minimal engine sound and the landing gear retracted. The video did not capture the accident. This witness noted that he heard the pilot trying to restart the engine two or three times. - Postaccident examination of the area surrounding the wreckage revealed damage to a palm tree about 12 ft above ground level. The palm tree was located about 4,069 ft east of the approach end of runway 27 and about 141 ft northwest from the last ADS-B target. The airplane made ground contact about 94 ft northwest from the tree contact. The airplane rolled about 45 ft while on an energy path of 348°, the left wing contacted the base of an oak tree, and the right wing impacted a parked trailer. The airplane came to rest upright about 180 ft from the palm tree. At the accident site, brown grass was noted. About 5 ft of the outer portion of the left wing was impact separated and no fuel could be seen in the left fuel tank which appeared to be intact. An unquantified amount of fuel was observed in the right fuel tank. Examination of the airplane revealed that the cockpit and cabin were extensively heat damaged. The magneto switch was between the 1 and 2 o’clock positions, which was consistent with the BOTH or RUN position, and the fuel selector was positioned to the left tank. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Examination of the control yoke revealed that the outer shaft was intact and that the yoke chains were connected to the inner shaft. Continuity of each fuel supply was confirmed from each fuel tank to the fuel selector valve. Both fuel vents were unobstructed from the inlet opening to each fuel tank. The auxiliary fuel pump was heat damaged, and the engine fuel supply and return lines from and to the fuel selector valve exhibited multiple breaks, but all lines were free of obstructions. The screen of the airframe fuel strainer was clear, and no fuel was present. The inlet and outlet flexible hoses connected to the engine-driven fuel pump were tightly installed; the hoses were removed and found to have no fuel. Examination of the engine revealed crankshaft, camshaft, and valve train continuity. During had rotation of the crankshaft, thumb suction and compression were noted to all cylinders except for the right front cylinder, which exhibited impact damage. Borescope inspection of all cylinders revealed no damage to any valves or pistons. The turbocharger rotated freely by hand, and the blades exhibited no damage. Examination of the air induction and exhaust systems revealed no evidence of blockage. The air filter, which was impact damaged, contained organic material. Inspection of the oil filter element revealed no ferrous or nonferrous materials. Impact damage was noted to the No. 2 top and Nos. 3 and 5 top and bottom ignition leads. The impulse couplings from both magnetos operated, and spark was noted at all ignition leads during hand rotation of the crankshaft. Examination of the left magneto revealed that it was tightly secured to the engine, but the magneto flange (near the upper securing nut) was cracked, and a linear gouge was noted on the cracked flange section, consistent with slippage or rotation. Examination of the bottom spark plugs revealed that all were oil soaked except for the Nos. 4 and 6 spark plugs. All spark plugs exhibited normal wear and color when compared with the Champion Aviation Check-A-Plug chart. Examination of the impact-separated throttle body and fuel metering valve revealed that the throttle lever was bent near both ends. When the throttle lever was rotated, the throttle shaft and throttle plate did not rotate. The internally locking hex nut that secured the throttle lever to the throttle shaft was tight and could not be moved by hand. Hand movement of the throttle plate caused movement of the throttle shaft and corresponding movement of the interconnect linkage to the throttle control. The throttle body fuel inlet screen was clean. A slight amount of fuel was drained from the flexible fuel hose between the metering valve and the flow divider. No contaminants were noted, and the smell was consistent with 100 low-lead fuel. Operational testing of the throttle body and metering valve at the engine manufacturer’s facility revealed no evidence of preimpact failure or malfunction. The No. 1 fuel injector nozzle was blocked by debris that appeared to be organic. The Nos. 2 through 4 fuel injector nozzles were covered with oil. After the oil was removed, they were free of obstructions. The Nos. 5 and 6 fuel injector nozzles were clear. Operational testing of the manifold valve, fuel injector lines, and nozzles at the engine manufacturer’s facility revealed that all nozzles passed the spray pattern test but that testing at various fuel flow rates revealed slight out-of-tolerance conditions. Disassembly of the manifold valve revealed that the screen was clean and that the diaphragm and spool had no issues. Impact damage was noted to the engine-driven fuel pump and surrounding area. The drive coupling of the engine-driven fuel pump was intact. Operational testing of the engine-driven fuel pump at the engine manufacturer’s facility revealed slight leakage from the seal drain but no evidence of preimpact failure or malfunction. -
Analysis
The pilot under instruction, who owned the airplane, and the flight instructor flew four flight legs on the day of the accident, totaling about 1 hour 17 minutes. The pilot under instruction stated that the airplane departed on the first flight leg with full fuel tanks and the fuel selector positioned to the left tank. Although he recalled moving the fuel selector to the right tank about 30 minutes into the flight, the actual flight duration based on ADS-B data was less than 30 minutes. The pilot under instruction reported that the fuel selector was positioned to the right tank during the second leg, then moved to the left tank position where it remained for the remainder of that flight and the accident flight. During the accident flight when the airplane was close to the destination airport, the engine suddenly quit. Airplane control was transferred to the flight instructor while the pilot under instruction attempted to restore power. Among the actions that the pilot under instruction took was to move the fuel selector from the left to right tank position (in accordance with emergency checklist procedures) and then back to the left tank position, but the engine did not start. While the flight instructor was maneuvering the airplane for an off-airport forced landing, the left wing struck a palm tree separating the outboard 5 ft of wing, which was followed by contact with the ground, contact with another tree, and a trailer before the airplane came to rest. A postcrash fire ensued. Postaccident examination of the powertrain, air induction, ignition, and exhaust systems of the engine revealed no evidence of preimpact failure or malfunction. No discrepancies were found with the airframe fuel supply, vent systems, or flight controls. Although no fuel was found in the left fuel tank; the engine fuel supply and fuel return lines from and to the fuel selector valve were fractured in multiple areas consistent with impact. Therefore, it is likely that any remaining fuel in the left fuel tank leaked from the open fuel lines. Additionally, based on the airplane departing on the first leg with full fuel tanks, adequate fuel should have been available in either the left or right fuel tank to complete the accident flight. The tested fuel metering components showed no evidence of preimpact failure or malfunction. The inability to rotate the throttle lever was likely the result of impact damage to the throttle lever and throttle shaft of the metering valve and was likely not a factor in the loss of engine power. Therefore, the reason for the reported sudden and total loss of engine power could not be determined based on the available evidence for this investigation.
Probable cause
The total loss of engine power for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N125WC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E781
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-13T23:26:50Z guid: 103010 uri: 103010 title: CEN21FA209 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103032/pdf description:
Unique identifier
103032
NTSB case number
CEN21FA209
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-05T00:01:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-05-05T21:25:56.346Z
Event type
Accident
Location
Hattiesburg, Mississippi
Airport
HATTIESBURG BOBBY L CHAIN MUNI (HBG)
Weather conditions
Instrument Meteorological Conditions
Injuries
4 fatal, 0 serious, 2 minor
Factual narrative
Standard LNAV/VNAV Approach FAA Advisory Circular (AC) 91-89, Mitsubishi MU-2B Training Program, states that before the final approach fix, the airplane should be configured with 5° flaps and a minimum airspeed of 140 kts. As the airplane approaches the final approach fix, the airplane should then be configured with 20° flaps, landing gear down, and a minimum airspeed of 120 kts. Performance Study A performance study was conducted on the accident flight using ADS-B data. The study found that when the airplane was in the procedure turn, the airspeed reached as low as 88 kts which coincided with the calculated stall speed for wings level, idle engine power, and 5° of flaps. The airplane’s airspeed increased towards 140 kts. The airplane descended before the final approach fix, then stopped the descent for about 30 seconds before it resumed a descent rate of about 1,300 ft per minute. As the airplane descended it continued to decelerate. The last calculated airspeed was at 85 kts which was about 7 kts above the calculated stall speed for 20° flaps and power idle. ADS-B data from the three flights before the accident were obtained for comparison purposes. Two approaches showed large variations in airspeed, either above or below the recommended approach speeds. The flight before the accident flight showed the airplane 200 ft above the glide path on final before regaining the glide slope. - The airplane’s logbooks were not located during the investigation. Maintenance facilities near the pilot’s routes of flight indicated the dates of the most recent annual inspection and the most recent maintenance record, which was October 3, 2020. The airplane was equipped with a Bendix/King KLN 94 GPS Navigation System that was certified for the lateral navigation (LNAV) approach only and would thus not be capable of displaying vertical navigation for the approach. - The minimum descent altitude for the LNAV approach to runway 13 at HBG was 580 ft msl. - On March 4, 2021, about 2301 central daylight time, a Mitsubishi MU2B-60 airplane, N322TA, was destroyed when it was involved in an accident near Hattiesburg Bobby L. Chain Municipal Airport (HBG), Hattiesburg, Mississippi. The pilot, two passengers, and one person on the ground sustained fatal injuries, and two people on the ground sustained minor injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The pilot was flying under an instrument flight rules flight plan and departed Wichita Falls Municipal Airport (SPS), Wichita Falls, Texas, about 2058. According to the Federal Aviation Administration, the pilot checked in with the Houston Air Route Traffic Control Center and requested a descent into HBG. The flight was cleared to descend to 2,400 ft mean sea level (msl). During the descent, the pilot reported that he had the current weather information and requested a clearance direct to the HILGA intersection for the area navigation (RNAV) GPS runway 13 approach to HBG. Automatic Dependent Surveillance–Broadcast (ADS-B) data provided by the Federal Aviation Administration captured the accident flight. About 2251, the pilot began to fly the procedure turn for the RNAV approach; at 2252:12, the airplane’s airspeed was 88 knots. The airspeed fluctuated before the airplane accelerated back to 140 knots as the airplane crossed HILGA and descended to 2,000 ft msl. As the airplane approached the final approach fix (CUPPA), the airplane descended before the fix and crossed it 300 ft low. The airplane’s descent stopped for about 30 seconds, and the airplane then descended about 1,300 ft per minute. The airplane’s airspeed decreased as the airplane continued to descend; at 2301:24, when the airplane’s airspeed was about 85 knots its altitude was 500 ft msl. The last recorded data point showed the airplane at an altitude of about 460 ft msl and 750 ft from the accident site. The airplane impacted the front of an occupied residence, and a postimpact fire ensued. Figure 1 shows the airplane’s approach path and wreckage location. Figure 1. Airplane’s approach path with accident site location with times and altitudes annotated. - An autopsy of the pilot was conducted by the Mississippi Office of the State Medical Examiner, Pearl, Mississippi. His cause of death was blunt force injuries. No significant natural disease was identified by the medical examiner. Toxicological testing by the FAA Forensic Sciences Laboratory detected zopiclone, which was related to the pilot’s use of eszopiclone. a sedative used to treat insomnia. On his application for an FAA medical certificate, date June 24, 2020, the pilot reported the use of losartan (to treat high blood pressure), sitagliptin-metformin (to treat diabetes), and atorvastatin (to treat high cholesterol). - Weather information for the accident flight revealed the potential for clouds between 700 to 1,400 ft, light low-level windshear between 1,100 and 2,300 ft, and light-to-moderate clear air turbulence below 4,000 ft. - The pilot’s logbooks were not located during the investigation. On his last application for a Federal Aviation Administration medical certificate, the pilot reported having accrued 30 hours of flight time in the preceding 6 months. He was issued a Continued Authorization for Special Issuance. On November 13, 2020, the pilot completed recurrent training to satisfy the Title 14 CFR Part 91, subpart N, Mitsubishi MU-2B series Special Training, Experience, and Operating Requirements. His training record indicated that the pilot received average scores. On December 28, 2011, the pilot was involved in a hard landing while piloting an MU2B20, which resulted in substantial damage to the fuselage (See NTSB Report ERA12CA128). The pilot purchased N322TA on February 1, 2012. - The accident site was located 2.24 miles from the approach end of runway 13. The postimpact fire consumed most of the airplane and the residence. The accident site was largely contained to one area with a small debris field, consistent with a low-energy impact, as shown in figure 2. Figure 2. Accident site. Postaccident examination of the wreckage found that the airplane was configured with its landing gear down and flaps at 20°. All major flight controls were found at the accident site. Disassembly of both engines revealed debris consistent with roofing tiles in the combustion chambers. In addition, both engines contained signatures of rotational scoring and torsional fractures. Both propellers displayed witness marks indicating blade positions between 25° and 28°, which was consistent with a low power setting. Examination of the airframe, engines, and propellers revealed no preimpact anomalies. The airplane’s Honeywell KMH 920 Enhanced Ground Proximity Warning System was found in the wreckage. Data downloaded from the device revealed that alerts for mode 1 excessive descent rates (“sink rate” and “pull up”) were generated before the accident. No input faults were detected. -
Analysis
The pilot was flying a nonprecision approach in instrument meteorological conditions at night. While flying the procedure turn for the approach, the airplane’s speed decayed toward the stall speed before the airplane accelerated back to the standard approach speed. During the descent from the final approach fix, the airplane’s descent stopped for about 30 seconds and then the airplane descended at a rate of about 1,300 ft per minute. The airplane decelerated and continued to descend until the airspeed was about 85 knots (about 7 knots above the calculated stall speed for flaps 20°) and the altitude was 500 ft mean sea level. The last recorded data point showed the airplane about 460 ft mean sea level and 750 ft from the accident site. The airplane impacted a private residence, and a postcrash fire ensued and destroyed the airplane. Impact signatures were consistent with a low-energy impact. Examination of the airframe and engines did not detect any preimpact anomalies that would have precluded normal operations. Signatures on the engines and propellers were consistent with both engines providing power at impact. A review of the pilot’s toxicological information found that the level of eszopiclone in his specimens was subtherapeutic and thus not likely a factor in the accident. The circumstances of the accident are consistent with an inadvertent aerodynamic stall from which the pilot was unable to recover.
Probable cause
The pilot’s failure to maintain control of the airplane during the night instrument approach which resulted in an inadvertent aerodynamic stall from which the pilot was unable to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MITSUBISHI
Model
MU2B
Amateur built
false
Engines
2 Turbo prop
Registration number
N322TA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
760 S.A.
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-05T21:25:56Z guid: 103032 uri: 103032 title: ERA21LA208 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103036/pdf description:
Unique identifier
103036
NTSB case number
ERA21LA208
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-05T11:33:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-05-17T16:40:04.271Z
Event type
Accident
Location
Ridgeland, South Carolina
Airport
RIDGELAND-CLAUDE DEAN (3J1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 5, 2021, about 1033 eastern daylight time, an Israel Aerospace Industries Gulfstream G150, N22ST, was substantially damaged when it was involved in an accident at Ridgeland-Claude Dean Airport (3J1), Ridgeland, South Carolina. The two pilots and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 executive/corporate flight. According to the PIC, a routine preflight was completed earlier on the morning of the accident, and he and the SIC flew a routine flight from Fort Lauderdale International Airport (FLL), Fort Lauderdale, Florida, to New Smyrna Beach Municipal Airport (EVB), New Smyrna Beach, Florida. The passengers boarded the airplane, and the flight to 3J1 departed. A review of the airplane’s cockpit voice recorder (CVR) revealed that, while en route to the destination airport, the crewmembers discussed the reported wind at nearby airports and noted that the direction was from 240° to 250°, which they said would favor landing on runway 36. When a passenger asked about the estimated arrival time; the PIC replied, “I’ll speed up. I’ll go real fast here.” About 1 minute later, the SIC remarked that the airplane’s airspeed was 300 knots and altitude was 9,000 ft. For the next few minutes, the crew discussed how the flight time could be shortened and that another jet on the frequency was also headed to 3J1. At 1009:52, the PIC stated that the estimated arrival time was 1035 and that the other airplane’s arrival was estimated to be 1033. The PIC stated to the SIC, “they’ll [the other aircraft] slow to 250 [knots] below 10 [thousand feet] and we won’t. We know what we’re doing right now we’re trying to win a race.” The SIC stated, “that’s right,” and the PIC replied, “this is NASCAR,” which was followed by sounds of laughter. During the descent, the crew discussed that the reported wind at a nearby airport was from 280° at 3 knots. In addition, the CVR recorded the overspeed warning tone multiple times during the descent, starting at 1025:30. During that instance, the tone was heard for 8 seconds. The PIC stated, “goal achieved,” and SIC remarked, “final lap.” At 1028:31, the airplane was cleared to 2,000 ft and the flight crew requested a straightin approach to runway 36. About 2 minutes later, the controller informed the other airplane inbound to 3J1 that it would be second in line for landing; the PIC expressed excitement and informed the passengers that their flight would be arriving ahead of the other inbound airplane. At 1031:35, the CVR recorded the sound of the autopilot being disconnected. About 1 minute later, the SIC remarked, “should we s-turn this thing?” The PIC replied, “nah we got it.” At 1032:28, the airplane was on final approach about 900 ft above ground level (agl) and about 1.5 nautical miles from the runway threshold. At that time, the SIC called out an airspeed of 170 knots. (The reference landing speed [Vref] was 121 knots). The PIC responded to add full flaps. About 10 seconds later, the airplane’s electronic voice announced “sink rate” and the SIC stated, “we know it.” At 1032:46, the SIC called out an airspeed of 150 knots, and the electronic voice stated, “sink rate, sink rate, sink rate, pull up.” At 1032:58, the electronic voice announced 200 ft agl. One second later, the electronic sink rate warning annunciated again, and the SIC called out an airspeed of 130 knots. The PIC stated, “yup, slowing.” At 1033:04, the electronic voice annunciated the 50-ft callout, and the airplane touched down afterward. At 1033:12, the PIC stated, “come on T-Rs [thrust reversers],” which was followed by an expletive. At 1033:20, the SIC asked if he should apply the brakes as well, to which the PIC stated “yes.” At 1033:26, sounds consistent with a runway excursion were recorded, and the CVR recording stopped shortly afterward. The airplane came to rest about 400 ft past the end of runway 36 in marshy and wet terrain. The airplane sustained substantial damage to the wings and fuselage. In a postaccident statement, the PIC reported that he observed runway 36 (the intended landing runway) about 25 miles away and planned a visual approach to the runway. During the approach, the SIC completed the before-landing checklist. The approach was completed with full flaps, and the flight air brakes were deployed to slow the airplane further. About 3 miles from the runway, the precision approach path indicator (PAPI) displayed three white lights and one red light (indicating that the airplane was too high on the glidepath). Subsequently, the PIC retracted the flight air brakes and determined that the flight was properly established on the glidepath. The PIC’s postaccident statement also indicated that, while the airplane was approaching the runway, the engine(s) power was at idle, and the touchdown occurred about 700 to 1,000 ft down the runway at an airspeed between about 120 to 128 knots. Upon touchdown, the PIC applied wheel brakes and thrust reversers, but the ground air brakes did not automatically deploy. As the ground roll progressed, the airplane was not slowing, so the PIC increased power to the thrust reversers and the SIC began braking with about 1,500 ft of runway remaining. When the SIC applied his wheel brakes, he stated “I have no brakes.” The PIC described the airplane’s departure from the runway surface into marshy wetlands and that the crew assisted the passengers in evacuating without incident. When asked if there were any mechanical malfunctions or failures of the airplane, the PIC reported “We did not have brakes, no thrust reversers and no ground air brakes.” The airplane was equipped with two N1 digital electronic engine controls, which were downloaded. The data from the download indicated that both engines were operating normally and responding to power lever inputs throughout the approach and landing roll. The data also revealed that both thrust reversers deployed about 2 seconds after touchdown and remained deployed for about 21 seconds. A witness who was type rated on the make and model of the accident airplane observed the airplane touch down near the A4 taxiway, which was near the location of the 1,000-ft markers on runway 36. About 2 seconds after touchdown, he saw both thrust reversers deploy and heard the “roar” of the reversers several seconds later. After several additional seconds, the witness still heard the engines running (even though he could not see the airplane due to ground obstacles between him and the airplane) and became concerned. He then saw that the airplane had departed the runway. A mobile phone video taken by an individual located at 3J1 captured about 15 seconds of the final approach, all of the landing roll, and a few seconds after touchdown. The video showed that, a few seconds after touchdown, the thrust reverser on the right engine (which was the only engine in the camera’s view at the time) was deployed. The video captured sound that was consistent with thrust reversers deploying. The video also showed that the left engine thrust reverser (which came into view about 11 seconds after touchdown) was deployed. The video indicated that, during the landing roll, neither the ground air brakes nor the flight air brakes deployed on either wing. The airport did not have an automated weather observing system, but the mobile phone video captured the airport’s windsock when the accident airplane landed. Throughout the airplane’s ground roll, the windsock indicated a quartering tailwind at varying speeds. The windsock was at times nearly fully extended, which corresponded to a wind speed of about 15 knots. The pilot-rated witness also reported that the wind was about 220° or 230° at 11 to 13 knots, as viewed from the windsock at the airport. Another witness at the airport observed a “strong and gusty” southwesterly wind, and the terminal aerodrome forecast for an airport about 31 nautical miles northeast indicated that the wind was from about 210° at 10 knots, gusting to 20 knots. Tire marks located on the runway were measured and correlated to the accident airplane’s main landing gear (MLG) orientation and tire width. Initial touchdown tire marks showed that the airplane landed about 1,000 to 1,200 ft down the runway. Most of the tire tread marks were light and not consistent with heavy braking or antiskid operation except for those tire tread marks that were located about 1,000 ft from the end of the runway. At that point, heavy braking tire marks appeared intermittently and continued off the runway toward the accident site. Airplane Information According to Gulfstream Aerospace documentation, the ground and flight air brakes had four control surfaces on each wing that were electrically controlled and hydraulically operated. The flight air brake system could be operated via the inboard surfaces and on the ground via the inboard and outboard surfaces. The ground air brakes were selected using the ground A/B switch, set to the land position. The system requirements for ground air brake deployment included airplane electrical power, main system hydraulic pressure, at least one of two MLG weight-on-wheel switches in ground mode, both throttle quadrant angle levers below 18°, and the ground A/B switch set to land. If these parameters were met, the ground air brakes would deploy automatically upon landing. According to the airplane flight manual, if the ground air brakes were inoperative for landing, landing performance would be affected. If all ground air brakes were inoperative, the landing distance must be increased by 30%. Gulfstream Aerospace completed a landing distance performance calculation with data that were consistent with those from the accident flight. The performance application had a 10-knot maximum tailwind speed given that 10 knots was the limiting tailwind speed in the airplane flight manual. The calculated unfactored landing distance was 3,034 ft. The landing distance with a 30% increase (due to inoperative ground air brakes), along with a 10-knot tailwind resulted in a ground roll landing distance of 3,944 ft. The accident airplane was observed landing about 1,000 ft down the 4,200-ft-long runway. Wreckage and Impact Information Postaccident examination of the airplane revealed that the nose landing gear and right MLG had partially sheared from the airplane. The left MLG remained attached to the airplane. The right MLG weight on wheels and wheel speed sensors were damaged due to impact forces. The hydraulic lines connecting to the right MLG were sheared, which would have compromised the hydraulic system. The flaps were found set to 40°, and all air brakes remained stowed. Inside the cockpit, the flight A/B air brake switch was found in the retract position, and the ground A/B air switch was found set to land. The air brake switches were tested with an electrical multimeter and produced normal currents. The electrical currents for the throttle quadrant microswitches were also tested and measured with an electrical multimeter. The left throttle microswitch electrical reading was normal, but the right throttle microswitch testing was inconclusive. The right throttle microswitch, when initially tested without manipulating the throttle, measured a resistance of about 600 ohms, which was higher than normal resistance and not consistent with the left throttle microswitch reading. When the right throttle was touched slightly, its resistance was lowered to a reading closer to normal resistance. Further manipulation of the right throttle by hand continued to lower the electrical resistance until normal readings were achieved. Additional Information According to the FAA airplane flying handbook, chapter 16, transition to jet-powered airplanes, several parameters must be considered when evaluating whether an approach is stabilized. Stabilized Approach The basic elements to the stabilized approach are listed below as follows: · The airplane should be in the landing configuration by 1,000 feet AGL in the approach. The landing gear should be down, landing flaps selected, trim set, and fuel balanced. Ensuring that these tasks are completed helps keep the number of variables to a minimum during the final approach. · The airplane should be on profile before descending below 1,000 feet. Configuration, trim, speed, and glidepath should be at or near the optimum parameters early in the approach to avoid distractions and conflicts as the airplane nears the threshold window. An optimum glidepath angle of about 3° should be established and maintained. · Indicated airspeed should be between zero and 10 knots above the target airspeed by 500 feet AGL. There are strong relationships between trim, speed, and power in most jet airplanes, and it is important to stabilize the speed in order to minimize those other variables. · The optimum descent rate is dependent upon ground speed. A rule of thumb is to multiply half of ground speed by 10. For example, a 130-knot ground speed should result in a (65 times 10) 650 feet per minute descent rate. Typical descent rates fall between 500 and 700 feet per minute. An excessive vertical speed may indicate a problem with the approach. Every approach should be evaluated at 500 feet. In a typical jet airplane, this is approximately 1 minute from touchdown. If the approach is not stabilized at that height, a go-around should be initiated. The guidance further stated that jet engines response at low rpm is slower. This characteristic requires that the approach be flown at a stable speed and power setting on final so that sufficient power is available quickly if needed. -
Analysis
The pilot in command (PIC) and second-in-command (SIC) completed an uneventful positioning flight to pick up passengers and then continued to the destination airport. Cockpit voice recorder (CVR) information revealed that, while en route, the PIC expressed a desire to complete the flight as quickly as possible and arrive at the destination before another airplane that was also enroute to the destination airport, presumably to please the passengers. The PIC compared the flight with an automobile race, and the airplane’s overspeed warning annunciated multiple times during the descent. The flight crew elected to conduct a straight-in visual approach to land. Throughout the final approach, the airplane was high and fast, as evidenced by the SIC’s airspeed callouts. When the SIC asked whether s-turns should be made, and the PIC responded that such turns were not necessary. An electronic voice recorded by the CVR repeatedly provided “sink rate” and “pull up” warnings while the airplane was on final approach, providing indications to the crewmembers that the approach was unstable, but they continued the landing. The airplane touched down about 1,000 ft down the 4,200-ft-long runway. The PIC described that the airplane’s wheel brakes, thrust reversers, and ground air brakes did not function after touchdown, but witness and video evidence showed that the thrust reversers deployed shortly after touchdown. In addition, tire skid marks indicated that wheel braking occurred throughout the ground roll and increased heavily during the final 1,500 ft of the runway when the antiskid system activated. The ground air brakes did not deploy. The airplane overran the runway and came to rest about 400 ft past the departure end of the runway in marshy terrain. The fuselage and wings sustained substantial damage. The switch that controlled the automatic deployment of the ground air brake system was found in a position that should have allowed for their automatic deployment upon landing. There was no evidence to indicate a preaccident mechanical malfunction or failure with the hydraulic system, wheel brakes, thrust reversers, and weight-on-wheel switches, or electrical issues with either air brake switches. The airplane’s ground air brake deployment system logic required that both throttle levers be below 18° (throttle lever angle) in order to activate. The accident airplane’s throttle lever position microswitches were tested after the accident. The left throttle microswitch tested normal, but the right throttle microswitch produced an abnormal electrical current/resistance during initial testing. When the throttle was touched and then further manipulated by hand, the electrical resistance tested normal. The investigation was unable to determine whether the intermittent right throttle microswitch resistance prevented the ground air brakes from deploying because the testing was inconclusive. Landing performance calculations showed that, without ground air brakes, the landing ground roll exceeded the runway that was available from the airplane’s touchdown point about 1,000 ft down the runway. Mobile phone video evidence revealed that a quartering tailwind of about 10 to 15 knots persisted during the landing, which exceeded the manufacturer’s tailwind landing limitation of 10 knots for the airplane, and thus would have further increased the actual ground roll distance beyond that calculated. Throughout the final approach, the flight crew received several indications that the approach was unstable. The flight crew was aware that the airplane was approaching the runway high, fast, and at an abnormal sink rate. Both pilots had an opportunity to call for a go-around, which would have been the appropriate action. However, it is likely that the external pressures that the PIC and SIC accepted to complete the flight as quickly as possible influenced their decisionmaking in continuing the approach.
Probable cause
The flight crew’s continuation of an unstable approach and the failure of the ground air brakes to deploy upon touchdown, both of which resulted in the runway overrun. Contributing was the crew’s motivation and response to external pressures to complete the flight as quickly as possible to accommodate passenger wishes and the crew’s decision to land with a quartering tailwind that exceeded the airplane’s limitations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ISRAEL AEROSPACE INDUSTRIES LTD
Model
GULFSTREAM G150
Amateur built
false
Engines
2 Turbo fan
Registration number
N22ST
Operator
Snider Fleet Solutions
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Executive/Corporate
Commercial sightseeing flight
false
Serial number
251
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-17T16:40:04Z guid: 103036 uri: 103036 title: ERA21FA212 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103044/pdf description:
Unique identifier
103044
NTSB case number
ERA21FA212
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-06T16:20:00Z
Publication date
2023-05-10T04:00:00Z
Report type
Final
Last updated
2021-05-14T01:02:18.989Z
Event type
Accident
Location
La Belle, Florida
Airport
LA BELLE MUNI (X14)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
Sound Spectrum Studies A spectrogram of the audio in the doorbell security camera video was created by the propeller manufacturer. A discrete noise trace was noted at approximately 95 Hz as the airplane approached the camera, decreasing to approximately 66 Hz as the airplane passed the camera. According to the report, the frequencies were consistent with a 3-bladed propeller turning at approximately 1,600 to 1,620 rpm on an aircraft at 100 kts true airspeed. There was also a faint noise signature at approximately 50 Hz while the airplane approached the camera, which was consistent with a propeller windmilling under no power at approximately 1,000 rpm. An NTSB recorders specialist reviewed the findings of the propeller manufacturer and completed a separate sound spectrum study. The spectrogram showed two signals within the frequency range of three-bladed propeller operation. One signal potentially corresponded with “Engine A” and was consistent with a three-bladed propeller turning at approximately 1,618 rpm. The other signal potentially corresponded to “Engine B” and was consistent with a three-bladed propeller turning at approximately 958 rpm. Owner’s Manual Procedures The airplane’s owner’s manual Engine Failure During Flight checklist stated, 1. Throttles – FULL FORWARD 2. Prop Controls – FULL FORWARD 3. Mixtures – FULL RICH 4. Boost Pumps – ON (if engine fails to restart, proceed with checklist) 5. Determine inoperative engine 6. Trim aircraft for single-engine flight 7. Inoperative engine: a) Mixture – IDLE CUTOFF b) Prop Control – FEATHER c) Boost Pump – OFF d) Fuel Selector Valve Switch – OFF e) Magneto Switch – OFF f) Alternator Switch – OFF 8. Attempt engine restart using procedure given for Restarting Feathered Engine in Flight 9. If engine does not start, land as soon as possible. 10. For prolonged single engine flight, refer to the Crossfeed System discussion in Section 1. Additional Guidance The FAA Practical Test Standards for the airplane multi-engine flight instructor rating stated, Feathering for pilot flight test purposes should be performed only under such conditions and at such altitudes (no lower than 3,000 ft above the surface) and positions where safe landings can be accomplished, in the event difficulty is encountered during unfeathering. At altitudes lower than 3,000 ft above the surface, simulated engine failure will be performed by throttling the engine and then establishing zero thrust. The Transport Canada Instructor Guide for the Multi-Engine Class Rating stated, Transport Canada no longer recommends actual inflight engine shutdown, feathering, engine restart and unfeathering procedures. It has been determined that the training value of conducting this procedure in-flight is not worth the increased safety risk and engine/airframe abuse/damage that is often incurred. - On May 6, 2021, about 1520 eastern daylight time, a Ted Smith Aerostar 600, Canadian registration C-FAAZ, was substantially damaged when it was involved in an accident near La Belle, Florida. The airline transport pilot was fatally injured, and the pilot-rated passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot-rated passenger reported that he was the proprietor of an aircraft maintenance facility at La Belle Municipal Airport (X14), and that the pilot, who was the owner of the airplane, brought his airplane to the facility for a 100-hour inspection. He said that as they began work on the airplane, they found discrepancies that required more work than originally anticipated. The owner wanted everything corrected and asked that they go ahead and perform a “full annual inspection” on the airplane, which they did. The work was completed almost 1 month before the pilot’s arrival to pick up the airplane on the day of the accident. The passenger said that he flew the airplane a “couple of times” while it was at his shop and that he “turned everything on” and all the systems and components worked as designed. The passenger said that he and the pilot went over some paperwork in his office when the pilot announced that he had not flown the airplane “for a long time” and asked if they could go for a flight. The passenger said that they completed a short flight, returned, serviced the airplane with 130 gallons of fuel, and then departed again. When asked how the pilot performed during the preflight, engine start, taxi, takeoff, and the flight he responded, “He seemed thorough… he was good.” The passenger could not recall any further details of the accident flight or accident sequence, but stated that he typically conducted familiarization and test flights east of X14, “over by Lake Okeechobee,” where the terrain was mostly rural and sparsely populated. Automatic Dependent Surveillance – Broadcast (ADS-B) track data showed that the airplane departed X14 about 1450 and climbed to an altitude about 3,100 ft on an approximate eastbound heading. The airplane continued about 34 miles when, about 1501:00, it entered a slow turn to the south near the intersection of Florida Route 27 and the shoreline of Lake Okeechobee. The airplane continued southbound for about 10 miles before it turned to the east. Correlation of data obtained from the engine data monitor (JPI EDM 760) indicated that, at 1505:18, the left engine exhaust gas temperature (EGT) and fuel flow values were consistent with a total loss of left engine power at an altitude about 2,500 ft. At 1507:30, recorded battery voltage showed a perturbation, consistent with engine starter engagement. At 1509:42, left engine EGT values were consistent with the left engine producing power. At the time of the power loss, Airglades Airport, Clewiston, Florida, was 10 miles ahead of the airplane, but the airplane continued a turn to the north, and overflew another airport, Clewiston Golf Course Airport, 1 minute before left engine power was fully restored. The airplane continued a northerly heading with both engines operating for about 1 minute before it turned westbound in the general direction of X14. For the next seven and a half minutes, recorded engine data values appeared nominal, until 1517:08, when right engine EGT and fuel flow values indicated a total loss of right engine power. Almost immediately thereafter, at 1517:12, the left engine EGT and fuel flow values also indicated a total loss of left engine power. At this time, the airplane was about 6 nautical miles from X14 at an altitude about 3,500 ft. A battery voltage perturbation was recorded at 1518:24 consistent with engine starter engagement. Around the same time as the voltage perturbation, EGT and fuel flow values for the left engine showed a slight increase, but the data indicated that the engine did not regain full power before the accident. A witness reported to a Federal Aviation Administration (FAA) aviation safety inspector that she was travelling eastbound in her car when the airplane appeared immediately in front of her at treetop height travelling westbound. She said that the airplane was in a wings-level attitude and that she heard no engine sound. It appeared to her that the propellers were not turning, and that the landing gear was down. The witness believed the airplane would land on the road on which she was travelling, when it turned slightly to its right, struck the top of a tree, and then impacted the ground in a flat, nose-right attitude, before it continued into trees and a memorial garden on a church property, where it came to rest. A doorbell camera located about 500 ft east of the accident site captured the airplane as it passed overhead at low altitude. The engine sound was smooth and continuous as it passed into and out of the camera’s view. Seconds later, the sounds of impact were heard. - The 67-year-old pilot was a Canadian national and had never applied for an FAA medical certificate. According to the Transportation Safety Board of Canada, the pilot’s most recent medical examination was completed in May 2020. The pilot was issued a category 1 license with knowledge of a previous condition and knowledge of currently taking Xarelto (rivaroxabam). The pilot had a restriction that he was to have reading glasses available. An autopsy of the pilot was performed by the District 21 Medical Examiner, Ft. Meyers, Florida. According to the autopsy report, the pilot’s cause of death was atlanto-occipital dislocation due to blunt force head and neck trauma due to airplane crash and the manner of death was accident. No significant natural disease was identified. Toxicology testing detected cetirizine in the pilot’s heart blood at 137 ng/mL and urine. Codeine was detected at 4 ng/mL in his heart blood and urine; morphine was detected in his urine. Lamotrigine was detected in the pilot’s heart blood and urine. The nonsedating pain medications acetaminophen and ketorolac were detected in blood and urine; caffeine was detected in his blood. - The Government of Canada issued the pilot an Airline Transport Pilot Certificate for helicopters with multiple type ratings. He was issued a private pilot certificate for airplanes in April 2017, with ratings for single and multiengine airplanes. The pilot’s most recent medical examination was completed April 4, 2019. - The wreckage path was oriented on a magnetic heading about 270° and measured about 230 ft long. The initial impact point was in a tree about 50 ft tall, and pieces of angularly-cut wood were found beneath the tree. The airplane came to rest upright, with both wings displaying significant impact damage. Each engine was secure in its nacelle and the flaps appeared to be set between 10° and 15°. A detailed examination of the flaps revealed that the flap actuator extension was consistent with a 14° flap position. Examination of the throttle quadrant revealed that the left throttle lever was in a full-forward position, while the right throttle lever was at or near the idle position. Both propeller levers were at or near the full-forward position. The left mixture lever was in the idle-cutoff position and the right mixture lever was slightly forward of mid-travel. Both left and right engine fuel boost pump switches were found in the off position. The left propeller blades were secure in the hub, and each displayed similar twisting, bending, and chordwise polishing. The blades of the right propeller were secure in the hub and were in the feathered position. The tail section of the airplane was separated and rested upright adjacent to the fuselage. The windshield posts were cut by rescue personnel and the roof was folded back over the cabin area. Flight control continuity was established from the cockpit area, through several breaks, to the flight control surfaces. The fractures at the breaks all displayed features consistent with overstress. The flap control handle was found in the “neutral” position, about midway between “up” and “down.” The wing fuel tanks were breached, and a slight odor of fuel was detected. An estimated 35 gallons of fuel was drained from the center fuselage tank, which remained intact. The airplane was recovered from the accident site, and examination continued at the recovery facility. The airplane was powered on using its own battery, and the fuel selectors were run through each position; the corresponding fuel valves energized, and their respective actuator arms moved as designed. Both fuel boost pumps worked when energized. The left engine was rotated by hand at the propeller and continuity was established from the powertrain through the valvetrain to the accessory section. Compression was confirmed using the thumb method. Borescope examination of the cylinders revealed normal wear and deposits. Ignition timing was confirmed, and when the magnetos were removed and energized with a drill, they produced spark at all terminal leads. The engine-driven fuel pump was removed, actuated with a drill, and pumped fluid. Examination of fuel and old screens and filters revealed that they were clean and absent of debris. Examination and a test run of the right engine was performed at Lycoming Engines, Williamsport, Pennsylvania. Before the engine run, the fuel pump was removed, and fuel pressure was provided by the test stand. The fuel nozzles installed in cylinder Nos. 1 through 4 matched in type (two-piece), and the fuel nozzles in cylinder Nos. 5 and 6 matched each other but differed in type (one-piece). The No. 5 fuel nozzle was loose and tightened to the prescribed torque values. The right magneto was impact damaged, but the engine started and ran with the magneto inoperative in its mount. The magneto was removed, disassembled, and failure of the points to open was confirmed. A slave magneto was installed, the engine was started, and a complete factory protocol was run on the engine in the test cell, during which the engine performed nominally. Examination of the right propeller revealed that all three blades were in the feathered position and could not be rotated by hand force. The propeller mounting flange was undamaged with all six mounting studs intact. The spinner dome and spinner bulkhead were not shipped/presented for examination. Blade R1 was the only blade with any remarkable bending. The propeller hydraulic unit was pressurized with shop air (95-100 psi) and cycled from feather to low pitch and onto the start lock. All three blades rotated freely and smoothly. The low pitch stop, feather stop, and start lock sleeve were then removed from the propeller. The low pitch stop contact points indicated forceful contact consistent with the propeller at or near the low pitch stop at the time of impact. -
Analysis
The pilot, who was the owner of the airplane, and the pilot-rated passenger, whose maintenance facility had recently completed work on the airplane, departed on the second of two local flights on the day of the accident as requested by the pilot, since he had not flown the airplane recently. Flight track and engine monitor data indicated that, about 15 minutes after takeoff, fuel flow and engine exhaust gas temperature (EGT) values were consistent with a total loss of left engine power at an altitude about 2,500 ft. Engine power was fully restored about 4 minutes later. Between the time of the power loss and subsequent restoration, the airplane directly overflew an airport and was in the vicinity of a larger airport. It is likely that the left engine was intentionally shut down to practice one engine inoperative (OEI) procedures. Had the loss of power been unanticipated, the pilot would likely have initiated a landing at one of these airports in accordance with the airplane’s published emergency procedure, which was to land as soon as possible if engine power could not be restored; however, data indicated that engine power was restored, and the flight continued back to the departure airport. About 7.5 minutes later, about 6 nautical miles from the departure airport, engine data indicated a total loss of right engine power, followed almost immediately by a total loss of left engine power, at an altitude about 3,500 ft. A battery voltage perturbation consistent with starter engagement was recorded about 1 minute later, followed by a slight increase in left engine fuel flow; however, the data did not indicate that left engine power was fully restored during the remainder of the flight. The airplane continued in the direction of the departure airport as it descended and ultimately impacted a tree and terrain and came to rest upright. A witness saw the airplane flying toward her with the landing gear extended and stated that it appeared as though neither of the two propellers was turning. A doorbell security camera near the accident site captured the airplane as it passed overhead at low altitude. Sound spectrum analysis of the footage indicated that one engine was likely operating about 1,600 rpm while the other was operating at less than 1,000 rpm. The right propeller was found feathered at the accident site. An examination and test run of the right engine revealed no anomalies that would have precluded normal operation. The left propeller blades exhibited bending, twisting, and chordwise polishing consistent with the engine producing some power at the time of impact. Examination of the left engine and engine-driven fuel pump did not reveal any anomalies. Based on the available information, it is likely that the pilots were conducting practice OEI procedures and intentionally shut down the right engine. The loss of left engine power immediately after was likely the result of the pilot’s failure to properly identify and verify the “failed” engine before securing it, which resulted in an inadvertent shutdown of the left engine. Although partial left engine power was restored before the accident (as indicated by fuel flow values, damage to the left propeller, and sound spectrum analysis of security camera video), the left engine power available was inadequate to maintain altitude for reasons that could not be determined, and it is likely that the pilot was performing a forced landing when the accident occurred. It is also likely that the pilot’s decision to conduct intentional OEI flight at low altitude resulted in reduced time and altitude available for troubleshooting and restoration of engine power following the inadvertent shutdown of the left engine. The 67-year-old pilot was a Canadian national and had never applied for a Federal Aviation Administration medical certificate. According to the Transportation Safety Board of Canada, the pilot was issued a category 1 license with knowledge of a previous condition and knowledge of currently taking Xarelto (rivaroxabam). No acute or historical cardiovascular event was found on autopsy. Toxicology testing detected the sedating antihistamine cetirizine just below therapeutic levels in the pilot’s blood. A very low concentration of the narcotic pain medication codeine was detected in the pilot’s blood and urine; codeine’s metabolite morphine was also detected in his urine. The mood stabilizing medication lamotrigine was detected but not quantified in the pilot’s blood and urine. Thus, the pilot was taking some impairing medications and likely had a psychiatric condition that could impact decision-making and performance; however, given the circumstances of the accident, including the presence of the pilot-rated passenger to operate the airplane, the effects from the pilot’s use of cetirizine, codeine, and lamotrigine were not likely factors in this accident.
Probable cause
The pilot's inadvertent shutdown of the left engine following an intentional shutdown of the right engine while practicing one engine inoperative (OEI) procedures. Contributing to the accident was the pilot’s decision to conduct OEI training at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Ted Smith
Model
Aerostar 600
Amateur built
false
Engines
2 Reciprocating
Registration number
C-FAAZ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
60-0148-065
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-14T01:02:18Z guid: 103044 uri: 103044 title: CEN21LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103071/pdf description:
Unique identifier
103071
NTSB case number
CEN21LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-11T16:00:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-05-12T22:13:36.373Z
Event type
Accident
Location
Merrill, Wisconsin
Airport
Merrill Municipal Airport (RRL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On May 11, 2021, at 1500 central daylight time, a Beech C23, N793Y, was substantially damaged when it was involved in an accident near Merrill, Wisconsin. The pilot and passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was returning to the airport after a 1-hour flight. When the airplane was about 5 miles from the airport and descending through about 1,300 ft above ground level, the engine started to run rough and gradually lost power. The pilot switched fuel tanks and cycled the magnetos, with no change in the engine power. He executed an off-airport forced landing. The airplane touched down, the landing gear collapsed, and the airplane slid to a stop coming to rest upright. The airplane sustained substantial damage to both wings and fuselage. Examination of the engine found that the oil filter contained metallic particles consistent with tappet material. Further examination revealed 7 of the 8 tappets were destroyed. The tappets were removed for further examination. Examination of the tappets by the National Transportation Safety Board Materials Laboratory revealed that the tappets fractured from overstress. The fracture started along the heads facing their corresponding camshaft lobes, which proceeded towards the back surface. While there were no indications of pre-existing cracks, such as from fatigue, there was evidence of pitting and surface wear on many of the tappet head faces that contact the camshaft. Of note was the No. 2 exhaust tappet, the only tappet that underwent wear on the tappet face significant enough to change its geometry. Figure 1 shows the No. 2 exhaust tappet face, which was reflective and consistent with polishing from repeated contact with the mating camshaft lobe. The depression at the center of the tappet head corresponding to the stem exhibited circular wear marks. The fracture surface on the bottom of the figure was circular, conforming to the geometry of the stem radius. Figure 2 shows the widespread spalling of the remaining surface, demonstrating the degree of material loss on this part. Review of the engine logbooks revealed that the engine was overhauled on February 19, 2002, and installed on the accident airplane on February 1, 2019. The last annual inspection was completed on February 24, 2021. At the time of the accident, the engine had about 838 hours of operation since overhaul. No record of tappet replacement was found in the maintenance records. The engine manufacturer recommends overhaul of the engine at 2,000 hours, or 12 years in service, whichever comes first. An oil sample collected on May 11, 2021, before the accident flight, was sent in for analysis. The vendor who conducted the oil sample analysis provided an oil sample report. Nothing remarkable was found in the oil sample report. Figure 1. View of the #2 exhaust tappet head. Figure 2. Worn areas of the #2 exhaust tappet head, showing spalling and pitting. -
Analysis
The pilot reported that he was returning to the airport after a 1-hour flight when the engine started to run rough and gradually lost power. The pilot switched fuel tanks and cycled the magnetos, with no change in the power loss. He executed an off airport forced landing. The landing gear collapsed during the landing and the airplane slid to a stop coming to rest upright. The airplane sustained substantial damage to both wings and fuselage. Examination of the engine found that the oil filter contained metallic particles that were determined to be consistent with tappet material. Further examination revealed 7 of the 8 tappets were destroyed. A metallurgical examination of the tappets revealed that the tappets fractured from overstress. The fracture started along the heads facing their corresponding camshaft lobes, which proceeded towards the back surface. While there were no indications of pre-existing cracks, such as from fatigue, there was evidence of pitting and surface wear on many of the tappet head faces that contact the camshaft. Of note was the No.2 exhaust tappet, the only tappet that underwent wear on the tappet face significant enough to change its geometry. The engine was overhauled 19 years before the accident and had accumulated 838 hours since the overhaul. The engine manufacturer recommends overhaul of the engine at 2,000 hours, or 12 years in service, whichever comes first. No record of tappet replacement was found in the maintenance records.
Probable cause
The loss of engine power due to tappet failure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C23
Amateur built
false
Engines
1 Reciprocating
Registration number
N793Y
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
M-2184
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-12T22:13:36Z guid: 103071 uri: 103071 title: CEN21FA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103073/pdf description:
Unique identifier
103073
NTSB case number
CEN21FA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-12T11:23:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-05-19T23:47:40.689Z
Event type
Accident
Location
Englewood, Colorado
Airport
CENTENNIAL (APA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 12, 2021, at 1023 mountain daylight time, a Cirrus SR22 airplane, N416DJ, and a Swearingen SA226TC airplane, N280KL, were substantially damaged when they collided in flight while approaching to land at Centennial Airport (APA), Englewood, Colorado. The pilot and passenger onboard the Cirrus were not injured, and the pilot onboard the Swearingen was not injured. The Cirrus was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight, and the Swearingen was operated as a Title 14 CFR Part 91 positioning flight. At the time of the accident, parallel runways 17R and 17L were being utilized for simultaneous operations at APA. Automatic Dependent Surveillance-Broadcast (ADS-B) data was provided by the Federal Aviation Administration (FAA), and data from the on-board Remote Data Module (RDM) was downloaded from the Cirrus. The data showed that the Cirrus departed APA for a local flight about 0921, and the Swearingen departed the Salida Airport (ANK), Salida, Colorado, about 0956. About 1022:43, the Swearingen was about 5.5 nm from APA and had completed a right turn to align with the final approach course to runway 17L. At this same time, the Cirrus was on the downwind leg of the right-hand traffic pattern for runway 17R just before commencing a right turn to the base leg of the traffic pattern. The Swearingen continued its approach and remained aligned with runway 17L. The Cirrus continued the right-hand traffic pattern through the base leg, and then began to turn toward the final approach course for the runway. The Cirrus continued through the extended centerline for runway 17R, and then continued to the extended centerline for runway 17L where it collided with the Swearingen. The airplanes collided at 1023:52 when they were about 3.2 nm from APA. The Swearingen was aligned with runway 17L while the Cirrus had not completed the turn from base to final and was heading about 146° when the collision occurred. Figure 1 – Plot of ADS-B and RDM flight path information After the impact, the pilot of the Swearingen declared an emergency, continued to APA, and landed successfully on runway 17L. The pilot of the Cirrus reported that the airplane was not controllable after the impact, and he deployed the Cirrus Airframe Parachute System (CAPS). The Cirrus came to rest about 3 nm north of APA. Both airplanes sustained substantial damage (see figures 2 & 3) Figure 2 – Photograph of the Swearingen after the accident. Figure 3 – Photograph of the Cirrus at the accident scene. Review of the data retrieved from the RDM from the Cirrus revealed that the airplane’s autopilot was disengaged at 1018:50 and stayed off for the remainder of the flight, indicating that the pilot was manually flying the airplane during the landing approach. At 1023:16, the avionics system issued a traffic alert which remained on until the collision. RDM data further indicated that that during the downwind portion of the airplane’s approach, the airspeed was about 125 kts and the flaps were up. Once the airplane was established on the base leg of the traffic pattern the recorded airspeed was about 148 kts and the flaps were still up. As the airplane maneuvered from the base leg to final approach, the airspeed was about 140 kts and the flaps were lowered to 50% about 4 seconds before impact. When the collision occurred, the airplane was about halfway through its turn from base to final at an airspeed of 140 kts, and an altitude of 6,619 ft msl. At 1023:54, the CAPS handle was pulled. According to the Cirrus “Pilot’s Operating Handbook and FAA Approved Airplane Flight Manual” (POH/AFM), the recommended approach speed for the airplane was 90-95 knots indicated airspeed (KIAS) with flaps up, 85-90 KIAS with 50% flaps, and 80-85 KIAS with 100% flaps. Review of communications between both airplanes and the APA Airport Traffic Control Tower (ATCT) revealed that the local control 1 (LC1) controller had cleared the Swearingen for a straight in landing to runway 17L and the local control 2 (LC2) controller had cleared the Cirrus to land on runway 17R. The two controllers communicated with the respective airplanes on different ATCT frequencies. FAA Order JO 7110.65Y detailed air traffic control procedures and phraseology for use by personnel providing air traffic control services. Included in the order were instructions for prioritizing the issuance of traffic alerts when potential conflicts with other aircraft exist. The order also specified conditions in which parallel runway operations could be authorized, including visual flight rules meteorological conditions, and that two-way radio communication be maintained with the aircraft involved and that pertinent traffic information be issued. Further review of the communications at APA revealed that although the LC2 controller had issued pertinent traffic advisories to the pilot of the Cirrus, the LC1 controller did not issue a traffic advisory to the pilot of the Swearingen regarding the location of the Cirrus. -
Analysis
A Cirrus SR22 and a Swearingen AS226TC were approaching to land on parallel runways and being controlled by different controllers on different control tower frequencies. The pilot of the Swearingen was established on an extended final approach for the left runway, while the pilot of the Cirrus was flying a right traffic pattern for the right runway. Data from an on-board recording device showed that the Cirrus’ airspeed on the base leg of the approach was more than 50 kts above the manufacturer’s recommended speed of 90 to 95 kts. As the Cirrus made the right turn from the base leg to the final approach, its flight path carried it through the extended centerline for the assigned runway (right), and into the extended centerline for the left runway where the collision occurred. At the time of the collision, the Cirrus had completed about ½ of the 90° turn from base to final and its trajectory would have taken it even further left of the final approach course for the left runway. The pilot of the Swearingen landed uneventfully; the pilot of the Cirrus deployed the airframe parachute system, and the airplane came to rest upright about 3 nautical miles from the airport. Both airplanes sustained substantial damage to their fuselage. During the approach sequence the controller working the Swearingen did not issue a traffic advisory to the pilot regarding the location of the Cirrus and the potential conflict. The issuance of traffic information during simultaneous parallel runway operations was required by Federal Aviation Administration Order JO 7110.65Y, which details air traffic control procedures and phraseology for use by persons providing air traffic control services. The controller working the Cirrus did issue a traffic advisory to the Cirrus pilot regarding the Swearingen on the parallel approach. Based on the available information, the pilot of the Cirrus utilized a much higher than recommended approach speed which increased the airplane’s radius of turn. The pilot then misjudged the airplane’s flight path, which resulted in the airplane flying through the assigned final approach course and into the path of the parallel runway. The controller did not issue a traffic advisory to the pilot of Swearingen regarding the location of the Cirrus. The two airplanes were on different tower frequencies and had the controller issued an advisory, the pilot of the Swearingen may have been able to identify the conflict and maneuver his airplane to avoid the collision.
Probable cause
The Cirrus pilot’s failure to maintain the final approach course for the assigned runway, which resulted in a collision with the Swearingen which was on final approach to the parallel runway. Contributing to the accident was the failure of the controller to issue a traffic advisory to the Swearingen pilot regarding the location of Cirrus, and the Cirrus pilot’s decision to fly higher than recommended approach speed which resulted in a larger turn radius and contributed to his overshoot of the final approach course.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SWEARINGEN
Model
SA226TC
Amateur built
false
Engines
2 Turbo prop
Registration number
N280KL
Operator
Key Lime Air
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
TC-280
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N416DJ
Operator
Independence Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4394
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-19T23:47:40Z guid: 103073 uri: 103073 title: WPR21LA200 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103110/pdf description:
Unique identifier
103110
NTSB case number
WPR21LA200
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-12T11:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-05-28T00:52:03.852Z
Event type
Accident
Location
Glenn, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On May 12, 2021, about 1030 Pacific daylight time, a Grumman ACFT ENG CORSchweizer G-164C, N6596K, was substantially damaged when it was involved in an accident near Glenn, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 agricultural flight. The pilot reported that the airplane had just departed with the fuel gauge indicating a half-full tank of fuel and a full load of product (2,200 pounds of rice seed). About 100 ft above ground level the engine lost total power. He saw a narrow dirt frontage road in between rice fields and made a forced landing, during which the airplane landed hard and came to rest upright, causing substantial damage to the wings and fuselage. The pilot reported that he did not refuel the airplane before the accident flight based on the fuel gauge indications. The operator reported that the center fuel tank, which draws fuel from the two wing tanks was empty of fuel. About 1 gallon of fuel was recovered from the fuel sump. The engine and the fuel systems remained intact and uncompromised. Maintenance personnel reported that they checked the fuel gauge in the cockpit, and it revealed that the center fuel tank was indicating half full. When the float connected to an arm in the center tank was manipulated, the fuel gauge in the cockpit moved but not in a manner coincident with the placement of the float, and that the fuel gauge may have been reporting false quantities of fuel. The engine was sent to a repair facility for overhaul with no discrepancies identified. Further testing of the fuel gauge was not accomplished. -
Analysis
The pilot reported that, he departed for the aerial application flight with the fuel gauge indicating a half-full tank of fuel and a full load of product. About 100 ft above ground level the engine lost total power. The pilot elected to make a forced landing to a narrow dirt frontage road. The airplane landed hard and came to rest upright. The wings and fuselage were substantially damaged. Postaccident examination of the airframe revealed that no usable fuel was present in the center fuel tank nor from the wing fuel tanks. Maintenance personnel reported that they checked the fuel gauge in the cockpit, and it revealed that the center fuel tank was indicating half full. When the float connected to an arm in the center tank was manipulated, the fuel gauge in the cockpit moved but not in a manner coincident with the placement of the float, and that the fuel gauge may have been reporting false quantities of fuel. An engine inspection revealed no preaccident mechanical failures or malfunctions that would have precluded normal operation. The pilot reported that he did not refuel the airplane based on the fuel gauge indications that the fuel tank was half full. Thus, the pilot did not properly manage the airplane’s fuel, which resulted in fuel exhaustion and the total loss of engine power.
Probable cause
The pilot’s fuel mismanagement, which resulted in fuel exhaustion, a total loss of engine power, and an off-airport hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164C
Amateur built
false
Engines
1 Turbo prop
Registration number
N6596K
Operator
Jones Aviation Inc.
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
6C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-28T00:52:03Z guid: 103110 uri: 103110 title: ERA21LA223 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103124/pdf description:
Unique identifier
103124
NTSB case number
ERA21LA223
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-15T17:47:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-06-04T20:49:40.376Z
Event type
Accident
Location
McKenzie, Tennessee
Airport
CARROLL COUNTY (HZD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 15, 2021, about 1647 eastern daylight time, an experimental amateur-built Zodiac 601 XL airplane, N493TG, was substantially damaged when it was involved in an accident in McKenzie, Tennessee. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the student pilot, he departed from Carroll County Airport (HZD), McKenzie, Tennessee for a solo local flight. Before takeoff he conducted an uneventful engine run, and since the wind was calm, decided to take off on runway 1 to avoid a back-taxi to runway 19. The takeoff and start of the climb were normal. About 300 ft above the runway surface, the airplane momentarily shook violently and he noticed that the propeller had separated from the engine. The airplane was directly over the runway when the propeller separated from the engine. After the propeller came off, the airplane turned right and the pilot did not have time to get the airplane back over the runway, so he landed on a berm. The airplane then traveled off the other side of the berm, dropped into a 3-to-4-ft depression, struck a fence, and was substantially damaged. The propeller was found about halfway between the takeoff point and where the airplane touched down on the berm. One blade was broken in half. The separated portion of the blade was discovered about 100 ft away. The engine was manufactured about 17 ½ years before the accident, in January, 2004. Logbook entries indicated that on May 19, 2012, at 672.6 hours of operation, the airplane incurred a propeller strike which was severe enough to destroy the blades of the propeller. A replacement propeller was installed by the airplane owner on September 3, 2016. The propeller was originally on another airplane and had about 154 hours in service when it was installed on the accident airplane. The airplane owner did not hold a mechanic certificate, nor did he have a certificate for the airplane, as he was not the original builder. The logbook entry did not indicate what technical data the airplane owner used for the installation. The maintenance logs also indicated that on October 16, 2020, A “Jabiru Maintenance Manual prop strike test was performed and recommended bolts” were replaced in the propeller flange and flywheel. The mechanic that performed the maintenance noted in the entry that “Brighton Best NF Socker Head Cap Screws 4001-0285, 4001-0345, 3/8 x ¾ UNF for prop flange, factory recommended ¾ length did not engage enough so changed to 3/8 x1. 5/16 1-1/4 UNF for flywheel.” The entry went on to say: “Changed to Nord-Lock washers for the prop flange and flywheel per Jabiru Service Bulletin JSB 012-3. Nord-Lock 1526 3/8” and Nord-Lock 1523 5/16.” Representatives of the engine manufacturer reviewed these maintenance log entries an noted that installation of 3/8” x 1” bolts and Nordloc washers on the propeller flange could result in the threads bottoming out and the bolts not being able to be torqued correctly. The maintenance log entry also indicated that during the installation, the mechanic used guidance for a flywheel installation (Jabiru Service Bulletin JSB 012-3) and not the guidance for a propeller installation (Jabiru Service Bulletin JSB 014-3). Postaccident examination of the cap screws that were installed to hold the propeller flange on to the engine crankshaft revealed that they had fractured. No evidence of thread locking adhesive, as required by the engine manufacturer during installation, was visible on the threads. Detailed examination of the cap screws revealed that they displayed fracture features consistent with fatigue cracking that initiated along the thread roots where the nuts were threaded. This fatigue initiated at multiple sites along the thread roots, where there were no indications of material or mechanical defects. This suggested that the cap screws were able to flex or move, allowing fatigue crack propagation to occur. The fracture damage to the propeller blades was consistent with impact without driven power—only one of the blades had fractured in a manner consistent with aft bending. Further, the propeller hub shell damage was consistent with impact with the ground, exhibiting features consistent with inward compressive impact. Further examination by the NTSB Materials Laboratory to confirm whether a thread locking adhesive had been applied to the cap screw threads revealed that not only were there no visual indications consistent with application to the thread screws, nor were any fluorescing substances observed within the threads. Examination using energy-dispersive X-ray spectroscopy also did not find any elements dissimilar to alloy steel along the threads. -
Analysis
The student pilot reported the initial takeoff was normal. About 300 ft above the runway, the airplane shook violently and the propeller separated from the engine. The airplane banked to the right and the student pilot lowered the nose of the airplane and landed on a grass berm. The airplane traveled off of the berm, dropped into a 3-to-4-ft depression, struck a fence, and was substantially damaged. The propeller was found about halfway between the takeoff point and where the airplane touched down on the berm. About 9 years earlier, the airplane had incurred a propeller strike that was severe enough to destroy the blades of the propeller. A replacement propeller was installed by the owner of the airplane. The airplane owner, who was not the original builder, did not hold either a mechanic certificate or repairman certificate for the airplane. About 7 months before the accident, a propeller strike test was performed, and the cap screws were replaced in the propeller flange and flywheel. The mechanic who performed the work noted that the manufacturer’s recommended bolts did not fit, so he installed cap screws that were longer. The bolts that were installed could result in the threads bottoming out and the bolts not being able to be torqued correctly. Postaccident examination of the cap screws indicated they fractured from fatigue cracking that initiated along the thread roots where the nuts were threaded. This fatigue initiated at multiple sites along the thread roots, where there were no indications of material or mechanical defects. This also suggested that the cap screws were able to flex or move, allowing fatigue crack propagation. Once the fatigue crack had progressed about halfway through a cap screw cross section, the remainder of the material would fracture from overstress (likely in bending). Without the cap screws to affix the propeller assembly to the engine, the hub would be able to separate. Examination also revealed that no thread locking adhesive was present on the cap screw threads as required by the manufacturer. The lack of a thread locking adhesive alone did not necessarily account for the lack of torque or clamping force on the cap screws. The fatigue pattern suggested a lack of preload, which may have developed during service as the nut backed off slightly or an indication of over-torquing at installation. If properly installed, the application of a thread locking adhesive to the cap screws would have helped keep the parts in place, reducing the chance of this type of fatigue cracking occurring (assuming the bolts had been torqued to an acceptable preload).
Probable cause
The improper installation and inspection of the propeller, which resulted in an in-flight separation of the propeller assembly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
Zodiac 601 XL
Amateur built
true
Engines
1 Reciprocating
Registration number
N493TG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6-5342
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-04T20:49:40Z guid: 103124 uri: 103124 title: CEN21FA220 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103091/pdf description:
Unique identifier
103091
NTSB case number
CEN21FA220
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-17T14:08:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-06-04T17:28:13.301Z
Event type
Accident
Location
St. Louis, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 17, 2021, about 1308 eastern daylight time, a Cessna 182H airplane, N2430X, was destroyed when it was involved in an accident near St. Louis, Michigan. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 pipeline patrol flight. According to the operator’s fleet monitoring data, about 0828, the airplane departed Clare Municipal Airport (48D), Clare, Michigan, and completed a pipeline patrol flight to the southeast. About 1128, the airplane landed at Romeo State Airport (D98), Romeo, Michigan. According to fueling records, the pilot purchased 48.19 gallons of 100 low-lead aviation fuel before he departed D98 about 1206. The accident occurred during a pipeline patrol flight that tracked northwest toward Kalkaska, Michigan. A review of Federal Aviation Administration (FAA) radar data revealed that, during the final 4.5 minutes of the flight, the airplane’s altitude was between 450 ft and 800 ft above ground level (agl) as it followed the intended pipeline. The airplane’s ground track was offset to the right of the pipeline until about 1307:35, at which point it crossed over the pipeline and continued northwest about 1,000 to1,250 ft to the left of the pipeline, as shown in figure 1. The operator reported that the airplane should be flown to the right of the pipeline to ensure that the pilot, who is seated in the left cockpit seat, can maintain an unobstructed view of the pipeline during the patrol flight. Figure 1 – Radar track data Two individuals reported that the pilot posted a Snapchat video shortly before the accident. The Snapchat video reportedly depicted the terrain ahead of the airplane’s position and showed the wind turbines and cornfields located about 5 to 10 miles southeast of the accident site. Although the video was automatically deleted from the Snapchat platform 24 hours after the accident, it reportedly did not include the final moments of the flight. One of the individuals provided a screenshot of the Snapchat application’s map that showed the approximate location of the pilot’s location when he posted the video. When compared to the airplane’s recorded radar ground track, the pilot’s Snapchat post was about 1.5 miles southeast of a 1,049-ft-tall radio tower, as shown in figure 2. According to a visual flight rules (VFR) sectional chart, the top of the radio tower was at 1,739 ft mean sea level (msl), as shown in figure 3. Figure 2 – Radar track data and approximate location of pilot’s snapchat post Figure 3 – VFR sectional chart with location of the radio tower (red circle) According to radar data, the airplane continued northwest toward the radio tower. At 1308:18, the airplane was 0.65 miles southeast of the tower in a shallow right turn when it entered a climb from 475 ft agl. The final radar return, at 1308:33, was about 600 ft east-southeast of the tower, at which point the airplane’s altitude, calibrated airspeed, and climb rate were about 1,370 ft msl, 104 knots, and 1,575 ft per minute, respectively, as shown in figure 4. The airplane’s final altitude was 370 ft below the top of the radio tower and its ground track was toward the guy wires located on the northeast side of the radio tower. Figure 4 – Airplane altitude, speed, and vertical speed Figure 5 – Airplane ground track, roll angle, and flight path angle - An autopsy of the pilot was authorized by the Midland County Coroner’s Office, Midland, Michigan, and completed at McLaren Bay Region Hospital, Bay City, Michigan. According to the autopsy report, the cause of death was blunt force injuries and thermal burns, and the manner of death was an accident. Toxicological testing completed by the Federal Aviation Administration’s Forensic Sciences Laboratory identified amlodipine in the pilot’s blood and liver. Amlodipine is a calcium channel blocker used to treat high blood pressure and coronary artery disease. The pilot reported the use of amlodipine to his FAA medical examiner who authorized its use and issued him a 1st class medical. The remaining toxicological testing did not detect any additional medications, ethanol, drugs of abuse, or carboxyhemoglobin. - The wreckage debris path began in the vicinity of the radio tower. The left wing, left horizontal stabilizer, left elevator, and left cabin door were found near the radio tower and within the support guy wire perimeter, as depicted in figure 6. Postaccident examination revealed that the airplane’s left wing collided with a support guy wire attached to the northeast side of the radio tower. The left wing separated from the fuselage at the wing root. Most of the left-wing leading edge separated from the main wing structure along a lateral rivet line and exhibited damage consistent with a guy wire impact. The fresh air inlet tube located in the leading edge of the left wing exhibited a U-shape compression that was consistent with the diameter of the outermost tower guy wires. The left-wing lift strut and front spar were severed in two portions about 4 ft from the wing attach point. The damage to the left-wing lift strut exhibited a U-shape compression that was consistent with the diameter of the outermost tower guy wires. The left horizontal stabilizer and left elevator separated the aft fuselage during the impact sequence, and the leading edge of the left horizontal stabilizer exhibited damage consistent with the left wing impacting the surface. The main wreckage was located in a dirt field about 0.3 mile northwest of the radio tower. All major airframe structural components and flight control surfaces were identified along the wreckage debris path. Most of the airplane fuselage, cabin, and cockpit were destroyed by the postaccident fire. Postaccident examination of the airplane wreckage did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal operation of the airplane before it collided with the radio tower guy wire. All physical damage to the airframe, flight controls, engine, and propeller was consistent with impact with a tower guy wire, impact with the ground, or the postaccident fire. Figure 6 – Wreckage Debris Path at Accident Site -
Analysis
The pilot was conducting a low-altitude pipeline patrol flight in day visual meteorological conditions when the airplane collided with a radio tower guy wire. According to radar data, during the final 4.5 minutes of the flight, the airplane’s altitude was between 475 and 800 ft above ground level (agl). The airplane’s ground track was offset to the right of the pipeline until about the final minute of the flight, at which point the airplane crossed over the pipeline and continued about 1,000 to 1,250 ft to the left of the pipeline. The operator reported that the airplane should be flown to the right of the pipeline to ensure that the pilot, who is seated in the left cockpit seat, can maintain an unobstructed view of the pipeline during the patrol flight. The airplane continued northwest toward the radio tower. About 15 seconds before the accident, the airplane was about 0.65 miles southeast of the tower in a shallow right turn when it entered a climb from 475 ft agl. At the final radar return, about 600 ft east-southeast of the tower, the airplane’s altitude, calibrated airspeed, and climb rate were about 1,370 ft msl, 104 knots, and 1,575 ft per minute, respectively. The airplane’s final altitude was 370 ft below the top of the radio tower and its ground track was toward the guy wires located on the northeast side of the radio tower. Based on the airplane’s ground track and rapidly increasing climb rate, the pilot was likely trying to avoid the tower guy wires during the final moments of the flight. The airplane’s left wing separated from the fuselage at the wing root when it collided with a support guy wire attached to the northeast side of the radio tower. The airplane then impacted a dirt field about 0.3 mile northwest of the radio tower where a postimpact fire destroyed most of the airplane. Postaccident examination of the airplane wreckage did not reveal any evidence of a mechanical malfunction or failure that would have prevented normal operation of the airplane before it collided with the tower guy wire. Two individuals reported that the pilot posted a Snapchat video shortly before the accident. The Snapchat video reportedly depicted the terrain ahead of the airplane while it was 5 to 10 miles southeast of the accident site. Although the video was automatically deleted from the Snapchat platform 24 hours after the accident, it reportedly did not include the final moments of the flight. One of the individuals provided a screenshot of the Snapchat application’s map that showed the approximate location of where the pilot posted the video. When compared to the airplane’s recorded radar ground track, the location of the pilot’s Snapchat post was about 1.5 miles southeast of the radio tower, and likely was posted about 35 seconds before the accident. The airplane’s ground track was already left of the pipeline when the pilot posted the Snapchat video. Based on the known information, it is likely the pilot was distracted while he used his mobile device in the minutes before the accident and did not maintain an adequate visual lookout to ensure a safe flight path to avoid the radio tower and its guy wires.
Probable cause
The pilot’s failure to maintain adequate visual lookout to ensure clearance from the radio tower and its guy wires. Contributing to the accident was the pilot’s unnecessary use of his mobile device during the flight, which diminished his attention/monitoring of the airplane’s flight path.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N2430X
Operator
Gateway Air Service, Inc.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
18256330
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-04T17:28:13Z guid: 103091 uri: 103091 title: ERA21LA222 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103119/pdf description:
Unique identifier
103119
NTSB case number
ERA21LA222
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-20T10:30:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-05-25T15:49:38.313Z
Event type
Accident
Location
Dawson, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On May 20, 2021, about 0930 eastern daylight time, a Mooney M20K, N9514R, was substantially damaged when it was involved in an accident near Dawson Municipal Airport (16J), Dawson, Georgia. The pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he had recently purchased the airplane. On the day of the accident, the pilot conducted a preflight inspection with no anomalies noted, and the airplane departed Orlando Apopka Airport (X04), Apopka, Florida, about 0815 for a flight to Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. While en route to the destination airport, the airplane lost total engine power. The pilot declared an emergency to air traffic control and diverted to the nearest airport, which was 16J. During the descent, the pilot operated the engine controls with no response from the engine. The pilot realized that the airplane would not reach the airport, and he landed the airplane on a road with the landing gear and flaps retracted. The airplane’s right wing and fuselage were substantially damaged. A postaccident teardown examination revealed two holes in the top of the engine crankcase, with the larger hole near the center and the smaller hole just aft. The cylinders remained attached to the crankcase. The No. 4 connecting rod was found fractured about midspan. A No. 4 connecting rod bolt nut was found in the oil pan. This nut exhibited no signs of impact damage or damage that would be consistent with separation. A cotter pin associated with the nut was not located. The other No. 4 connecting rod nut was found secured to its bolt with the cotter pin installed. All other connecting rod bolt nuts remained attached to their respective bolts with cotter pins in place. The oil filter pleats and oil sump contained a large amount of metallic debris. Review of maintenance records revealed that the engine had accumulated about 1,240 hours of operation since its last major overhaul, which was completed on September 18, 1992. The engine manufacturer recommended that the engine be overhauled every 2,000 hours or 12 calendar years, whichever occurred first. Further review of the records revealed that the engine was disassembled, cleaned, and inspected due to a crankcase crack in 2005 and that the No. 3 cylinder was replaced in 2013. -
Analysis
The pilot reported that, while en route to the destination airport, the airplane lost total engine power. The pilot declared an emergency with air traffic control and began to divert to the nearest airport. The pilot recognized that the airplane would not be able to glide to the airport, and he decided to land on a road with the landing gear and flaps retracted. The pilot and passenger sustained serious injuries, and the airplane was substantially damaged. A postaccident teardown examination of the engine revealed that the No. 4 connecting rod was fractured midspan. One of the No. 4 connecting rod bolt nuts was found in the oil pan and exhibited no signs of pre- or postaccident damage. The cotter pin for that nut was not found; the other No. 4 connecting rod nut was found secured to its bolt with the cotter pin installed. Additionally, all other connecting rod bolt nuts remained attached to their respective bolts with cotter pins in place. Thus, it is likely that the nut found in the oil pan was not secured with a cotter pin and that the unsecured No. 4 connecting rod bolt nut became loose over time and backed out of the connecting rod bolt during the accident flight, resulting in the total loss of engine power. Review of maintenance records revealed that the engine had accumulated about 1,240 hours of operation since major overhaul, which was completed more than 28 years before the accident. The engine manufacturer recommended that the engine be overhauled every 2,000 hours or 12 calendar years, whichever occurred first. The investigation could not determine when the No. 4 connecting rod nut was installed without a cotter pin.
Probable cause
Maintenance personnel’s failure to properly secure the No. 4 connecting rod bolt nut with a cotter pin, resulting in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY AIRCRAFT CORP.
Model
M20K
Amateur built
false
Engines
1 Reciprocating
Registration number
N9514R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25-0484
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-05-25T15:49:38Z guid: 103119 uri: 103119 title: WPR21LA204 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103144/pdf description:
Unique identifier
103144
NTSB case number
WPR21LA204
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-20T11:30:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2021-06-08T03:23:29.877Z
Event type
Accident
Location
Eugene, Oregon
Airport
MAHLON SWEET FLD (EUG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
History of Flight On May 20, 2021, about 1030 Pacific daylight time, an experimental amateur-built McClure Glasair III, N54CB, was substantially damaged when it was involved in an accident near Eugene, Oregon. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Recorded automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that the airplane departed from runway 35 at Aurora State Airport (UAO), Aurora, Oregon, about 1007. The airplane made a right turn onto a south-southwest heading and climbed to a cruise altitude of about 2,500 ft mean sea level (msl) en route toward MahlonSweet Field Airport (EUG), Eugene, Oregon. According to the FAA, the pilot contacted Cascade approach control, and a controller cleared the airplane to land on runway 16R at EUG. The controller also cautioned the pilot about wake turbulence from landing traffic. About 8 nautical miles (nm) north of EUG, the airplane made a left turn that was consistent with a straight-in approach to runway 16 at EUG and began a descent, leveling off briefly at an altitude of 1,200 ft msl. ADS-B data showed that, when the airplane was about 1.5 nm from the runway 16 threshold, the airplane entered a left-hand spiral descent and continued to lose altitude. The airplane’s groundspeed was between 115 and 125 knots until about 1031, when the ADSB data track ended, and the airplane was about 1.5 nm north of the accident site. During the approach to land, the pilot reported, “going down, going down.” No further radio communications were received from the pilot. The airplane impacted tall grass about 1.5 nm north of EUG. The figure below shows the accident site and the surrounding area. Witnesses in the surrounding area reported observing a low-flying airplane that made a banking turn before it disappeared. Figure 1. Airplane track and accident area overview. Aircraft Information A review of the airplane’s records revealed that the landing gear had been inspected and returned to service on May 14, 2021; at that time, the tachometer showed 188.1 hours. There was no evidence found of any recent maintenance on the flaps to include the clevis pin and cotter key. Wreckage and Impact Information Examination of the accident site revealed that the first identified point of contact was the left-wing tip; the wreckage continued for about 150 ft, where the engine was located. Flight control continuity could not be established due to impact damage and multiple separations. All major structural components were observed at the accident location. Postaccident examination of the recovered airframe revealed that the entire wing assembly with landing gear separated from the fuselage in one piece. The left-wing flap actuator push-pull tube assembly was detached from the welded plate at the adjustable turnbuckle fork, but it remained attached to the flap actuator rod end at the wing-to-flap attachment. The left steel clevis pin and cotter key were not found. The rightwing flap hardware remained connected and intact from the flap tubular bar welded plate to the wing-to-flap attachment. The engine crankshaft was manually rotated via the propeller, and mechanical and valve train continuity was established. The engine examination revealed no mechanical anomalies that would have precluded normal operation. -
Analysis
The pilot departed on a daytime cross-country flight in visual meteorological conditions. Automatic dependent surveillance-broadcast (ADS-B) data indicated a normal flight and a cruising altitude of about 2,500 ft mean sea level. The airplane generally flew a south-southwest heading toward the destination airport. About 1.5 nautical miles north of the destination airport, the airplane entered a descending left-hand spiraling turn, after which the track data ended. During the approach to land, the pilot radioed two times that he was ‘going down.’ The airplane impacted terrain about 1.5 nautical miles north of the airport. Postaccident examination of the engine revealed no preimpact mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airframe revealed that the flap system is connected via a tubular bar in the center of the wing that extends out into each wing root. At each end of the bar is a welded plate which a flap actuator push-pull assembly is connected to and terminates at the wing flap. The pilot manipulates the flaps from inside the cockpit via a flap switch which electrically actuates the flaps into various positions depending on the phase of flight. The right-wing flap hardware remained connected from the wing root out to the flap. The left-wing flap was disconnected at the flap bar welded plate. The left-wing flap non-threaded steel clevis pin and cotter key, which connected the welded plate to the flap actuator turnbuckle fork at the wing root, were missing and not located within the wreckage. Review of the aircraft records revealed no evidence of any recent maintenance within the area of the missing clevis pin and cotter key. A condition inspection was completed 45 days prior to the accident. The aircraft records also identified maintenance performed on the landing gear six days prior to the accident. This situation likely created an asymmetrical “split” flap condition, with only one flap deploying when the pilot extended the flaps during the approach to landing, causing the airplane to depart controlled flight. The pilot would likely not have been aware of a faulty flap until the landing approach.
Probable cause
The pilot’s loss of airplane control during the approach to landing due to an asymmetrical flap deployment for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MCCLURE B J
Model
GLASAIR III
Amateur built
true
Engines
1 Reciprocating
Registration number
N54CB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3064
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-08T03:23:29Z guid: 103144 uri: 103144 title: ERA21FA225 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103127/pdf description:
Unique identifier
103127
NTSB case number
ERA21FA225
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-22T18:42:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-06-01T21:15:43.012Z
Event type
Accident
Location
Winterville, North Carolina
Airport
South Oaks Aerodrome (05N)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The engine was equipped with two carburetors, Nos. 1/3 and 2/4, which were connected to the cockpit throttle control by Bowden cables. According to the engine installation manual, a return spring was attached at each carburetor. With minimal friction of the Bowden cable, the spring would move the throttle completely open. - 05N was privately owned and open to the public. Postaccident examination of the runway revealed that the grass on the runway was cut about 1 to 2 inches tall, and no soft spots on the runway were noted. Examination of the entire length of the runway revealed no marks that were consistent with the accident airplane, and no parts of the airplane were found on the runway surface. - On May 22, 2021, about 1742 eastern daylight time, a Flight Design CTSW light sport airplane, N708JM, was destroyed when it was involved in an accident near South Oaks Aerodrome (05N), Winterville, North Carolina. The pilot and passenger were fatally injured. The airplane was operated as a Title 14?Code of Federal Regulations Part 91 personal flight. According to Federal Aviation Administration radar track data, a target was noted departing runway 23 at Cape Fear Regional Jetport/Howie Franklin Field Airport (SUT), Oak Island, North Carolina, about 1627. After takeoff, the flight turned left to a northeast heading for about 21 nautical miles and then turned slightly left to a north-northeast heading to proceed toward 05N. While en route, the passenger sent a text to a relative, “it is 5:27 [p.m.] right now and we are 12 minutes from landing.... Had a headwind that slowed us down a little bit. Will text when we get settled.” The flight continued toward 05N, but the radar target was lost at 1735:52, when the flight was about 6.2 nautical miles and 181° from 05N. According to security camera videos from houses located north and south of the runway, the airplane touched down about 122 ft from the approach end of runway 25 and remained on the ground for about 340 ft. An engine sound was heard increasing, and the video depicted the airplane in a nose-high taillow attitude. The airplane then became airborne when it was about 464 ft past the approach end of runway 25. The airplane began a climbing left turn and rolled to the left to about 90° while descending. The airplane subsequently impacted a wooded area behind a house on the airstrip. The airplane began a climbing left turn, which a pilot-rated witness located near the departure end of runway 25 reported that, at the time of the airplane’s climbing left turn, the bank angle was between 15° and 20°. The pilot-rated witness reported seeing fire about 10 seconds after hearing the impact. He added that the smoke from the postcrash fire rose vertically and that there was no or minimal wind. - The East Carolina Brody School of Medicine, Department of Clinical/Forensic Pathology, performed an autopsy on the pilot. His cause of death was multiple injuries. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory identified losartan in the pilot’s blood and urine. Losartan is a blood pressure medication that is generally considered not to be impairing. - The accident site was about 1,246 ft and 229° from the approach end of runway 25. Examination of the accident site revealed that a tree, which was about 10- to 12-inches in diameter was uprooted. The tree also exhibited an impact scar about 25 ft above ground level. The tree was located along a magnetic heading of 344°. The surrounding area exhibited evidence of a postcrash fire. The airplane’s fuel system was destroyed by the postcrash fire. One fuel tank pick-up screen was found attached to an end of the fuel tank, and the other fuel tank pick-up screen was found loose in the wreckage; both were free of obstructions. The airframe fuel strainer had separated from the fuel system, but the screen was clean. Examination of the engine revealed extensive heat damage that precluded rotation of the crankshaft. Borescope inspection revealed that all rods remained connected to the crankshaft. Additionally, the positions of the front and rear pistons (relative to each other) were consistent with an intact crankshaft. Examination of the camshaft, cylinders, air induction, ignition, cooling, lubricating, exhaust systems, and reduction gearbox revealed extensive heat damage and no evidence of preimpact failure or malfunction. Examination of both carburetors, which had separated from the engine, revealed extensive heat damage and both throttle plates in their wide-open position. Examination of the throttle control cables by the National Transportation Safety Board Materials Laboratory revealed that both throttle cables to the cockpit for the Nos. 1/3 and 2/4 carburetors and the choke cable to the cockpit for the No. 2/4 carburetor exhibited fracture features consistent with overstress. The choke cable for the No. 1/3 carburetor sustained extensive thermal damage. -
Analysis
After a cross-country flight, the light sport airplane pilot and passenger arrived at the destination airport. Security camera video captured the airplane touching down normally about 122 ft past the approach end of the runway. The airplane remained on the ground for about 340 ft; afterward, the video recorded engine power increasing in a manner consistent with a go-around. The airplane became airborne and began a climbing left turn with between 15° and 20° left bank. The airplane rolled left beyond 90° of bank and descended in a left-wing-low attitude. A witness heard the sound of impact and saw a postcrash fire. Evidence at the accident site confirmed that the airplane was in a steep descent before impact. The reason for the go-around could not be determined based on the available evidence for this investigation. One of the throttle control cables was found fractured. However, no evidence indicated any preimpact mechanical failure or malfunction to the throttle control cables, flight controls, engine, or its systems. On the basis of the available evidence, the pilot likely exceeded the airplane’s critical angle of attack during the go-around, which caused the airplane to stall and descend uncontrolled.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during a go-around, which resulted in an aerodynamic stall and a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FLIGHT DESIGN
Model
CTSW
Amateur built
false
Engines
1 Reciprocating
Registration number
N708JM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
06-08-09
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-01T21:15:43Z guid: 103127 uri: 103127 title: CEN21FA230 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103128/pdf description:
Unique identifier
103128
NTSB case number
CEN21FA230
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-23T15:47:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-05-25T21:23:52.286Z
Event type
Accident
Location
Shreveport, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Title 14 CFR Part 91, General Operating and Flight Rules, Subpart D Special Flight Operations, Paragraph 91.303 Aerobatic flight states: No person may operate an aircraft in aerobatic flight— (a) Over any congested area of a city, town, or settlement; (b) Over an open air assembly of persons; (c) Within the lateral boundaries of the surface areas of Class B, Class C, Class D, or Class E airspace designated for an airport; (d) Within 4 nautical miles of the center line of any Federal airway; (e) Below an altitude of 1,500 feet above the surface; or (f) When flight visibility is less than 3 statute miles. For the purposes of this section, aerobatic flight means an intentional maneuver involving an abrupt change in an aircraft's attitude, an abnormal attitude, or abnormal acceleration, not necessary for normal flight. - The pilot/owner acquired the airplane on July 17, 2020. No mechanical discrepancies were noted in the maintenance logbook. According to entries in the airframe logbook, the airplane completed its Phase One flight testing for airworthiness for standard flights on July 10, 2017. No entries were found after Phase Two for flight testing to perform aerobatics maneuvers. The airplane was equipped with a Ballistic Recovery System (BRS). Upon recovery, the BRS system appeared to have been activated and deployed upon impact - On May 23, 2021, about 1447 central daylight time, a Sub-Sonex JSX-2 experimental jet airplane, N465JC, was destroyed when it impacted Cross Lake near Shreveport, Louisiana. The pilot sustained fatal injuries. The airplane was operated under the provisions of Title 14 CFR Part 91 as a personal flight. The intent of the flight was to fly over Cross Lake after departing the Shreveport Regional Airport (SHV). Automatic dependent surveillance broadcast (ADS-B) track data indicated the airplane departed runway 24 at SHV, about 1439:00. The airplane made a right turn to the northeast and proceeded to fly over Cross Lake. (Figure 1) Figure 1. Overall flight track. Figure 2. Flight path over Cross Lake and the accident location. The ADS-B track data showed the airplane maneuver low-level over the lake until track data was lost at 1446:14. (Figure 2) At the last track data point, the airplane was over Cross Lake at an altitude of 625 ft above mean sea level, 142 kts ground speed, and on a 100o heading. An onboard Garmin GDU 460 cockpit display recorded 13 minutes and 9 seconds of the airplane’s flight. At the last recorded point at 1446:20, the airplane was about 400 ft above ground level (agl), 170 knots indicated airspeed, and heading 100o. Before the data was lost, the airplane pitch showed an abrupt pitch up to 15°. A witness reported that he and several other people were on a pier and saw the airplane fly low across the lake at about 200 ft agl. The witness reported that just before the accident he saw the airplane roll to the right until it was inverted and then it abruptly nosed down and impacted the water in a near vertical attitude. One person asked the witness if it was a “little red jet” that had crashed, and the witness said that it was. The person then told the witness that he and his wife had been on the lake the previous Sunday and saw the airplane performing a barrel roll over the lake. - An autopsy of the pilot was performed by the Louisiana State University Health Sciences Center, Department of Pathology, Shreveport, Louisiana. The cause of death was determined as blunt force injuries due to an airplane crash and the manner of death was an accident. The FAA Civil Aerospace Medical Institute Bioaeronautical Sciences Research Branch, Forensic Sciences Laboratory performed toxicology testing of postmortem specimens from the pilot. Sertraline was detected at 31 ng/mL and its metabolite desmethylsertaline was detected at 53 ng/mL in cardiac blood. Both sertraline and desmethylsertaline were also detected in urine. Bupropion was detected at 18 ng/mL and its metabolite hydroxybupropion was detected at 128 ng/mL in cardiac blood. Both bupropion and hydroxybupropion were also detected in urine. Quetiapine was detected in cardiac blood and urine. Gabapentin was detected at 719 ng/ml in cardiac blood and was also detected in urine. Pramipexole was detected in urine but not in cardiac blood. Amlodipine was detected in cardiac blood and urine. Ethanol was not detected in cardiac blood. - The pilot held type ratings in the CE-500, EA-500S, IA-Jet, LR-60 (Second-in-Command only), LR-Jet, and MS-760. He was authorized to fly the AV-L39 and the Sub-Sonex experimental aircraft VFR only. - The airplane's wreckage was located submerged in a shallow recreational lake. The airplane’s cabin and cockpit sections were broken open. The right wing was crushed aft along the entire span of the spar. The left wing was separated at the fuselage and was folded rearward and buckled. The empennage was buckled forward. The right ruddervator showed impact crush damage to its leading edge. The left ruddervator had minimal impact damage. Flight control continuity was confirmed. The airplane’s engine was separated from the fuselage at the pylon base. Witness marks on the ring cowling corresponded to similar marks on the top fuselage. The engine was rotated by hand and drive continuity was established from the compressor rearward to the exhaust. The inlet compressor blades did not show any deformation and showed no binding during rotation. The engine control unit was recovered and downloaded and showed that the engine functioned normally up to the time of the accident. The BRS cockpit deployment lever was found in the stowed position. -
Analysis
Automatic dependent surveillance broadcast track data showed the airplane take off and shortly thereafter maneuver low-level over the lake until track data was lost. A witness reported that he and several others saw the airplane fly across the lake at an altitude of about 200 ft above the water. The witness reported that just before the accident he saw the airplane roll to the right until it was inverted and then it abruptly nosed down and impacted the water in a near vertical attitude. Another witness reported seeing the airplane performing a barrel roll over the lake during the previous week. The airplane's wreckage was recovered and examined. Airframe damage showed that the airplane impacted the water in a near-vertical, nose-low, right-wing-down attitude. Flight control continuity was confirmed, and the engine and engine control unit showed no preaccident malfunctions or failures that could have contributed to the accident. Toxicology testing showed the pilot had used the potentially impairing drugs sertraline, bupropion, quetiapine, gabapentin, and pramipexole. However, is not possible to reliably predict the combined effects of these drugs or how they affected any impairment from underlying medical conditions the pilot had. In addition, the small amount of ethanol detected may have been produced after the pilot’s death.
Probable cause
The pilot’s failure to maintain clearance with the water while performing aerobatics, resulting in the airplane’s impact into a lake. Contributing was the pilot’s decision to perform aerobatics at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Sub-Sonex
Model
JSX-2
Amateur built
true
Engines
1 Turbo jet
Registration number
N465JC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JSX-0006
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-25T21:23:52Z guid: 103128 uri: 103128 title: ERA21FA229 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103135/pdf description:
Unique identifier
103135
NTSB case number
ERA21FA229
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-24T14:30:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-06-02T17:36:17.08Z
Event type
Accident
Location
Van Cleve, Kentucky
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 24, 2021, about 1330 central daylight time, an amateur built Rans RV-8, N284RM, was destroyed when it was involved in an accident near Van Cleve, Kentucky. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated from Haller Airpark (7FL4), Green Cove Springs, Florida, on a visual flight rules (VFR) flight and made a fuel stop at Pickens County Airport (LQK), Pickens, South Carolina. According to air traffic control (ATC) data provided by the Federal Aviation Administration, the airplane departed LQK, then made a climbing left turn followed by a series of turns while gradually ascending to about 9,000 ft. The flight continued under VFR until ATC assigned a transponder code for flight following. The airplane maintained this code for the remainder of the flight while flying northbound. Upon reaching the vicinity of Van Cleve, the pilot declared an emergency, reporting a loss of oil pressure and loss of engine power. ATC informed the pilot about an airport located to the airplane’s "2 o'clock and 3 miles." The pilot stated that he did not have the airport in sight and chose to perform a forced landing in a field instead. The airplane entered a 270° turn while descending, with the ground speed decreasing, until flight track data was no longer available. WRECKAGE EXAMINATION The wreckage came to rest on a heading of 353°, and all structural components of the airplane were located at the accident site. The accident site contained all flight control surfaces, and flight control continuity was observed from the surfaces to the fire-damaged area within the cockpit. The fuselage from the firewall to approximately two feet from the empennage was destroyed by the post-impact fire. The engine also displayed significant fire damage. The flight instruments and flight controls within the cockpit were also destroyed by the fire. Additionally, the main landing gear were sheared off from the fuselage. Both propeller blades were broken from the hub and found in the impact crater, along with the spinner and pieces of the nose cone. The propeller governor was separated from the engine and partially consumed in the post-impact fire. The wings were destroyed by fire, although remnants of the wing root structure remained attached to the fuselage. Some parts of the flight control surfaces were observed still connected to the wing structures. Examination of the empennage revealed fire damage, with both the horizontal and vertical stabilizers being attached to the empennage but showing signs of impact and fire damage. Burnt oil streaks were discovered on the right horizontal stabilizer and elevator. Notably, fresh oil was observed on broken pieces of the windscreen at the wreckage site. The engine crankcase and cylinders were intact and the engine's accessory section was fire damaged. The rear-mounted accessories, rocker covers, and upper spark plugs were removed. The crankshaft was rotated about 2 degrees by turning the propeller hub. After the accessory case was removed the crankshaft could be rotated through 360 degrees of rotation by turning the propeller hub. Continuity of the crankshaft to the rear gears and to the valve train was confirmed. Compression and suction were observed from all four cylinders. The interiors of the cylinders were observed through a lighted borescope and no anomalies were observed. Components in the accessory section, as well as the oil and fuel lines, also showed signs of fire damage. One of the oil lines connecting the engine to an aftermarket oil valve was broken at the attachment fitting, but due to the fire damage, it could not be determined if the failure occurred before or after ground impact. The oil valve itself was also fire damaged. The engine’s oil sump was partially consumed by the post-impact fire. A review of a maintenance logbook excerpt revealed that the oil valve had been “resealed” on March 25, 2021.The oil valve (Christen 802) was part of an accessory kit for Lycoming engines that provided normal engine lubrication with minimal oil loss during aerobatic flight. It functioned as a self-contained extension of the normal engine oil and breather systems. MEDICAL AND PATHOLOGICAL INFORMATION According to the Kentucky Justice and Public Safety Cabinet, Office of the Chief Medical Examiner, the cause of death was multiple blunt force injuries, and the manner of death was accident. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified 0.010 gm/dl of ethanol in cavity blood but none in brain or muscle. -
Analysis
During a cross-country flight at cruise altitude, the pilot reported a loss of engine oil pressure and loss of engine power to air traffic control and subsequently performed a forced landing to a field. The airplane impacted the ground and the wreckage was partially consumed by a post impact fire. Examination of the wreckage revealed oil staining on a portion of the horizontal stabilizer and broken pieces of the windscreen that were found at the site. Examination of the engine revealed that with the exception of the oil sump, which had been partially consumed by the postimpact fire, the crankcase, cylinders were intact, and continuity of the crankshaft and valvetrain were confirmed. The examination also found that an oil line connecting the engine to an aftermarket oil valve had separated, though it could not be determined if the separation occurred prior to, or as a result of the airplane’s impact with the ground. Overall, the engine did not display signatures consistent with a catastrophic loss of engine power and accompanying breach of the engine crankcase. Given the pilot’s report of a loss of oil pressure (and loss of engine power), and the oil staining observed on the wreckage, it is likely that such a failure was imminent. Given the extent of the fire damage to the engine, the reason for the loss of oil pressure could not be determined. A review of the pilot’s pathological information revealed the presence of ethanol, which was most likely from postmortem production rather than ingestion. Therefore, the presence of ethanol did not contribute to the circumstances of the accident.
Probable cause
A loss of engine power due to loss of engine oil pressure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MUNSON ROGER J
Model
RV-8
Amateur built
true
Engines
1 Reciprocating
Registration number
N284RM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
81670
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-02T17:36:17Z guid: 103135 uri: 103135 title: WPR21FA203 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103137/pdf description:
Unique identifier
103137
NTSB case number
WPR21FA203
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-24T15:17:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Last updated
2021-06-10T01:52:26.031Z
Event type
Accident
Location
Las Vegas, Nevada
Airport
NELLIS AFB (LSV)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Draken International completed an assessment of the accident aircraft’s final turn performance by attempting to match the accident flight parameters (at a safer and higher altitude) in similarly equipped F-1 aircraft. An aircraft configuration of gear up, flaps up, and slats down was assumed. The assessment noted that the accident airplane’s overhead pattern track was flown at a tighter track than normal pattern spacing flown by the number two aircraft in the formation. During final turns, at various power settings, the assessment noted that the airplane required an additional 1,000 ft to 1,300 ft to recover from the end of the turn and also had a tendency to continue turning at the end of the profile (180-190 kts and 17° AOA). It also noted that the pilots needed to unload to roll wings-level to regain airspeed, and furthermore that the afterburner took about 5 seconds to light. All of the final turn test runs resulted in excessive AOA of 17° incidence or greater, except for one run, at a low power setting, which resulted in the airplane unable to turn more than 110°. A review of the airplane’s performance charts indicated that the accident airplane’s no-flap configuration would have depleted energy even at maximum afterburner during the final turn and would be at or above 17°AOA incidence (the maximum limit). Failure of the flaps to extend would require additional airspeed and AOA to compensate for the loss of lift, which would increase the airplane’s turning radius. Additionally, as shown in the organization’s flight assessment and airplane’s performance charts, there was insufficient thrust available to overcome the configuration issue of no-flaps while flying a final turn profile based on the flaps extended. - The F-1 Mirage was a French fighter and attack aircraft that was imported into the United States and registered under the experimental category. It is a single-engine, swept-wing, supersonic airplane capable of Mach 2+. The airplane had a maximum takeoff weight of over 35,000 lbs. The airplane is equipped with high-lift devices consisting of two types of leading-edge slats and double-slotted flaps on each wing. The internal drooping slats occupy the 2/5 of the leading edge and have a camber of 25°. The external slotted slats occupy 3/5 of the leading edge, are in line with the drooping slats, and have a variable camber. The flaps have slots and slips in two parts (internal and external). Their camber is different and variable depending on the configuration. In the 1/2 extended position, the internal flap is about 28° and the external flap is 13°. In the fully extended position, the internal flap is about 48° and the external flap is 25°. The airplane’s manual control of the high-lift devices was controlled electronically by the “SLATS-FLAPS” lever. This control level must be used on takeoff and landing and overrides the combat high-lift device controls. There were three positions of the handle: the forward position was fully retracted and guarded by a guard cover, the middle position was ½ flaps and slats completely extended. The rear position was flaps and slats completely extended. The slat control system and the two flap actuating jacks were supplied by the hydraulic system 1, ancillary subsystem. The airplane’s high-lift device selector switch had an EMERGENCY RETRACTION position for slat and flap emergency retraction. This position would take precedence over all other current functions selected. The combat flaps were for use during combat and increase the lift performance by 25% up to about 18° nose up. The F-1 Aircraft Flight Manual for “Landing High-Lift Devices Fail to Extend” checklist calls to check the Slats/Flaps (S/F) circuit breaker, utility hydraulic pressure, and that the high-lift device selector switch in not at EMERGENCY RETRACT position; S/F light out. If the checks confirm the failure, set the slat/flap lever to IN and land without high-lift devices: angle-of-attack (AOA) incidence about 11°. The no-flap landing speeds were incorporated in the hydraulic system ancillary shutoff emergency checklist. The checklist states that if the high-lift devices (slats and flaps) do not extend, land with and airspeed between 195 kts to 215 kts depending on aircraft weight and also with an AOA incidence about 11° as per the “Landing High-Lift Devices Fail to Extend” checklist. Given the accident airplane was at landing weight, its no-flap landing speed would have been about 195 kts, which assumes the airplane was straight and level and configured with the gear extended. Additionally, Draken International’s F-1 procedures call for no-flap patterns to be flown from a straight in approach. The aircraft flight manual for the normal F-1 “Break” pattern depicts initiating the break to downwind about 350 kts, 60° of bank, throttle back to below 6,500 rpm and airbrakes as required. Abeam the runway, the airplane should be about 215 kts, configured with the airbrakes in, gear down, and flaps down. The pilot should, according to the manual, extend the downwind leg sufficiently to stabilize speed before the final turn. Approaching the runway at 45°, the key point for the final turn, airspeed should be about 160 kts and AOA incidence about 10°, and RPM about 7,300 rpm. During the final turn, airspeed should be about 150 kts and the pilot should use the AOA incidence indicator to control airspeed, less or equal to 13° (12° - 13° on average). Draken International flies their normally configured F-1s in the overhead pattern at a minimum of 165 kts in the final turn. Additionally, an incidence of 13°AOA is used only after touchdown and aerobraking, which would equal about 135 kts (assuming about a 1000L of fuel landing weight). The airplane’s incidence indicator is attached to the left side windshield post and displays incidence (AOA) information. At a greater than 17° limit incidence, a warning horn activates, and cuts off when the incidence is reduced to 14°. The maximum permissible incidence (AOA) is 17°. According to the airplane’s flight manual: The aircraft behavior at high incidence is very sound. The permissible limit is easily exceeded unless the incidence indicator is watched, the control forces on the control stick are very light and the buffeting level is low and constant. The control stick is often pulled up to the pitch travel limit without any obvious anomaly, especially with the combat flaps. The airplane was scheduled on an Other Approved Inspection Program (AAIP). The program consisted of three levels of progressive aircraft inspections. The maintenance and inspection levels were organizational, intermediate, and depot. Organizational inspections consisted of servicing, preventive maintenance, and operational inspections. Intermediate level inspections consisted of intermediate inspections at an interval of 250 flight hours and a minor inspection at 800 flight hours. The depot inspections consisted of a major inspection at 2,400 flight hours. The operator performed a daily inspection on the accident airplane prior to its flight. Additionally, the airplane’s last intermediate and depot level inspections were accomplished on November 9, 2020, at an airframe total time of 4,589.7 hours. - LSV is a United States Air Force owned, towered airport, with a reported field elevation of 1,869 ft. The airport was equipped with two concrete runways, runway 3L/21R (10,120 ft long by 200 ft wide) and runway 3R/21L (10,051 ft long by 150 ft wide). Airport remarks for runway 21R listed a caution for a crane training site north of the departure end of runway 3L, which had a maximum height of 100 ft. The LSV overhead traffic pattern altitude is 3,500 ft mean sea level (msl). Overhead traffic patterns are usually flown to both runways simultaneously. Aircraft on initial to Runway 3L would normally use the left “break” and aircraft on initial to runway 3R would normally use the right “break.” In addition, because of the Class B airspace surrounding Harry Reid International Airport (LAS) Las Vegas, Nevada (known as McCarran International Airport during the time of the accident), and the local radar approach boundaries, on an East (right) break to runway 3R, pilots are to complete the final turn north of Lake Mead boulevard (about 2.5 miles south of the approach of runway 3R) according to local flying regulations. Near the time of the accident, a review of the tower controller transcripts revealed communications with several airplanes in the overhead traffic patterns. Within a minute after the accident airplane reported initial for runway 3R, two airplanes (in sequence) were cleared to land on runway 3L after reporting their final turn. Additionally, a flight of two airplanes were cleared for a midfield, right break for runway 3R, to follow the accident airplane, which was now on downwind for runway 3R. Shortly after the accident airplane declared a flap issue, another flight of two airplanes reported over Craig (LSV 264/5.5) for initial. The tower controller cleared the two ships for the right break on runway 3R. After the accident, the airplanes in the overhead pattern were instructed to land on runway 3L. - The airplane was equipped with a Dassault ESPAR solid-state FDR customized for use in the F-1 Mirage. The ESPAR was capable of recording between 3-6 hours of flight data and could record 25 parameters. The readout software then calculated additional parameters using the base recorded parameters. - On May 24, 2021, about 1417 Pacific daylight time, an experimental Dassault Aviation Mirage F-1 Turbo-jet, N567EM, was destroyed when it was involved in an accident near Nellis Air Force Base, (LSV), Las Vegas, Nevada. The pilot was fatally injured. The airplane was operated by Draken International as a public-use aircraft in support of the United States Air Force’s simulated combat training. The accident airplane was the No.1 (lead) airplane in a flight of 2 airplanes that were returning to LSV after completion of their Weapons School support flights in the Nevada Test and Tactics Range. The No. 2 airplane in the formation returned to LSV before the lead airplane since it reached its briefed fuel status first. About 15 minutes later, the lead airplane returned to LSV. While en route to LSV and about several minutes out, the lead pilot reported that the airplane was “code 1,” signifying that the airplane had no maintenance discrepancies. A review of LSV airport surveillance radar and air traffic control communications revealed that the lead airplane entered the traffic pattern and reported initial for runway 3R at 14:16:05. At 14:16:26, the airplane was aligned with runway 3R, flying about 2,000 ft above ground level (agl) and at an airspeed of about 260 kts. The airplane broke right for the overhead pattern and while on downwind and approaching the final turn (a 180° turn towards the landing runway), at 14:17:12, the pilot reported that he would be accomplishing a low approach and then proceeding out to Flex (LSV 338/04). As the airplane began the final turn it was about 1,400 ft agl, and the airspeed was 170 kts and slowing. Shortly after, the airplane’s descent rate increased from 1,000 fpm to more than 3,000 fpm. At 14:17:20, the airplane’s airspeed decreased below 160 kts, and the pilot reported “we are having a ugh flap issue” and the tower responded, “are you declaring an emergency” to which the pilot responded “affirm.” At 14:17:36 the last recorded point, about 400 ft agl, the airplane’s airspeed was 135 kts and slowing. The airplane’s airspeed was slower than the listed low-speed limitation, without flaps (160 kts), for about the final 14 seconds of flight. Furthermore, the airplane continued to slow to below the low-speed limitation for the flaps extended. The flight manual advises that if the flaps do not lower, to land at a speed between 195 and 215 kts. The airplane continued to descend in the final turn in a bank angle in excess of 40°. The pilot ejected from the airplane but was fatally injured. Shortly thereafter, the airplane struck terrain in a residential area southwest of the approach end of the runway. The wreckage was consumed by a post-crash fire. Ground personnel stated that during the preflight check of the slats and flaps the leading-edge slats operated appropriately but the flaps did not initially extend during the first cycle of the check. The pilot was able to correct the issue and completed at least two additional cycles during the operational checks of the slats and flaps with no further issue. - The Clark County Office of the Coroner/Medical Examiner, Las Vegas, Nevada, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “blunt force injuries.” The FAA's Forensic Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The pilot’s results for the testing were negative except for positive results for ethanol in the muscle specimen. The pilot had ethanol detected in the muscle tissue but not detected in the brain tissue. It is likely that some or all of the small amount of ethanol detected was formed by postmortem microbial activity. - Draken International operated the airplane and was a contract air support organization that provided aggressor support, red air, and close air support for the United States military, Department of Defense, and allied militaries, globally. The organization operated one of the world’s largest commercial fleets of tactical ex-military jet aircraft consisting of the F-1 Mirage, A-4, L-159, and L-39 aircraft. The accident airplane was part of the contract to provide adversarial support to the United States Air Force at LSV. Draken International accomplished both the maintenance of its airplanes and provided initial and recurrent ground and flight training to its F-1 pilots. The F-1 pilots interviewed stated that their F-1 training was thorough and was comparable to the flight training they received in their previous fighter aircraft. Additionally, the organization had a safety department that was managed by the Director of Safety. The safety department managed the organization’s Safety Management System (SMS). - The pilot held a commercial pilot certificate with an airplane single-engine and multi-engine land and airplane instrument ratings. He also held an experimental aircraft authorization for the DA-F1. The pilot was issued a Federal Aviation Administration (FAA) second-class medical certificate on January 19, 2021, without limitations. The pilot logged 2,859 total hours of flight experience and 152 hours in the F-1 aircraft. He was a former fighter pilot in the United States Air Force. The pilot had completed training provided by the company and was qualified in the F-1 airplane for the mission flown. The pilot appeared to be in good spirits and rested on the day of the accident and on the previous workday. - Examination of the ejection hardware revealed that the ejection equipment functioned normally, and there was no evidence of any preimpact mechanical anomalies that would have precluded normal operation. A review of the airplane’s ejection seat envelope revealed that at 130 kts; at a bank of 45°, the minimum altitude was about 300 ft, and at 60° of bank, the minimum altitude was about 450 ft. - Examination of the accident site revealed that the jet airplane impacted flat desert terrain in the back of a residence about 1.5 miles southwest from the approach threshold of runway 3R. All major components of the airplane were found at the main wreckage site. The main portion of the fuselage came to rest by a flatbed semi-truck trailer on a heading of about 195° magnetic. Small fragments of aircraft debris were scattered several hundred feet from the accident site. The wreckage site was at an elevation of about 1,791 ft msl. There was a postimpact fire that consumed the majority of the airplane wreckage. The ejection seat and parachute were found about one block away to the east-southeast. A postaccident examination of the airplane wreckage revealed that the airplane’s configuration was consistent with the slats being extended and the flaps being retracted. Observation of the airplane’s engine revealed significant impact damage consistent with the engine operating at a high rotational velocity at the time of impact and that there was no evidence of internal catastrophic damage. The engine rpm gauge as found indicated about 7,100 rpm, which was consistent with “break” pattern procedures for a normally configured aircraft. Additionally, the position of the variable exhaust nozzle was consistent with the previous engine observations. Examination of the Master Failure Warning light filament revealed that the amber portion of the light was likely illuminated. The amber light would illuminate an annunciator on the Failure Warning Panel, which depicts specific system failures, malfunctions, or cautions. Illumination of an amber light on both the Master Failure Warning light and Failure Warning Panel would allow for delayed action for the issue. If a red light was illuminated, it would call for immediate action. Examination of the airplane’s Flight Data Recorder revealed that no flight data was able to be extracted from the unit. The recorder’s memory chips in the accident module were likely failed at the time of the accident. Because of the post-crash condition of the airplane and the absence of onboard recorded data, the nature of the flap issue reported by the pilot could not be determined. No additional evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation were observed. -
Analysis
A fighter jet airplane providing combat training support to the Department of Defense collided with terrain shortly after entering the final turn in the traffic pattern. The pilot was returning to the airport after completion of tactical area work. As the airplane began the final turn (a 180° turn to align with the runway), its airspeed was about 170 kts and slowing. Shortly after, the pilot reported that he was having a flap issue and the airplane’s descent rate increased from 1,000 fpm to more than 3,000 fpm. The airplane’s airspeed dropped to below the listed low-speed limitation without flaps (160 kts) for about the final 14 seconds of flight. The flight manual advises pilots to land at a speed between 195 and 215 kts if the flaps do not lower. At the last recorded data point, the airspeed was 135 kts and slowing. Shortly thereafter, the pilot initiated an ejection. The airplane subsequently struck terrain in a residential area and was consumed by a postimpact fire. Postaccident examination of the airplane revealed that the flaps were likely not extended. During the preflight check of the slats and flaps, the leading-edge slats operated appropriately but the flaps did not initially extend during the first cycle of the check. The pilot was able to correct the issue and completed at least two additional cycles during the operational checks of the slats and flaps with no further issue. Whether this flap issue was a reoccurrence of the ground check anomaly, or another cause could not be determined due to the post-crash condition of the airplane and the absence of onboard recorded data. Postaccident analysis of the bulb filament revealed that the airplane’s master failure warning light was showing an amber light indication. Which annunciator caused the amber light to illuminate could not be determined but an amber light indication allowed for delayed action for the issue. If a red light was illuminated, it would call for immediate action. No additional evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane were observed. Failure of the flaps to extend would require additional speed to compensate for the loss of lift, which would increase the airplane’s turning radius. Because the traffic pattern’s normal ground track is based on the airplane being configured with the flaps extended, a no-flap configuration would require the airplane to increase bank and angle of attack (AOA) to maintain the track. However, insufficient thrust was available to overcome the configuration issue and increased AOA. Under a failed flap scenario, the pilot would have needed to maintain adequate airspeed, AOA, and rolled out of bank and discontinued the final turn for an airplane configured with the flaps extended and then flown a traffic pattern ground track consistent with a no-flap configuration. The pilot likely maintained his ground track during the final turn in order to reduce the chance of conflict with potential landing traffic on the opposite runway if he rolled out of bank and pattern/airspace restrictions. It is likely that the pilot initiated an ejection outside of the airplane’s ejection seat minimum altitude ejection envelop due to the airplane’s increased bank, decreased airspeed, low altitude, and sink rate.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack on approach and failure to fly a traffic pattern track consistent with a no-flap configuration. Contributing to the accident was the failure of the airplane’s flaps to extend while in the traffic pattern for an undetermined reason.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DASSAULT AVIATION
Model
MIRAGE F-1
Amateur built
false
Engines
1 Turbo jet
Registration number
N567EM
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Commercial sightseeing flight
false
Serial number
56
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-10T01:52:26Z guid: 103137 uri: 103137 title: ERA21FA232 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103145/pdf description:
Unique identifier
103145
NTSB case number
ERA21FA232
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-25T08:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-06-02T00:49:46.842Z
Event type
Accident
Location
Crossville, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 25, 2021, about 0730 central daylight time, a Gulfstream American AA-5A, N26889, was destroyed when it was involved in an accident near Crossville, Tennessee. The student pilot was fatally injured. The airplane was operated as a Title Code of Federal Regulations Part 91 instructional flight. Track data obtained from the Federal Aviation Administration (FAA), an interview with the pilot’s flight instructor, and telephone records revealed that the airplane departed Crossville Memorial Airport (CSV), Crossville, Tennessee, on the second leg of a cross-country flight about 0715. The next planned stop was Cleveland Regional Jetport (RZR), Cleveland, Tennessee, about 50 miles south of CSV. The airplane climbed on a southerly track to 3,700 ft mean sea level (msl) before beginning a gradual descent about 0718. The airplane continued its descent on its southerly track until about 0723 and 3,000 ft msl, when the airplane entered a 450° descending right turn. Figure 1. – Overview of Accident Flight At 0726, about 2,300 ft msl, the pilot placed a phone call to his flight instructor. The instructor stated that the pilot reported that the engine was not making full power, producing about 1,700 rpm versus the normal cruise power setting of about 2,400 rpm. The instructor stated that the pilot remained calm during the conversation, and he assisted with troubleshooting, including asking about the fuel state, magneto switch position, and carburetor heat position. The pilot thought he was “40 to 50” miles from CSV. The instructor told him to land at the nearest airport, but the pilot reported that the airplane had slowed to 70 knots. The instructor then advised the pilot to perform an emergency landing to a field. The pilot reported that there were “trees and mountains.” Shortly thereafter, the instructor heard the sound of an impact and the connection was lost. Figure 2. Profile View of Accident Flight The airplane completed its course reversal about 8 miles south of CSV and traversed a large cultivated field before impacting rising terrain on a heavily wooded ridgeline. Figure 3. View of Flight Track Final Segment The pilot had begun flight lessons about 1 month before the accident. According to his instructor, the pilot had accrued 44 total hours of flight experience, all of which was in the accident airplane. The pilot was a conscientious student who flew an average of three times per week. The instructor stated that the pilot was enrolled in an online ground school and that they would discuss the lessons before each flight. The accident flight was the pilot’s first solo cross-country flight.   The airplane’s most recent annual inspection was completed on December 11, 2020, at 5,221.84 total aircraft hours.   Examination of the airplane at the accident site revealed that the wreckage path was about 1,800 ft elevation, oriented about 030° magnetic and was about 75 ft long. The initial impact point was in a tree about 50 ft tall, and pieces of angularly-cut wood were found along the wreckage path.   The airplane was consumed by postcrash fire. Remnants of each wing and the main wing spars were found adjacent to main fuselage area. The tail section was impact damaged but remained largely intact. Control cable continuity was established from the control column and rudder pedals to the rudder and elevators. Continuity was established from the control column through breaks at each wing root to the ailerons. The cable breaks displayed features consistent with overload failure. The instrument panel and its contents were consumed by fire. The engine displayed significant fire damage, and the accessories, along with their associated wires, hoses, and fittings, were consumed by fire. Examination of the throttle control at the carburetor revealed that the ball-joint end of the throttle control cable was fractured at the carburetor arm. The carburetor end of the throttle control cable assembly with attached support bracket, carburetor arm with attached ball screw piece, and carburetor arm attachment nut and cotter pin were retained and forwarded to the NTSB Materials Laboratory in Washington, DC. Examination of the fracture surfaces revealed fracture features consistent with high temperature overstress fracture and ductile overstress fracture. The weather reported at Crossville Memorial Airport, Crossville, Tennessee, about 20 minutes after the accident included clear skies and calm wind. The temperature was 22°C and the dewpoint was 17°C. Review of the icing probability chart contained withing the FAA Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were “conducive to serious icing at glide power.” According to the Gulfstream American Model AA-5A Cheetah Pilot’s Operating Handbook, Normal Procedures: Page 4-11, DESCENT, (3) Carburetor Heat – As required by engine power setting and weather conditions page 4-19, NOTE – If engine runs rough during cruise with carburetor heat on, it may be due to an over-rich condition. To correct for engine roughness in such a situation, lean mixture to smooth engine operation.” Section 3, Emergency Procedures, page 3-16: ROUGH ENGINE OPERATION OR LOSS OF POWER - Carburetor Icing – An unexplained drop in RPM and engine roughness may result from the formation of carburetor ice. To clear the ice, apply full throttle (do not exceed red line) and pull the carburetor heat knob full out until the engine runs smoothly. Then remove carburetor heat and readjust the throttle. If conditions require the continued use of carburetor heat in cruise flight use the minimum amount of heat necessary to prevent ice from forming and lean the mixture for smooth engine operation. FAA Special Airworthiness Information Bulletin (SAIB) CE-09-35, Carburetor Icing Prevention Pilots should be aware that carburetor icing doesn’t just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. To recognize carburetor icing, the warning signs are: A drop in rpm in fixed pitch propeller airplanes. … The pilot should respond to carburetor icing by applying full carburetor heat immediately. The engine may run rough initially for short time while ice melts. -
Analysis
The student pilot was on a multi-leg, solo cross-country flight in atmospheric conditions conducive to serious carburetor icing at descent power. Track data and interviews with the pilot’s instructor revealed that the airplane entered a gradual descent over a 5-minute span that included a 450° descending right turn. Shortly thereafter, the pilot called his instructor via cell phone and reported that the airplane’s engine was producing only partial power. The instructor stated that the pilot’s demeanor was calm, and as such, the discussion felt conversational and that there was time to discuss fuel state, engine control positions, landing at the nearest airport, or selecting a forced landing site. When asked, the pilot reported he was “40 to 50 miles” from his departure airport; however, track data revealed that the airplane was about 8 miles south of the departure airport. The instructor suggested the pilot make an “emergency landing in a field,” but the pilot reported that there were trees and mountains ahead of him before the sounds of impact were heard. The airplane was consumed by postcrash fire. Control continuity to all flight control surfaces was confirmed; examination of the engine revealed the accessories were destroyed by fire and that the core exhibited no preimpact anomalies. The fracture surfaces on a separated carburetor heat control revealed signatures consistent with overstress due to impact and high temperatures. Based on the lack of mechanical anomalies and the partial loss of engine power as reported by the pilot, it is likely that the engine lost partial power as the result of carburetor ice accumulation, which resulted in descent into terrain. It is likely that the pilot’s prompt application and use of carburetor heat in accordance with the airplane’s operating handbook would have restored engine power.
Probable cause
A partial loss of engine power due to carburetor icing, which resulted in a descent and impact with terrain. Contributing to the accident was the pilot’s failure to apply carburetor heat following the initial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AMERICAN CORP
Model
AA-5A
Amateur built
false
Engines
1 Reciprocating
Registration number
N26889
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA5A0792
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-02T00:49:46Z guid: 103145 uri: 103145 title: ERA21FA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103146/pdf description:
Unique identifier
103146
NTSB case number
ERA21FA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-25T18:47:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-05-30T21:52:22.746Z
Event type
Accident
Location
Leesburg, Florida
Airport
LEESBURG INTL (LEE)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
A supplemental type certification (STC) is the FAA’s approval of a major change in the type design of a product that was previously type certificated. An FAA aircraft certification office (ACO) issues the STC. Guidance for applying for and approving an STC is contained in FAA Advisory Circular (AC) 2140A. The FAA ACO establishes a project team that generally consists of a project manager, engineers or technical specialists, flight test engineers and pilots, manufacturing inspectors, and operations inspectors. The FAA project team coordinates with the STC applicant to develop a project-specific certification plan (PSCP). Blackhawk Mission Equipment hired a program manager and numerous FAA designated engineering representatives (DER) to design the water tank and snorkel system, conduct testing, and provide associated documentation to the FAA project team. The PSCP listed the following technical disciplines involved in the STC application: structures, electrical systems, mechanical and structures systems, flight analyst and pilot, Designated Airworthiness Representative for Manufacturing, coupon fabrication, and electrical systems and equipment. The Denver ACO assigned a project officer, electrical systems engineer, structures engineer, flight test engineer, flight test pilot, and flight standards representative. Section 4 of the PSCP, titled Project Type, stated the following: This project is a Supplemental Type Certificate for 14 CFR part 29 regulations as determined by the Administrator, for installation of the internal water tank & snorkel install on the BHI H60A/L & S-70A/C model helicopters. The modifications are used in rotorcraft performing “External Load Operations & Do Carriage of Cargo’ per 14 CFR Part 21.25(a)(2), (b)(1)(2) and (7). The PSCP did not specify the rotorcraft-load combination that would be applicable to the STC. According to the Denver ACO, the airworthiness standards for external loads for a transport-category rotorcraft (14 CFR 29.865) were not applied because the standard was directed toward human and nonhuman external cargo and the PSCP did not have 14 CFR 29.865 included as part of the certification basis for the project. The PSCP also did not include the airworthiness standards for rotor blade clearances from rotorcraft structure per 14 CFR 29.661. A review of the Blackhawk Mission Equipment STC application package included a structural analysis of the water tank installation report, hose test report, flight test report, and functional hazard assessment (FHA) and system safety assessment (SSA). The structural analysis quantitively evaluated the water tank design and structural materials for emergency landing load cases per 14 CFR 29.561(a)(c) at amendment O. Review of the analysis report identified that an inaccurate amount of 100 pounds was used for snorkel and pump weight when the snorkel and pump weight was 137.5 pounds. The 100-pound vertical load was applied to the tank snorkel support calculation and given a margin of safety of +1.25. Additionally, the calculations considered a static vertical load applied only to the snorkel support. The structural analysis of the snorkel support did not account for the type of dynamic loading that would be seen in operation, such as air loads imparted by the snorkel, lateral loads imparted by the snorkel, water loads imparted by the tank filling operation, water loads imparted by movement of the snorkel and pump horizontally through the water, or loads imparted by the snorkel if the assembly were snagged. After the accident, the FAA stated the following: Subpart C-Strength Requirements in the PSCP, for General (29.301, 29.305(a), 29.307(a)), for flight loads (29.321-29.251, & 29.561(a)(c)) were part of the certification basis. This would have required determination of the lateral and dynamic forces on the snorkel to be used in the analysis. A hose test was conducted to determine the force required for the hose to fail in tension. The hose assembly contained a pump at one end and a hose coupler at the other end. The coupler was attached to a steel fixture, and the pump assembly was fixed to the ground. A forklift was used to lift the steel fixture with the coupled end and put tension on the hose assembly until it failed. The test found that the pump separated from the hose with 2,500 pounds of force. The test did not include the water tank snorkel support where the snorkel attaches to the tank or the lighting protection cable. The flight test report documented the details of the ground and flight test results that were conducted to demonstrate compliance with the applicable FAA requirements. The flight tests included observation of the behavior of the tank and snorkel system at airspeeds from 0 to 193 knots indicated airspeed (1.1 times the never-exceed speed), angle of bank up to 30°, climbs, normal descents, and autorotative descents. Although the snorkel had been flight tested with up to 30° of bank, the FAA-approved rotorcraft flight manual supplement contained no limitation to restrict operation with the tank and snorkel system to a maximum of 30° of bank. When asked after the accident why the flight test did not either test an angle of bank greater than 30° or establish a 30°-degree angle of bank limitation, the FAA stated the following: “Flight testing was accomplished up to 30 deg. AOB [angle of bank] in both directions….as can be found in the company flight test report BHJ-213-107, Rev A. There was not a AOB limitation created by the applicant as part of the STC.” Thus, without an angle of bank limitation specified in the rotorcraft flight manual supplement, normal operation of the tank and snorkel system beyond 30° of bank would be permitted, which would exceed the maximum angle of bank that had been demonstrated during flight testing. An FHA and SSA documented the most likely failure conditions and mitigations for the water tank and snorkel system. The functional hazard assessment identified 13 discrete failure/hazard conditions and their effect on the rotorcraft or crew. All 13 conditions were verified using a qualitative analysis method. Three conditions were classified as “no safety effect,” seven were classified as “minor failure condition,” and two were classified as “major failure condition”: water tank attachments become unsecure in flight and snorkel pump becomes snagged on ground obstacle or object. The failure condition of the snorkel hitting or getting entangled in the aircraft (other than the tail or main rotor) was classified as a minor failure condition. Additionally, the possibility of the snorkel contacting any portion of the rotor system was not addressed in the FHA or the SSA. The FAA stated the following regarding why neither assessment addressed snorkel contact with the rotor system: The FHA/SSA did not include snorkel contact to the rotor system due to required compliance to [14 CFR] 29.251 – vibration, using flight testing. Flight test data showed that under normal operating parameters the snorkel structure would not create excessive vibrations to lead to the failure mode of the snorkel contacting the rotor system. These results satisfied [14 CFR] 29.1309, ‘The equipment, system, and installations whose function is required by this subchapter must be designed and installed to ensure that they performed their intended functions under any foreseeable operating condition.’ A key part of the system safety assessment is the methodology. Section 5.1 of the FHA/SSA for the water tank and snorkel described the methodology as follows: The safety assessment process begins with the FHA and ends with the verification that the design meets the safety requirements and regulatory standards, The safety assessment process can be either qualitative, quantitative, or both. o Qualitative – Those analytical processes that assess system and aircraft safety in an objective non-numerical manner. Qualitative assessment is based on engineering judgement. o Quantitative – Those analytical processes that apply mathematical methods to assess the system and aircraft safety. From the flow chart (ref [FAA] AC 29-2C) it was determined that a qualitative analysis would be appropriate because the failure conditions identified in the FHA were not hazardous or catastrophic, the dominant failure condition was Major, with the majority of failure conditions either minor or having no safety effect. The water tank system and snorkel are not complex, and the system and installation is similar to a previous design. The FHA depth of analysis flow chart (in Advisory Circular 29 2C) states that “Catastrophic and Hazardous/Severe-major failure conditions will likely require both qualitative and quantitative analysis, depending on the system complexity.” - Blackhawk Mission Equipment’s STC for the internal water tank and snorkel installation on the UH-60A helicopter was approved on May 21, 2020, by the Federal Aviation Administration’s aircraft certification office (ACO) in Denver, Colorado. - Aviation Investigation Final Report Location: Leesburg, Florida Accident Number: ERA21FA233 Date & Time: May 25, 2021 17:47 Local Registration: N9FH Aircraft: Bhi H60 Helicopters Llc Uh-60A Aircraft Damage: Destroyed Defining Event Collision with terr/obj (non-CFIT) Injuries: 4 Fatal Flight Conducted Under: Part 91: General aviation - Flight test Analysis According to the operator, a new water tank and snorkel were installed on the helicopter to facilitate firefighting operations. Several days of ground testing and calibration were performed before the accident flight, which was the first flight after the water tank was installed. The purpose of the local flight was to check the operation of the fire tank system. The helicopter made six uneventful passes in front of the operator’s hangar at the airport and dropped water that was picked up from a lake adjacent to the airport. During each of these passes, the snorkel was observed to be stable. However, during the seventh pass, the snorkel was swinging from the helicopter. The helicopter then began to hover, released the water from the fire tank, and transitioned to forward flight, gaining altitude and airspeed. The snorkel continued to make large and slightly erratic oscillations as the helicopter climbed. Afterward, witnesses heard a loud bang, pieces of the main rotor blade and tail section separated, and the helicopter descended vertically to the ground. A postimpact fire ensued. Given the sudden change in behavior of the snorkel from a consistently stable condition in normal flight to one with large and erratic oscillations, it is likely that the tank snorkel support structure was compromised and allowed the snorkel’s oscillations to increase in such a way that the pump assembly at the end of the snorkel hose contacted the main rotor blade. The contact imparted enough energy to fracture the rotor blade at the contact point, which resulted in an imbalanced rotor system and a subsequent in-flight breakup of the helicopter. The supplemental type certificate (STC) application for the water tank and snorkel had been approved by the Federal Aviation Administration (FAA) about 1 year prior to the accident. A review of the STC application documentation revealed that the FAA had not classified the water tank and snorkel system as an external load. The structural analysis of the tank used the incorrect weight of the snorkel hose and pump combination and did not account for operational loads that would be imparted into the tank by the snorkel as called for in the certification basis in the project-specific certification plan (PSCP). Testing of the snorkel and pump loads did not incorporate the water tank structure to which the snorkel was attached. The system safety analysis did not address the hazard of the snorkel contacting the main rotor system. Increased consideration in any of these areas could likely have identified design insufficiencies. In addition, the production tank that was used during flight testing was examined after the accident. A manual load test was performed with the snorkel attached to the tank snorkel support structure. When the snorkel was pulled manually from the tank, the tank structure between the hose coupler and the tank face deformed between 0.03 and 0.05 inches. These manual loads represented only a small fraction of the loads that the tank snorkel support structure would experience during normal operation. Thus, the documentation that supported the FAA’s approval of the STC was insufficient because it failed to consider the failure scenario that occurred during the accident. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: The failure of the water tank snorkel support structure, which allowed the snorkel to contact the main rotor blades. Contributing to the accident was insufficient Federal Aviation Administration oversight of the supplemental type certificate process for the water tank and snorkel. Findings Aircraft (A1) Equip attach fittings (on fus) - Failure Organizational issues (A1) Oversight of reg compliance - FAA/Regulator Factual Information History of Flight Maneuvering-low-alt flying Collision with terr/obj (non-CFIT) (Defining event) Maneuvering-low-alt flying Part(s) separation from AC Maneuvering Miscellaneous/other On May 25, 2021, about 1747 eastern daylight time, a BHI H60 Helicopters LLC, UH-60A, N9FH, was destroyed when it was involved in an accident near Leesburg International Airport (LEE), Leesburg, Florida. The pilot, copilot, and two crewmembers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 post-maintenance test flight. According to the operator, 8 days before the accident, a new water tank and snorkel were installed on the helicopter, in accordance with supplemental type certificate (STC) SR00933DE, to facilitate firefighting operations. Several days of ground testing and calibration were performed before the accident flight, which was the first flight after the water tank and snorkel were installed. The purpose of the local flight was to check the operation of the fire tank system, which included the new water tank and snorkel. The helicopter made six uneventful passes in front of the operator’s hangar at LEE and dropped water that was picked up from a lake adjacent to the airport. On the seventh pass, an employee of the operator noticed that the snorkel was swinging. He called the LEE air traffic control tower and told the controller to ask the pilot to slow down and land immediately. Before the controller could contact the pilot, the helicopter transitioned to forward flight, gaining altitude and airspeed. The employee noticed that the snorkel was “violently” swinging, and he heard a loud bang. The employee saw pieces of the helicopter, including the tail section, separate from the helicopter. Afterward, the helicopter started to spin and descended below the tree line. The employee then heard an explosion and saw smoke rise above the tree line. According to another employee of the operator, she did not observe the helicopter’s first pass but watched the next six passes. She noted that the water being dropped from the tank was “very dirty.” During the helicopter’s last pass, this employee noticed that the snorkel was swinging in a large circle and that the snorkel end came very close to the main rotor blades. She immediately started waving her arms at the pilot to try and get his attention, but the pilot did not see her. Shortly after the helicopter climbed transitioned to forward flight and gained airspeed, this employee heard a loud bang and saw multiple main rotor blades separate and hit the tail section of the helicopter. She then saw the tail section fall to the ground and the helicopter enter a flat spin. Numerous other witnesses from the operator were present at the airport during the helicopter’s flight, including some who were recording the helicopter’s practice water drops. Twenty-two video clips were provided to the National Transportation Safety Board for review; 19 clips showed the helicopter performing water drops before the accident water drop pass, and 3 clips showed the accident water drop pass. In all the video clips before the accident pass, the helicopter was seen flying straight and level at a constant airspeed and releasing water over a specific point in the airport infield. As the helicopter approached the water release area, the snorkel hose was stable off the left side of the helicopter. As water was released from the water tank, the water was seen impinging on the snorkel hose, and the hose remained stable. In all the video clips showing the accident water drop pass, the snorkel hose made large and slightly erratic oscillations as the helicopter approached the water drop area. The helicopter began to hover and released the water from the tank, and the water impinged on the hose. None of the 22 video clips showed the helicopter’s transition to forward flight or climbout immediately before the accident. A security video camera mounted to a hangar that faces runway 3 captured the helicopter accident after it dropped off the water supply and proceeded down the runway heading. The video showed the helicopter flying away from the camera in level flight. The helicopter yawed suddenly, started to rotate around its vertical axis, and broke apart. The helicopter then descended vertically into the wooded area beside the runway. The behavior of the snorkel could not be observed in the video. Pilot Information Certificate: Commercial Occupant #1; Commercial Occupant #2 Age: 35, Male Occupant #1; 35, Male Occupant #2 Airplane Rating(s): Single-engine land Occupant #1; Single-engine land Occupant #2 Seat Occupied: Left Occupant #1; Right Occupant #2 Other Aircraft Rating(s): Helicopter Occupant #1; Helicopter Occupant #2 Restraint Used: 4-point Occupant #1; 4-point Occupant #2 Instrument Rating(s): Helicopter Occupant #1; Helicopter Occupant #2 Second Pilot Present: Yes Instructor Rating(s): Helicopter Occupant #1; None Occupant #2 Toxicology Performed: Yes Occupant #1, Yes Occupant #2 Medical Certification: Class 1 Without waivers/limitations Occupant #1; Class 1 Without waivers/limitations Occupant #2 Last FAA Medical Exam: January 21, 2021 Occupant #1; January 21, 2021 Occupant #2 Occupational Pilot: Yes Occupant #1; Yes Occupant #2 Last Flight Review or Equivalent: December 9, 2020 Occupant #1 Flight Time: 4873 hours (Total, all aircraft), 1344 hours (Total, this make and model) Occupant #1; 2135 hours (Total, all aircraft), 2135 hours (Total, this make and model) Occupant #2 Aircraft and Owner/Operator Information Aircraft Make: BHI H60 HELICOPTERS LLC Registration: N9FH Model/Series: UH-60A Aircraft Category: Helicopter Year of Manufacture: 1981 Amateur Built: [SAFTIAmateurBuilt] Airworthiness Certificate: Restricted (Special) Serial Number: 80-23461 Landing Gear Type: Tailwheel; Seats: 4 Date/Type of Last Inspection: December 21, 2020 Continuous airworthiness Certified Max Gross Wt.: 2100 lbs Time Since Last Inspection: [SAFTITimeSinceLastInspectionHrs] Engines: 2 Turbo shaft Engine #1: ; 2 Turbo shaft Engine #2: Airframe Total Time: 6603 Hrs as of last inspection Engine Manufacturer: GE Engine #1: ; GE Engine #2: ELT: Installed Engine Model/Series: T700-GE-701D Engine #1: ; T700-GE-701D Engine #2: Registered Owner: BRAINERD HELICOPTERS INC Rated Power: [SAFTIEngineRatedPower] Operator: BRAINERD HELICOPTERS INC Operating Certificate(s) Held: Rotorcraft external load (133), On-demand air taxi (135) Operator Does Business As: Fire hawk Operator Designator Code: [SAFTIOperatorDesignatorCode] Blackhawk Mission Equipment’s STC for the internal water tank and snorkel installation on the UH-60A helicopter was approved on May 21, 2020, by the Federal Aviation Administration’s aircraft certification office (ACO) in Denver, Colorado. Meteorological Information and Flight Plan Conditions at Accident Site: Visual (VMC) Condition of Light: Day Observation Facility, Elevation: LEE, 75 ft msl Distance from Accident Site: 1 Nautical Miles Observation Time: 17:53:00 Local Direction from Accident Site: 157° Lowest Cloud Condition: Clear Visibility 10 miles Lowest Ceiling: None Visibility (RVR): [SAFTIVisualRangeFT] Wind Speed/Gusts: 8 knots / Turbulence Type Forecast/Actual: None / None Wind Direction: 170° Turbulence Severity Forecast/Actual: N/A / N/A Altimeter Setting: 30.15 inches Hg Temperature/Dew Point: 32°C / 16°C Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: Leesburg, FL Type of Flight Plan Filed: Company VFR Destination: Leesburg, FL Type of Clearance: VFR Departure Time: [SAFTIDepartureTime] Type of Airspace: Class D Airport Information Airport: LEESBURG INTL LEE Runway Surface Type: Asphalt Airport Elevation: 75 ft msl Runway Surface Condition: Dry Runway Used: 13 IFR Approach: None Runway Length/Width: 6300 ft / 100 ft VFR Approach/Landing: Traffic pattern Wreckage and Impact Information Crew Injuries: 2 Fatal Aircraft Damage: Destroyed Passenger Injuries: 2 Fatal Aircraft Fire: On-ground Ground Injuries: N/A Aircraft Explosion: On-ground Total Injuries: 4 Fatal Latitude, Longitude: 28.817965°, -81.80863° estimated The wreckage was located in a localized swamp approximately 1,000 ft southeast from the approach end of runway 3. The wreckage was contained in a 31-ft diameter impact crater and had been consumed by fire. Section of all four rotor blades were contained with the main wreckage. The tail rotor remained attached to the vertical stabilizer and was located about 150 ft north-northeast of the main wreckage. Parts of the newly installed water tank and snorkel assembly were found on the west edge of runway 3. The water pump housing, which was installed near the snorkel inlet, was heavily fragmented. The stainless-steel snorkel suction cage was located about 50 ft west of runway 3 along with a section of main rotor blade. Several pieces of fairings and light material were lodged in the top of trees along the flightpath from the edge of the tree line to the main wreckage. The landing gear, main rotor system, main rotor drive system, engines, hydraulic system, and forward portion of the tail rotor drive system were thermally damaged by the postcrash fire. Most of the cockpit, cabin, and flight controls were consumed by the postcrash fire. Portions of the water tank and snorkel hose connecting port were located next to the left main landing gear within the main wreckage. A 10-ft section of the hose assembly (not including the suction pump) was located underneath the forward left side of the fuselage. The upper hose remained attached to the tank snorkel support, and the coupler levers were in the locked position. Portions of the hose had torn away from the tank snorkel support, and the edges were melted. The suction pump and cage were not present on the end of the hose, and the recuperator and fragmented sections of the crown housing remained attached. Most of the molded front section of the tank was fragmented and was largely destroyed by fire. The snorkel port that extends out of the molded front section of the tank was recovered. Examination of the snorkel port where the metal snorkel attachment fixture (coupler) fastened to the tank snorkel port showed that the gasket between the carbon-fiber flange plate and the tank port structure had torn and separated on the aft side. All the flange fasteners were in place. Additional Information A supplemental type certification (STC) is the FAA’s approval of a major change in the type design of a product that was previously type certificated. An FAA aircraft certification office (ACO) issues the STC. Guidance for applying for and approving an STC is contained in FAA Advisory Circular (AC) 2140A. The FAA ACO establishes a project team that generally consists of a project manager, engineers or technical specialists, flight test engineers and pilots, manufacturing inspectors, and operations inspectors. The FAA project team coordinates with the STC applicant to develop a project-specific certification plan (PSCP). Blackhawk Mission Equipment hired a program manager and numerous FAA designated engineering representatives (DER) to design the water tank and snorkel system, conduct testing, and provide associated documentation to the FAA project team. The PSCP listed the following technical disciplines involved in the STC application: structures, electrical systems, mechanical and structures systems, flight analyst and pilot, Designated Airworthiness Representative for Manufacturing, coupon fabrication, and electrical systems and equipment. The Denver ACO assigned a project officer, electrical systems engineer, structures engineer, flight test engineer, flight test pilot, and flight standards representative. Section 4 of the PSCP, titled Project Type, stated the following: This project is a Supplemental Type Certificate for 14 CFR part 29 regulations as determined by the Administrator, for installation of the internal water tank & snorkel install on the BHI H60A/L & S-70A/C model helicopters. The modifications are used in rotorcraft performing “External Load Operations & Do Carriage of Cargo’ per 14 CFR Part 21.25(a)(2), (b)(1)(2) and (7). The PSCP did not specify the rotorcraft-load combination that would be applicable to the STC. According to the Denver ACO, the airworthiness standards for external loads for a transport-category rotorcraft (14 CFR 29.865) were not applied because the standard was directed toward human and nonhuman external cargo and the PSCP did not have 14 CFR 29.865 included as part of the certification basis for the project. The PSCP also did not include the airworthiness standards for rotor blade clearances from rotorcraft structure per 14 CFR 29.661. A review of the Blackhawk Mission Equipment STC application package included a structural analysis of the water tank installation report, hose test report, flight test report, and functional hazard assessment (FHA) and system safety assessment (SSA). The structural analysis quantitively evaluated the water tank design and structural materials for emergency landing load cases per 14 CFR 29.561(a)(c) at amendment O. Review of the analysis report identified that an inaccurate amount of 100 pounds was used for snorkel and pump weight when the snorkel and pump weight was 137.5 pounds. The 100-pound vertical load was applied to the tank snorkel support calculation and given a margin of safety of +1.25. Additionally, the calculations considered a static vertical load applied only to the snorkel support. The structural analysis of the snorkel support did not account for the type of dynamic loading that would be seen in operation, such as air loads imparted by the snorkel, lateral loads imparted by the snorkel, water loads imparted by the tank filling operation, water loads imparted by movement of the snorkel and pump horizontally through the water, or loads imparted by the snorkel if the assembly were snagged. After the accident, the FAA stated the following: Subpart C-Strength Requirements in the PSCP, for General (29.301, 29.305(a), 29.307(a)), for flight loads (29.321-29.251, & 29.561(a)(c)) were part of the certification basis. This would have required determination of the lateral and dynamic forces on the snorkel to be used in the analysis. A hose test was conducted to determine the force required for the hose to fail in tension. The hose assembly contained a pump at one end and a hose coupler at the other end. The coupler was attached to a steel fixture, and the pump assembly was fixed to the ground. A forklift was used to lift the steel fixture with the coupled end and put tension on the hose assembly until it failed. The test found that the pump separated from the hose with 2,500 pounds of force. The test did not include the water tank snorkel support where the snorkel attaches to the tank or the lighting protection cable. The flight test report documented the details of the ground and flight test results that were conducted to demonstrate compliance with the applicable FAA requirements. The flight tests included observation of the behavior of the tank and snorkel system at airspeeds from 0 to 193 knots indicated airspeed (1.1 times the never-exceed speed), angle of bank up to 30°, climbs, normal descents, and autorotative descents. Although the snorkel had been flight tested with up to 30° of bank, the FAA-approved rotorcraft flight manual supplement contained no limitation to restrict operation with the tank and snorkel system to a maximum of 30° of bank. When asked after the accident why the flight test did not either test an angle of bank greater than 30° or establish a 30°-degree angle of bank limitation, the FAA stated the following: “Flight testing was accomplished up to 30 deg. AOB [angle of bank] in both directions….as can be found in the company flight test report BHJ-213-107, Rev A. There was not a AOB limitation created by the applicant as part of the STC.” Thus, without an angle of bank limitation specified in the rotorcraft flight manual supplement, normal operation of the tank and snorkel system beyond 30° of bank would be permitted, which would exceed the maximum angle of bank that had been demonstrated during flight testing. An FHA and SSA documented the most likely failure conditions and mitigations for the water tank and snorkel system. The functional hazard assessment identified 13 discrete failure/hazard conditions and their effect on the rotorcraft or crew. All 13 conditions were verified using a qualitative analysis method. Three conditions were classified as “no safety effect,” seven were classified as “minor failure condition,” and two were classified as “major failure condition”: water tank attachments become unsecure in flight and snorkel pump becomes snagged on ground obstacle or object. The failure condition of the snorkel hitting or getting entangled in the aircraft (other than the tail or main rotor) was classified as a minor failure condition. Additionally, the possibility of the snorkel contacting any portion of the rotor system was not addressed in the FHA or the SSA. The FAA stated the following regarding why neither assessment addressed snorkel contact with the rotor system: The FHA/SSA did not include snorkel contact to the rotor system due to required compliance to [14 CFR] 29.251 – vibration, using flight testing. Flight test data showed that under normal operating parameters the snorkel structure would not create excessive vibrations to lead to the failure mode of the snorkel contacting the rotor system. These results satisfied [14 CFR] 29.1309, ‘The equipment, system, and installations whose function is required by this subchapter must be designed and installed to ensure that they performed their intended functions under any foreseeable operating condition.’ A key part of the system safety assessment is the methodology. Section 5.1 of the FHA/SSA for the water tank and snorkel described the methodology as follows: The safety assessment process begins with the FHA and ends with the verification that the design meets the safety requirements and regulatory standards, The safety assessment process can be either qualitative, quantitative, or both. Qualitative – Those analytical processes that assess system and aircraft safety in an objective non-numerical manner. Qualitative assessment is based on engineering judgement. Quantitative – Those analytical processes that apply mathematical methods to assess the system and aircraft safety. From the flow chart (ref [FAA] AC 29-2C) it was determined that a qualitative analysis would be appropriate because the failure conditions identified in the FHA were not hazardous or catastrophic, the dominant failure condition was Major, with the majority of failure conditions either minor or having no safety effect. The water tank system and snorkel are not complex, and the system and installation is similar to a previous design. The FHA depth of analysis flow chart (in Advisory Circular 29 2C) states that “Catastrophic and Hazardous/Severe-major failure conditions will likely require both qualitative and quantitative analysis, depending on the system complexity.” Injuries to Persons Damage to Aircraft Other Damage Communications Flight recorders Medical and Pathological Information Fire Survival Aspects Tests and Research The tank that underwent flight testing as part of the STC application process was production tank No. 1. The tank that was installed in the accident helicopter was production tank No. 2. An examination of production tank No.1 and a UH-60A helicopter (N135BH) was performed to document the snorkel attachment assembly in the remaining production water tank. The water tank, snorkel, and water release gate were combined into a single system that could be placed in the cabin area of a UH-60 helicopter. The system was secured by a square tube-steel external frame that attached to the helicopter's existing upper cargo tie-down points and existing floor tie-down points. The molded front section that contained the snorkel attachment port, motorized water gate assembly (manufactured by Trotter Controls), and vent was designed and manufactured by Leading Edge Composites, which also assembled the tank side panels, integrated the molded front section to the tank, and installed the water gate assembly and associated controls. The 15-ft-long and 6-inch-diameter snorkel hose was attached to the water tank using a metal port that was attached to the tank via a carbon-fiber flange that contained a flapper valve fastened by eight AN4 bolts to a nut plate. The snorkel connected to the tank port using two lever camlocks (coupler). The water pump was attached to the free end of the snorkel. A power cable for the pump and a lightning protection cable extended down the length of the snorkel and were secured to the hose using nylon zip ties. The snorkel hose was not secured by any means other than the tank attachment point. The snorkel hose was not retractable. To determine the tank structure deformation at the snorkel-to-tank interface, the tank port was fastened with 12 AN4 bolts and was torqued. The snorkel was attached to the tank using the coupler camlocks, as designed. A dial gauge was positioned at various points around the tank port. The snorkel was then placed on a wheeled dolly, and manual loads were applied in three separate directions (forward, lateral, and aft). (These test loads represented a fraction of the load that the tank port structure would be subjected to during flight and operation of the snorkel system.) The deflection of the tank port structure was measured as the snorkel was manually pulled away from the port and released back to a static position. The maximum deflection recorded was between 0.03 and 0.05 inches at the tank structure between the hose coupler and the tank face when the snorkel was pulled laterally from the tank. Organizational and Management Information Useful or Effective Investigation Techniques [SAFTISafetyMessage] - On May 25, 2021, about 1747 eastern daylight time, a BHI H60 Helicopters LLC, UH-60A, N9FH, was destroyed when it was involved in an accident near Leesburg International Airport (LEE), Leesburg, Florida. The pilot, copilot, and two crewmembers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 post-maintenance test flight. According to the operator, 8 days before the accident, a new water tank and snorkel were installed on the helicopter, in accordance with supplemental type certificate (STC) SR00933DE, to facilitate firefighting operations. Several days of ground testing and calibration were performed before the accident flight, which was the first flight after the water tank and snorkel were installed. The purpose of the local flight was to check the operation of the fire tank system, which included the new water tank and snorkel. The helicopter made six uneventful passes in front of the operator’s hangar at LEE and dropped water that was picked up from a lake adjacent to the airport. On the seventh pass, an employee of the operator noticed that the snorkel was swinging. He called the LEE air traffic control tower and told the controller to ask the pilot to slow down and land immediately. Before the controller could contact the pilot, the helicopter transitioned to forward flight, gaining altitude and airspeed. The employee noticed that the snorkel was “violently” swinging, and he heard a loud bang. The employee saw pieces of the helicopter, including the tail section, separate from the helicopter. Afterward, the helicopter started to spin and descended below the tree line. The employee then heard an explosion and saw smoke rise above the tree line. According to another employee of the operator, she did not observe the helicopter’s first pass but watched the next six passes. She noted that the water being dropped from the tank was “very dirty.” During the helicopter’s last pass, this employee noticed that the snorkel was swinging in a large circle and that the snorkel end came very close to the main rotor blades. She immediately started waving her arms at the pilot to try and get his attention, but the pilot did not see her. Shortly after the helicopter climbed transitioned to forward flight and gained airspeed, this employee heard a loud bang and saw multiple main rotor blades separate and hit the tail section of the helicopter. She then saw the tail section fall to the ground and the helicopter enter a flat spin. Numerous other witnesses from the operator were present at the airport during the helicopter’s flight, including some who were recording the helicopter’s practice water drops. Twenty-two video clips were provided to the National Transportation Safety Board for review; 19 clips showed the helicopter performing water drops before the accident water drop pass, and 3 clips showed the accident water drop pass. In all the video clips before the accident pass, the helicopter was seen flying straight and level at a constant airspeed and releasing water over a specific point in the airport infield. As the helicopter approached the water release area, the snorkel hose was stable off the left side of the helicopter. As water was released from the water tank, the water was seen impinging on the snorkel hose, and the hose remained stable. In all the video clips showing the accident water drop pass, the snorkel hose made large and slightly erratic oscillations as the helicopter approached the water drop area. The helicopter began to hover and released the water from the tank, and the water impinged on the hose. None of the 22 video clips showed the helicopter’s transition to forward flight or climbout immediately before the accident. A security video camera mounted to a hangar that faces runway 3 captured the helicopter accident after it dropped off the water supply and proceeded down the runway heading. The video showed the helicopter flying away from the camera in level flight. The helicopter yawed suddenly, started to rotate around its vertical axis, and broke apart. The helicopter then descended vertically into the wooded area beside the runway. The behavior of the snorkel could not be observed in the video. - The tank that underwent flight testing as part of the STC application process was production tank No. 1. The tank that was installed in the accident helicopter was production tank No. 2. An examination of production tank No.1 and a UH-60A helicopter (N135BH) was performed to document the snorkel attachment assembly in the remaining production water tank. The water tank, snorkel, and water release gate were combined into a single system that could be placed in the cabin area of a UH-60 helicopter. The system was secured by a square tube-steel external frame that attached to the helicopter's existing upper cargo tie-down points and existing floor tie-down points. The molded front section that contained the snorkel attachment port, motorized water gate assembly (manufactured by Trotter Controls), and vent was designed and manufactured by Leading Edge Composites, which also assembled the tank side panels, integrated the molded front section to the tank, and installed the water gate assembly and associated controls. The 15-ft-long and 6-inch-diameter snorkel hose was attached to the water tank using a metal port that was attached to the tank via a carbon-fiber flange that contained a flapper valve fastened by eight AN4 bolts to a nut plate. The snorkel connected to the tank port using two lever camlocks (coupler). The water pump was attached to the free end of the snorkel. A power cable for the pump and a lightning protection cable extended down the length of the snorkel and were secured to the hose using nylon zip ties. The snorkel hose was not secured by any means other than the tank attachment point. The snorkel hose was not retractable. To determine the tank structure deformation at the snorkel-to-tank interface, the tank port was fastened with 12 AN4 bolts and was torqued. The snorkel was attached to the tank using the coupler camlocks, as designed. A dial gauge was positioned at various points around the tank port. The snorkel was then placed on a wheeled dolly, and manual loads were applied in three separate directions (forward, lateral, and aft). (These test loads represented a fraction of the load that the tank port structure would be subjected to during flight and operation of the snorkel system.) The deflection of the tank port structure was measured as the snorkel was manually pulled away from the port and released back to a static position. The maximum deflection recorded was between 0.03 and 0.05 inches at the tank structure between the hose coupler and the tank face when the snorkel was pulled laterally from the tank. - The wreckage was located in a localized swamp approximately 1,000 ft southeast from the approach end of runway 3. The wreckage was contained in a 31-ft diameter impact crater and had been consumed by fire. Section of all four rotor blades were contained with the main wreckage. The tail rotor remained attached to the vertical stabilizer and was located about 150 ft north-northeast of the main wreckage. Parts of the newly installed water tank and snorkel assembly were found on the west edge of runway 3. The water pump housing, which was installed near the snorkel inlet, was heavily fragmented. The stainless-steel snorkel suction cage was located about 50 ft west of runway 3 along with a section of main rotor blade. Several pieces of fairings and light material were lodged in the top of trees along the flightpath from the edge of the tree line to the main wreckage. The landing gear, main rotor system, main rotor drive system, engines, hydraulic system, and forward portion of the tail rotor drive system were thermally damaged by the postcrash fire. Most of the cockpit, cabin, and flight controls were consumed by the postcrash fire. Portions of the water tank and snorkel hose connecting port were located next to the left main landing gear within the main wreckage. A 10-ft section of the hose assembly (not including the suction pump) was located underneath the forward left side of the fuselage. The upper hose remained attached to the tank snorkel support, and the coupler levers were in the locked position. Portions of the hose had torn away from the tank snorkel support, and the edges were melted. The suction pump and cage were not present on the end of the hose, and the recuperator and fragmented sections of the crown housing remained attached. Most of the molded front section of the tank was fragmented and was largely destroyed by fire. The snorkel port that extends out of the molded front section of the tank was recovered. Examination of the snorkel port where the metal snorkel attachment fixture (coupler) fastened to the tank snorkel port showed that the gasket between the carbon-fiber flange plate and the tank port structure had torn and separated on the aft side. All the flange fasteners were in place. -
Analysis
According to the operator, a new water tank and snorkel were installed on the helicopter to facilitate firefighting operations. Several days of ground testing and calibration were performed before the accident flight, which was the first flight after the water tank was installed. The purpose of the local flight was to check the operation of the fire tank system. The helicopter made six uneventful passes in front of the operator’s hangar at the airport and dropped water that was picked up from a lake adjacent to the airport. During each of these passes, the snorkel was observed to be stable. However, during the seventh pass, the snorkel was swinging from the helicopter. The helicopter then began to hover, released the water from the fire tank, and transitioned to forward flight, gaining altitude and airspeed. The snorkel continued to make large and slightly erratic oscillations as the helicopter climbed. Afterward, witnesses heard a loud bang, pieces of the main rotor blade and tail section separated, and the helicopter descended vertically to the ground. A postimpact fire ensued. Given the sudden change in behavior of the snorkel from a consistently stable condition in normal flight to one with large and erratic oscillations, it is likely that the tank snorkel support structure was compromised and allowed the snorkel’s oscillations to increase in such a way that the pump assembly at the end of the snorkel hose contacted the main rotor blade. The contact imparted enough energy to fracture the rotor blade at the contact point, which resulted in an imbalanced rotor system and a subsequent in-flight breakup of the helicopter. The supplemental type certificate (STC) application for the water tank and snorkel had been approved by the Federal Aviation Administration (FAA) about 1 year prior to the accident. A review of the STC application documentation revealed that the FAA had not classified the water tank and snorkel system as an external load. The structural analysis of the tank used the incorrect weight of the snorkel hose and pump combination and did not account for operational loads that would be imparted into the tank by the snorkel as called for in the certification basis in the project-specific certification plan (PSCP). Testing of the snorkel and pump loads did not incorporate the water tank structure to which the snorkel was attached. The system safety analysis did not address the hazard of the snorkel contacting the main rotor system. Increased consideration in any of these areas could likely have identified design insufficiencies. In addition, the production tank that was used during flight testing was examined after the accident. A manual load test was performed with the snorkel attached to the tank snorkel support structure. When the snorkel was pulled manually from the tank, the tank structure between the hose coupler and the tank face deformed between 0.03 and 0.05 inches. These manual loads represented only a small fraction of the loads that the tank snorkel support structure would experience during normal operation. Thus, the documentation that supported the FAA’s approval of the STC was insufficient because it failed to consider the failure scenario that occurred during the accident.
Probable cause
The failure of the water tank snorkel support structure, which allowed the snorkel to contact the main rotor blades. Contributing to the accident was insufficient Federal Aviation Administration oversight of the supplemental type certificate process for the water tank and snorkel.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BHI H60 HELICOPTERS LLC
Model
UH-60A
Amateur built
false
Engines
2 Turbo shaft
Registration number
N9FH
Operator
BRAINERD HELICOPTERS INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
80-23461
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-05-30T21:52:22Z guid: 103146 uri: 103146 title: CEN21LA237 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103157/pdf description:
Unique identifier
103157
NTSB case number
CEN21LA237
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-27T08:50:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-06-04T07:16:30.557Z
Event type
Accident
Location
Celina, Ohio
Airport
Lakefield Airport (KCQA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
The engine was previously installed on a Mitsubishi MU-2B-20 airplane and was removed on November 12, 2014. On March 24, 2015, the engine was installed on the accident airplane in accordance with supplemental type certificate (STC) No. SA7987SW. The airplane HOBBS meter indicated 1,382.4 hours at the accident site. The airplane had accumulated 14.1 hours since the last 100-hour and annual inspection completed on May 19, 2021, and May 20, 2021, respectively. The airframe and engine total time since new were 9,187.2 hours and 7,733 hours, respectively. The engine had accumulated 521.2 hours since the last overhaul completed on May 17, 2019. On July 29, 1975, the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 75-16-20 for several Mitsubishi MU-2 models requiring repetitive inspections of the propeller pitch control lever for security and proper rigging. On December 21, 2011, the engine manufacturer released service bulletins (SB) TPE331-72-2190, TPE331-72-2191, and TPE331-72-72291 that recommended TPE331 operators inspect the PPC assembly to verify the splined end of the shouldered shaft had an internally threaded hole to accommodate a secondary retention feature for the aircraft linkage control interface. If the hole was not present or damaged, the SB included instructions to drill, tap, and countersink a threaded hole. The aircraft linkage control and secondary retention (bolt, washer, and lockwire) are considered airframe components. On December 29, 2020, the FAA issued AD 2020-26-14 for the Mitsubishi MU-2 fleet that superseded AD 75-16-20 and required the installation of a secondary retention feature on the PPC lever linkage, repetitive inspections of the PPC lever linkage, and reporting inspection results to the FAA. However, because AD 2020-26-14 was only applicable to Mitsubishi MU-2 airplanes it did not include other airplane make/models that were modified by STCs with a TPE331 engine and a comparable PPC linkage like the accident airplane (Grumman G-164B AgCat). In response to the accident, on May 17, 2023, the Federal Aviation Administration released Airworthiness Directive (AD) 2022-01801-A to mandate the installation of the PPC secondary retention feature on Allied Ag Cat Productions, Inc. model G-164A and G-164B airplanes to include those airframes that were equipped with a TPE331 engine installed under several identified STCs. According to the Honeywell TPE331 overhaul manual: The propeller pitch control (PPC) is mounted at the rear of the [engine’s] reduction gear section on the propeller shaft centerline. The PPC is composed of a ported sleeve, which is positioned by cam. The control end of the beta tube (which also has oil-supply ports) rides inside the ported sleeve. The positioning cam-control shaft is connected to the main metering valve power-lever shaft by mechanical linkage. During propeller-governing mode, the propeller pitch control serves no basic function other than oil passage and housing for the beta tube. In beta-mode (under-speed governing) the propeller pitch control provides for operator control of propeller blade pitch angle. Operator control is accomplished by manually positioning the propeller pitch control cam. The beta tube oil supply holes are then aligned with the ported sleeve so that the pressure supplied to the propeller balances the propeller piston spring. During takeoff, the propeller governor controls propeller pitch. The only function the PPC has in propeller governing mode is to act as an oil passageway. The PPC and FCU main metering valve are connected through the concentric shaft and are rigged to move together. The cockpit power lever is connected to the splined end of the shouldered shaft of the PPC in the Grumman G-164B (AgCat) installation. The cockpit condition lever is connected to the propeller governor. According to Honeywell Service Bulletin TPE331-76-2002, a disengagement of the airframe PPC linkage will result in the pilot’s inability to change fuel flow and/or propeller pitch (blade angle) during flight and landing. - On May 27, 2021, about 0750 eastern daylight time, a Grumman G-164B airplane, N8376K, was substantially damaged when it was involved in an accident near Celina, Ohio. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Earlier in the morning, the pilot repositioned the airplane from Defiance Memorial Airport (DFI), Defiance, Ohio, to Lakefield Airport (CQA), Celina, Ohio. Shortly after he departed DFI the pilot noticed that he forgot to bring his GPS and returned and landed at DFI. After retrieving the GPS, the pilot departed DFI a second time and flew to Charloe Airport (53OH), Paulding, Ohio, where he retrieved a hose connector before continuing to CQA. According to the pilot, there were no issues with the airplane or its engine during his preflight inspection or the repositioning flights. The accident occurred during the first agricultural flight of the day. Before departure, the retailer who sold the fungicide and insecticide loaded the water/product solution on the airplane while the pilot fueled the airplane with 27 gallons of Jet-A aviation fuel. The pilot estimated the fuel load at departure was about 80 gallons, and the water/product solution was likely about 330 gallons in total. The pilot stated that the loaded airplane was below the airplane’s maximum gross weight, and that he had previously flown the airplane with similar loads without any performance issues. The pilot back taxied on runway 8 at CQA and completed an uneventful engine runup before starting the takeoff roll. During the takeoff roll, the engine torque and propeller speed gauges indicated about 52 psi and 100%, respectively. The pilot stated that he did not perform a maximum-performance takeoff and a normal liftoff was achieved without any issues. The pilot reported that during the initial climb, about 20-75 ft above ground level, the airplane had a sudden fluctuation in engine power from high-power to low-power and back to high-power. The pilot stated that he was “thrown forward” into his safety restraints and then “thrown back” into his seat. The forward/backward motion only occurred once and was “pretty quick and hard.” The pilot stated that after the loss of engine power the propeller speed remained at 100% but the airplane’s climb performance was significantly diminished. He did not cross-check any other engine gauges. The pilot pitched the airplane for best glide airspeed and entered a slight right turn from the runway heading to avoid trees. Believing the engine was still running, the pilot did not want to jettison the airplane’s load unnecessarily into the river near the airport. The engine lost all power shortly after he entered the right turn. The pilot was wearing an active noise-canceling helmet, but he noticed there was a noticeable lack of engine noise, and that he only heard the wind passing outside the cabin. The pilot jettisoned the airplane’s load in an attempt to maintain a climb, but the airplane descended and impacted a levee, where it nosed over into the river. - The airplane came to rest inverted on the bank of a small river. The airplane sustained substantial damage to the vertical stabilizer, rudder, upper wings, and the fuselage. Examination of the engine before it was removed from the airframe revealed that the airframe control linkage to the propeller pitch control (PPC) was disconnected from the splined end of the shouldered shaft of the PPC, and the retaining bolt was loose and was not secured by safety wire, as shown in figure 1. The PPC shouldered shaft did have an internally threaded hole, but there was no evidence that the secondary retention feature was installed at the time of the accident. The secondary retention feature is discussed in more detail in the Additional Information section. Postaccident engine examination and disassembly revealed rotational scoring at multiple locations, including the compressor impeller blades, impeller shroud, and propeller shaft. Light metal spray was adhered to the 3rd stage turbine stator vanes. Surfaces throughout the engine gaspath were coated with earthen debris. The torsion shaft aft spline was fractured 1.25 inches from the aft end. The disassembly and examination of the engine revealed no evidence of a preimpact failure or other anomalies that would have prevented normal operation. The engine fuel pump was unable to hold pressure during bench testing and was subsequently disassembled. The high-pressure gear stage carbon bushing was found fractured and, according to the engine manufacturer, is consistent with impact-related damage. Otherwise, the fuel pump examination was unremarkable. The fuel control unit (FCU) and propeller governor were tested and examined at the manufacturer. The FCU Standard Day Acceleration Schedule had significantly high out-of-limits fuel flow discharge at all test points and FCU pressure readings did not respond normally to speed input changes. The Deceleration Schedule fuel flow discharge readings were low out-of-limits during testing. All other schedules were within the expected range for similar service run units that have undergone customer adjustments. The FCU was disassembled and there was no evidence of internal failure. All springs were intact, and all bearings and levers moved freely. The propeller governor was bench tested, and all test points were consistent with similar service run units. The propeller remained attached to the engine propeller shaft flange, and all three blades remained attached to the propeller assembly. A counterweight puncture mark on the spinner dome was consistent with the propeller in the normal range of operation at about 24° blade angle at impact. There was no damage or evidence to indicate the propeller was feathered or in the beta/reverse range at the time of impact. All three blade shanks remained attached via the retention clamps and no pilot tubes were fractured. All three blades were fractured near the tip. The damage to the blades included chordwise/rotational scoring on both camber and face sides, bending opposite rotation, leading edge gouging with material deformation towards high pitch, and progressive compound bent/twisting, as shown in Figure 2. The propeller examination and disassembly revealed no evidence of a preimpact failure or other anomalies that would have prevented normal operation. All observed damage was consistent with high impact forces. Blade damage and impact signatures on the cylinder and spinner dome indicated the propeller was rotating in the normal blade angle range of operation at moderate power. Figure 1 – Airframe propeller pitch control (PPC) linkage disconnected from PPC splined shaft, and loose retaining bolt without safety wire (Honeywell Photo) Figure 2 – Propeller (Hartzell Propeller Photo) -
Analysis
The pilot was departing on an agricultural flight when shortly after liftoff the airplane had a sudden engine power fluctuation from high-power to low-power and back to high-power. The pilot stated that he was “thrown forward” into his safety restraints and then “thrown back” into his seat. The forward/backward motion only occurred once and was “pretty quick and hard.” The pilot stated that after the loss of engine power, the propeller speed remained at 100% but the airplane’s climb performance was significantly diminished. The pilot pitched the airplane for best glide airspeed and entered a slight right turn from the runway heading to avoid trees. Believing the engine was still running, the pilot did not want to jettison the airplane’s load unnecessarily into the river near the airport. The pilot reported that the engine lost all power shortly after he entered the right turn. He then jettisoned the airplane’s load in an attempt to maintain a climb, but the airplane descended and impacted a levee, where it nosed over into the river. The airplane sustained substantial damage to the vertical stabilizer, rudder, upper wings, and the fuselage. Postaccident examination of the engine and propeller revealed no evidence of internal failure or other anomalies that would have precluded normal operation. The rotational rub/scoring observed in the engine, metal spray on the turbine stator vanes, and earthen debris throughout the engine core are all consistent with the engine producing power at impact. The engine’s torsion shaft aft spline was fractured consistent with sudden stoppage damage sustained when the propeller impacted the ground. The propeller exhibited impact-related damage that was consistent with high impact forces with the propeller rotating in the normal blade angle range of operation at moderate engine power. During takeoff and initial climb, the engine speed is controlled by the propeller governor and fuel flow is determined by the fuel control unit (FCU) Power Lever Schedule. Although postaccident testing of the FCU revealed anomalies with the Standard Day Acceleration and Deceleration Schedules, the FCU did not contribute to the loss of engine power because the Power Lever Schedule controls fuel flow to the engine during takeoff/initial climb. Additionally, according to the pilot, the propeller speed remained at 100% after the initial power fluctuation and is consistent with the engine operating with the condition lever set for takeoff. Postaccident examination revealed that the airframe control linkage to the engine propeller pitch control (PPC) was disconnected from the splined end of the shouldered shaft of the PPC, and the retaining bolt that normally secured the airframe linkage to the splined end was loose and was not secured by safety wire. Additionally, although the PPC shouldered shaft had an internally threaded hole for a secondary retention feature, there was no evidence that the secondary retention feature was installed at the time of the accident. There are no outside forces acting on the PPC other than the linkage connection to the cockpit power lever. The PPC and FCU main metering valve are connected through the concentric shaft and are rigged to move together. A disengagement of the airframe PPC linkage will result in the pilot’s inability to change fuel flow and/or propeller pitch (blade angle) during flight and landing. If the airframe control linkage disconnected from the PPC shouldered shaft during initial climb at takeoff power, vibration could potentially rotate the PPC cam and reduce engine power as if the cockpit power lever had been pulled back by the pilot. The pilot’s description of being thrown-forward and then backward would have required the PPC cam to rotate from high-power to low-power and back to high-power before settling at a low power setting that would not sustain a climb. However, it is unlikely the propeller blade angle pitch change would be fast enough to cause the pilot to believe the engine had surged. As such, the pilot’s description of being thrown-forward and then backward is not consistent with a disconnected PPC airframe linkage. Although the airframe control linkage to the PPC shouldered spline was found disconnected after the accident with a loose retention bolt that was not secured with safety wire, the investigation was unable to conclusively determine if the control linkage disconnected from the PPC while inflight or during impact. Additionally, the investigation did not reveal any evidence of a preimpact failure or other anomalies that would have prevented normal engine operation.
Probable cause
A loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
G164
Amateur built
false
Engines
1 Turbo prop
Registration number
N8376K
Operator
Gaerte Ag Service, LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
675B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-04T07:16:30Z guid: 103157 uri: 103157 title: WPR21FA210 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103160/pdf description:
Unique identifier
103160
NTSB case number
WPR21FA210
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-27T19:35:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-06-09T20:14:04.34Z
Event type
Accident
Location
Stoneville, North Carolina
Airport
ROCKINGHAM COUNTY NC SHILOH (SIF)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Federal Aviation Administration (FAA) Advisory Circular 90-89C, Amateur-Built Aircraft and Ultralight Flight Testing Handbook, recommended establishing an airplane’s preliminary stall speed and low-speed handling characteristics during the first flight at a safe altitude of 5,000 ft above ground level. The AC also stated the following: Note: In an effort to reduce maneuvering accidents in all aircraft the FAA and the EAA [Experimental Aircraft Association] strongly urge all amateur builders to install an AOAI [angle of attack indicator] or lift reserve indicator in their aircraft and learn how to use it effectively. Since most experimental amateur-built aircraft do not have any stall warning device installed, the AOAI can fulfill the need to serve that safety function…The potential life-saving benefit of those devices should not be underestimated. - The airplane’s experimental amateur-built airworthiness certificate was issued on August 4, 2019. Review of excerpts from the airplane’s maintenance log indicated that the most recent condition inspection was completed by the accident pilot on August 15, 2020, at which time the airplane had 7.6 hours of operation. The co-owner of the airplane reported that he and the accident pilot took turns flying the airplane and were working through the 40-hour Phase 1 requirement. He stated that the airplane was “very docile” but that they were still getting comfortable in it and “stayed in the middle of the envelope.” The co-owner also reported that neither he nor the accident pilot had conducted any aerodynamic stalls at altitude. The airplane was not equipped with a stall warning system. The co-owner reported that he and the accident pilot were initially concerned with weight and balance limitations because of the accident pilot’s weight (about 300 pounds based on his most recent medical certificate), but they were careful not to exceed aft center-of-gravity limitations. Weight and balance limitations for the airplane were not located, so the weight and balance condition at the time of the accident was not determined. The co-owner reported that, on the day of the accident, the airplane was fueled to capacity with automotive gas kept in cans in his and the accident pilot’s hangar and that the airplane likely consumed about 2 gallons during his flight. The airplane was not refueled before the accident flight. Before the day of the accident, the airplane’s most recent flight was in January 2021. The day of the accident was both pilots’ first time flying the airplane in warmer weather. - On May 27, 2021, about 1835 eastern daylight time, an experimental amateur-built Early Bird Jenny, N831HC, was destroyed when it was involved in an accident near Stoneville, North Carolina. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The co-owner/co-builder of the airplane stated that he flew the airplane on the morning of the accident, returning to the airport after about 30 minutes due to rain. The co-owner reported that the flight was uneventful and that the airplane performed well and handled as expected, even though the takeoff profile was “flatter than usual” due to the warmer temperature. He and the accident pilot, who was the other owner/builder of the airplane, moved the airplane into their hangar, where they waited for the rain to move through the area. Later that afternoon, the accident pilot departed on runway 31 for his flight.   The co-owner reported that the pilot’s taxi to runway 31 was normal and that the engine was producing power, but the takeoff did not “look right.” He described the airplane’s pitch attitude as “a little steep” and stated that the airplane looked slow. He saw the wings rock left and right and the airplane “buffet” before the right wing dropped and the airplane impacted terrain. Another witness to the accident reported that the airplane appeared to be “hanging off the prop” during the initial climb and that its wings were “rocking.” About 150 ft above ground level, the airplane entered an abrupt turn and “dropped” to the ground and that a “big ball of flame” ensued. He reported that the engine did not sputter and sounded as if it had been producing full power until impact. - An autopsy of the pilot was performed at the Office of the Chief Medical Examiner, Raleigh, North Carolina. His cause of death was multiple blunt force injury. The autopsy revealed that the pilot had an enlarged heart with left ventricular wall thickening. The pilot’s lungs had anthracosis (black pigment often seen with heavy cigarette smoking) and minimal soot deposits in the trachea. Toxicology testing revealed a carboxyhemoglobin saturation of 13%. Toxicology testing performed by the FAA Forensic Sciences Laboratory revealed salicylic acid (commonly known as aspirin) and the high blood pressure medications amlodipine, metoprolol, and valsartan in the pilot’s blood and urine. His carboxyhemoglobin saturation was measured at 11%. - Reported weather conditions at the airport about the time of the accident included calm wind, temperature 27°C, dew point 18°C, and an altimeter setting of 29.97 inches of mercury. The calculated density altitude was about 2,446 ft. - Review of excerpts from the pilot’s logbook dated from July 3, 2019, to May 11, 2021, indicated that he had a total of about 755 hours of flight experience. The excerpts contained two flights in the accident airplane; the first, dated September 8, 2019, had a duration of 0.4 hours, and contained an annotation indicating, “first flight of N831HC.” The second flight in the accident airplane, dated November 29, 2020, was also 0.4 hours in duration. The entries for these flights did not annotate the maneuvers performed. - The accident site was located about 175 ft north of the runway 13/31 centerline and about 2,500 ft from the runway 31 threshold. The airplane came to rest on a southerly heading and was destroyed by the postimpact fire. All major components of the airplane were accounted for at the site, and flight control continuity was established from the flight control surfaces to the cockpit area. The wooden propeller, which had separated from the engine, was highly fragmented. The engine displayed extensive thermal damage. The crankshaft could not be rotated by hand, but valve train continuity was achieved upon rotation of the camshaft. The throttle control cable was continuous from the carburetor to the cockpit area. -
Analysis
The pilot, who was the co-owner/co-builder of the experimental amateur-built airplane, was departing on a local flight. The other co-owner/co-builder of the airplane witnessed the accident takeoff and stated that the airplane’s pitch attitude was “a little steep” and that the airplane looked slow as it approached 150 ft above ground level in the climb. Both the co-owner and another witness stated that the airplane’s wings were rocking before one wing dropped and the airplane entered a nose-down descent. The airplane impacted terrain about halfway down the 5,200-ft-long runway, and a postimpact fire ensued. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. Review of the pilot’s logbook indicated that the accident flight was his third flight in the accident airplane and that he had recorded a total of 0.8 hours of flight experience. The co-owner stated that he and the accident pilot took turns flying the airplane and that the day of the accident was the warmest day on which they had flown the airplane. The co-owner had flown the airplane earlier on the day of the accident and stated that, although the airplane’s takeoff profile was “flatter than usual,” the airplane otherwise performed well and handled as expected. The co-owner also stated that neither he nor the accident pilot had conducted any aerodynamic stalls in the airplane, which was not equipped with a stall warning system. The extent to which the accident pilot had explored the airplane’s low-speed handling characteristics during flight could not be determined based on the available evidence for this accident. Review of the atmospheric conditions about the time of the accident indicated a density altitude of about 2,400 ft. Weight and balance documents for the airplane were not located, and the airplane’s weight and balance condition at the time of the accident was not determined. Autopsy and toxicology results for the pilot revealed evidence of an enlarged heart, anthracosis of the lungs, a carboxyhemoglobin saturation between 11% and 13%, and medications to treat high blood pressure. Minimal soot deposits were found in the trachea. Given the available evidence for this accident investigation, it is unlikely that the pilot’s cardiac condition was a factor in this accident. His carboxyhemoglobin saturation was not likely associated with impairment and was most likely the result of postcrash exposure to carbon monoxide. The circumstances of the accident are consistent with the pilot’s exceedance of the airplane’s critical angle of attack during takeoff, which resulted in an aerodynamic stall and a loss of control. It is likely that the density altitude conditions at the time of the accident degraded the airplane’s takeoff performance and that the pilot’s unfamiliarity with the airplane’s handling characteristics (especially in higher-density-altitude conditions) and with low speed/aerodynamic stalls contributed to his failure to recognize and correct the airplane’s angle of attack before the stall occurred.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the takeoff initial climb, which resulted in an aerodynamic stall and a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MARK COBY
Model
EARLY BIRD JENNY
Amateur built
true
Engines
1 Reciprocating
Registration number
N831HC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
532
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-09T20:14:04Z guid: 103160 uri: 103160 title: WPR21LA220 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103201/pdf description:
Unique identifier
103201
NTSB case number
WPR21LA220
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-29T13:47:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-06-03T21:26:12.453Z
Event type
Accident
Location
Paris, Idaho
Airport
Bear Lake County (1U7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On May 29, 2021, about 1247 mountain daylight time, a Piper PA-24, N6334P, was substantially damaged when it was involved in an accident near Paris, Idaho. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the flight departed from South Valley Regional Airport (U42), Salt Lake City, Utah, with an intended destination to Jackson Hole Airport (KJAC), Jackson, Wyoming. The pilot had the airplane’s fuel tanks topped off at U42 on the day of the accident flight. The preflight, engine start and run up, and departure were normal; they departed from U42 at 1122. The pilot reported that during the flight he navigated around Class B airspace. Near the Primary Childrens Medical Center Heliport (UT08), Salt Lake City, Utah, he contacted Salt Lake Center and requested flight following and activated his previously filed flight plan. The pilot reported that he climbed to his filed flight plan altitude of 9,500 ft mean sea level (msl). Due to turbulence, the flight further climbed to 11,500 ft msl for a brief period; however, due to turbulence, the flight descended back to 9,500 ft msl. The pilot reported that the flight was uneventful, and all engine gauges were normal and in the green, including the oil pressure and temperature. Shortly after passing Bear Lake County Airport (1U7), Paris, Idaho, the engine oil temperature gauge was “registering too high,” but the oil pressure gauge was still in the green. The pilot elected to divert to 1U7 to have the engine inspected. About halfway through the turn toward 1U7, which was about 3 nm away, the engine sustained a total loss of power. The pilot reported that he did not recall the engine surging, just an “immediate drop of RPM and oil pressure.” The propeller continued to turn, but the engine would not engage. The pilot pulled back on the yoke and trimmed for best glide airspeed, which he estimated to be 75 knots. He made several unsuccessful attempts to restart the engine. The pilot stated that he did not remember at what point he lowered the landing gear, but he did recall waiting until he was comfortable lowering the landing gear as part of his final landing “GUMP” checklist. He stated that he did not lower the flaps or activate carburetor heat. About 500 ft agl, he realized the airplane would not make it to the runway. During touchdown, the airplane impacted a berm and fence posts, and came to rest about 100 ft short of the runway. The airplane sustained substantial damage to the right wing. The engine’s crankshaft was rotated by hand utilizing the propeller and mechanical continuity was established throughout the rotating group, valve train, and accessory gear section. Examination of the cylinders with a lighted borescope revealed no anomalies. The magnetos were removed, and manual rotation produced spark at each lead. The fuel pump was internally intact and free of damage. The air induction lines were free of obstruction. Examination and disassembly of the carburetor revealed no anomalies. Postaccident examination of the engine did not reveal evidence of any mechanical anomalies that would have precluded normal operation. -
Analysis
On a personal cross-country flight, during cruise, the pilot noted an increase in oil temperature. He made the decision to divert to a nearby airport that was about 3 nautical miles (nm) away. As the pilot made the turn back to the airport, the engine lost total power. During the descent he made several unsuccessful attempts to restart the engine. He did not recall lowering the landing gear but determined that it was safe to do so. He did not lower the flaps or turn on the carburetor heat. About 500 ft above ground level (agl), he realized that he was not going to make the runway and elected to make a forced landing to the surrounding area. During the landing sequence, the airplane impacted a berm and a fence post before it came to rest about 100 ft short of the runway. Postaccident engine examination revealed no evidence of preaccident mechanical malfunction or failure that would have precluded normal operation.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24
Amateur built
false
Engines
1 Reciprocating
Registration number
N6334P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-1444
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-03T21:26:12Z guid: 103201 uri: 103201 title: WPR21LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103185/pdf description:
Unique identifier
103185
NTSB case number
WPR21LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-05-30T18:20:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-06-17T01:41:45.982Z
Event type
Accident
Location
Cashmere, Washington
Airport
CASHMERE-DRYDEN (8S2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On May 31, 2021, about 0720 Pacific daylight time, a Piper PA-22-150, N7159B, was substantially damaged when it was involved in an accident near Cashmere, Washington. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he purchased the airplane about 1 month before the accident. He had purchased the airplane from a personal estate, and it had not undergone recent maintenance before the purchase. He performed a pre-buy inspection and hired a mechanic to complete an annual inspection. Following the maintenance, the pilot checked the fuel and verified the throttle rigging. He added about 5 gallons of fuel to the right fuel tank, which brought the quantity to more than half full. He then positioned the fuel selector to the right wing tank, where it remained the entire flight. The pilot stated that, after a normal engine start, he completed various taxi checks including a high-speed taxi with full engine power. The pilot then began a takeoff and applied full takeoff power (about 75% throttle). After reaching about 75 mph, the pilot rotated the airplane and it began to climb. After reaching about 250 to 300 ft above ground level, the engine power smoothly reduced to idle and in response, the pilot lowered the nose; the pilot verified that the throttle control in the cockpit remained at the takeoff power setting. The engine power temporarily increased back to full power for several seconds before the engine lost total power. The pilot maneuvered the airplane away from the town ahead and performed a forced landing to a marshy area, where the airplane came to rest inverted. The pilot added that he attempted to troubleshoot the engine failure by verifying that the fuel selector was on the right tank and that both magnetos were selected. A Federal Aviation Administration (FAA) inspector stated that the pilot relayed to him that there was no fuel in the left tank. The mechanic who assisted in the recovery of the airplane following the accident told the inspector that, during the retrieval, the airplane was pulled straight up by the tail tie-down and gently set it on its wheels without any further damage. There was no evidence of breached wing tanks, blue stain leakage from the nose cowl, wing fuel caps, belly, or fuselage. AIRPLANE INFORMATION The airplane was equipped with one 18-gallon fuel tank located at each wing root. Each fuel tank had two lines, forward and aft, adjacent to the fuselage which can feed the fuel system. The FAA inspector stated that the mechanic indicated that, if a steep departure climb is performed by a pilot, and the airplane is only partially fueled, unporting of the fuel lines in the wing tanks is possible. Subsequent fuel starvation to the engine would be imminent. The Piper PA-22 Type Certificate Data Sheet (TCDS) "NOTE 2" states in part, "The following placards must be displayed…On right fuel quantity gauge…'No take-off on right tank with less than 1/3 tank.'" The airplane had undergone numerous fuel system modifications, including replumbing the right fuel tank. The change made the right tank similar to the left tank; therefore, it was not susceptible to the starvation event that was cautioned in the TCDS. An FAA inspector examined the fuel system and engine with a mechanic who was familiar with the airplane. They verified continuity from the mixture and throttle to the carburetor. He stated that, when they disconnected the main fuel line from the inlet of the carburetor, no fuel came out. Because the fuel selector valve was in the “OFF” position as part of the recovery process, they turned the selector to the “RIGHT” and “LEFT” positions, and still no liquid came out. A visual inspection of both wing tanks revealed that they both appeared empty. When manipulating the right wing, they were able to drain about one-half cup of fuel from the right wing’s sump. The examination was limited in scope because the engine was unavailable for a complete examination.  Removal of the right fuel cap revealed that the rubber seal was intact and the two vent holes were clear. The fuel cap filler area had a cork gasket that was not secured, and it could not be determined if it was able to properly seal. -
Analysis
The pilot purchased the airplane about 1 month before the accident. It had not undergone recent maintenance before the purchase, and the pilot hired a mechanic to perform an annual inspection. The pilot stated that the right-wing fuel tank contained about 12 gallons of fuel and the left fuel tank was empty. He positioned the fuel selector to the right tank. During the initial climb, when the airplane reached about 250 to 300 ft above ground level, the engine power smoothly reduced to idle. The pilot lowered the airplane’s nose, and engine power temporarily increased for several seconds before the engine then lost total power. The pilot maneuvered the airplane for a forced landing in a marshy area, where it came to rest inverted. Postaccident examination revealed that the fuel system was intact, and the tanks were not breached. Removal of the fuel line at the carburetor revealed no fuel in the system. A visual inspection of both wing tanks revealed that they both appeared empty. When manipulating the right wing, about one-half cup of fuel drained from the sump. Removal of the right fuel cap revealed that the rubber seal was intact and the two vent holes were clear. The fuel cap filler area had a cork gasket that was not secured, and it could not be determined whether the cap was able to properly seal. Although postaccident examination revealed only trace amounts of fuel in the fuel system, the amount of fuel onboard at the time of the accident could not be determined. The examination was limited in scope because the engine was unavailable for a complete examination. The reason for the loss of engine power could not be determined based on the available information.
Probable cause
A total loss of engine power shortly after takeoff for reasons that could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N7159B
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-4384
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-17T01:41:45Z guid: 103185 uri: 103185 title: WPR21LA224 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103226/pdf description:
Unique identifier
103226
NTSB case number
WPR21LA224
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-02T09:00:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-06-16T07:14:21.187Z
Event type
Accident
Location
Washington, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 02, 2021, about 1000 Pacific daylight time, a Cessna 172G, N3871L, was substantially damaged when it was involved in an accident near Washington, California. The pilot and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot reported that the airplane was climbing at full power at 80 mph, and he progressively leaned the mixture during the climb. About 30 minutes into the climb profile, the airplane’s altitude was near 6,000 ft msl, and the pilot observed that the airplane’s engine oil temperature gauge had reached its maximum limit of 240°F. He attempted to arrest the increasing oil temperature by lowering the nose of the airplane to increase airspeed and subsequently decreased the engine power setting. About 10 minutes later, the oil temperature decreased below 240°F and the pilot resumed his climb to 9,500 ft msl using a richer mixture setting. About 8,500 ft msl, the pilot heard the engine produce a “backfire” type sound, and confirmed a loss of engine power as he observed the engine rpm gradually decrease. The pilot began to troubleshoot but was unable to restore engine power. Unable to maintain altitude, he declared an emergency and maneuvered the airplane toward a clear area within the mountainous terrain. During the forced landing, the airplane sustained substantial damage to both wings and the lower fuselage. A review of the airframe and engine maintenance logbooks indicated that the last annual inspection was completed 6 months before the accident, on December 6, 2020. At the time of the annual inspection, the engine had amassed a total time of 4,027 hours, and 1,896 hours since major overhaul. The engine tachometer indicated 2,277 hours during the last annual inspection and indicated 2,288.8 at the time of the accident. The engine-manufacturer recommended overhaul interval is 1,800 hours or 12 years, whichever occurs first. Examination of the engine revealed that magneto-to-engine timing was Left: 33° before top dead center (BTDC) and Right: 32° BTDC. The engine manufacturer specification for magneto-to-engine timing was Left: 28° BTDC and Right: 26° BTDC. About 6 qts of engine oil were extracted from the oil sump. The No. 2 cylinder displayed low compression. All cylinders were removed from the crankcase for further examination. Removal of cylinder Nos. 1 and 4 revealed no anomalies. Removal of the No. 2 cylinder revealed that the top compression ring was seized to the piston ring land, with flat spots observed on the top ring. Removal of the No. 3 cylinder revealed that the top compression ring was broken into two pieces, and the exhaust valve was stuck in the valve guide. Removal of the No. 5 cylinder revealed excessive key-holing of the intake valve within its guide. The No. 6 cylinder top compression ring was broken into four pieces. -
Analysis
The pilot reported that he was climbing the airplane at full engine power and an airspeed of 80 mph, and he had progressively leaned the fuel/air mixture during the climb. About 6,000 ft mean sea level (msl), he noted that the the engine oil temperature was indicating its maximum limit of 240°F. The pilot lowered the nose to increase airspeed and reduced engine power to cool the engine. About 10 minutes later, the engine oil temperature decreased below redline and he resumed his climb with a slightly richer mixture setting. About 8,500 ft msl, the engine produced a “backfire” sound, the engine rpm decreased, and a loss of engine power ensued. The pilot declared an emergency and performed a forced landing to mountainous terrain, during which the airplane sustained substantial damage. Examination of the engine revealed that the No. 2 cylinder’s piston exhibited a stuck top compression ring. The No. 3 cylinder exhibited a stuck exhaust valve, and the No. 3 piston’s top compression ring had separated into two. The No. 5 intake valve exhibited excessive clearance within its guide. The No. 6 cylinder’s piston top compression ring had separated into four pieces. A review of the airframe and engine maintenance logbooks indicated that the last annual inspection was completed 6 months before the accident. At the time of the annual inspection, the engine had amassed a total time of 4,027 hours, and 1,896 hours since major overhaul. The engine tachometer indicated 2,277 hours during the last annual inspection and indicated 2,288.8 at the time of the accident. The engine-manufacturer recommended overhaul interval is 1,800 hours or 12 years, whichever occurs first.
Probable cause
A total loss of engine power during an enroute climb due to a stuck exhaust valve and multiple failed piston compression rings.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172G
Amateur built
false
Engines
1 Reciprocating
Registration number
N3871L
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17254040
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-16T07:14:21Z guid: 103226 uri: 103226 title: CEN21LA259 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103244/pdf description:
Unique identifier
103244
NTSB case number
CEN21LA259
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-04T10:54:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-06-12T00:26:01.908Z
Event type
Accident
Location
Aspen, Colorado
Airport
ASPEN-PITKIN COUNTY/SARDY FLD (ASE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s landing gear system was electrically controlled and hydraulically actuated. The landing gear actuators incorporated an internal lock to hold the gear in the extended position. The actuators were held in the retracted position by mechanical uplocks that are normally released hydraulically. In the cockpit, the landing gear control panel contained the landing gear handle, an audible warning system, three gear safe lights, and a red gear unlock indicator (see figure 1). Each green light corresponded to one gear and indicated that it was in the down-and-locked position. The red light indicated an unsafe gear position (in transit or not locked). The landing gear handle had two positions, full up (RETRACT) and full down (EXTEND). The gear handle had to be pulled out to clear a detent before the handle could be repositioned. Operation of the gear and gear doors began after the handle was positioned in one of the two detents. A gear handle locking solenoid, which was activated by the left main gear squat switch, would physically prevent inadvertent movement of the gear handle while an airplane was on the ground. Figure 1. Landing gear control panel (Source: Cessna 560XL Operators Manual). The landing gear warning system sounded an audible warning when one of the following three conditions existed: 1. Gear not down and locked, both throttles retarded below approximately 70% N2 [high pressure rotor rpm] and flaps greater than 15°. 2. Gear not down and locked, both throttles retarded below approximately 70% N2, and valid radio altimeter signal indicates less than 500 feet AGL [above ground level]. 3. Gear not down and locked, both throttles retarded below approximately 70% N2, and a non-valid radio altimeter signal and airspeed below 150 KIAS [knots indicated airspeed]. The audible warning would cease only if the conditions that initiated the activation of the warning were corrected. - On June 4, 2021, about 0954 mountain daylight time, a Cessna 560XL airplane, N615RG, was substantially damaged when it was involved in an accident near Aspen-Pitkin County Airport (ASE), Aspen, Colorado. The two pilots and three passengers were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the cockpit voice recorder (CVR) transcript, at 0933:17, as the flight neared ASE, the crew obtained the current weather information via automatic terminal information service (ATIS) information, which indicated that the wind was calm at ASE. At 0948:05, the crew contacted the ASE tower controller, who reported that the wind was from 030° at 3 knots. The CVR recorded an increase in ambient noise at this time, consistent with the landing gear extension. At 0948:48, the crew confirmed that landing gear was extended. At 0952:52, the crew completed the before-landing checklist, including a confirmation that the landing gear was down. Shortly after touchdown, the CVR recorded the aural landing gear warning, which sounded for the remainder of the recording. At 0954:05, the airplane stopped, and the crewmembers commented that the gear had failed and that they had previously confirmed the illumination of three green landing gear indicator lights. In postaccident statements, the flight crewmembers reported that the pilot flying was in the left seat and that the copilot was in the right seat. The approach was stabilized and normal, and the three green landing gear indicator lights were illuminated. The aural landing gear warning annunciated during landing and after speed brake deployment. The right wing gradually dropped and scraped the runway, and the airplane veered to the right and then came to rest on the right side of the runway. Airport surveillance video showed the airplane landing and all three landing gear were visible. After the airplane touched down, the right wing contacted the runway surface, and sparks emanated from the lower side until the airplane came to rest. - The right main landing gear was found retracted, and the left main landing gear and nose gear were found extended and locked in place. The landing gear handle was found in the UP (retracted) position. (The copilot did not recall manipulating the landing gear handle after the accident.) Figure 2 shows a postaccident view of the cockpit, throttle quadrant, and landing gear handle. Figure 2. Postaccident configuration of the cockpit with the landing gear handle (circled in red) in the retracted (UP) position. Postaccident examination of the airplane revealed substantial damage to the right wing. During the examination, the landing gear handle was removed from the airplane for further testing, and an exemplar landing gear handle was installed. The on-site electrical, mechanical, and hydraulic system functional tests with the exemplar landing gear handle revealed no failures or malfunctions that would have preclude normal operation. The landing gear actuators, uplock actuators, and printed circuit boards were removed for functional testing, which found that they met the requirements of the component maintenance manuals or acceptance test procedures (ATP). The internal configuration of the airplane’s landing gear handle was documented using radiographic images. A review of the scanned images determined that the landing gear handle was in the extended (down) position and that there were no indications that the internal components of the landing gear handle had malfunctioned. At the airplane manufacturer’s facility, a visual inspection of the landing gear handle found that the handle was in the retracted (UP) position, as shown in figure 3. No abnormal wear or damage was noted. Figure 3. Left-side view of the accident landing gear handle. Functional testing of the landing gear handle was accomplished per the airplane manufacturer’s ATP. The unit passed all ATP requirements except for the test that required the landing gear handle return to either the UP or DOWN position when released from any position. During testing, the handle exhibited (multiple times) a tendency to stick in place when released. The handle was released anywhere between mid-travel and within about 0.25 inches of the retract detent, and the handle remained in the released position on the retract half of the travel. When the handle was released on the extend side of travel, the handle would snap completely to the extend detent. When the landing gear handle was stuck in a position outside of the extend or retract detents, the handle would only move if vibration was applied to the outer cover, or the handle was moved manually. After the handle moved less than 0.25 inches out of the retract position, an extend command was provided, which was sustained throughout the remaining travel between the extend and retract detents. This allowed the handle to provide an extend command while the handle was stuck in a mid-travel position, as shown in figure 4. With some vibration applied to the case, the handle would slowly move toward the retract position and would eventually move into the retract detent position and provide a retract command. Figure 4. Landing gear handle stuck in a mid-travel position during testing. Engine Data Collection Units (DCU) The airplane’s engine DCUs were successfully downloaded, and the data files were provided to the engine manufacturer for conversion and assessment. According to the manufacturer, the DCUs contained the engine running time, which was the time recorded from selection of the engine electronic control power ON to power OFF and not the time from engine start to engine stop; thus, the engine running time does not typically match the engine logbook times. The engine manufacturer also stated that the DCUs contained a flight number, which was based on the weightonwheels (WOW) switch changing from WOW OFF to WOW ON to identify a single flight. Although the DCU files could not be directly correlated to specific dates and times, the manufacturer was able to reasonably match the recorded data to the accident landing based on the DCU faults. The final two trace recordings on the right engine DCU show that an event occurred immediately after the airplane completed an approach and a landing at an elevation similar to that of the accident airport. The trace recording showed the following sequence of events: o “Gear-down” was “true” for the 3 minutes before the event. o As the airplane touched down, the WOW switch was “true”; a few seconds later, the “gear-down” switch was “false.” o About 8 seconds later, the WOW switch changed to “false,” which triggered an impending thrust reverser fault and a WOW cross-check fault. -
Analysis
The pilots were on approach to the destination airport. They reported that the approach was stabilized and normal and that the landing gear indications were normal with three green landing gear indicator lights illuminated. During landing and after speed brake deployment, an aural landing gear warning sounded, the right wing gradually dropped and scraped on the runway, and the airplane veered to the right and subsequently came to rest on the right side of the runway, which resulted in substantial damage to the right wing. After the accident, the right main landing gear was found retracted, and the left main landing gear and nose gear were found extended and locked in place. The landing gear handle was found in the UP (retracted) position. The copilot did not recall manipulating the landing gear handle after the initial landing gear extension during flight. Further, cockpit audio captured the crew verifying the gear extension twice, and recorded data showed that the landing gear were extended. Functional testing of the landing gear handle revealed that the unit passed all manufacturer acceptance test procedure requirements except for the test that required the landing gear handle return to either the UP or DOWN position when released from any position. During the testing, the handle exhibited a tendency (multiple times) to stick in place when released. When the landing gear handle was stuck in a position outside of the extend and retract detents, the handle would move if vibration was applied to the case or if the handle was moved manually. After the handle moved out of the retract detent, it sent an “extend” command throughout the remaining travel to the extend position. This allowed the handle to send an “extend command” while the handle was stuck in a mid-travel position and, with some vibration on the case, it would slowly transition towards the retract position and would eventually move into the retract detent position and provide a “retract command.” The results of the testing as well as the postaccident examination of the landing gear handle did not reveal the reason that the handle would stick in a midtravel position. However, the results of the testing showed that a malfunction of the landing gear handle occurred, which likely caused the right main landing gear to collapse during the landing roll. The reason why only the right main landing retracted could not be determined. Postaccident examination and functional testing of the rest of landing gear system revealed no mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The malfunction of the landing gear handle for reasons that could not be determined, which caused the right main landing gear to collapse during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
560XL
Amateur built
false
Engines
2 Turbo jet
Registration number
N615RG
Operator
AIRCRAFT LEASING & SALES INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
560-5016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-12T00:26:01Z guid: 103244 uri: 103244 title: WPR21FA223 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103224/pdf description:
Unique identifier
103224
NTSB case number
WPR21FA223
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-07T15:20:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-06-23T08:21:52.181Z
Event type
Accident
Location
Porterville, California
Airport
PORTERVILLE MUNI (PTV)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The two-seat, low-wing, fixed-gear experimental amateur-built airplane, serial number 23286, was completed in 2004. The pilot purchased the airplane on May 19, 2021. The fuel receipt from the last known fueling was the day of the accident at 1341. The invoice showed the pilot added 17.53 gallons of 100LL AvGas. The airplane was powered by a Superior XP-IO-360-B1CC2 engine and was equipped with a Catto two-bladed constant speed propeller. Partially burned maintenance logbooks were found at the accident site. It is unknown when the most recent maintenance was performed because the pages were burned. - On June 07, 2021, about 1420, a Vans RV-6A experimental airplane, N94PJ, was substantially damaged when it was involved in an accident in Porterville, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed from his home airport in Fresno, California about 1320 and landed at Porterville shortly thereafter. A witness at the airport observed the pilot and airplane before the accident. They stated that the pilot refueled the airplane with about 17.5 gallons at the self-serve fuel tanks located mid-field. A witness observed the pilot, positioned in the right seat, start the airplane after refueling. The start-up was abnormal and sounded as though it was a “hot start” with the engine rpm’s immediately accelerating to a near-maximum setting. The airplane then continued to the departure end of the runway and proceeded to takeoff. The airplane began to climb and the engine was making “popping” sounds while continuing left of centerline. The nose pitched down and the engine momentarily sounded normal as the airplane then climbed to about 300 ft above ground level (agl). The “popping sounds” continued and some witnesses observed that the engine then experienced a loss of power (see Figure 1 below). Figure 1: Visual of Witness Reports Video footage was obtained from a fixed security camera at the airport. A review of the footage revealed that the airplane made a hard right bank, with the wings near perpendicular to the ground.,. The witnesses further stated that the airplane then momentarily maneuvered to a wings-level attitude and then rolled left. The airplane then rapidly descended in a left-wing-low attitude nearly perpendicular to the terrain before impacting the ground and immediately erupted into flames. - The ground track, ground speed, and altitude of the airplane were estimated based on a video recorded by an airport camera in a Video Study. When the airplane climbed to about 158 ft, the ground speed at that time was about 62 knots. This speed is above the stall speed of the Van’s RV-6A and near the typical takeoff speed of the airplane. The climb rate estimated during the first two analyzed seconds was about 1,500 ft per minute (fpm). The airplane continued climbing for about 8 seconds past, but its ground speed was decreasing. When the airplane reached its maximum agl altitude of about 240 ft, its ground speed was down to about 14 knots, well below the stall speed. Thereafter, the speed was increasing because the altitude was decreasing. The descent speed was increasing rapidly, reaching about 3,850 fpm at the time of ground impact. - The accident site was located about 250 ft from the approach end of runway 12 on flat terrain composed of hard, dry dirt and short vegetation. The wreckage was found distributed over an approximate 40-ft distance with the nose pointed on a median magnetic bearing of about 350°. The fuselage and inboard sections of the wings had been consumed by fire. The first identified pieces of debris were fragments of red lens, consistent with the tip of the left wing contacting the ground at the beginning of the accident sequence. From the lens fragments was pieces of propeller blades and pieces of the skin (see Figure 2 below). Figure 2: Main Wreckage The fuselage came to rest upright and was partially consumed by fire, with only the outboard right wing and tail not thermally damaged. After collection and examination of the flight control system components, control continuity was established from the flight controls in the cockpit to the breaks in the system, which displayed evidence of tensile overload and from the breaks in the system to the flight control surfaces. The cockpit was consumed by fire and the gauges and switches were unreliable. The keys were found loose in the wreckage. An external examination of the engine revealed that the crankcase had fractures in numerous areas around the casing. There was no oil visible seeping around the engine, nor was the evidence of oil on the windscreen. Investigators were able to rotate the engine by exerting force on the remaining propeller blades. The airplane was equipped with a dual ignition system. A Light Plasma III electronic module provided ignition to the upper spark plugs and a Slick magneto was used for the lower spark plugs. The electronic modules found were partially burned and could not be tested. Disassembly of the magneto revealed the internal mechanisms were thermally destroyed. The spark plugs were removed revealing a No. 4 massive-electrode style plug exhibiting a fractured insulator at the electrode area. It is unknown if the cracked insulator led to a pre-ignition or detonation event since the piston dome had deposits similar to the other pistons. Investigators removed the cylinders, which revealed no evidence of foreign object ingestion or detonation. All valves were intact and the internal cylinder domes and piston crowns exhibited similar combustion deposits, with the No. 2 and No. 4 exhaust appearing to be more reddish in color, consistent with hot operation. The valves and guides were examined and no evidence of material transfer was visually apparent. The crankshaft, idler gear, and camshaft gears were all aligned with their respective marks aligning. The oil pump was disassembled revealing intact gears; the pump rotated freely. The crankshaft was intact and the connecting rods remained secured with a dark coloration consistent with thermal damage. The bearings were free of wear and no fretting was observed. The fuel selector handle was attached and found in the “OFF” position. The selector position plate was affixed to the structure and bent over on the handle. There was a divot in the plate metal consistent with the selector handle being in the “OFF” position at the time of impact. Continuity and functionality of the fuel system could not be ascertained due to the thermal damage incurred following the impact. -
Analysis
The pilot departed from his home airport earlier in the day and landed at the accident airport to refuel. The pilot refueled the airplane with about 17.5 gallons and then started the engine. A witness reported the engine start sounded as though it was a “hot start” with the airplane rpm’s immediately accelerating to a near-maximum setting. The airplane then proceeded to take off and, as it climbed, the engine was making “popping” sounds. Surveillance video showed the airplane made a hard right bank, with the wings near perpendicular to the ground, consistent with the pilot attempting to return to the airport. A performance study of the video revealed that when the airplane reached its maximum altitude of about 240 ft, its ground speed had decreased well below the stall speed. The airplane then assumed a wings-level attitude consistent with the pilot correcting for the steep attitude. Thereafter, the airplane rapidly descended in a left-wing-low attitude nearly perpendicular to the terrain before impacting the ground and immediately erupted into flames. Postaccident examination revealed that the keys were out of the ignition and the fuel selector was in the “OFF” position. Given the available evidence it is unknown if the pilot had intentionally chosen to configure the airplane with the selector off. The engine examination revealed no obvious reason for the loss of engine power as described by the witness. The fuel system was partially destroyed by fire; as a result, the continuity and functionality of the fuel system could not be ascertained.
Probable cause
A loss of engine power for reasons that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
true
Engines
1 Reciprocating
Registration number
N94PJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
23286
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-23T08:21:52Z guid: 103224 uri: 103224 title: HWY21MH008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103239/pdf description:
Unique identifier
103239
NTSB case number
HWY21MH008
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-09T23:07:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2023-03-28T04:00:00Z
Event type
Accident
Location
Phoenix, Arizona
Injuries
4 fatal, 5 serious, 6 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Phoenix, Arizona, multivehicle crash was the truck driver’s failure to respond to the fully conspicuous traffic queue, likely as the result of fatigue. Contributing to the crash was Arizona Milk Transport’s (1) poor oversight of its drivers, (2) lack of fatigue management program, and (3) failure to enforce its own policies, such as those regarding on-duty hours—all a consequence of its inadequate safety culture. Contributing to the severity of injuries to several passenger vehicle occupants was their lack of or improper lap/shoulder belt use.
Has safety recommendations
true

Vehicle 1

Traffic unit name
2016 Freightliner Cascadia Truck Tractor
Traffic unit type
Combination Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2021 Chevrolet Equinox
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 3

Traffic unit name
2015 Nissan Altima
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 4

Traffic unit name
2015 Dodge Charger
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 5

Traffic unit name
2013 Lexus CT200H
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 6

Traffic unit name
2013 Toyota Prius
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 7

Traffic unit name
2018 Mercedes C300W
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 8

Traffic unit name
2016 Ford Fusion
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-03-28T04:00:00Z guid: 103239 uri: 103239 title: CEN21LA284 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103308/pdf description:
Unique identifier
103308
NTSB case number
CEN21LA284
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-10T16:15:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-06-25T18:49:31.59Z
Event type
Accident
Location
Reserve, Louisiana
Airport
Port of South Louisiana Exec Regional Airport (APS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 10, 2021, about 1515 central daylight time, a Robinson R44 II helicopter, N202SM, was substantially damaged when it was involved in an accident near Reserve, Louisiana. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot reported that after refueling the helicopter, he performed a normal start. After all gauges reached the normal operating temperatures, he performed a magneto check, and brought the helicopter to a hover. He then hover-taxied to runway 35 with the intention of performing takeoffs and landings. Upon entering runway 35, the pilot increased power and applied forward cyclic. The pilot reported that when the helicopter reached an altitude of about 10 ft above the runway and a forward airspeed of about 20 knots he heard a sputtering sound from the engine with an associated loss in power. The pilot described the sound as being similar to when the mixture is leaned to idle cut off and the engine starts to shut down. The helicopter yawed briefly to the left, and touched down hard onto the runway surface. The right landing skid collapsed and the helicopter slid off the runway surface onto the grass. The helicopter’s lower fuselage structure was substantially damaged. The helicopter’s most recent inspection was an annual inspection, completed on November 20, 2020. As part of this inspection, the electric fuel pump was replaced with a serviceable pump and the engine air intake hose was replaced in accordance with Robinson Helicopters Service Bulletin SB-100. Examination of the helicopter and engine following recovery was performed by a Federal Aviation Administration airworthiness inspector. The inspection of the helicopter revealed that both the main and auxiliary fuel tanks were about half full with a liquid consistent with aviation gasoline, with no signs of contamination. The gascolator was removed and found to be full of fuel, with fuel freely flowing from the inlet. The engine controls moved free and correct with no binding. The lower spark plugs from all six cylinders were removed and found to be unremarkable. The engine was rotated by hand with no signs of binding or mechanical noises. Thumb compression was attained on all six cylinders. All rocker arms moved appropriately with oil flowing thru rocker arms with valve covers removed. The spin-on engine oil filter was removed, cut open for examination and was found to be unremarkable. No obstruction in engine air intake was observed. -
Analysis
The pilot reported that he started the helicopter at the refueling pad and hover-taxied to the taxiway and then onto the runway. He increased collective and started the takeoff sequence. When the helicopter was about 10 ft above the runway, and airspeed reached about 20 kts, the engine lost total power. The helicopter touched down hard onto the runway surface. The right landing skid collapsed, and the helicopter slid off the runway surface onto the grass. The helicopter’s lower fuselage structure sustained substantial damage. Examination of the helicopter and engine revealed no evidence of preimpact failure of the engine that would have precluded normal operation. No determination was made as to the reason for the reported loss of engine power.
Probable cause
A total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N202SM
Operator
State Machinery & Equipment Acquisition LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12277
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-25T18:49:31Z guid: 103308 uri: 103308 title: OPS21LA003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103275/pdf description:
Unique identifier
103275
NTSB case number
OPS21LA003
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-10T18:45:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-06-18T01:17:30.765Z
Event type
Incident
Location
San Diego, California
Airport
SAN DIEGO INTL (SAN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 2, 2021, Southwest Airlines produced a Flight Safety Alert for SAN, specifically for runway 27 approaches. The alert stated that data indicate a potential for “unstable approaches” and “GPWS Terrain/Obstacle Warnings.” It further provided conditions that may result in an unstabilized approach with those conditions being “a steeper glidepath,” “Parking garage approximately 0.4 NM from RWY 27 threshold” and “high gross weight and tailwinds may require vertical speeds in excess of 1000 fpm during final approach segment.” Southwest Airlines General Approach Policies The Southwest Airlines B737NG Operating Manual, Section 11.1.3.1 provided, in part, the following general approach guidance: If available, follow glidepath guidance on final. Use at least one of the following, if available: • Electronic glideslope (ILS) • Glidepath from an RNAV approach in the FMC navigation database • Visual glideslope Pilots may fly slightly above the glidepath for wake turbulence avoidance during visual approaches. (PF) Prior to the final approach segment, position hands and feet on the aircraft controls when the autopilot is engaged and flaps are extended for maneuvering or approach. (PM) Prior to the final approach segment, position hands and feet to immediately assume control of the aircraft if circumstances warrant. Go-Around/Missed Approach The Southwest Airlines B737NG Operating Manual, Section 11.5.1 provided the following guidance: The Pilot Flying must execute a go-around/missed approach if any of the following occur: • Any Flight Deck Crew Member directs or calls for a go-around. • ATC directs a go-around. • The approach does not meet stabilized approach criteria. • The CDI exceeds a 2-dot deflection while on the FAS in IMC. • The expanded LOC pointer becomes "unfilled" while on the FAS in IMC. • A 2-dot low glideslope deflection on the FAS in IMC is exceeded. • The VOR pointer exceeds 10° from the desired course on a VOR approach inside the FAF in IMC. • Sufficient visual references for landing are not present and any of the following occur: - (ILS) Radio Altitude display flashes and turns amber. - The aircraft altimeter indicates that the DA or DOA is reached. - The missed approach point, if applicable, is reached. • The Pilot initially has sufficient visual references but then loses them below DA, ODA, or MDA. • A landing in the touchdown zone cannot be safely accomplished. Note: The touchdown zone is the area of the runway 500 ft to 3,000 ft beyond the landing threshold not to exceed the first one-third of the usable length beyond the threshold. • The aircraft touches down beyond 1,500 ft with an insufficient PWB System-computed stopping margin. • Before reaching DA, DDA, or MDA, any required portion of ground equipment/system elements become inoperative, unless adequate and appropriate backup exists for the type of approach being flown. • An HGS malfunction occurs during an HGS approach and adequate runway visual references have not been established. • An APCH WARN or HGs FAIL occurs and the Captain does not have the runway in sight (actual runway is in sight, not just part of the runway environment, such as lead-in lights or other approach lights). • For CAT Ill operations, if any controlling RVR is reported below the lowest authorized minima. • During an RNAV (RNP) or RNAV (GPS) approach, when a visual approach cannot be accomplished: - From the IAF to the MAP. o Lateral Navigation Performance Scale ANP bar amber indication or o NPS pointer cannot be maintained at less than 1 x RNP (NPS full scale deflection). o Both Pilots' primary altimeters differ by more than 100 ft at the FAF. o FMC Alert message UNABLE REQD NAV PERF-RNP appears. o Dual FMC failure. o Dual CDU failure. o Dual GPS failure. o Loss of MAP display. o Autopilot failure with RNP less than 0.30 NM. - From the FAF to the MAP, unless a safer course of action can be taken. o If any required aircraft equipment fails o Vertical Navigation Performance Scale pointer cannot be maintained between the ANP bar limits. o The following FMC alert messages appear: FMC DISAGREE or any VERIFY POS alerting message. · For a Predictive Windshear (PWS) caution or warning. On approach, initiate a normal go-around. Be prepared to execute a windshear recovery. · For a Ground Proximity Warning System (GPWS) warning or caution: - Warning-Any time, immediately initiate the Terrain Avoidance Maneuver. - Caution-On approach, initiate a go-around in any of the following situations: o At night o In IMC o If unable to acquire terrain visually Stabilized Approach Criteria The Southwest Airlines, Flight Operations Manual, dated July 23, 2020, Section 11.1.1 “Stabilized Approach Criteria – All Approaches” provided the following guidance: Good landings start with a stabilized approach. Southwest Airlines uses the following criteria for stabilized approaches. Significant speed and configuration changes during an approach complicate aircraft control, increase the difficulty of safely evaluating an approach as it progresses, and complicate the decision at the decision point (i.e., DA, DDA, MDA). Assess the probable success of an approach before reaching the decision point. This requires both Pilots to determine that the requirements for a stabilized approach have been met and are being maintained. Comply with the following stabilized criteria for all approaches. Deviations within normal limit criteria are acceptable for operational conditions. The intention is that the PF completes a stabilized final approach entry by 1,000 ft above touchdown zone elevation (TDZE). Above 1,000 ft, PMs should make necessary informative callouts to assist the PF to achieve stabilized conditions by 1,000 ft above TDZE. Momentary deviations of glidepath, course, airspeed, and sink rate do not require an immediate go-around. Make required deviation callouts. • By 1,000 ft above TDZE, the aircraft must be in the planned landing configuration (landing gear down and landing flaps). For approaches flown in vertical speed, the aircraft must be in the planned landing configuration by the final approach segment. • By 1,000 ft above TDZE, the aircraft must be in the VTARGET speed range. VTARGET speed range is VTARGET + 10 and -5 kt. The PF should clearly communicate adjustments for an updated wind report from tower. • By 1,000 ft above TDZE, the aircraft must be on appropriate glidepath with a normal descent rate. Maintain a stable approach path. Normal glidepath descent rate is 700-800 fpm. Final approach segments with glidepaths greater than 3° and/or high groundspeeds may require a sustained descent rate in excess of 1,000 fpm. This is acceptable as long as this condition is briefed and all other stabilized approach criteria are met. Use 1,000 fpm maximum for normal maneuvering during visual, circling, non-precision, and sidestep approaches. This directive does not restrict Pilots from flying slightly above the glidepath for wake turbulence avoidance during visual approaches. • For approaches where maneuvering is required, the aircraft is on and maintaining final approach course or runway centerline with wings essentially level by 500 ft above TDZE. The intention is for Pilots to comply with the configuration, speed, descent rate, and checklist requirements by 1,000 ft above TDZE, and then continue necessary maneuvering to be essentially wings level by 500 ft above TDZE. Some charted approach procedures may require a turn below 500 ft. Once established, stabilized approach criteria must be maintained throughout the rest of the approach. If stabilized approach criteria are not met, execute or direct a go-around/missed approach. It is the duty and responsibility of any Flight Deck Crew Member to execute or direct a go-around/missed approach when the stabilized approach criteria are not met. Additionally, any time the approach or landing appears unsafe, execute or direct a go-around/missed approach. When a go-around/missed approach is called for, the Pilot Flying must immediately execute the go-around/missed approach. Intended Touchdown Point Southwest Airlines Flight Operations Bulletin 20-38 dated December 28, 2020 “Intended Touch Down Point,” provided, in part, the following guidance: The procedural directive regarding touch down is being revised to more accurately reflect the intent of the supporting information following that directive. “Plan to” and “in the Touchdown Zone (TDZ)” have been added to the procedural directive regarding touch down: “Plan to touch down between 1,000 and 1,500 ft from the landing threshold on centerline in the Touchdown Zone (TDZ).” It is still the goal to touch down between 1,000 and 1,500 ft from the landing threshold, but if touchdown occurs past 1,500 ft, Pilots must know the latest touchdown point (LTP) based on the most restrictive of either: · The performance capabilities of the aircraft (i.e., 1,500 ft plus the PWB stopping margin) · The end of the TDZ (i.e., TDZ ends at 3,000 ft or 1/3 of the usable landing length)… Do not make unnecessary changes to flight deck systems below 1,000 ft. The intention is for both Pilots to remain focused on flying/monitoring the aircraft. Do not perform discretionary tasks such as making FMC changes or presetting ATC ground control frequencies. Essential changes are permitted (e.g., operating windshield wipers). (PF) Maintain any gust correction to touchdown. (PF) Bleed off any steady wind correction as the aircraft approaches touchdown. (PF) Plan to touch down between 1,000 and 1,500 ft from the landing threshold on centerline in the Touchdown Zone (TDZ). Keep the aircraft in trim while on final. Avoid rapid control column movements, pumping, or trimming in the flare. These actions could increase the chances for a tailstrike. PWB stopping margin information is based on the assumption that aircraft touchdown occurs at the 1,500-ft mark from the usable end of the runway (or the glideslope intercept point plus 500 ft if that value is greater than 1,500 ft). If touchdown occurs beyond the 1,500-ft mark, the available runway length remaining will be less than the PWB System-computed stopping margin, and in some cases, the remaining runway length will be insufficient to stop the aircraft. If the AIII mode is selected, the PWB System subtracts 1,150 ft from the stopping margins to account for the possibility of a long landing due to AIII flare guidance. Note: When using the AIII mode to touch down, follow the HUD guidance cue in the HUD to touch down. Precisely flying the HUD guidance cue in AIII mode to touch down ensures touchdown within acceptable parameters. If the current conditions are significantly different than the anticipated conditions at the time of PWB programming (e.g., wet runway 5-GOOD vs. runway with standing water 2-MED TO POOR, tailwind vs. calm wind), the PWB System-computed stopping margin may be incorrect for the significantly different conditions. If a landing is made in either of these situations (i.e., touchdown past 1,500 ft plus the PWB stopping margin or landing conditions are significantly different than anticipated), higher than planned braking may be needed to account for the reduced or insufficient stopping margin. If touchdown occurs beyond 1,500 ft plus the PWB stopping margin (for the level of autobrakes selected or approximated), the ability to stop on the remaining runway may be compromised. The situation becomes more critical on shorter runways; therefore, a go-around is the better option. If touchdown occurs beyond 1,500 ft past the threshold/displaced threshold, the shortest of the following distances is the latest touchdown point (LTP) and a go-around is required if touchdown occurs past the LTP: · 1,500 ft plus PWB stopping margin (for the level of autobrakes selected or approximated) · 3,000 ft · One-third of the usable landing length A go-around is possible until the thrust reverser levers are raised. FAA Guidance The FAA Aeronautical Information Manual, Chapter 4 “Air Traffic Control” Section 2 “Radio Communications Phraseology and Techniques” provided, in part, the following: 4-2-2. Radio Technique a. Listen before you transmit. Many times you can get the information you want through ATIS or by monitoring the frequency. Except for a few situations where some frequency overlap occurs, if you hear someone else talking, the keying of your transmitter will be futile and you will probably jam their receivers causing them to repeat their call. If you have just changed frequencies, pause, listen, and make sure the frequency is clear. b. Think before keying your transmitter. Know what you want to say and if it is lengthy; e.g., a flight plan or IFR position report, jot it down. c. The microphone should be very close to your lips and after pressing the mike button, a slight pause may be necessary to be sure the first word is transmitted. Speak in a normal, conversational tone. d. When you release the button, wait a few seconds before calling again. The controller or FSS specialist may be jotting down your number, looking for your flight plan, transmitting on a different frequency, or selecting the transmitter for your frequency. e. Be alert to the sounds or the lack of sounds in your receiver. Check your volume, recheck your frequency, and make sure that your microphone is not stuck in the transmit position. Frequency blockage can, and has, occurred for extended periods of time due to unintentional transmitter operation. This type of interference is commonly referred to as a “stuck mike,” and controllers may refer to it in this manner when attempting to assign an alternate frequency. If the assigned frequency is completely blocked by this type of interference, use the procedures described for en route IFR radio frequency outage to establish or reestablish communications with ATC. f. Be sure that you are within the performance range of your radio equipment and the ground station equipment. Remote radio sites do not always transmit and receive on all of a facility's available frequencies, particularly with regard to VOR sites where you can hear but not reach a ground station's receiver. Remember that higher altitudes increase the range of VHF “line of sight” communications. Undetected Simultaneous Transmissions Phenomenon Eurocontrol, European Organisation for the Safety of Air Navigation wrote a document titled “Risk Assessment of the Undetected Simultaneous Transmissions Phenomenon” dated April 9, 2010 provided, in part, the following information: The phenomenon of Simultaneous Transmissions is not new…have identified more frequent occurrences contributing in some cases to safety related incidents… “Situations arise when two or more radio transmissions occur, simultaneously, on the same frequency. In this context ‘simultaneous’ is defined as two or more transmissions that overlap in such a way that the controller is not aware that more than one transmission has occurred leading to a potential safety hazard.” In the context of this initiative, the notion of “simultaneous” is extended to transmissions that overlap in such a way that the controller or a pilot is not aware that more than one transmission has occurred. - Airport Information San Diego International Airport was located about 2 miles west of San Diego, California. The airspace surrounding the airport was designated as Class B at the time of the incident. It had one paved landing surface for airplanes which was designated as 9/27. The airport had an air traffic control tower that operated 24-hours a day; it was staffed and in operation at the time of the incident. Airport Diagram According to the FAA Chart Supplements, runway 9/27 was a 9,401-foot-long and 200-foot-wide, grooved, asphalt, and concrete runway. Runway 27 was equipped with 4-light PAPI system and had 7,591 ft of runway available for landing and 9,401 ft available for takeoff. The runway had an 1,810-foot displaced threshold. NOT FOR NAVIGATION Figure 3: SAN Airport Diagram (Source: Jeppesen) - On June 10, 2021, about 1745 Pacific Daylight Time (PDT), a runway incursion occurred at the San Diego International Airport (SAN), San Diego, California, when air traffic control cleared Southwest flight 1648 to land on runway 27 and subsequently instructed SkyWest flight 3371 to line up and wait on the same runway. Both flights were being operated under Title 14 Code of Federal Regulations (CFR) Part 121. There were no injuries reported to the occupants of either flight or damage to either airplane. Daytime visual meteorological conditions (VMC) prevailed at the time of the incident. Southwest flight 1648 push backed from the gate at Phoenix Sky Harbor International Airport (PHX), Phoenix, Arizona about 1647 and was airborne about 1656. The original departure time was 1630. According to the flight crew interview transcripts there were no issues with their airplane that would affect their landing and that everything was “normal.” For the event flight the first officer was the pilot flying and the captain was the pilot monitoring. The Southwest flight’s arrival into SAN was the LUCKI1 arrival and then the Area Navigation (RNAV) Z approach to runway 27 (see section 5.0 for details on the arrival and approach). According to the flight crew “it was VMC, clear” and they were going to follow the RNAV approach for lateral and vertical guidance to the airport. Air traffic control (ATC) was going to sequence another aircraft in front of them on the approach; however, after the other aircraft went south of the extended final to the runway, the ATC controller vectored that flight off the approach and the incident flight became the number one aircraft for the airport. They were cleared to the initial approach fix for the approach to runway 27 “near the end” of the LUCKI1 arrival. The flight crew stated that once they reported the airport in sight, they were cleared for the visual approach to runway 27. At 1741:54, the Southwest flight contacted the SAN ATC tower inside of the VYDDA waypoint. The ATC tower controller cleared Southwest flight 1648 to land on runway 27 and informed them that there was going to be an airplane in the takeoff position on runway 27. The flight crew accepted the landing clearance and acknowledged that there was to be an airplane in position on the runway. At 1744:00 the ATC tower controller advised the SkyWest flight that Southwest was on a 5-mile final and instructed them to line up and wait on runway 27. As the Southwest flight got closer to the runway, they observed the SkyWest airplane at the beginning of the displaced threshold for runway 27 and they had not heard the tower controller issue a takeoff clearance to the SkyWest flight. At 1745:47 the tower controller instructed SkyWest to exit the runway, first at Bravo then corrected the clearance to Charlie 2 (C2) which was read back by the SkyWest flightcrew. At 1745:58, the Airport Surface Detection System – Model X (ASDE-X) alerted the tower controller that runway 27 was occupied and provided a mandatory go-around alert. The FAA audio recording captured the pilot of the Southwest flight starting to transmit with “Ah” followed by the tower controller instructing the Southwest flight to go around. However, immediately after the tower controller stopped transmitting the audio recording captured the Southwest flight crew stated, “Southwest sixteen forty-eight.” However, LiveATC audio recording of the event captured the pilot of SWA1648 transmitting, “Ah, is that an airplane on the runway, for Southwest sixteen forty-eight.” Radar data of the event indicated that the Southwest flight was less than 1 nautical mile from the end of runway 27 at the time of those transmissions. At 1746:02 The ATC tower controller stated, “do not overfly the aircraft on the runway.” According to the Southwest pilots’ interviews, the pilot monitoring unknowingly keyed the transmit button and stated, “how are we going to do that.” According to written statements from the SkyWest flight crew, the captain, after receiving clearance from the controller to line up and wait on runway 27 and that there was traffic on a 5-mile final, taxied into position for departure. The flight crew reported hearing several transmissions from the tower to several other aircraft including an aircraft requesting a clearance into the airspace and to fly near “Petco Park.” They heard several airlines receive a landing clearance after they reported on the frequency with the tower controller. However, there was no takeoff clearance issued to them and the next instruction they were issued was to exit the runway. While their flight began moving to exit the runway, they heard the Southwest plane ask if that was a plane on the runway. The controller transmitted that the airplane was exiting and not to overfly them, to which Southwest queried about how they are going to do that. The crew reported that the controller’s response was “just off-set.” After they exited the runway, they heard several transmissions between the controller and the Southwest flight crew. After the SkyWest flight stopped and was holding short of runway 27, they informed the tower controller that they did not hear a go-around instruction for Southwest. According to the flight crew interview transcripts, the Southwest first officer, who was flying, queried the captain if he wanted him to move a little to the left to not fly over the SkyWest airplane, which the captain agreed. Prior to landing, the ATC controller queried the flight with “are you going around.” However, according to the crew, the transmission trailed off just as the main landing gear was touching down. The flight landed on the runway and the first officer reported he applied “normal thrust reversers” and at some point, prior to exiting the runway onto a taxiway, he transferred control to the captain to taxi. During the rollout, the ATC controller told Southwest 1648 “I told you to go around” to which the captain responded they did not hear him say that and that they were only told not to overfly the aircraft. The controller then told them to go ahead and contract ground control. The flight taxied to the gate uneventfully. The first officer reported that after they returned to Dallas that night, he listened to a publicly available transmission recording of their flight. He stated that on one recording he could hear the controller issue a go-around to their flight and as soon as the controller’s transmission ended the remainder of the captain’s transmission was heard, which was their call sign only. He further heard another recording in which he could not hear the controller’s transmission but only the captain’s transmissions. - Southwest Flight Crew Information Documentation provided by Southwest Airlines indicated that since 2015 the pilots had flown with each other on 10 flights, including the incident flight. The most recent time they flew together before the day of the incident was on December 7, 2019; however, other than the incident flight no other flights they operated together were to SAN. Documentation further indicated that since 2010 the captain had operated flights into SAN a total of 88 times including the incident flight. The most recent flight into SAN prior to the incident was on September 27, 2020. The first officer had operated flights into SAN a total of 42 times, including the event flight, with the most recent prior to the incident being on May 15, 2021. Captain The captain was 56 years old and held an Airline Transport Pilot (ATP) certificate with rating for multiengine land, commercial privileges airplane single-engine land, and type ratings on the B-737, CE-500, DC-9, HS-125, and LR-JET which included limitation of DC-9 Circling approach – VMC only, CE-500 Second in Command required. He held a flight instructor certificate with airplane single and multiengine, and instrument airplane rating, and a mechanic certificate with an airframe and powerplant rating. He held an FAA first-class medical certificate dated February 23, 2021, with a limitation of “must wear corrective lenses”. At the time of the incident, he reported that he was wearing contacts. His date of hire with Southwest Airlines was May 10, 2000. He was based at Dallas Love Field Airport (DAL), Dallas, Texas. His most recent training event occurred in January of 2021 with a return-to-service training on the B-737 Max. Prior to that his most recent recurrent training was accomplished in October 2020. The Captain further provided that he had approximately 9,000 total hours of flight experience as a captain in the B737 series aircraft. First Officer The first officer was 41 years old and held an ATP certificate with a rating for multiengine land, commercial privileges airplane single-engine land, and a type rating on the B-737. He held an FAA first-class medical certificate dated February 1, 2021, with no limitations. His date of hire with Southwest Airlines was April 2, 2014. He was based at DAL. Following a voluntary leave of 6-months from Southwest Airlines, he requalified on the B-737 in March of 2021 following a checkride. The requalification training included a day of ground school, maneuver observation training and line observation training, followed by a few days off. Then he did the Southwest Airlines Advanced Qualification Program (AQP) qualification which included a day of ground school, maneuvers in the simulator, a checkride, and then B-737 Max return-to-service training. -
Analysis
On June 10, 2021, about 1745 Pacific Daylight Time (PDT) a runway incursion occurred at the San Diego international airport when a SkyWest flight was positioned on Runway 27 for takeoff at the same time a Southwest flight was cleared to land on the same runway. The SkyWest flight was instructed to Line Up and Wait (LUAW) on Runway 27. According to FAA recordings, the Southwest flight was instructed to go around on an approximate 0.84-mile final (about 1.2 miles from the runway 27 displaced threshold); however, the transmission was blocked and the instruction was not heard by the crew. The air traffic control tower controller instructed the SkyWest flight to exit the runway at taxiway C2 about 11 seconds prior to instructing the Southwest flight to go around and to not overfly the SkyWest airplane. The Southwest flight maneuvered around the SkyWest flight exiting the runway and subsequently landed on Runway 27. The closest proximity was 0.18 miles laterally and 200 feet vertically. A review of the FAA audio recordings indicated that the tower controller informed the Southwest flight that there would be traffic holding in position for takeoff on the runway following a preceding arrival aircraft. The controller then issued instructions to other uninvolved aircraft, including a helicopter that was transitioning the airspace. Just after the controller issued instructions for the SkyWest flight to exit the runway, and when the Southwest flight was on an approximate 1.2-mile final, the ASDE-X provided a mandatory go-around alert, and the controller issued go-around instructions to Southwest. The Southwest flight subsequently maneuvered and offset to the left of Runway 27, and then back to the right, and the aircraft aligned with and landed on Runway 27. The SkyWest crew did not hear the air traffic controller’s transmission to the Southwest flight to go around. The SkyWest crew reported they did hear the Southwest flightcrew’s query about the airplane on the runway. According to the FAA, the tower controller was communicating with a helicopter transitioning the airspace after they had instructed SkyWest to LUAW. This additional communication likely distracted the controller from monitoring the position of the SkyWest and Southwest airplanes. Although the FAA reported that tower communication was working normally at the time of the event, they were requested to conduct testing on the strength of the radio signal from the tower cab at various distances away from the airport. However, there was no indication that the FAA was able to conduct such testing and therefore it could not be conclusively determined if the control tower’s frequency strength was adequate to overpower an airborne aircraft’s transmission for other aircraft operating on the airport. Therefore, it is likely that the air traffic controller and the Southwest flightcrew’s simultaneous transmissions canceled each other with no indication to the controller, the arriving aircraft, nor any other aircraft on the frequency.
Probable cause
The blocked go-around radio instruction from the air traffic control tower to the arrival aircraft which resulted in the arrival aircraft continuing the landing approach. This led to a loss of separation between the landing aircraft and the aircraft awaiting departure on the runway. Contributing to the loss of separation was the controller’s distraction communicating with a helicopter transitioning the airspace.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-8H4
Amateur built
false
Engines
2 Turbo fan
Registration number
N8674B
Operator
SOUTHWEST AIRLINES CO
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
36734
Damage level
None
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
EMBRAER S A
Model
ERJ 170-200 LR
Amateur built
false
Engines
2 Turbo fan
Registration number
N197SY
Operator
SKYWEST AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
17000709
Damage level
None
Events
Findings
creator: NTSB last-modified: 2021-06-18T01:17:30Z guid: 103275 uri: 103275 title: CEN21LA264 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103259/pdf description:
Unique identifier
103259
NTSB case number
CEN21LA264
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-13T14:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-06-15T21:27:56.298Z
Event type
Accident
Location
Elwood, Nebraska
Airport
Johnson Lake (2NE0)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 13, 2021, about 1330 central daylight time, a Boeing B75N1 Stearman airplane, N777JG, was substantially damaged when it was involved in an accident near Elwood, Nebraska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while the airplane was in cruise flight at an altitude of about 1,000 ft above ground level, he heard a “loud bang” from the engine, which was followed by “severe vibration.” The pilot moved the throttle to idle, but the vibration got worse. The pilot applied full throttle, and the engine seemed to run smoother. Subsequently, the engine began to lose power, and the airplane was unable to maintain altitude. The engine lost total power when the airplane was in the base-to-final turn about 0.75 miles from the runway at an altitude of 200 ft above ground level. The pilot executed a forced landing to a cornfield. The airplane nosed over when the landing gear dug into the soft dirt, resulting in substantial damage to the upper left wing and struts. The pilot, who was also the owner of the airplane, reported that a partial disassembly of the engine revealed that the master rod, that connects the piston in one cylinder to the crankshaft, had failed. Several radial engine mechanics the pilot spoke to commented that a master rod failure was consistent with his description of the loss of engine power. The reason for the failure was not determined. The engine total time was 1,910 hours, and the time since major overhaul was 655.0 hours. -
Analysis
The pilot reported that he heard a “loud bang” from the engine during cruise flight, which was followed by “severe vibration.” The pilot moved the throttle to idle, but the vibration got worse. The pilot then applied full throttle, and the engine seemed to run smoothly. However, the engine subsequently began to lose power, and the airplane was unable to maintain altitude. About 0.75 miles from the runway, the engine completely lost power, and the pilot executed a forced landing to a cornfield, during which the airplane nosed over which resulted in substantial damage to the upper left wing and struts. Partial disassembly of the engine revealed that the master rod, that connects the piston in one cylinder to the crankshaft, had failed.
Probable cause
The failure of the engine master rod, resulting in a total loss of engine power and a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
B75N1
Amateur built
false
Engines
1 Reciprocating
Registration number
N777JG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
75-3291
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-15T21:27:56Z guid: 103259 uri: 103259 title: CEN21LA271 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103271/pdf description:
Unique identifier
103271
NTSB case number
CEN21LA271
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-14T08:00:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-06-17T02:03:33.05Z
Event type
Accident
Location
Buena Vista, Colorado
Airport
Leadville (LXV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 14, 2021, about 0700 mountain daylight time, a Cessna T210L, N30286, was substantially damaged when it was involved in an accident near Buena Vista, Colorado. The pilot sustained minor injuries, and the pilot-rated passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while the airplane was flying over mountains and near the destination airport, the engine temperature and fuel flow gauges “dropped” immediately, and the engine lost partial power. The pilot reported that the power loss felt as if someone had retarded the throttle, so he “instantly” pushed the throttle in and turned on the auxiliary fuel pump to the “high” position. These actions had no effect on the engine, so the pilot tried to restart the engine, including attempting a hot start, but was unable to do so. The pilot located a flat, treeless area for a forced landing. During the forced landing the landing gear separated, and the airplane came to a stop upright. The airplane sustained substantial damage to the forward fuselage, firewall, and left outboard wing. A postaccident examination of the airplane’s engine-driven fuel pump showed that one of the pump’s two carbon vanes had fractured in half. No debris was found in the pump housing. No other preaccident failures or malfunctions were found that would have precluded normal operation of the airplane or engine. According to the engine manufacturer, operation of the pump with a severed vane would likely cause fuel cavitation, which would cause a drop in pump outlet pressure and could result in a gradual decrease in engine rpm. -
Analysis
The pilot reported that the airplane was over mountains and near the destination airport when the engine temperature and fuel flow gauges “dropped” and the engine lost partial power. The pilot pushed the throttle in and turned on the auxiliary fuel pump to the “high” position, but those actions had no effect on the engine power. The pilot troubleshot the loss of power; however, there was no change. The pilot then located a flat, treeless area for a forced landing. During the forced landing the landing gear separated and the airplane came to a stop upright. The airplane sustained substantial damage to the forward fuselage, firewall, and left outboard wing. A postaccident examination of the airplane’s engine-driven fuel pump showed that one of the pump’s two carbon vanes had fractured in half. How the carbon vane fractured was not determined. The severed fuel pump vane likely resulted in fuel cavitation, a drop in pump outlet pressure, a gradual decrease in engine rpm, and subsequent partial loss of engine power.
Probable cause
The partial loss of engine power due to a vane failure in the engine-driven fuel pump.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210L
Amateur built
false
Engines
1 Reciprocating
Registration number
N30286
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21059910
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-17T02:03:33Z guid: 103271 uri: 103271 title: CEN21LA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103260/pdf description:
Unique identifier
103260
NTSB case number
CEN21LA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-14T09:52:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-06-15T20:56:26.223Z
Event type
Accident
Location
Columbus, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 14, 2021, at 0852 eastern daylight time, a Cessna 180K, N13159, was substantially damaged when it was involved in an accident near Columbus, Ohio. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot reported that she took off uneventfully and executed a climbing right turn before leveling off at 1,000 ft above ground level. Shortly thereafter, the airplane’s engine sputtered briefly. The pilot contacted air traffic control and initiated a 180° turn toward the airport when the engine lost all power. Unable to make it to the airport, the pilot initiated a slight left turn towards an open field; she also noted that airplane’s radios lost power. The airplane struck trees in a heavily wooded area short of the open field before impacting terrain. The airplane sustained substantial damage to the wings and empennage.   The airplane and engine were examined. The airplane had been modified from a carbureted to a fuel injected engine and the wings had been changed from bladder fuel tanks to integral fuel tanks. Examination of the right wing showed that the fuel tank was intact, and no anomalies were noted inside of the tank. The fuel cap was not in place; however, no fuel staining was evident. Examination of the left wing identified fragments of off-white sealant found loose within the fuel tank, varying in size up to about 1 inch and consistent with Chem Seal 3204. The sealant appeared to have been applied to the vertical and lower skin structure of the fuel tank, exhibiting cracking and flaking. The middle and outboard wing drains had a grey color sealant observed over the off-white sealant. About 12 pieces of grey sealant were also observed loose in the fuel tank. The fuel cap was in place. The finger screens in both tanks were clear of debris. The fuel strainer was removed and contained fuel. No water was observed. Within the fuel strainer screen a minor dark substance was observed, but the screen was otherwise clear. Air was blown through the fuel lines at both wing roots and fuel was expelled through the fuel strainer. The fuel selector valve was manipulated and functioned normally. Examination of the engine showed no visual signs of catastrophic failure. Further examination of the engine’s fuel components identified a minor blockage in the No. 2 nozzle and a white powder on the surface of the fuel distributor spring on its larger side. The fuel control unit was removed and displayed minor leaking at the fuel metering unit. The electrical system was not tested. Review of the airplane’s maintenance logbooks showed that on June 10, 2021, four days before the accident, the airplane’s left fuel tank was drained and resealed with Chem Seal CS3204B2. The entry noted that tank was refilled with 100LL and leak checked. The mechanic was not interviewed. According to Chem Seal documentation, the surface area for Chem Seal application must be free of contaminants and the sealant has a specific mixing and cure schedule. The NTSB Materials Laboratory examined the residue from a fuel distribution spring as well as sealant fragments. When examined by a Fourier Transform Infrared spectrometer, the residue from the spring was not consistent with the sample of the sealant. The analysis was not able to identify the residue and its source could not be determined. -
Analysis
The airplane was in cruise flight at 1,000 ft above ground level when the engine sputtered. As the pilot executed a 180° turn toward the airport, the engine lost all power. The pilot also reported that the radios lost power. The airplane impacted trees in a heavily wooded area short of the open field and sustained substantial damage to the wings and empennage during the forced landing. The airplane had undergone numerous modifications, including a change from bladder fuel tanks to integral fuel tanks in the wings. Four days before the accident, a mechanic had drained the left wing of fuel and resealed it with a sealant. The wing was then refueled, and leak checked. Postaccident examination showed sealant contamination in the left fuel tank, varying in size up to 1 inch. The sealant was not adhering to the inside of the wing tank. Although the fuel screens were found unobstructed, due to the size and number of the sealant pieces fuel flow from the left tank could likely have been obstructed, resulting in a loss of engine power.
Probable cause
The loss of engine power due to fuel starvation resulting from sealant contamination in the wing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180K
Amateur built
false
Engines
1 Reciprocating
Registration number
N13159
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18053166
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-15T20:56:26Z guid: 103260 uri: 103260 title: WPR21FA227 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103267/pdf description:
Unique identifier
103267
NTSB case number
WPR21FA227
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-15T09:20:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Last updated
2021-06-30T01:16:21.795Z
Event type
Accident
Location
Gila Bend, Arizona
Airport
GILA BEND MUNI (E63)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On June 15, 2021, about 0820 mountain standard time, an experimental, amateur-built Tri-Quickie, N8054Y, was destroyed when it was involved in an accident near Gila Bend, Arizona. The pilot was seriously injured, and the pilot-rated passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot had recently purchased the airplane and was flying it home to Texas from California. A friend of the pilot reported that he had told the pilot not to take a passenger with him on the trip until he had more experience in the airplane. According to the airport manager, the pilot and passenger arrived at the airport the evening before the accident and refueled the airplane that evening with 17.5 gallons of 100 low-lead aviation fuel. The pilot and passenger departed the following morning from runway 4 on the accident flight. A witness reported that he was working on his airplane when he saw two men perform a preflight and then board the accident airplane. The pilot started the engine and taxied the airplane to the runway hold short line where it sat for about 20 minutes with the engine running before the airplane departed. During the takeoff run, about a 1/3 of the way down the 5,200-ft-long runway, the witness observed a dirt cloud and surmised that the landing gear must have departed the runway surface. The airplane returned to the runway centerline and continued down the runway; about halfway down the runway, it appeared that the airplane was “yanked off the runway” and it “struggled” to gain altitude. The witness estimated that the airplane reached an altitude of about 50 ft when it made a left turn, stalled, and impacted the ground. The weight and balance information for the airplane was not located. Additionally, no performance specifications for the accident airplane were available. The closest weather reporting station to the accident airport was located 5 nautical miles southwest at Gila Bend Air Force Auxiliary Airport (GXF), Gila Bend, at an elevation of 883 ft mean sea level. The recorded weather conditions at 0758 included wind from 120° at 4 kts, temperature 93.2°F, dewpoint 42.8°F, and an altimeter setting of 29.81 inches of mercury. The calculated density altitude was 3,486 ft. At 0858, recorded weather conditions at GXF included wind from 280° at 3 kts, temperature 98.6°F, dew point 42.8°F, and altimeter setting of 29.81 inches of mercury. The calculated density altitude was 3,810 ft. The airplane came to rest about 200 ft west of runway 4, adjacent to the airport perimeter fence. The first identified points of impact were witness marks from the landing gear on the hard packed desert floor. The debris path continued an additional 140 ft before the airplane impacted a ditch and came to rest; a postcrash fire ensued. The airframe was mostly destroyed by the postcrash fire, exposing the inner hardware of the airplane. The main wreckage came to rest inverted with the wing and landing gear lying adjacent to the cockpit. Flight control cables were identified from the cockpit to each wing and the tail section. The engine separated from the airframe and was found near the main wreckage. The propeller hub remained attached to the engine crankshaft; however, all three propeller blades separated from the propeller hub. A visual examination of the engine revealed no holes in the crankcase. The engine had sustained thermal and impact damage to the accessory case and engine accessories. The crankshaft could not be rotated, and the engine was subsequently disassembled. Pooled molten metal was observed in the accessory case area. The cylinders and pistons displayed varying degrees of thermal damage. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. -
Analysis
The pilot had recently purchased the airplane and was flying it back to his home airport with a passenger onboard. The pilot had stopped at the accident airport the evening before the accident and refueled the airplane for departure the following day. A witness observed the accident airplane taxi to the runway hold short line, where it remained for about 20 minutes with the engine running. The witness saw the airplane depart, and about a 1/3 of the way down the 5,200-ft-long runway, observed a dirt cloud and surmised that the landing gear must have departed the runway surface. The airplane returned to the runway centerline. The witness stated that the airplane continued, and about midway down the runway, it appeared the airplane was “yanked off the runway,” and struggled to gain altitude. The witness estimated that the airplane reached an altitude of about 50 ft above ground level when it turned to the left, stalled, and impacted the ground. Using recorded weather conditions from a nearby weather reporting station, the calculated density altitude was about 3,486 ft at the time of the accident. Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation; however, the examination was limited due to thermal damage sustained in the post-impact fire. It is likely that the airplane’s takeoff performance was degraded by the high-density altitude conditions, which would have resulted in an increased takeoff distance and decreased climb performance. It is also likely that, after the airplane became airborne, the pilot inadvertently exceeded the airplane’s critical angle of attack, which resulted in an aerodynamic stall, loss of control and impact with the ground.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the takeoff initial climb, which resulted in an aerodynamic stall and loss of airplane control. Contributing to the accident was the reduced airplane performance due to high density altitude conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
COVEY
Model
Tri Quickie
Amateur built
true
Engines
1 Reciprocating
Registration number
N8054Y
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
31569
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-30T01:16:21Z guid: 103267 uri: 103267 title: ERA21FA253 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103266/pdf description:
Unique identifier
103266
NTSB case number
ERA21FA253
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-15T11:31:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-06-30T21:28:34.017Z
Event type
Accident
Location
Buckingham, Pennsylvania
Airport
DOYLESTOWN (DYL)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Engine Operating Temperatures The engine could be operated at a peak exhaust gas temperature of 1,650°F. Motor oil will burn at temperatures from 302°F to 392°F. The oil quick drain valve was specified for use at temperatures between -60°F and 260°F. FAA Advisory Circular 91-59A FAA Advisory Circular (AC) 91-59A, Inspection and Care of General Aviation Aircraft Exhaust Systems, stated in part that a review of accident and incident reports revealed numerous fatalities and injuries to pilots and passengers because of exhaust system component failures. The AC also stated that many light airplane cabins are warmed by air circulating around the engine exhaust pipes and that many of the most common exhaust system component failures are muffler or exhaust gas-to-air heat exchanger related. The AC further stated that potential failures included the following: (1) Escape of exhaust gas into the cabin, possibly through the cabin heat system, when there is muffler or heat exchanger leakage. (2) Material failures in components of heat exchangers and mufflers that function as both, leading to leakage of the exhaust gas directly into the cabin or through the cabin heat system. (3) Partial or full engine power loss caused by loose baffles, cones, or diffusers on mufflers and heat exchangers that partially or completely block the exhaust gas outlet flow. This condition may occur intermittently if internal components are loose within the muffler and move around during subsequent flights. (4) Impingement heating or torching of the surrounding structure can occur in any area where exhaust system components exist or are breached and may lead to structural failure or fire conditions. Torching is of particular concern on turbocharged engines, which operate at higher exhaust gas temperatures and pressures. - The RV-6A was a two-seat, single-engine, low-wing airplane that was sold in kit form. According to FAA and airplane maintenance records, the airplane’s experimental airworthiness certificate was issued in 2008. The airplane's most recent condition inspection was completed by the pilot on September 21, 2020. At the time of the inspection, the airplane had accrued a total of about 484 hours. A review of the National Transportation Safety Board’s (NTSB) accident database indicated that the engine in the airplane had been involved in a previous accident on August 8, 1998, in Bainbridge, Georgia (NTSB case no. ATL98LA108); at that time, the engine was installed in an experimental amateur-built Vans RV-6, N245DF. During the 1998 accident, the pilot was seriously injured, and the airplane was substantially damaged. Review of maintenance records indicated that the engine was removed from the wreckage of N245DF on November 6, 1999. The maintenance records also indicated that an “engine inspection” was conducted due to a “propeller strike” and that the crankshaft, bearings, gear bolt, rod bolts, fuel pump, and the No.1 cylinder stud and rings were replaced. The records further stated that the vacuum pump was rebuilt and that the engine case and camshaft were inspected, with the ferrous parts undergoing non-destructive testing (magnafluxed). - On June 15, 2021, about 1031 eastern daylight time, an experimental amateur-built Vans RV-6A airplane, N74MS, was substantially damaged when it was involved in an accident in Buckingham, Pennsylvania. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. About 0817 on the morning of the accident, the pilot departed Doylestown Airport (DYL), Doylestown, Pennsylvania, for Sky Manor Airport (N40), Pittstown, New Jersey, arriving about 0827. About 30 minutes later, the pilot departed N40 for South Jersey Regional Airport, VAY, Mount Holly, New Jersey, arriving there about 0913. About 1 hour later, the pilot departed VAY to return to DYL. About 1020, the pilot transmitted over the common traffic advisory frequency for DYL that he had an emergency and was making a straight-in landing to runway 5. About 1021, the pilot transmitted that the airplane had an in-flight fire, would be landing on runway 5, and was inbound, to DYL. The pilot made no further intelligible transmissions. According to witnesses, the airplane was flying in a northwest direction just before the accident. The engine sounded rough and sputtered, and then a “pop” sound was heard. The airplane appeared to be on fire with trailing smoke. The airplane then appeared to bank right and left and then appeared to follow a flightpath toward DYL while losing altitude quickly. The airplane was later observed striking the tops of trees, which was followed by the sound of impact. Flames were observed emanating from the airplane. Review of video camera footage from a home security system indicated that a fire was present on the airplane near the engine and that smoke, which was bluegray in color, was trailing from the airplane. Review of another video from a home security camera system indicated that the airplane struck a large tree and that a fire around the engine was present before ground impact. A photograph taken by the Township of Buckingham Fire Marshall after the accident also showed that the area near the engine was on fire. - The Bucks County Coroner’s Office, Warminster, Pennsylvania, performed an autopsy on the pilot. His cause of death was smoke inhalation complicating hypertension. Toxicology testing performed by the FAA Forensic Sciences Laboratory identified salicylic acid, quinine, and azacyclonol in the pilot’s specimens. Salicylic acid is a metabolite of aspirin and is used to treat several conditions. The use of aspirin is acceptable for flying if the underlying condition being treated is also acceptable. Quinine is commonly used to treat leg cramps and restless leg syndrome. It is also consumed in tonic water. Azacyclonol is both a drug and a metabolite of fexofenadine (Allegra), which is an over-the-counter nonsedating antihistamine used to treat seasonal allergies. The medication is acceptable for pilots. - According to Federal Aviation Administration (FAA) records, in addition to the pilot’s airmen certifications, he held a mechanic certificate with ratings for airframe and powerplant, and a repairman experimental aircraft builder certificate with an inspection certificate for the Vans RV-6A. The pilot also held type ratings on the B757, B-767, DC-6, DC-7, DC-9, and L-1011. The pilot reported, at the time of his most recent FAA third-class medical certificate, that he had a total of 12,225 hours of flight experience. - Examination of the accident site revealed that the airplane came to rest upright in a field on a 148° magnetic heading and about 0.5 nautical miles from runway 5. The airplane struck a tree that was about 50 ft above ground level; impacted, in a nose-down attitude, a tree limb that was about 36 ft above ground level; and pivoted to an upright position before coming to rest on top of a standpipe-mounted sprinkler head, which had vertically punctured and traveled through the right wing. The wing flaps and ailerons remained attached to their respective wings, but the left aileron displayed bending and impact damage. The vertical stabilizer, rudder, horizontal stabilizers, and elevators also remained attached, but the left stabilizer and elevator displayed impact damage and wrinkling. Control continuity was established for pitch, roll, and yaw. Most of the instrument panel had been consumed by fire, and the forward portion of the cabin back to the front of both seats, had been exposed to the fire, with portions of the right seat displaying fire damage on the upper surface of the bottom seat cushion. The canopy displayed thermal, and impact damage, and was almost completely separated from the fuselage. The exterior of the fuselage and wings also displayed sooting, on the sides and top surfaces, along with more delineated areas which displayed heavy thermal and fire damage toward the front of the airplane, both near, and adjacent to the firewall, and on the sides and bottom of the fuselage Examination of the propeller and engine revealed that the propeller remained attached to the crankshaft flange and that the engine remained attached to the engine mounts. The propeller displayed minimal damage, and the spinner displayed crush and compression damage primarily on one side. The propeller governor also remained attached along with the governor oil line, which had no oil. The governor could not be rotated by hand, and the gasket installed did not have an oil screen. The engine was damaged by fire. A crack was observed in the crankcase above the No.1 cylinder, and a large hole appeared in the crankcase above the No. 4 cylinder. The No. 4 connecting rod was separated from the connecting rod cap. The large end of the connecting rod was laying against the camshaft, and the tappets for the No. 4 cylinder were exposed. A borescope inspection of the cylinders noted no abnormalities. A portion of the cap of the dislocated connecting rod was found in the crankcase below the crankshaft. The carburetor remained attached to the bottom of the engine with the mixture and throttle cables attached. The carburetor displayed minimal impact damage but displayed signs of thermal damage. The fuel inlet screen was found to be contaminated in a manner consistent with thermal exposure, and the floats in the unit were melted. The fuel pump remained attached to the accessory housing but was destroyed by fire. The remaining part of the fuel pump was removed and actuated by hand. The magneto and the electronic ignition system on the accessory pad were both thermally damaged. The spark plugs remained installed in their cylinder heads with minor thermal signatures noted. The ignition harness was damaged due to impact and fire. The oil suction screen remained safety-wired into the oil sump. The suction screen contained ferrous and nonferrous metal debris. The oil filter remained attached to the accessory housing but displayed thermal damage. The oil pump displayed thermal damage and remained safety wired in place. The torque on the oil pump body nuts appeared loose. The oil pump body and gears displayed rotational scoring, and a small amount of metal was found in the pump. The oil sump contained ferrous and nonferrous metal, and portions of the connecting rod cap material and connecting rod bolts from the No. 4 connecting rod were present. The oil quick drain was not seating properly, allowing fluid to exit the sump. The crankshaft was rotated, and thumb compression and valvetrain continuity were established on cylinders Nos. 1, 2, and 3. Compression on the No. 4 cylinder could not be established because of the damage to the connecting rod and valvetrain in that area. The crankshaft displayed damage and heat signatures on the No. 4 connecting rod journal, and a portion of the connecting rod bearing was melted to the crankshaft journal. The faces of the No. 3 exhaust tappet and both tappets for the No. 4 cylinder were fractured. Oil passages in the crankshaft and crankcase were checked with compressed air for any blockages, and the oil lines for the oil cooler were checked for blockages; none were noted. The oil pressure line above the electronic ignition system was also checked for blockages; the 90° fitting on the end away from the accessory housing and the fitting at the start of the oil line both appeared to be blocked, and the passage through the accessory housing to the oil pressure point appeared not to be blocked. Oil Quick Drain The oil quick drain on the oil sump was leaking, even though it was in the closed position. Examination of the oil quick drain revealed that it was gold in color instead of the manufacturer’s blue anodized color and that the O-rings were melted. Further examination of the area around the oil quick drain revealed the presence of soot on the bottom of the oil sump downstream of the No. 2 cylinder where the engine’s left-side exhaust pipe was separated from the exhaust collector. Additional examination of the exhaust system indicated that the left exhaust pipe had a slip fit design and that no exhaust pipe clamp was present. Laboratory Examination of Engine Parts Pieces of the No. 4 connecting rod assembly, chips from the oil sump, an oil line, and an elbow fitting were submitted to the NTSB Materials Laboratory for examination. The examination determined that the connecting rod, end cap, end cap bolts, and bearing insert all exhibited thermal distress signatures. The bearing insert had fragmented into multiple chips, and both bolts used to secure the end cap had fractured. The fractures exhibited coarse striated features consistent with fatigue separations. One arm of the connecting rod yoke had also fractured in a manner consistent with a bending fatigue separation. The chips from the oil sump consisted primarily of fragments from the connecting rod bearing inserts. Two chips were determined to be an aluminum/silicon alloy, and another chip was determined to be a fragment of a main bearing insert. The bearing surface was stripped of babbitt material in some regions and coated by a smeared metal in other regions. The smeared metal was determined to be an aluminum/silicon alloy that was similar in composition to the two aluminum/silicon alloy chips. The oil line and elbow fitting were blocked. The blockages consisted primarily of silicon and aluminum oxides with traces of alkalis, alkaline, and halogens. -
Analysis
The pilot was en route to his home airport. While approaching the airport, the pilot transmitted over the common traffic advisory frequency that he had an emergency and then that he would be making a straight-in landing due to an inflight. Witnesses stated that the airplane’s engine sounded rough and was sputtering before a “pop” sound was heard. The airplane appeared to be on fire with trailing smoke. The airplane then banked right and left, and turned toward the airport while losing altitude quickly. The airplane then struck the tops of trees before it impacted the ground. Security camera video footage confirmed the witness observations that there was an inflight fire, showed that the fire appeared to be near the engine, and that blue-gray smoke consistent with an oil-fed fire was trailing from the airplane. Postaccident examination of the engine revealed extensive damage both internally and externally, including a crack in the crankcase above the No.1 cylinder and a large hole in the crankcase above the No. 4 cylinder. The No. 4 connecting rod was separated from the connecting rod cap. The crankshaft displayed damage and heat signatures on the No. 4 connecting rod journal that were consistent with an oil starvation event, and a portion of the connecting rod bearing was melted to the crankshaft journal. The 90° fitting on the oil pressure line above the electronic ignition system on the end away from the accessory housing and the fitting at the start of the oil line were blocked. The bulk of the obstruction in the oil line appeared to consist primarily of aluminum and silicon oxides, as well as other ash products with no apparent metal chips or fragments. This evidence showed that a thermal decomposition event had occurred with the ash products collecting at the elbow and backing into the flexible oil line. The connecting rod assembly, connecting rod bearing inserts, end cap attachment bolts, and a main bearing fragment all exhibited indications of thermal distress, likely due to a loss of oil lubrication. Freestanding aluminum chips and smeared metal on the main bearing fragment indicated that the main bearings were made from aluminum, which was stripped from the metal backing. The fatigue fractures observed on the bolts and connecting rod were likely secondary to the decomposition of the connecting rod bearing insert and the thermal distress event. The oil quick drain on the engine oil sump was found to be leaking, even though it was in the closed position. Examination of the oil quick drain revealed that it was discolored and that the O-rings were melted, indicating that the oil quick drain had been exposed to a high heat condition. Further examination of the area around the oil quick drain revealed the presence of soot on the bottom of the oil sump downstream of the No. 2 cylinder where the engine’s left-side exhaust pipe was separated from the exhaust collector. Additional examination of the exhaust system indicated that the left exhaust pipe was a slip fit design and that no exhaust pipe clamp was present. This evidence indicated that the source of the thermal distress event was most likely an exhaust system leak that impinged on the oil quick drain, melting the O-rings and resulting in the oil draining from the engine and subsequently igniting. A review of the operating temperatures associated with the engine indicated that the exhaust gas temperature was hot enough to exceed the upper limit of the temperature specifications of the oil quick drain and was also hot enough to ignite the oil. This ultimately resulted in the in-flight fire and led to the pilot’s subsequent loss of airplane control.
Probable cause
An exhaust system leak that resulted in failure of the oil quick drain, a loss of oil lubrication, an in-flight fire, and the pilot’s subsequent loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
true
Engines
1 Reciprocating
Registration number
N74MS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24821
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-30T21:28:34Z guid: 103266 uri: 103266 title: CEN21FA270 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103270/pdf description:
Unique identifier
103270
NTSB case number
CEN21FA270
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-15T17:32:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-06-22T18:50:04.572Z
Event type
Accident
Location
Paragould, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On June 15, 2021, at 1632 central daylight time, an Air Tractor AT 502B airplane, N6088K, was destroyed when it was involved in an accident near Paragould, Arkansas. The pilot was fatally injured. The airplane operated as a Title 14 Code of Federal Regulations Part 137 agricultural flight. A witness reported that he observed the airplane about one mile away flying directly toward him. It appeared to be straight and level, about treetop height. Without warning, he observed a small puff of white smoke; the airplane immediately nosed down, impacted the ground and a post-crash fire ensued. The witness did not hear any abnormal noises with the airplane or engine, nor did he observe any wildlife in the area. He stated, “everything appeared normal until it wasn’t." A second pilot reported that, on the day of the accident, he was working with the accident pilot from the same grass strip. Throughout the day they dispersed about 28 loads of fertilizer; during which, the accident pilot did not report any anomalies with the airplane. Shortly before the accident, the accident airplane was loaded with full fuel and fertilizer. The accident pilot was actively spraying a field when the second pilot departed the area to refill fertilizer. When the second pilot returned, he observed the airplane burning on the ground about 0.5 miles east of the field it was spraying. - The airplane came to rest upright on the edge of a field; the dirt was moderately hard and mostly dry. The nose of the airplane was embedded into the dirt at about a 45° angle and only one propeller blade was visible. The forward fuselage, cockpit, inboard right and left wings, and the aft fuselage exhibited extensive thermal damage. The cabin area was destroyed by fire exposing the underlying airframe structure. The instruments and instrument panel were not present. Both wings remained attached at the wing spar. Flight control continuity was established to the control surfaces through multiple fractures and thermal damage. A postaccident examination of the airframe and engine revealed no preimpact mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
A witness reported that he observed the airplane about 1 mile away flying directly toward him. He stated that it appeared to be straight and level, about treetop height. Without warning, he observed a small puff of white smoke; the airplane immediately nosed down and impacted the ground. A post-crash fire ensued. The witness did not hear any abnormal noises with the airplane or engine, nor did he observe any wildlife in the area. He stated that “everything appeared normal until it wasn’t.” The airplane came to rest upright on the edge of a field. The nose of the airplane was embedded into the dirt at about a 45° angle and only one propeller blade was visible. The forward fuselage, cockpit, inboard right and left wings, and the aft fuselage exhibited extensive thermal damage. A postaccident airframe and engine examination did not reveal any anomalies with the airframe or engine that would have precluded normal operations. The engine displayed signatures of rotation, and control continuity was established throughout. Another pilot reported that, on the day of the accident, he was working with the accident pilot from the same grass strip. Throughout the day they dispersed about 28 loads of fertilizer; the accident pilot did not report any anomalies with the airplane during these flights.
Probable cause
An inflight loss of control and subsequent impact with terrain during an aerial application flight for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Air Tractor
Model
502B
Amateur built
false
Engines
1 Turbo prop
Registration number
N6088K
Operator
Scott Flying Service
Flight conducted under
Part 137: Agricultural
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
502B-0281
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-22T18:50:04Z guid: 103270 uri: 103270 title: ERA21LA262 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103303/pdf description:
Unique identifier
103303
NTSB case number
ERA21LA262
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-18T09:45:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-07-02T21:33:15.219Z
Event type
Accident
Location
SWAN LAKE, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On June 18, 2021, around 0845 eastern daylight time, a McDonnell Douglas Helicopter 369E, N371EE, was substantially damaged when it was involved in an accident near Swan Lake, New York. The pilot and lineman sustained serious injuries. The helicopter was being operated by Haverfield Corporation as a Title 14 Code of Federal Regulations Part 133 rotorcraft external load operation. The helicopter was performing maintenance work to electric power transmission equipment. The pilot visually confirmed there was adequate clearance to work as he approached the tower and positioned the helicopter near one of the tower structures. The lineman, seated on a platform attached externally on the skids, removed the safety voltage detector to make room for his shunt and started the maintenance. The pilot described that during this process it felt a “bang came from behind them” and the helicopter began to shake violently while various cockpit alarms sounded. He stated that he had “limited control authority” as he pulled away from the tower and looked for a safe area to land. He descended the helicopter through the tree branches while attempting to keep it level. The lineman reported that as he began the maintenance, he heard a “bang” and then repeated “bang” noises and felt the helicopter shaking as it pulled away from the tower. He attempted to turn around to see if they had struck something but was unable to do so given the force that was pushing him onto the platform. His equipment began to fly off the platform and he tucked himself into a ball on the platform when he saw that the helicopter was descending through the trees. The helicopter impacted trees and came to rest upright in a heavily wooded area. The tailboom remained attached to the fuselage with left bending and crushing deformation forward of the empennage. A photo of the powerline tower being worked on revealed damage to a lifeline support bracket for the tower catwalk (see figure). Figure - Tower where lineman was working with close-up view of damage. A postaccident microscopic examination of one main rotor blade tip showed witness marks consistent with metal impact. The tail rotor assembly exhibited little to no damage. The examination revealed no evidence of any preimpact failure or malfunction of the helicopter’s controls or engine that would have precluded normal operation. A postaccident examination of the tower revealed that, unlike most of the towers being maintained, it was equipped with a catwalk which had a lifeline support bracket protruding from the top of it for the tower catwalk. Review of the helicopter technical description as well as a diagram of the tower at which the upset occurred revealed that there was a negative vertical and lateral clearance from the main rotor blades to the lifeline support bracket for the tower catwalk. -
Analysis
The pilot positioned the helicopter near one of the power transmission tower structures as the lineman, seated on a platform that was attached externally on the skids, began the maintenance. The pilot and the lineman both reported that they then heard a bang, and the helicopter began to shake violently. The pilot maneuvered the helicopter away from the tower and descended through the tree branches. The helicopter came to rest upright in a heavily wooded area. A microscopic postaccident examination of one main rotor blade tip revealed witness marks consistent with metal impact, and a support bracket for the tower catwalk displayed impact damage. A postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. A postaccident examination of the tower revealed that, unlike the majority of the towers being maintained, it was equipped with a catwalk which had a lifeline support bracket protruding from the top of it for the tower catwalk. Given this information, it is likely that the pilot did not note this hazard and that main rotor blade tip impacted the tower structure and resulted in the subsequent loss of control.
Probable cause
The pilot's failure to maintain adequate clearance from the power transmission tower structure during powerline maintenance work, which resulted in the helicopter's main rotor striking the lifeline support bracket for the tower catwalk and the subsequent loss of control and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MCDONNELL DOUGLAS HELICOPTER
Model
369E
Amateur built
false
Engines
1 Turbo shaft
Registration number
N371EE
Operator
Haverfield International
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
External load
Commercial sightseeing flight
false
Serial number
0371E
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-02T21:33:15Z guid: 103303 uri: 103303 title: ERA21FA258 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103288/pdf description:
Unique identifier
103288
NTSB case number
ERA21FA258
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-18T12:06:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-06-25T17:54:17.795Z
Event type
Accident
Location
Yulee, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The FAA Airplane Flying Handbook (FAA-H-8083-3C) addresses upset prevention and recovery training, including slow flight and stalls. It states, in part: As in all maneuvers that involve significant changes in altitude or direction, the pilot should ensure that the area is clear of other air traffic at and below their altitude and that sufficient altitude is available for a recovery before executing the maneuver. It is recommended that stalls be practiced at an altitude that allows recovery no lower than 1,500 feet AGL for single-engine airplanes… The FAA Private Pilot – Airplane Airman Certification Standards (FAA-S-ACS-6B) addresses power-on stalls, power-off stalls, and slow flight. It requires that all tasks be completed no lower than 1,500 ft agl for single-engine aircraft. - According to the operator, the airplane was purchased in December 2020 and was used for flight instruction since its purchase. - On June 18, 2021, about 1106 eastern daylight time, a Cessna 150L, N1300Q, was destroyed when it was involved in an accident near Yulee, Florida. The flight instructor and the student pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to air traffic control (ATC) radar data obtained from the Federal Aviation Administration (FAA), the flight departed Fernandina Beach Municipal Airport (FHB), Fernandina Beach, Florida, about 1056 and proceeded on a northwesterly heading for about 7 miles until over the St. Mary’s River. No ATC services were provided. The airplane performed several 360° turns, at slow speed, about 800 to 1,000 ft above ground level (agl). The last radar return was about 300 ft south of the accident site, at 800 ft agl.   Several witnesses at a nearby boat dock reported that the airplane descended into the St. Mary’s River in a near-vertical, nose-down attitude. One witness stated that the airplane was circling and turning while descending; another reported that the airplane descended nose down in a “corkscrew” path. Two of the witnesses recalled that the engine was running until impact with the water. - Toxicology testing performed by the FAA Forensic Sciences Laboratory detected acetaminophen (Tylenol) in the flight instructor’s cavity blood and in his urine. No ethanol was detected. Toxicology testing on the student pilot was performed by the FAA Forensic Sciences Laboratory. No evidence of drugs or ethanol were found. - According to the student pilot’s logbook, the accident flight was her fifth flight at the flight school that operated the airplane. All flights were with the accident flight instructor. She had also logged flight instruction at a different flight school in a Diamond DA-20 airplane and had soloed in the DA-20. The operator’s ground operations director reported that she was a “sharp” student. She took her lessons seriously and was always prepared. The ground operations director reported that he met the flight instructor in May 2021, when the flight instructor was hired. He held the flight instructor in “high regard.” The flight instructor did not exhibit any unusual personality traits or poor flying habits. He was very cautious and was not one to take any risks while flying. The chief flight instructor where the flight instructor was previously employed reported that the flight instructor was an experienced pilot in both single- and multiengine airplanes and was an excellent pilot and instructor. He also stated that he was very professional and would never perform any risky maneuvers. The flight instructor flew a instructional flight with another student in the airplane during the morning before the accident. The student reported that they took off about 0800 and proceeded up the St. Mary’s River at an altitude of about 1,000 ft agl. He then performed clean stalls, stalls with flaps extended, and a power-off glide at altitudes between 1,000 and 1,200 ft agl. He stated that there were no issues with the airplane mechanically, and there was no unusual looseness or binding in the flight controls. When asked about previous flights with the flight instructor, he reported that they always performed air work, including stalls, at 1,000 to 1,200 ft agl, and never above 1,800 ft agl. A-Cent Aviation’s policy regarding minimum altitude for recovery from stalls and other air work was 1,500 ft agl; however, most instructors at the school performed stalls at a much higher altitude than the minimum recovery altitude of 1,500 ft agl. - The airplane impacted the St. Mary’s River and sank in about 17 ft of water. There was no fire. The accident site was about 7 nautical miles northwest of FHB. After recovery from the river, the wreckage was transported to an aircraft salvage facility for examination.   Initial examination of the wreckage revealed that all major structural components of the airplane were present. The fixed, tricycle landing gear remained attached to the airframe. The engine was broken from the engine mounts; however, it was held in position by control cables and wires. The fixed-pitch propeller remained attached to the engine. The leading edges of the wings were compressed aft, equally, to about two-thirds of their original chord width. The right wing separated from the forward mount but remained attached at the aft mount. The left wing remained attached at both mounts. The wing flaps remained attached to the wings and were found in the retracted positions. The right aileron was complete and remained attached to the inboard hinge and the push/pull rod. The left aileron was intact and remained attached to the inner and center hinges and the push/pull rod. Aileron cable continuity was confirmed from the control surfaces to the cockpit controls. The rudder remained attached to the vertical stabilizer. The elevators remained attached at the outboard hinge locations and to the elevator control bellcrank and did not exhibit impact damage. The elevator bellcrank was fractured at the bulkhead attach point. The attach bolt and bushing remained attached to the bulkhead. Neither the vertical stabilizer nor the horizontal stabilizer exhibited signs of impact damage. The elevator push/pull rod was intact from the control column to the elevator sector beneath the seats. Rudder cable continuity was confirmed from the rudder horn to the cockpit controls. The elevator bellcrank, rudder, and a portion of tail cone were submitted to the National Transportation Safety Board Materials Laboratory for further examination. The elevator bellcrank had been assembled to the tail cone via a bolted joint; however, a portion of the connection through-hole in the bellcrank had separated. The separated portion consisted of roughly one-half of the through-hole circumference, which allowed the bellcrank to separate from the mating bolt. Both fracture surfaces had rub damage that obscured large areas. The undamaged areas on the fracture surfaces had features consistent with overstress. According to FAA Airworthiness Directive (AD) 2009-10-09, all Cessna 150 model aircraft should have either a placard prohibiting spins and other aerobatic maneuvers or service kit part number SK152-25 installed. SK152-25 replaces the rudder stop, rudder stop bumpers, and the attachment hardware with new duplicate parts and includes the addition of a doubler. Neither stop bolt on the accident aircraft had a doubler nor a nut and washer assembled on the inside surface of the tail cone skin, which indicated that SK152-25 was not installed. A damaged placard was found on the instrument panel that appeared to comply with the AD. The engine exhibited damage from impact and from exposure to salt water and sand. The examination of the engine did not reveal evidence of a preexisting malfunction or anomaly that would have precluded normal operation. One propeller blade was bent aft about 90° and exhibited “s” bending signatures. The other blade was bent slightly aft and exhibited slight “s” bending signatures. -
Analysis
The flight instructor and the student pilot proceeded to the usual training area over a river for an instructional flight. Radar data indicated that the airplane completed several 360° turns, at slow speed, about 800 to 1,000 ft above ground level (agl); the observed maneuvering was consistent with the performance of slow flight. The last radar return was about 300 ft south of the accident site, at 800 ft agl. Several witnesses at a nearby boat dock reported that the airplane descended into the river in a near-vertical, nose-down attitude. One witness stated that the airplane was circling and turning while descending; another reported that the airplane descended nose down in a “corkscrew” path. The witness observations were consistent with the airplane having entered an aerodynamic stall and subsequent spin. Two of the witnesses recalled that the engine was running until impact with the water. The airplane sank in about 17 ft of water. An examination of the wreckage after recovery from the river did not reveal evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation. The flight school that operated the airplane reported that the minimum altitude for recovery during air work, including stalls and slow flight, was 1,500 ft agl. Another student, who flew with the same flight instructor earlier that day, reported that the flight instructor routinely conducted air work below the 1,500 ft minimum. It is likely that the flight instructor allowed the student to stall the airplane at low altitude and delayed remedial action; the airplane subsequently entered a spin from which the instructor was unable to recover before impact.
Probable cause
The flight instructor’s decision to conduct slow flight training at an altitude below the flight school’s minimum recovery altitude and his delayed remedial action when an aerodynamic stall occurred.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N1300Q
Operator
A-Cent Aviation Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15072600
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-06-25T17:54:17Z guid: 103288 uri: 103288 title: HWY21MH009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103291/pdf description:
Unique identifier
103291
NTSB case number
HWY21MH009
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-19T15:21:00Z
Publication date
2023-06-02T04:00:00Z
Report type
Final
Last updated
2023-04-26T04:00:00Z
Event type
Accident
Location
Greenville, Alabama
Injuries
10 fatal, 2 serious, 16 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Greenville, Alabama, crash was the unsafe speeds of multiple vehicles during rain, low visibility, and wet road conditions. Contributing to the fatal injuries of the transit van passengers was the postcrash fire.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2020 Volvo & Car Carrier
Traffic unit type
Combination Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2020 Ford Explorer
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 3

Traffic unit name
2005 Freightliner & Dry Van Trailer
Traffic unit type
Combination Vehicle
Units
Findings

Vehicle 4

Traffic unit name
2017 VW Passat
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 5

Traffic unit name
2017 Ford F-350 Transit Van
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 6

Traffic unit name
F150 King Ranch
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 7

Traffic unit name
2016 Ram 1500
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 8

Traffic unit name
2021 Chrysler Pacifica
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 9

Traffic unit name
2017 Kia Sedona
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 10

Traffic unit name
2017 Toyota Camry
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 11

Traffic unit name
2020 Acura TLX
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 12

Traffic unit name
2017 Buick Lacrosse
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-04-26T04:00:00Z guid: 103291 uri: 103291 title: CEN21LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103314/pdf description:
Unique identifier
103314
NTSB case number
CEN21LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-20T08:00:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-06-23T23:56:07.342Z
Event type
Accident
Location
Sedgwick, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 20, 2021, about 0700 central daylight time, a Grumman G-164B airplane, N62375, was substantially damaged when it was involved in an accident near Sedgwick, Arkansas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial-application flight. The pilot stated that he had completed 5 to 6 aerial-application passes over the intended rice field when the airplane had a total loss of engine power while in level flight. The pilot stated that the sound of the engine went from normal to silent, with no indication of an issue before the loss of engine power. The airplane impacted a levee and nosed over in a flooded rice field during the forced landing. The airplane’s empennage, aft fuselage, and engine mounts were substantially damaged during the forced landing. - A postaccident engine examination and disassembly revealed the torque sensor assembly front spur gear was loose and disengaged from the splined shouldered shaft on which it was installed. Furthermore, the self-locking nut that secured the front spur gear to the shaft had backed off which allowed the front spur gear to disengage from the shaft. A disassembly of the torque sensor assembly revealed that the internal spline teeth of the front spur gear and the corresponding external forward spline teeth of the splined shouldered shaft were heavily damaged, smeared over, and exhibited loss of teeth material. Metallurgical examination of the splined shouldered shaft found stepped wear and deformation consistent with meshing with the fretted internal spline teeth of the front spur gear. Wear and deformation were also observed on the last (rearward) threads of the splined shouldered shaft consistent with contact with the worn threads of the self-locking nut. The internal spline teeth of the front spur gear exhibited corresponding wear and deformation consistent with meshing with the fretted external forward spline teeth of the splined shouldered shaft. Dimensional inspection of the splined shouldered shaft away from the damaged region was consistent with the manufacturing drawing. The average hardness of the splined shouldered shaft and front spur gear were within their respective manufacturing drawing ranges. The self-locking nut that secured the front spur gear to the splined shouldered shaft has slightly ovalized threads so that the nut must elastically deform to mate with the threads of the splined shouldered shaft, causing increased surface friction that resists loosening when fully and properly torqued. Metallurgical examination of the self-locking nut exhibited wear marks on one side of each wrenching flat consistent with contact from the installation/torque tool, wear marks on the aft face of the nut consistent with contact with the mating washer, and wear of the internal threads consistent with engagement with the splined shouldered shaft. The average hardness of the self-locking nut met the minimum hardness design requirement. However, the examination and testing were unable to determine if the self-locking nut had been improperly torqued at installation or if it became loose during operation due a loss of retention. According to overhaul documentation, a new self-locking nut was used when the torque sensor assembly, part number 3101726-3, serial number P-4184C, series 2, was last overhauled on October 3, 2013. The engine logbook indicated that the overhauled torque sensor assembly was installed on the engine on February 11, 2015. At the time of the accident, the torque sensor assembly had accumulated 2,541.5 hours since its last overhaul. The engine-driven fuel pump and fuel control unit (FCU) are driven through a series of gears in the accessory gearbox, including the front spur gear, and any failure in the gear train that drives the fuel pump and FCU would prevent the fuel pump from delivering fuel to the FCU to sustain engine operation, resulting in an uncommanded engine shutdown. -
Analysis
The pilot was conducting an agricultural flight when the airplane had a sudden total loss of engine power. The pilot stated that the sound of the engine went from normal to silent, with no indication of an engine issue before the loss of engine power. The airplane impacted a levee and nosed over in a flooded rice field during the forced landing. The airplane’s empennage, aft fuselage, and engine mounts were substantially damaged during the forced landing. A postaccident engine examination and disassembly revealed the torque sensor assembly front spur gear was disengaged from the splined shouldered shaft on which it was installed. Additionally, the self-locking nut that secured the front spur gear to the shaft had backed off which allowed the front spur gear to disengage from the shaft. The examination and testing were unable to determine if the front spur gear self-locking nut was improperly torqued at installation or if it became loose during operation due a loss of retention. However, had the self-locking nut not been seated properly at installation, the disengagement of the front spur gear would likely have occurred well before the accident (2,541.5 hours since the overhauled torque sensor was installed on the engine). Additionally, no anomalies were found with the self-locking nut to suggest why it would have lost retention during operation. The engine-driven fuel pump and fuel control unit (FCU) are driven through a series of gears in the accessory gearbox, including the front spur gear, and any failure in the gear train that drives the fuel pump and FCU would prevent the fuel pump from delivering fuel to the FCU to sustain engine operation, resulting in an uncommanded engine shutdown.
Probable cause
The total loss of engine power due to the failure and disengagement of the torque sensor assembly front spur gear from its splined shouldered shaft due to a loose self-locking nut.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
G164
Amateur built
false
Engines
1 Turbo prop
Registration number
N62375
Operator
Scott Flying Service
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
806B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-23T23:56:07Z guid: 103314 uri: 103314 title: WPR21FA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103294/pdf description:
Unique identifier
103294
NTSB case number
WPR21FA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-20T15:40:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-07-07T01:07:57.238Z
Event type
Accident
Location
White City, Oregon
Airport
BEAGLE SKY RANCH (OR96)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On June 20, 2021, at 1440 Pacific daylight time, a Piper PA-22-135, N2618A, was destroyed when it was involved in an accident near White City, Oregon. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A friend of the pilot reported that the pilot departed from Bend, Oregon, around 1415, with the intention of relocating the airplane to Beagle Sky Ranch Airport (OR96), White City, Oregon, for its annual inspection. The friend was waiting at OR96 for the pilot to arrive so that he could drive the pilot back to his home. The friend reported that he saw the airplane fly over OR96 an assumed that the pilot was going to enter the traffic pattern for landing, but the airplane flew out of sight. About 30 minutes later, he received a telephone call from the pilot who had landed at another nearby airport (Shady Cove). He stated he could hear someone in the background giving the pilot directions on how to get to OR96. The friend reported that, a while later, he observed the airplane enter the pattern on a left downwind for runway 33; however, the pilot initiated a go-around when the airplane was not aligned with the runway. The airplane made multiple attempts to land and on the last attempt the airplane was east of the runway, maneuvering back toward the airport when it contacted trees. The friend subsequently heard the crash but did not witness the accident. The outside air temperature near the accident airport around the time of the accident was about 95°F and the density altitude was over 4,000 ft. Another witness located the Shady Cove Airpark, about 5 nautical miles northeast of the accident site, stated that he was outside in a neighbor’s yard when they saw the airplane enter the traffic pattern and land. They were concerned because the airplane appeared erratic on downwind, and when the airplane turned onto the base leg, the turn was wide, and the pilot had to overcorrect back to final. The witness stated that the airplane touched down midfield, bounced, and went out of his field of view. They were concerned he had crashed but saw that the airplane had parked in his front yard and was shut down. The witness stated that spoke to the pilot and the pilot seemed lethargic and confused and was slow to respond to their questions. The pilot asked multiple times if he was at Beagle airport, and they answered him numerous times that he was not. The witness stated that they offered the pilot water and asked him if he wanted to get out of the airplane. They stated the pilot had on long pants and fuzzy socks and seemed to be overdressed for the weather conditions. The pilot declined their offer of assistance and did not get out of his airplane. The witnesses watched him take off about 20 minutes later. They noted that it sounded like he only had partial power on takeoff, the engine was running normally and sounded normal. The witness further reported that the airplane did not look like it was under control when it took off. Another witness located about 5 miles southwest of the accident site reported seeing an older tricycle gear Piper tri-pacer with the flaps fully extended and in a nose-high attitude that appeared to be having trouble gaining altitude and was on a verge of a stall. PILOT INFORMATION The 80-year-old private pilot’s last Federal Aviation Administration (FAA) medical certificate was issued on January 19, 1979. The pilot reported 550 total hours of flight experience, with 12 flight hours accrued with in the last six months of the exam date. The pilot’s personal logbook was found in the wreckage and had sustained thermal damage in the post-crash fire. The edges of the logbook had burned, and the last readable and totaled time of 623.1 was in 1979; however, the date was unreadable. His private pilot certificate was issued on September 22, 1974. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed by the Oregon State Medical Examiner, Clackamas, Oregon. The cause of death was blunt and thermal trauma due to an aircraft crash and manner of death was accident. The medical examiner reported that the pilot had severe atherosclerosis of his coronary arteries and aorta, stents in his coronary arteries, evidence of prior myocardial infarction, and evidence of congestive heart failure. In addition, the medical examiner reported that the pilot had a significant medical history that included atrial fibrillation and stage III chronic kidney disease. The medical examiner also reported that the pilot had evaluations on June 9, and June 11, 2021, at a local hospital for shortness of breath, epigastric pain, and lower extremity edema. The pilot refused hospital admission on both dates. Toxicology testing performed at the FAA Forensic Sciences Laboratory found 2991 ng/mL, ng/g gabapentin detected in blood (cardiac), 106985 ng/mL, ng/g gabapentin detected in urine, doxylamine inconclusive in blood (cardiac), 303 ng/mL, ng/g doxylamine detected in urine, torsemide detected in blood (cardiac) and urine, carvedilol inconclusive in blood (cardiac) and detected in urine, and dextromethorphan detected in urine. The toxicology testing found gabapentin, doxylamine, torsemide, and carvedilol in blood and urine. Gabapentin is a prescription antiseizure medication commonly marketed as Neurontin. Doxylamine is a sedating antihistamine often used to treat allergy symptoms. FAA provides guidance on wait times before flying after using this medication. Torsemide is a prescription fluid retention medication, commonly marketed as Demadex, for congestive heart failure, kidney disease, or liver disease. It can also treat high blood pressure. Carvedilol is a prescription beta blocker medication used to treat high blood pressure and heart failure. According to the pilot’s wife, he had a heart attack 5 years previous and was taking nitroglycerin. She further reported that he had a mild heart attack 3 weeks before the accident. The wife also stated that her husband was easily confused, irritable, and was in poor health. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the first identified point of impact were the tops of 75-ft-tall trees about 205 ft east of the approach end of runway 33. The airplane continued in an arc-like trajectory, where it travelled across a street, about 1 mile to the northeast, impacted a chimney and trees, before it came to rest in the side yard of a residence, where a post-crash fire ensued. The entire airplane came to rest on its left side against a barbed-wire fence oriented on a magnetic heading of 021°. Flight control continuity was established from the cockpit, through the tee-bar, to each wing and to the empennage. The engine examination established engine drivetrain continuity. The cylinders were borescoped with no anomalies identified. Manual rotation of the crankshaft produced thumb compression in all cylinders. The propeller had separated from the crankshaft flange and was partially embedded in the ground about 10 ft from the main wreckage. One propeller blade was bent aft with S-bending, and the tip had separated. The other propeller blade was bent aft. Propeller blade strikes were identified to several tree limbs. There was no evidence of a preimpact mechanical anomaly or malfunction observed with the airframe or engine. -
Analysis
The pilot was repositioning his airplane to the accident airport for an annual inspection. He had planned to have a friend meet him at the destination airport to drive him home. The friend waiting to pick the pilot up at the destination airport stated that the pilot initiated a go-around when the airplane was not aligned with the runway on the first landing attempt. The friend stated that the pilot attempted another landing and once again the airplane was not aligned with the runway, so the pilot initiated another go-around. The pilot made two landing attempts, and during the last attempt, the airplane contacted trees off the left side of the departure end of the runway. The airplane then impacted terrain and a postimpact fire ensued. At the time of the accident, the density altitude at the airport was over 4,000 ft. A witness located at a residential airpark about 5 nautical miles from the pilot’s intended destination, where the accident subsequently occurred, reported that the accident airplane had landed at their private airpark just before the accident. They were worried because the airplane’s approach was erratic, and fast, and touched down about midfield and bounced before it went out of their view. The witness went to find the airplane and found it parked in his front yard. The pilot seemed lethargic, confused, and slow to answer questions. The pilot asked multiple times if he was at his destination airport, and the witnesses replied that he was not. Witnesses reported that about 20 minutes later the pilot departed from their airport. The witness reported that, although the airplane’s engine was running and sounded normal, it also sounded like the pilot had only applied partial power on takeoff. The witness noted that the airplane did not appear to be under control during the takeoff. Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. According to the pilot’s wife, the pilot had heart issues that included two previous heart attacks, one of which was 3 weeks before the accident. The pilot’s wife also stated that her husband was easily confused, irritable, and was in poor health. His two visits to the emergency room about 10 days before the accident suggest that the pilot’s condition was not well-controlled. The pilot’s toxicology testing detected gabapentin, doxylamine, dextromethorphan, torsemide and carvedilol in his system. In addition, the pilot’s autopsy identified severe cardiovascular disease, chronic kidney disease, and previous atrial fibrillation. Based on the operational evidence, the pilot had actively attempted several landings when the accident occurred; therefore, it is unlikely that the pilot experienced sudden incapacitation. However, operational evidence and witness reports indicate that the pilot was behaving in a confused manner. The pilot was taking a diuretic medication and other medications that decrease sweating and body cooling. He was also taking gabapentin, which is associated with dizziness and sleepiness. Even without a heat stressor, people with chronic heart failure can experience mental confusion and impaired thinking. The pilot also had moderate chronic kidney failure that would decrease his heat tolerance. Additionally, heat stress can further impact kidney function. Decline in kidney function with subsequent buildup of body wastes in the blood can lead to confusion. Given the high outside temperatures, the pilot’s medical conditions, as well as the prescribed medication detected in his system, it is likely that the pilot experienced mental confusion and impaired thinking/judgement, which resulted in his inability to safely operate the airplane.
Probable cause
The pilot’s failure to maintain control of the airplane during a go-around, which resulted in a collision with trees. Contributing to the accident was the pilot’s impairment due to his medical conditions and the effects of his medications.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-135
Amateur built
false
Engines
1 Reciprocating
Registration number
N2618A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-2186
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-07T01:07:57Z guid: 103294 uri: 103294 title: ERA21FA263 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103304/pdf description:
Unique identifier
103304
NTSB case number
ERA21FA263
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-21T10:30:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-06-29T15:27:28.709Z
Event type
Accident
Location
Mercer, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Review of the airplane’s maintenance records revealed that the most recent annual inspection was completed on March 3, 2021, at an airframe and engine total time of 1,217.9 hours. During the annual inspection, the left turbocharger was replaced with an overhauled turbocharger. According to the airplane pilot operating handbook (POH), the Cirrus Airframe Parachute System (CAPS) is designed to lower the aircraft and its passengers to the ground in the event of a life-threatening emergency. CAPS deployment is likely to result in damage to the airframe and, possibly injury to aircraft occupants, its use should not be taken lightly…. If a forced landing on an unprepared surface is required CAPS activation is recommended unless the pilot in command concludes there is a high likelihood that a safe landing can be accomplished. If a condition requiring a forced landing occurs over rough or mountainous terrain…CAPS activation is strongly recommended….” - On June 21, 2021, about 0930 central daylight time, a Cirrus Design Corporation SR22T, N333LZ, was substantially damaged when it was involved in an accident near Mercer, Tennessee. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to air traffic control communications obtained from the Federal Aviation Administration, the airplane departed Memphis International Airport (MEM), Memphis, Tennessee, about 0900 on an instrument flight rules flight plan with an intended destination of Asheville Regional Airport (AVL), Asheville, North Carolina. The pilot established radio communication with air traffic control while climbing through 3,000 ft mean sea level (msl) to 15,000 ft msl; however, after the airplane climbed to 6,600 ft msl, it began to lose altitude. The pilot advised the controller that the airplane was experiencing engine issues associated with manifold pressure. The pilot then requested to divert to McKellar-Sipes Regional Airport (MKL), Jackson, Tennessee, where the airplane was maintained. The pilot further stated that he was not declaring an emergency. The controller cleared the airplane to MKL with a descent to 3,000 ft msl at the pilot’s discretion. The controller then transferred communications to the MKL controller. The pilot contacted the MKL controller while the airplane was descending through 3,900 ft msl for 3,000 ft msl. He asked for the RNAV RWY20 approach to MKL and requested a descent at pilot’s discretion to maintain airspeed. The controller advised the pilot that he needed to maintain 2,500 ft msl, which was the minimum vectoring altitude (MVA) for the area. The airplane subsequently gradually descended below the MVA and the controller advised the pilot that Bolivar Airport (M08), Bolivar, Tennessee, was located on his right side; however, the pilot continued to MKL (At that time, M08 was located about 10 nautical miles (nm) east, and MKL was located about 27 nm northeast of the airplane’s position; respectively). When the airplane was at 720 ft msl, the pilot reported that he was attempting to land in a field. The controller advised the pilot that radar contact was lost; however, he asked the pilot the altitude of the airplane, and the pilot stated 600 ft msl. The controller also asked the pilot if he intended to use the parachute, and the pilot responded that he was trying for a field. No further communications were received from the pilot. - The Office of the Medical Examiner, Nashville, Tennessee, performed an autopsy on the pilot. His cause of death was reported as blunt force injuries. Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot’s blood and urine identified no evidence of impairing drugs. - The wreckage was located in a field on the edge of a tree line about 10 miles southwest of MKL. The airplane came to rest upright on a magnetic heading of 360°. Several large tree branches were lying beside the wreckage. The left wing leading edge exhibited tree impression marks along its length. All three landing gear were separated but remained under the main wreckage. The empennage remained attached to the fuselage. The horizontal stabilizer remained attached to the empennage and exhibited impact damage. The vertical stabilizer remained attached to the empennage; however, the rudder was separated from the vertical stabilizer at the top and mid-point hinges. Control cable continuity was established to all flight control surfaces from the flight controls to the cockpit. The Cirrus Airframe Parachute System (CAPS) was found intact. The safety pin was out of the handle, but the system was not activated. Both wings remained attached to the fuselage and exhibited impact damage. The engine remained attached to the fuselage; however, the engine mounts were fractured in numerous places. The propeller remained attached to the engine. One propeller blade was fractured and found about 20 ft from the main wreckage. The spinner dome was crushed and creased and contained tree bark. The airplane was recovered to a salvage facility for further examination. The bottom spark plugs were removed and exhibited normal wear. The propeller was rotated by hand through 360° and crankshaft continuity was established through the valvetrain. Thumb compression was attained on all cylinders. A lighted borescope was used to examine the pistons, valves, and cylinder walls and all exhibited normal wear. Both turbochargers rotated smoothly by hand. The left exhaust exhibited cracking and melting at the turbocharger attachment flange. The waste gate was removed, and a small metal fragment was wedged between the housing and the valve, which was about 75% closed. The waste gate controller mounting bracket was fractured and the connecting rod was bent. The metal fragment was sent to the National Transportation Safety Board Materials Laboratory for identification. The metallic section was examined using an x-ray fluorescence (XFR) alloy analyzer. The metallic section was consistent with stainless steel. The Recoverable Data Module (RDM) was removed from the vertical stabilizer. It was not damaged. The RDM was partially downloaded on scene and the data included the accident flight in its entirety. The manifold air pressure (MAP) limit was exceeded about 10 minutes into the flight. The maximum normal operating range for MAP for the airplane according to the POH was 36.5 inches. The peak recorded value during the exceedance was 53.9 inches. Additionally, the MAP fluctuated from the time of the exceedance until the end of the data about 19 minutes later. -
Analysis
While climbing to cruise altitude during a cross-country flight, the pilot advised the air traffic controller that the airplane was experiencing engine issues associated with manifold pressure and requested to divert to an airport where the airplane was maintained; however, this was not the nearest airport. The pilot further stated that he was not declaring an emergency. The controller cleared the airplane to the requested airport with a descent to 3,000 ft msl at the pilot’s discretion, and subsequently transferred communications to the controller at the diversion airport. The controller advised the pilot that he needed to maintain 2,500 ft msl, which was the minimum vectoring altitude (MVA). The airplane gradually descended below the MVA, and the controller advised the pilot that a closer airport was located on his right side (about 10 nm); however, the pilot continued to the diversion airport (about 27 nm). When the controller asked if the pilot was going to use the airframe parachute, the pilot indicated that he was attempting to land in a field. The airplane impacted trees and came to rest in a field about 10 miles from the diversion airport. Data retrieved from the airplane’s Recoverable Data Module (RDM) revealed that the manifold air pressure (MAP) limit was exceeded about 10 minutes into the flight, reaching a peak recorded value of 53.9 inches. The maximum normal operating range for MAP for the airplane according to the pilot operating handbook (POH) was 36.5 inches. The MAP fluctuated from the time of the exceedance until the end of the data, about 19 minutes later. Examination of the engine revealed that the left turbocharger waste gate contained a small metal fragment wedged between the housing and the valve, which was about 75% closed. Metallurgical examination of the fragment revealed it was consistent with stainless steel. Review of the airplane’s maintenance records revealed that the left turbocharger was replaced 3 months before the accident during the most recent annual inspection. It is likely that the maintenance performed on the airplane during the inspection resulted in foreign object deposited into the exhaust system and jammed the waste gate, resulting in an overboost of the turbocharger and partial loss of engine power.
Probable cause
A partial loss of engine power due to foreign object debris contamination of the left turbocharger wastegate. Contributing to the accident was the pilot’s failure to divert to the nearest airport.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N333LZ
Operator
Skylane Partners LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0243
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-06-29T15:27:28Z guid: 103304 uri: 103304 title: ERA21LA267 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103329/pdf description:
Unique identifier
103329
NTSB case number
ERA21LA267
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-24T12:15:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-07-06T23:51:19.622Z
Event type
Accident
Location
Easton, Maryland
Airport
EASTON/NEWNAM FLD (ESN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 24, 2021, about 1115 eastern daylight time, a Piper PA-28-161, N2143G, was destroyed when it was involved in an accident near Easton, Maryland. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the student pilot, he conducted a preflight inspection before he and his instructor completed the engine run-up and takeoff with no anomalies noted. They stayed in the airport traffic pattern, conducting three takeoffs and landings before stopping to let the instructor out, so that the student pilot could perform three solo take-offs and landings. After the second take-off, the student pilot was turning onto the downwind leg of the airport traffic pattern when he heard a reduction in engine power and could see the propeller slowing down. He was at an altitude of about 700 ft above ground level and had to pitch the airplane forward so it would not stall. The pilot did not think he could make it back to the airport, so he selected a field and maneuvered for a forced landing, during which the airplane impacted a pile of metal on the ground. Witnesses reported that the airplane appeared to pitch nose-up before reaching the field, then stalled and impacted a construction area. Ground personnel rescued the student pilot before a postcrash fire ensued. The wreckage was taken to an aircraft recovery facility for further examination. The fuselage above the lower fuselage skin and structure below the floorboards was consumed by fire. The instrument panel, most of the instruments, avionics, gauges, and switches were fire damaged and unreadable. The firewall was separated from the fuselage and the rudder pedal assembly remained attached to the firewall. Flight control cable continuity for the aileron, stabilator, and rudder cables were continuous from the cockpit to the respective control surfaces, except for separations consistent with cuts made during the recovery process near the wing roots and the tailcone. The propeller remained attached to the crankshaft flange. Both magnetos remained installed on the back of the accessory housing; however, both units were consumed by fire. The cylinders were examined using a borescope and minor scoring was noted. No anomalies were noted with the engine or airframe that would have precluded normal operation. Due to fire damage, the ignition and fuel systems could not be tested. -
Analysis
The student pilot was conducting his first solo flight. After his second takeoff, while turning onto the downwind leg of the airport traffic pattern, he heard the engine lose power. At an altitude of 700 ft above ground level, he did not think he could make it back to the airport, so he maneuvered the airplane for a forced landing to a field. During the approach, the airplane stalled and impacted a construction area before reaching the field. A postcrash fire ensued. Flight control cable continuity for the aileron, stabilator, and rudder cables were continuous from the cockpit to the respective control surfaces, except for separations consistent with recovery cuts near the wing roots and the tailcone. The engine cylinders were examined with a borescope and minor scoring was noted. No anomalies were noted with the airframe or engine that would have precluded normal operation; however, due to the extent of the postcrash fire damage, the ignition and fuel systems could not be examined or tested, and the reason for the loss of engine power could not be determined.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-161
Amateur built
false
Engines
1 Reciprocating
Registration number
N2143G
Operator
Trident Aircraft Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7916176
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-06T23:51:19Z guid: 103329 uri: 103329 title: ERA21LA269 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103346/pdf description:
Unique identifier
103346
NTSB case number
ERA21LA269
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-25T17:50:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-07-14T21:22:54.855Z
Event type
Accident
Location
Alpine, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On June 25, 2021, about 1650 central daylight time, a Garlick Helicopters OH-58+, N372NS, was substantially damaged when it was involved in an accident in Alpine, Alabama. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Before the accident flight, the pilot, along with a loader/fueler (ground crewmember), had been conducting chemical spraying operations from an abandoned drag strip about 3/4 mile southwest of the accident site. The ground crewmember stated the pilot had sprayed about 5 loads (500 acres) and had 5 loads remaining to spray. Each load took between 15 and 20 minutes. The ground crewmember was not aboard the helicopter during the accident flight. About 1650, a local resident heard a helicopter that was flying “real low,” but she could not see the helicopter because of trees. The helicopter kept getting closer, and she heard a sound “like propellers hitting a tree, and then a boom like an explosion.” When she eventually saw the helicopter, it was “turned all to pieces.” The local resident could smell fuel, and she “started to see a little bit of smoke, but there was no fire.” A video recording captured the helicopter during an application flight over an adjacent cornfield before the accident flight. Review of the video recording revealed that the helicopter was flying at a low altitude and below the trees and powerlines that surrounded the field, and the helicopter would gain altitude at the end of each pass over the field to clear the surrounding trees and powerlines. The helicopter would then turn back and descend once again below the trees and powerlines for the next pass. According to Federal Aviation Administration (FAA) and pilot records, the pilot held a type rating in the C/S-70 (UH-60) helicopter. He had accrued flight time in multiple aircraft, including the PA-28, 7GCAA, C150, C170, C210, S2R-T34, OH-58, and UH-60. On June 22, 2005, the helicopter was involved in an accident while maneuvering during an aerial application flight in Graham, Texas (NTSB case no. DFW05CA172). The helicopter struck wires during a pull-up maneuver. Evidence at the accident site showed that the tailboom struck the top wire of a hightension string and separated in flight. After the tailboom separated, the helicopter entered an uncontrolled descent to ground impact. The wires did not have fixed aerial obstruction features (for example, orange balls) installed to make the wires more conspicuous. A review of FAA airworthiness records revealed that FAA Form 337, Major Repair and Alteration, had not been filed with the FAA when the helicopter was rebuilt after the accident. At the time of the accident, the helicopter was equipped with high-skid landing gear; a spray system; and a wire strike protection system, which consisted of cable cutters mounted above the windshield and below the forward fuselage. The helicopter was not equipped with a wire strike prevention system. The helicopter was not required to have, and was not equipped with, a cockpit voice recorder or a flight data recorder. Other electronic devices that might have contained nonvolatile memory were recovered from the wreckage, including a Garmin GPS unit and an AgNav unit. The NTSB Vehicle Recorders Laboratory found that the GPS track log recording function was “off,” so no data could be recovered. Also, the internal memory module from the Ag-Nav unit was removed and sent to the manufacturer, which determined that the module sustained internal damage and that no data could be recovered. Examination of the accident site indicated that the helicopter had struck a fiber-optic cable that was collocated with high-voltage transmission lines on the south side of the cornfield and then impacted terrain about 415 ft from the initial wire strike with the fiber-optic cable. The transmission lines were not equipped with wire markers (aircraft warning markers). Further examination of the accident site revealed a debris path that contained a piece of cable in a tree near the south side of the field and a section of bent cable core that had come to rest in the cornfield. This debris path began near the area of the wire strike and continued on a magnetic heading of about 300° to the helicopter’s impact location. Examination of the helicopter revealed that it was substantially damaged and had broken into numerous pieces on impact, with the landing gear (skids), fuselage, and tailboom all receiving varying degrees of impact damage. Further examination of the helicopter also revealed that the main rotor mast, pitch change links, main rotor hub, tail rotor, and tail rotor drive shaft were substantially damaged. Examination of the flight control system revealed numerous breaks in the cyclic control system, collective control system, and anti-torque system. Flight control continuity was able to be established from the cockpit to the breaks in the flight control system, and from the breaks in the system to the main rotor and tail rotor. Examination of the engine revealed that it displayed signatures consistent with operation during the impact sequence as some of the blades in the compressor section downstream of the air inlet were broken off opposite the direction of rotation, with the remaining blades displaying bend back and leading edge gouging. Additionally, rotational scoring was present on the walls of the compressor section. Examination of the drive train revealed that the tail rotor drive shaft displayed twisting at several breaks in the drive shaft which was indicative of production of engine power. Drivetrain continuity was able to be established from the engine to the main transmission and from the main transmission to the rotor head. Drivetrain continuity was also established from the main transmission to the breaks in the tail rotor drive shaft and from the breaks in the tail rotor drive shaft to the tail rotor gearbox, and from the tail rotor gearbox to the tail rotor. Both the main rotor hub and tail rotor could be rotated by hand, and the magnetic chip detectors were free of debris. Examination of the two tail rotor blades revealed that they had remained attached, but both had been bent near the blade root, with one blade bent about 45 degrees away from the tail boom, and the other bent about 135 degrees towards the tail boom. Examination of the two main rotor blades revealed that one blade displayed an area, on the outboard section of the blade, that contained leading-edge damage, scratching oriented at an angle of about 45° from the tip inward and toward the trailing edge. That same blade had a wire strike signature about 8 inches inboard of the blade tip. The other blade was missing about 3 1/2 ft of the outboard portion of the blade. According to the FAA Safety Briefing magazine article, “Avoiding Wire Strikes in Rotorcraft Operations,” dated October 30, 2020, the number of wire strike accidents has increased, and wire strikes remain one of the leading fatal accident causes in low-level helicopter operations. The safety briefing continued as follows: Many pilots mistakenly believe that just watching for wires will provide sufficient reaction time. Statistics show that all pilots flying low are susceptible to a strike, regardless of experience and ability. Several capable and experienced pilots who have survived a wire strike say the same things: ’I just didn’t see it.’ ’The wires just appeared.’ ’There was no time to think or react.’ According to the US Energy Information Administration, the United States has about 200,000 miles of high-voltage transmission lines and millions of miles of low-voltage distribution lines throughout the United States. Wire strike hazards exist for operations below 500 ft above ground level. Because this environment has an inherent risk of wire strikes, flight crews must be properly trained to assess the environment and verify the presence of wires without relying solely on “see and avoid.” The FAA Safety Briefing article presented the following tips for wire hazard mitigation: o Avoid low-level flight whenever it is not essential to the operation. o Become familiar with all known hazards in the operations area prior to low-level flight. o Brief all crew and passengers to speak up and be specific if they see power lines, towers, or other obstacles. o Look for all indicators of a power line (e.g., right of way clearing or support structures). o Always cross transmission lines at the point of the supporting structure. o Be prepared to climb out of the wire environment if any distraction or confusion occurs (e.g., irrelevant crew conversation, radio call, etc.). o Assume that wires are always present in any unfamiliar operations area until proper high reconnaissance confirms otherwise. -
Analysis
The pilot had completed multiple aerial application flights over a cornfield on the day of the accident. During the accident flight, the helicopter contacted a fiber-optic cable that was collocated with high-voltage transmission lines. The wire strike resulted in a loss of control, and the helicopter impacted terrain, fatally injuring the pilot and substantially damaging the helicopter. A video recording of the helicopter during a previous application flight that day revealed that the helicopter was flying at low altitude and below the trees and powerlines that surrounded the field. After each pass over the field, the helicopter gained altitude to clear the surrounding trees and powerlines, turned back, and then descended again below the trees and powerlines for the next pass. Also, a witness heard a helicopter that sounded as if it was flying “real low,” but she could not see the helicopter because of trees. The witness reported that she heard a sound “like propellers hitting a tree, and then a boom like an explosion.” No evidence indicated a preimpact mechanical malfunction or anomaly that would have precluded normal operation of the helicopter. Postaccident examination of the wreckage revealed that one of the main rotor blades displayed an area, on the outboard section of the blade, that contained leading-edge damage, a wire strike signature about 8 inches inboard of the blade tip and scratching oriented at an angle that was about 45°-from the tip inward and toward the trailing edge. The other main rotor blade was missing about 3 1/2 ft of the outboard portion of the blade. These observations were consistent with the helicopter being in a right turn when the main rotor blades contacted the fiber-optic cable. It is likely that the pilot lost positional awareness during the turnaround at the end of the final application pass. Also, because the helicopter was not equipped with a wire strike prevention system and the transmission lines did not have fixed aerial obstruction features such as wire markers, which would have made the transmission lines more visible, the pilot’s attention was not likely drawn to the wires before the wire strike. Additionally, even though the helicopter was equipped with a wire strike protection system, the areas of damage on the outboard portions of the main rotor blades indicated that the contact with the fiber-optic cable likely occurred outside of the effective angle of the cable cutters.
Probable cause
The pilot’s failure to maintain clearance from powerlines during a low-level aerial application flight, resulting in main rotor blade impact with a fiber-optic cable, a loss of control, and the helicopter’s subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
GARLICK HELICOPTERS INC
Model
OH-58A+
Amateur built
false
Engines
1 Turbo shaft
Registration number
N372NS
Operator
EWING FLYING SERVICE LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
70-15372
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-14T21:22:54Z guid: 103346 uri: 103346 title: WPR21FA242 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103347/pdf description:
Unique identifier
103347
NTSB case number
WPR21FA242
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-26T08:07:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-07-08T22:43:01.42Z
Event type
Accident
Location
Albuquerque, New Mexico
Weather conditions
Visual Meteorological Conditions
Injuries
5 fatal, 0 serious, 0 minor
Factual narrative
The Federal Aviation Administration Balloon Flying Handbook, Chapter 7 Inflight Maneuvers. (Page 7-9): “descending over an obstacle give the greatest opportunity to misjudge the clearance over an obstacle.” Additionally, in Chapter 8, Landing and Recovery, (Page 8-8): “During the approach one of the pilot’s most important observations is watching for power lines.” The Handbook in Chapter 8, Obstacles and Approach angles, (Page 8-6): “To summarize, if there is an obstacle between the balloon and the landing site, the following are the three safe choices. 1. Give the obstacle appropriate clearance and drop in from altitude. 2. Reject the landing and look for another landing site. 3. Fly a low approach to the obstacle, fly over the obstacle allowing plenty of room, and then make the landing. The first choice is the most difficult, requiring landing from a high approach and then a fast descent at low altitude. The second choice is the most conservative, but may not be available if the pilot is approaching the last landing site. The third choice is preferable. Flying toward the site at low altitude provides an opportunity to check the surface winds. By clearing the obstacle while ascending—always the safest option—the pilot ends up with a short, but not too high, approach.” - The balloon envelope and basket were manufactured in June 2013 by Cameron Balloons U.S. The balloon’s standard airworthiness certificate was issued on August 7, 2013, and was current until July 31, 2022. The balloon’s last annual inspection was on June 14, 2021, at an airframe time of 286.75 hours. The balloon was registered to a LLC in Albuquerque, New Mexico. The balloon’s flight manual, section 3, Emergency Procedures states: ‘Contact with electrical power lines by any part or the balloon, by anything attached to the balloon, or by occupants of the balloon, may cause fatal or serious injuries to the occupants and must be avoided. However, if contact with electrical power lines becomes inevitable: pull the parachute or rip line to ensure that the basket is as close to the ground as possible before contact.” - On June 26, 2021, about 0707 mountain daylight time, a Cameron Balloons US, O-120 Balloon, N158NM, was destroyed when it was involved in an accident in Albuquerque, New Mexico. The pilot and 4 passengers were fatally injured. The balloon was operated as Title 14 Code of Federal Regulations Part 91 sightseeing passenger flight. After about 1 hour of an uneventful flight, the pilot maneuvered the balloon for landing. The landing site was located in an open field near a major road intersection. Power lines were orientated east/west nearly perpendicular to the balloon’s flightpath to the field. The power lines were hung between metal poles that were about 78 ft high. The power lines were configured with two noncharged ground lines on each side at the top along with several charged lines below each side. A review of surveillance video from a local business revealed that the balloon began a climb before the road intersection where the power lines were located across from the road. Video then depicted the balloon descending into the power lines as it crossed about perpendicular to the wires. Shortly thereafter, the balloon contacted a high-tension power line, an arc appeared, and the basket separated from the envelope. The balloon’s envelope was later located about 0.6 miles south from the accident site in a private residence. - The New Mexico Office of the Medical Examiner, University of New Mexico, Albuquerque, New Mexico, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “blunt trauma.” Toxicology testing by FAA Forensic Sciences Laboratory detected marijuana’s primary psychoactive compound delta-9-tetrahydrocannabinol (THC) at 19.6 nanograms per milliliter (ng/mL) in the pilot’s cavity blood and at 65.4 ng/mL in his urine. The FAA laboratory identified cocaine at 51 nanograms per milliliter (ng/mL) in the pilot’s cavity blood and at 2,083 ng/mL in his urine. - The surface analysis chart depicted a high-pressure system over Colorado to the north of the accident site with a ridge extending southward into northern New Mexico. The chart also depicted a low-pressure system extending into southern New Mexico. The accident site was located on the cold air side of the cold front under the influence of the ridge of high pressure. The station models surrounding the accident site indicated winds from the north at 5 knots or less and no significant weather was indicated over New Mexico at the time. A sounding model indicated that a surface-based temperature inversion was noted to 309 ft above ground level. The wind profile indicated a light surface wind from the east, with wind backing counterclockwise to the north above 2,000 ft. Additionally, the sounding depicted a light potential for low-level wind shear (LLWS) below 300 ft above ground level or 5,597 ft mean sea level. A couple of witnesses in the area noted the low-level wind shear but there were no reports of other balloon landing accidents in the area that morning. - The accident pilot and his balloon were used as contracted labor by Hot Air Balloonatics, LLC, when they had excess passengers to fly. Hot Air Balloonatics LLC, would refer the passengers to him and he would operate independently, in accordance with his own LLC’s procedures. - The accident site was located at a major road intersection. Several power lines ran perpendicular to the south/north road and crossed the intersection. The power lines were located on the south side of the road that went east to west. The power lines were hung between metal poles that were about 78 ft in height. Additionally, between the two poles that the power lines crossed the road intersection, there were two static lines that were located on top of all the wires. One static line was missing on the south side. Further, there was a discoloration on a power line above, near where the balloon’s basket was located on the road. The basket separated from the balloon’s envelope and came to rest on its side. Electrical arcing damage was found on the envelope support cables and the basket support frame. The location of the arcing damage was consistent with the balloon impacting the power lines at or near the burner support frame and basket, severing enough of the support cables to separate the basket from the burner support frame and envelope. The basket fell about 75 ft to the road after separation from the envelope and burner assembly. The envelope and burner assembly were located about 0.6 miles south of the accident site. Postaccident examination of the balloon revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot was conducting a sightseeing flight, with four passengers on board the balloon. Near the conclusion of the flight, the pilot maneuvered the balloon to land in an open field across a major intersection. Power lines were orientated nearly perpendicular to the balloon’s flight path to the field. The power lines were hung between metal poles that were about 78 ft high. A review of surveillance video from a local business revealed that the balloon began a climb before the intersection, with the power lines across the road. Video then depicted the balloon descending into the power lines as it crossed about perpendicular to the wires. Shortly thereafter, the balloon contacted a high-tension power line, an arc appeared, and the basket separated from the envelope and subsequently impacted the road. A postaccident examination of the balloon revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Postmortem toxicology testing of specimens from the pilot was consistent with the recent use of cannabis (THC) and cocaine. The pilot’s cavity blood THC concentration was detected at 5.5 ng/mL, suggesting that usage was within the last few hours. Some impairing effects of THC would likely have been present that would have affected the pilot’s ability to successfully operate the balloon. Cocaine was detected in blood and urine at levels that suggested recent use. At the time of the accident, the impairing effects of the pilot’s use of THC and cocaine likely contributed to the accident.
Probable cause
The failure of the pilot to maintain adequate clearance from power lines while maneuvering for landing. Contributing to the accident was the pilot’s use of impairing, illicit drugs.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
CAMERON BALLOONS US
Model
O-120
Amateur built
false
Registration number
N158NM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
true
Serial number
6692
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-08T22:43:01Z guid: 103347 uri: 103347 title: ERA21LA275 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103375/pdf description:
Unique identifier
103375
NTSB case number
ERA21LA275
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-29T14:47:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-07-11T05:38:24.759Z
Event type
Accident
Location
Rome, New York
Airport
GRIFFISS INTL (RME)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On June 29, 2021, at 1347 eastern daylight time, a Bell 206B, N134VG, was substantially damaged when it was involved in an accident at Griffiss International Airport (RME), Rome, New York. The airline transport pilot and two pilot-rated passengers sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The purpose of the flight was to conduct an initial Part 135 competency check ride for the pilot. On board were two Federal Aviation Administration (FAA) aviation safety inspectors, one seated in the left seat performing the check ride and another in the left rear seat providing oversight and on-the-job training to the other inspector. According to the pilot, after performing maneuvers, the flight returned to the airport where he was to perform a straight-in autorotation with a powered recovery to runway 33. He briefed the inspectors on the maneuver, carried out clearing turns and landing checks, and entered the autorotation at an altitude of 1,500 ft mean sea level. He lowered the collective and reduced the throttle to idle and maintained a speed of 65 knots. Before the flare, he advanced the throttle to the full open position and noted the power turbine and rotor RPM needles were in the green arc. Both he and the FAA inspector confirmed that the throttle was full open. As he raised the collective for recovery, the low rotor warning light and low rotor warning horn both activated. The engine lost partial power and the helicopter landed hard on the runway and rolled over on to its left side. According to the FAA inspector seated in the left front seat, as the pilot reduced the collective at the start of the maneuver, he noticed a needle split on the tachometer and concluded the throttle had been reduced. He did not observe any yawing motion of the helicopter at the time. The helicopter “floated” somewhat after the entry and the descent was smooth. As the airspeed was reduced at the beginning of the recovery, he noticed that the altitude was “slightly high” (he estimated slightly above 100 ft above ground level). He checked the throttle position by attempting to rotate it towards full, and it did not move. He did not recall if he checked the tachometer at that time. He noticed that the helicopter was “higher than usual at the completion of the power recovery,” and then felt the helicopter descend and thought the pilot was lowering the helicopter to a “more reasonable altitude.” As the low rotor RPM horn sounded, he glanced inside and attempted to locate the tachometer but was unable to readily see it. As he looked back outside, the helicopter impacted the ground. After the helicopter came to rest with the engine still running, he rotated the right-side throttle grip to idle, noting that it took several iterations of gripping the throttle and rotating it with his fingers to rotate it to the IDLE position. He then struggled to press the detent button before he was able to rotate the throttle further to the OFF position. In retrospect, the FAA inspector in the left front seat considered, when he checked the throttle position just prior to recovery by attempting to rotate it, that it may have been held in position by the pilot, who had been gripping the controls somewhat tightly, and was not against the stop in the full position as he assumed. Or, if it had been, perhaps it was rotated away from full, as the collective was raised to arrest the descent at the end of the autorotation. A statement provided by the FAA inspector seated in the rear left seat, stated in part: [the pilot] initiated the maneuver by reducing the collective and simultaneous bringing the throttle to the idle position. The initiation was performed at a proper point to ensure we made our intended point of termination. During the auto, I could hear the pilot making proper call-outs (i.e. Airspeed, rotor, touchdown point.) The deceleration was begun too high and a little too aggressive. Because of this, it is not uncommon for the “low rotor” audio warning to come on. I knew there was a problem when the audio warning continued. I attempted to look at the rpm gauge, but before I could verify whether or not the throttle was returned to the “open” position, we impacted the ground. Initial examination of the helicopter by a third FAA inspector revealed substantial damage to the fuselage above the windscreen and the left horizontal stabilizer. A subsequent examination of the helicopter demonstrated drive continuity within the main transmission. The tail rotor drive system rotated by hand freely throughout the entire system, demonstrating tail rotor drive continuity, and the tail rotor hub and blades remained intact. Both main rotor blades exhibited detached tips, trim tab separations, chordwise fractures and fragmenting of the blade skins and internal foam core. The main rotor hub was intact and the main rotor pitch change links exhibited overload fractures. The throttle was manipulated by hand during the examination to the three positions—Off, Idle, Full On (Fly)—and the proper corresponding positions at the fuel control unit (FCU) pointer were observed. The fuel valve switch was found in the “On” position. The fuel shutoff valve was removed from the helicopter before battery power was engaged during the examination and the valve was observed to be in the Full Open position. The remaining fuel within the fuel cell appeared to be clear and the airframe fuel filter was not obstructed. The fuel boost pumps were activated and operated properly in the green pressure range. Control continuity was confirmed from the flight controls in the cockpit to the corresponding flight control surfaces. All of the engine and transmission chip detectors, fuel, and oil filters were free of debris. Fuel was present up to the fuel spray nozzle. All engine control pneumatic B-nuts were tight and torque-striped. Control continuity from the cockpit to the engine was confirmed. A borescope examination of the engine revealed metal splatter in the combustion chamber consistent with combustion taking place when the compressor ingested metallic fragments. There were no anomalies with the engine that would have precluded normal operation prior to the accident. A review of the maintenance records revealed that the most recent 100-hour inspection was performed on April 19, 2021, about 60 flight hours before the accident. At that time, the fuel nozzle and filter were disassembled and cleaned, the starter generator was removed and its brushes were inspected, an engine oil flow check was performed and the fuel system was bled. No other maintenance activity was logged in the engine logbook after this inspection. Entries made in the airframe logbook since that inspection included replacement of the turbine outlet temperature indicator, after a pilot report of an abnormal reading during engine starting, on May 14, 2021. On June 4, 2021, the fuel cell was replaced and the fuel cell/sump drain valve was disassembled and cleaned. After a report of leaking, the drain valve was replaced on June 11, 2021. According to the FAA Helicopter Flying Handbook: “This is one of the most difficult maneuvers to perform due to the concentration needed when transitioning from powered flight to autorotation and then back again to powered flight. For helicopters equipped with the power control on the collective, engine power must be brought from flight power to idle power and then back to a flight power setting. A delay during any of these transitions can seriously affect rotor rpm placing the helicopter in a situation that cannot be recovered.” Furthermore, it stated under the section that listed common errors: “Failure to coordinate throttle and collective pitch properly, which results in either an engine overspeed or loss of rotor rpm…Late engine power engagement causing excessive temperature or torque, or rpm drop…Failure to go around if not within limits and specified criteria for safe autorotation.” -
Analysis
The accident occurred during a Part 135 competency check ride for the pilot. On board were two Federal Aviation Administration (FAA) aviation safety inspectors, one seated in the left seat performing the check ride and another in the left rear seat providing oversight and on-the-job training to the other inspector. After performing maneuvers, the flight returned to the airport where the pilot was to perform a straight-in autorotation with power recovery. As the recovery began, the pilot recalled that he advanced the throttle to the full open position, which the FAA inspector confirmed by attempting to rotate the throttle to the open position, and noted the power turbine and rotor RPM needles were in the green arc. As the pilot raised the collective for recovery, the low rotor warning light and low rotor warning horn both activated. The helicopter impacted the runway hard, rotated right and rolled over on its left side with the engine still operating. The engine continued to run until the inspector in the left seat was able to reach and rotate the right throttle grip “several times” until the engine stopped. The helicopter’s fuselage was substantially damaged. Examination of the helicopter after the accident did not reveal any preaccident malfunctions or failures that would have precluded normal operation. According to the inspector in the left seat, as the pilot began the recovery and rotated the throttle, the inspector checked the throttle position, attempting to rotate the (left side) throttle grip towards the open position, and it did not move. In retrospect, the inspector considered, when he attempted to rotate the throttle grip and it did not move, that it may not have been in the fully open position and the resistance he felt in the (left) grip may have been a result of the pilot holding his (right) throttle grip tightly. The pilot had been holding the controls somewhat tightly during the flight. If the throttle were not in the fully open position during the recovery from the autorotation, the governor would not automatically maintain the rotor RPM. As the pilot raised to collective to flare, this could result in a reduction of rotor RPM and apparent partial loss of power.
Probable cause
The pilot's improper termination of a practice autorotation with power recovery, which resulted in low rotor rpm, an unstable landing, and a rollover. Contributing to the accident was the evaluator's inadequate oversight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206
Amateur built
false
Engines
1 Turbo shaft
Registration number
N134VG
Operator
Aviation Services Unlimited LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1512
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-11T05:38:24Z guid: 103375 uri: 103375 title: ERA21FA274 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103374/pdf description:
Unique identifier
103374
NTSB case number
ERA21FA274
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-29T15:27:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-07-07T22:51:19.976Z
Event type
Accident
Location
St. Augustine, Florida
Airport
NORTHEAST FLORIDA RGNL (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On June 29, 2021, about 1427 eastern daylight time, a Cessna 152, N25513, was destroyed when it was involved in an accident at Northeast Florida Regional Airport (SGJ), St. Augustine, Florida. The flight instructor and a passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The purpose of the local flight was to take the passenger, a prospective student pilot, on a discovery flight. Radar data indicated the airplane departed SGJ at 1344 from runway 13. The airplane flew about 14 miles south, returned to circle the city of St. Augustine, Florida, then flew north along the coastline about 21 miles before returning to land. A witness observed the airplane approach runway 13 about 100 ft above ground level with “the wings swaying up and down.” He also stated the nose of the airplane appeared to be in a nose-up attitude before the airplane pitched down about 45° and impacted the runway. The impact was followed by a fire that engulfed the airplane as it slid about 200 ft before coming to rest. The airplane’s wreckage came to rest about 927 ft before the displaced threshold for runway 13 at SGJ, and the wreckage was oriented on a heading of 148°. All components of the airplane were accounted for at the accident site. Ground scars were consistent with the propeller spinner and left wing impacting the asphalt first followed by the nosewheel. Most of the cockpit, cabin, and instrument panel were consumed by fire. The inboard portion of the right wing was consumed by fire, including the fuel tank. Both the left and right forward and aft wing attach fittings remained connected via the attach bolts. The left wing sustained fire damage at the wing root, but the fuel tank remained intact and about 2.5 gallons of 100 low lead aviation fuel was drained from the tank. No debris or water was noted in the fuel. The tail section was consumed by fire. The empennage remained intact and attached the fuselage. The right horizontal stabilizer and elevator was mostly consumed by fire. The left horizontal stabilizer and elevator remained intact. The vertical stabilizer and rudder remained intact and sustained fire damage to the right side. Flight control continuity was established by tracing the flight control cables from the cockpit controls to the respective flight controls. The left rudder cable, which ran from the copilot side rudder torque tube to the left side of the rudder control horn, displayed 3 broken strands, and there were 4 remaining strands that appeared to be abraded. The area of apparent abrasion was located 92” from the cable connection at the copilot’s side rudder torque tube. Despite the separated strands, the majority of the remaining cable strands were otherwise intact. Crankshaft and valvetrain continuity were confirmed during a postaccident engine examination when the crankshaft was rotated using a tool inserted into the vacuum pump drive pad. Compression and suction were attained from all four cylinders. The interiors of the cylinders were examined using a lighted borescope and no anomalies were noted. The carburetor was impact-separated, fragmented, and the fuel inlet screen was absent of debris. The propeller was impact-separated from the engine crankshaft flange, and found on the runway about 45 ft from the engine. Multiple slash marks, consistent with propeller strikes, were observed on the asphalt surface near the initial impact point. -
Analysis
The purpose of the local flight was to provide a discovery flight experience for a prospective student pilot. A witness reported that they saw the airplane flying about 100 ft above ground level, with “the wings swaying up and down” during its approach to land. The nose of the airplane was pitched upward, but suddenly the airplane pitched down before it impacted the runway, consistent with an aerodynamic stall. A postimpact fire ensued and the airplane slid for about 200 ft before coming to a stop. A postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. While a rudder control cable was found with several strands separated, the cable and the majority of its strands were otherwise intact, and it is unlikely that this contributed to the accident. Based on the witness report, it is likely that the airplane’s critical angle of attack was exceeded during the approach, resulting in an aerodynamic stall. Given that the reported purpose of the flight was to provide an initial flight experience to a prospective pilot, it is likely that the flight instructor was either manipulating the controls, or was a least directing the manipulation of the controls, when the accident occurred.
Probable cause
The flight instructor’s exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall during the landing approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N25513
Operator
Florida Flyers
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15280707
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-07T22:51:19Z guid: 103374 uri: 103374 title: CEN21FA297 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103391/pdf description:
Unique identifier
103391
NTSB case number
CEN21FA297
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-06-30T05:50:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-07-08T06:55:34.932Z
Event type
Accident
Location
Curtiss, Wisconsin
Airport
Private (PVT)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The FAA Civil Aeromedical Institute's publication, Introduction to Aviation Physiology, defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in IMC, frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude. The FAA's Airplane Flying Handbook (FAA-H-8083-3A) described hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - The airplane was not equipped for flight in instrument meteorological conditions (IMC). - On June 30, 2021, about 0450 central daylight time, an Earthstar Aircraft Gull 2000 experimental light-sport airplane, N1712L, was substantially damaged when it was involved in an accident near Curtiss, Wisconsin. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. An individual who was interested in purchasing the airplane stated that the pilot offered to fly the airplane from Curtiss, Wisconsin, to New Richmond Regional Airport (RNH), New Richmond, Wisconsin, where he could examine it. The potential buyer suggested to meet at RNH about 1200, but the pilot subsequently asked to meet at 0600. The potential buyer agreed to meet at 0600 believing that the pilot had to return for work after their meeting. The potential buyer stated that on the morning of the accident, about 0600, there was low ground fog at RNH. When the airplane did not arrive at RNH, about 0615, he began to call and send text messages to the pilot but never received any replies. Around 1100, he called the Clark County Sheriff’s Office to report that the pilot did not arrive at RNH. According to the Clark County Sheriff’s Office, the last cellular activity recorded for the pilot’s mobile phone occurred about 0447. A witness who lived near the private airstrip saw the airplane on the ground at the airstrip a few minutes before 0500. The witness stated that it was foggy and that she could only see the airplane’s lights but heard the airplane’s engine operating as the airplane took off to the west. Another witness who lived near the private airstrip reported that he was awoken by the sound of the airplane departing the airstrip about 0450 or 0455. A review of air traffic control radar sensor data and ADS-B data revealed no track data for the flight. According to the Clark County Sheriff’s Office, the wreckage was located by the property owner about 1706. - According to the autopsy authorized by Clark County Coroner’s Office, Neillsville, Wisconsin, and completed by the Ramsey County Medical Examiner Office, St. Paul, Minnesota, the pilot experienced traumatic head and neck injuries. No significant natural disease was identified by the medical examiner. Toxicology testing performed for the Medical Examiner’s office was negative for ethanol and drugs of abuse in the pilot’s blood. Toxicological testing, completed by the Federal Aviation Administration Forensic Sciences Laboratory, detected ethanol in the pilot’s brain and lung tissue at 0.012 grams per hectogram (gm/hg) and 0.042 gm/hg, respectively. Ethanol was detected in his urine at 0.010 grams per deciliter (gm/dL). N-propanol was also detected in his lung tissue. Tissue samples exhibited putrefaction. No other tested for medications or drugs of abuse were detected in urine. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. Ethanol can be produced after death by microbial activity; sometimes in conjunction with other alcohols, such as propanol. Extensive trauma increases the spread of bacteria and raises the risk of ethanol production after death. - Multiple Clark County Sheriff’s Office deputies reported that weather near the accident location in the early morning included dense fog with limited surface visibility. The visibility on the roadways near the accident location was 20 to 100 ft and required the use of windshield wipers while driving. Additionally, a semi-trailer truck had inadvertently departed the side of Wisconsin State Highway 29 because the driver reportedly could not see the road while driving in the dense fog. At 0250, the National Weather Service (NWS) Weather Forecast Office in La Crosse, Wisconsin, issued an Area Forecast Discussion that stated, in part: Weak boundary layer flow and residual low-level moisture will result in areas of early morning fog, especially in low-lying areas/valleys, but should quickly erode after sunrise. The fog may be locally dense, and will continue to monitor over the next few hours. At 0400, the NWS Weather Forecast Office in La Crosse, Wisconsin, issued a Dense Fog Advisory for an area that included the accident location which called for locally dense fog that reduced visibilities to 0.5 statute mile (sm) or less and stated, in part: Light winds, mostly clear skies and wet grounds from the recent rains have resulted in areas of fog early this morning, mostly in low lying areas and near bodies of water. The fog will be locally dense, reducing visibilities to 1/2 mile or less. Early morning travelers should be prepared for rapidly reduced Visibilities at times. Visibilities could go from good to poor within a few hundred feet. Much of the fog will lift and dissipate by 8 to 9 am. Exercise caution. At 0345, an Airman’s Meteorological Information (AIRMET) SIERRA advisory for IFR conditions was issued for an area that included the accident location and included ceilings below 1,000 ft above ground level (agl), visibilities less than 3 sm, precipitation, and fog. At 0400, the Graphical Forecasts for Aviation (GFA) depicted few and scattered clouds with variable surface visibilities between 0 sm and 5 sm at or near the accident location. At 0435, the weather at Taylor County Airport (MDZ), Medford, Wisconsin, about 10 sm northeast of the accident location, included a calm surface wind, 0.5 sm surface visibility with fog, and 500 ft vertical visibility. At 0455, the weather at MDZ improved to 5 sm visibility with mist and clear skies. On the day of the accident, civil twilight began at 0442 and the official sunrise was at 0519. - The pilot was not instrument rated. According to his flight logbook, the pilot logged 3 hours of simulated instrument flight before his checkride for his private pilot certificate on March 14, 2020. He logged an additional 0.2 hours of simulated instrument time during his checkride. - The main wreckage was in a wooded area at the edge of a cornfield about 0.33 nautical miles (nm) southwest of the west end of the grass airstrip that the pilot used for takeoff, as depicted in figure 1. The airplane sustained substantial damage to both wings, the empennage, and the fuselage. Based on damage to trees at the accident site, the airplane was traveling to the south when it descended into the trees in an approximately 30° nose-down flight path angle. The airframe parachute rocket deployed due to impact forces; the activation handle was stowed with the safety pin removed. All structural components and flight control surfaces were located at the accident site. A postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have prevented normal operation of the airplane. All structural damage to the airplane was consistent with tree and ground impact. Figure 1 – Aerial view of the accident site location and departure airstrip -
Analysis
The pilot, who was not instrument rated, was departing on an early morning crosscountry flight. The airplane descended into trees and terrain near the departure airstrip. The airplane sustained substantial damage to both wings, the empennage, and the fuselage. Postaccident examination revealed no evidence of a preexisting mechanical malfunction or failure that would have prevented normal operation of the airplane. Based on witness accounts and reviewed weather data, instrument meteorological conditions (IMC) with dense fog and low clouds existed at the accident time. The airplane was not equipped for flight in IMC. The accident occurred about 8 minutes after civil twilight began and about 29 minutes before the official sunrise; it likely was still substantially dark as the flight departed toward the west and away from the rising sun. It is likely the pilot had self-imposed pressure to depart on the round-trip flight in the early morning hours so he could return for work. Additionally, he likely became spatially disorientated shortly after takeoff when the airplane entered IMC, which resulted in his loss of airplane control and the unintentional descent into trees and terrain. Toxicology testing detected low levels of ethanol in the pilot’s specimens; however, the identified ethanol was likely from a source other than ingestion and was not a factor in the accident.
Probable cause
The non-instrument-rated pilot’s decision to depart into instrument meteorological conditions with dense fog and low clouds, which resulted in spatial disorientation and a loss of airplane control. Contributing to the accident was the pilot’s self-imposed pressure to depart on the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Earthstar Aircraft
Model
Gull 2000
Amateur built
false
Engines
1 Reciprocating
Registration number
N1712L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
007
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-08T06:55:34Z guid: 103391 uri: 103391 title: CEN21FA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103400/pdf description:
Unique identifier
103400
NTSB case number
CEN21FA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-02T03:25:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-07-04T05:15:56.981Z
Event type
Accident
Location
Roff, Oklahoma
Airport
Ada Regional Airport (ADH)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA Civil Aeromedical Institute’s publication titled “Introduction to Aviation Physiology” defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude. The FAA’s Airplane Flying Handbook (FAA-H-8083-3C) describes hazards associated with flying when the ground or horizon is obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot…false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. As a result, the pilot “needs to believe what the flight instruments show about the airplane’s attitude regardless of what the natural senses tell.” - On July 2, 2021, about 0225 central daylight time, a Beech 35-33 airplane, N302Z, was destroyed when it was involved in an accident near Roff, Oklahoma. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The Federal Aviation Administration’s (FAA) ADS-B data showed that the airplane made two flights on the day before the accident. The first flight departed from Ada Regional Airport (ADH), Ada, Oklahoma, about 2015; the airplane climbed to 3,000 ft and slowly descended until arriving at Ardmore Municipal Airport (ADM), Ardmore, Oklahoma, about 2035. The second flight departed from ADM about 2200 and flew toward ADH. The airplane made several circles southwest of ADH and then returned to ADM, landing there about 2253. During a postaccident interview, the pilot’s wife stated that her husband decided to return to ADM after observing a “big” cloud over ADH. She also stated that, according to her husband, instrument flight rules (IFR) flight conditions existed at the time and that he was not going to fly in those conditions. About 0211 on the day of the accident, the airplane again departed from ADM and was en route to ADH. Shortly before takeoff, the pilot had informed his wife that the weather would be visual flight rules along the entire route. According to ADS-B data, during the initial portion of the flight, the airplane’s altitude varied between 1,000 and 2,000 ft mean sea level (msl). (All altitudes are expressed as msl unless noted otherwise.) The pilot subsequently climbed the airplane to 3,000 ft before descending back to an altitude between 1,400 and 1,500 ft about 4.5 minutes before the accident occurred. The pilot continued to fly the airplane at that altitude (which was 200 to 300 ft above ground level) for about the next 2 minutes. The airplane’s groundspeed during the flight fluctuated between 70 and 139 knots with most of the flight conducted at a groundspeed of about 87 knots. Toward the end of the flight, the airplane made a left turn during which the airplane climbed to an altitude of about 1,600 ft at a rate of about 2,000 feet per minute. Subsequently, the airplane began descending at a rate that exceeded 2,700 feet per minute. The last ADS-B return showed that the airplane was about 0.2 miles west of the last radar return, about 280 ft above ground level, and along a track of 190°. The airplane’s last recorded groundspeed was 89 knots. The airplane impacted trees on a remote ranch about 14 nautical miles southwest of ADH. The figure below shows the airplane’s flight track (based on ADS-B data) during the accident flight. Figure. Accident airplane flight track. The ranch owner stated that heard a loud noise about the time of the accident and went outside but did not observe anything abnormal. He noted that the weather conditions were “very foggy and misty with low visibility.” - The National Weather Service (NWS) Weather Forecast Office (WFO) in Norman, Oklahoma, issued the following information in the Area Forecast Discussion at 1743 on the day before the accident: “mostly MVFR [marginal visual flight rules] conditions will persist through the period, with some chance at IFR cigs [ceilings] as storms move through.” The information also stated that scattered showers and thunderstorms would move out of northern and central Oklahoma by midday on the day of the accident. AIRMET Sierra was issued at 2145 on the day before the accident and was valid for the accident site at the accident time. The AIRMET was issued for IFR conditions and identified ceilings below 1,000 ft, visibility below 3 statute miles, precipitation, and mist. A Graphical Forecast for Aviation forecast imagery depicting IFR conditions was issued about 2300 on the day before the accident and was valid for 0100 on the day of the accident. This forecast imagery depicted surface visibilities as 1 to 3 statute miles, 3 to 5 statute miles, and greater than 5 statute miles at or near the accident location with scattered thunderstorms near the accident site. A graphical AIRMET for IFR conditions was depicted at the accident location. According to his wife, the pilot used Foreflight for weather information. The available evidence for this investigation did not indicate whether the pilot reviewed weather information before or during the accident flight. - The pilot did not have an instrument rating. The pilot’s wife stated that he was an “excellent” pilot and did “quite a bit” of night flying. She also stated that he was used to flying in the dark. - The debris field was about 210 ft in length along a heading of about 110°. The first identified piece of wreckage in the debris field was the left wingtip, which was followed by the left aileron; a small portion of the left-wing leading edge; the pitot tube, which was found on a large narrow ground scar in the dirt; and the right wing, which had separated from the fuselage at the wing root. The right wing came to rest with its leading edge down and the root of the wing wrapped around a tree, which was bent in the direction of the debris path. The main wreckage was located about 12 ft beyond the right wing and consisted of the cabin, aft fuselage, and inboard left wing. The engine was located about 6 ft beyond the main wreckage. The engine had separated from the firewall (which exhibited crush damage) and engine mounts and came to rest on its left side against two trees. The left side of the engine exhibited more impact damage than the right side. Postaccident examination revealed no evidence of a pre-existing mechanical malfunction or failure that would have precluded normal operation of the airplane. -
Analysis
The pilot was conducting a personal flight at night in low-visibility conditions. According to automatic dependent surveillance-broadcast (ADS-B) data, during the initial portion of the flight, the airplane’s altitude was generally between 1,000 and 2,000 ft before the airplane climbed to 3,000 ft. About 4.5 minutes before the accident, the airplane entered a gradual descent to an altitude between about 1,400 and 1,500 ft and continued to fly at that altitude (200 to 300 ft above ground level) for about the next 2 minutes. The airplane then entered a left turn that became increasingly tighter. During this turn, the airplane climbed to about 1,600 ft before descending. The last ADS-B return showed that the airplane was about 0.2 miles west of the last radar return, about 280 ft above ground level, and along a track of about 190°. Postaccident examination revealed no evidence of a pre-existing mechanical malfunction or failure that would have precluded normal operation of the airplane. The pilot was not instrument rated. The available evidence for this accident did not indicate whether the pilot received weather information for the route of flight. The pilot likely anticipated visual meteorological conditions given that, shortly before takeoff, he informed his wife that the airplane would be in those conditions along the entire route. The low-visibility night conditions were conducive to the development of spatial disorientation. Although ADS-B data showed that the airplane was flying close to terrain during the final portion of the flight, the airplane was maneuvering over an area without much cultural lighting (such as the illumination from the reflection of lighting in a metropolitan area). Without such lighting, the pilot would not have had reliable visual references for maintaining attitude control. The spiral flightpath was consistent with the pilot experiencing the known effects of spatial disorientation. Also, the wreckage distribution and extensive airplane fragmentation were consistent with a highenergy impact resulting from the effects of spatial disorientation.
Probable cause
The pilot’s loss of airplane control due to spatial disorientation during low-level nighttime flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35-33
Amateur built
false
Engines
1 Reciprocating
Registration number
N302Z
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CD-201
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-04T05:15:56Z guid: 103400 uri: 103400 title: DCA21FA174 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103407/pdf description:
Unique identifier
103407
NTSB case number
DCA21FA174
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-02T04:00:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2021-07-03T00:15:35.676Z
Event type
Accident
Location
Honolulu, Hawaii
Airport
HNL (PHNL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
The search for the airplane began on the day after the accident, July 3, 2021. The aft fuselage was located on July 7 about 0.13 miles north-northwest of the last recorded FAA automatic dependent surveillance-broadcast data point. The aft fuselage (with both wings and the tail still attached, as shown in figure 5) was found on a sloped area of the seafloor with the forward end at a depth of about 340 ft and the tail at a depth of about 363 ft. On July 8, several more parts of the airplane were located, including the forward fuselage (see figure 6), engine cores, thrust reversers, inlet cowls, and nose landing gear. The water depths where these structures were located ranged from 354 to 437 ft. The debris field was about 0.12 miles long (north-south) and about 0.10 miles wide (eastwest). All major portions of the airplane were identified in the debris field. Figure 5. Aft fuselage (Source: Sea Engineering Inc.). Figure 6. Forward fuselage (Source: Sea Engineering Inc.). Planning for the wreckage recovery included awarding a contract to recover the wreckage; consulting and coordinating with the State of Hawaii, the USCG, and other federal agencies; and developing and finalizing a recovery plan. Wreckage recovery operations began on October 12 and concluded on November 2, 2021. - The airplane was owned and operated by several different companies before Rhoades Aviation purchased it on December 23, 2014. Rhodes Aviation registered the airplane with the FAA on January 23, 2015, and the airplane was added to the company’s operations specifications on February 2, 2015. According to company records, the airplane had accumulated 72,871 total hours and 69,446 total cycles before the accident flight. The airplane was powered by two Pratt & Whitney JT8D-9A turbofan engines, which were installed on the accident airplane on October 28 (left) and September 20, 2019 (right). The left engine was manufactured on June 24, 1971, and had accumulated 32,305 total hours and 33,670 total cycles. The right engine was manufactured on January 10, 1968, and had accumulated 70,827 total hours and 101,368 total cycles. After their last shop visit, the left and right engines were returned to service on September 19 and April 5, 2019, respectively, and they accumulated 1,055 hours and 2,085 cycles through the date of the accident. The JT8D-9A engine has a six-stage low-pressure compressor driven by a three-stage low-pressure turbine, a seven-stage high-pressure compressor driven by a single-stage high-pressure turbine, and a can-annular combustor. Both engine rotors turn in the clockwise direction (as viewed aft of the engine looking forward). The high-pressure compressor, combustion chamber, and high-pressure turbine are collectively referred to as the engine core. All required inspections and maintenance checks listed in the Rhoades Aviation aircraft inspection program were completed for the airplane. The airplane underwent a routine daily check on July 1, 2021, and no discrepancies were identified. All reviewed items in the airplane logbooks from January 1, 2020, to July 1, 2021, were properly signed off and closed. No minimum equipment list items for the airplane were open at the time of the accident. A review of time-limit component reports for the airframe, engines, and auxiliary power unit revealed no discrepancies. A review of the FAA’s service difficulty report database showed three reports that pertained to the accident airplane; the most recent report (related to the failure of the left engine at 2,000 ft) occurred about 2.5 years before the accident. A previous Rhoades Aviation chief inspector (who resigned from that position 6 weeks before the accident) recalled “chronic” maintenance writeups for issues related to the accident airplane’s EGT and fuel indications but could not remember specific details about those issues. The company’s director of maintenance stated that he was unaware of any flight crew reports about high EGT indications on the accident airplane. The director of maintenance further stated that an engine trend monitoring report for the accident airplane’s engines, which the company received 2 days before the accident, showed “everything normal.” The airplane’s basic empty weight as of April 19, 2021, was 59,720 pounds. The accident flight was estimated to have a basic operating weight of 60,160 pounds, which included the standard weight for two flight crewmembers and their bags. The accident flight was loaded with 19,897 pounds of cargo and 14,000 pounds of fuel. The airplane’s takeoff weight was 93,557 pounds, which was below the airplane’s maximum takeoff weight of 119,500 pounds. Transair stated that, on the day of the accident, the accident airplane was fueled from the same fuel truck as another airplane in the company’s fleet (N809TA). A fuel sample taken from N809TA’s sump tank on July 3, 2021, showed that the fuel met specifications. - The accident airplane was equipped with an Allied Signal (now Honeywell) solid-state universal FDR. The FDR recorded 18 parameters in accordance with federal requirements. Defects in the rubber RTV sealant surrounding the memory module were found; these defects resulted from the way that the sealant was applied and cured at the time that the FDR was manufactured. The RTV sealant is designed to protect the unit’s internal memory boards from water damage and corrosion, but the defects allowed sea water to flood the boards as the airplane wreckage sank. Despite the manufacturing defects in the sealant, data from the accident flight were successfully recovered. The accident airplane was also equipped with a Honeywell 6022 solid-state CVR, which, according to federal requirements, recorded at least the last 2 hours of the airplane’s operation. Specifically, the CVR contained a two-channel recording of the last 2 hours of operation and a separate three-channel recording of the last 30 minutes of operation. The 2-hour portion of the recording comprised one channel that combined three audio panel sources and a second channel that contained the cockpit area microphone source. The 30-minute portion of the recording contained three channels of audio information for each flight crewmember and a cockpit observer. The CVR had a similar manufacturing defect in the RTV sealant for the internal memory boards, which resulted in water intrusion that led to corrosion; this corrosion rendered the 30-minute recordings unusable. The 2-hour CVR channels were unaffected and were able to be successfully downloaded. - On July 2, 2021, about 0145 Hawaii-Aleutian standard time, Rhoades Aviation flight 810, dba Transair flight 810, a Boeing 737-200, N810TA, experienced an engine anomaly shortly after takeoff from Daniel K. Inouye International Airport (HNL), Honolulu, Hawaii, and was subsequently ditched into Mamala Bay (in the Pacific Ocean), about 5.5 miles southwest of HNL. The captain sustained serious injuries, the first officer sustained minor injuries, and the airplane was destroyed. The flight was operating under Title 14 Code of Federal Regulations Part 121 as a cargo flight from HNL to Kahului International Airport (OGG), Kahului, Hawaii. The flight crew arrived at Rhoades Aviation’s flight-following office at HNL by 0015 for the flight to OGG, which was scheduled to depart at 0100. The flight was the first of the day’s six planned flight legs for the captain and first officer. According to postaccident interviews, the flight crew discussed the weather for the flight and other related information. The captain then determined the performance limitations of the airplane and provided that information to the flight follower, who in turn provided the information to the cargo load manager. The flight crewmembers monitored cargoloading activities, and the cargo load supervisor gave the crewmembers the weight and balance paperwork. The first officer conducted a preflight external inspection of the airplane. He found dried fluid that appeared to have leaked onto the right main landing gear. The first officer reported his findings to the captain, who examined the area with a mechanic. They determined that no active leak was occurring, the landing gear hydraulic reservoir had an appropriate amount of fluid, and the dried fluid was not a concern. According to the CVR, the flight crew completed the Before Engine Start checklist at 0119:33 and the Engine Start checklist at 0120:01. During a postaccident interview, the captain stated that both engines started normally. At 0123:08, the tower controller cleared the airplane to taxi to runway 8R; the flight crew reported that the airplane left the gate behind schedule because of delays with cargo loading. The flight crew began the Taxi checklist at 0124:45, and the captain recalled that the engine indications looked normal at that time. After taxiing the airplane onto the runway, the first officer recalled that he brought up the power to an EPR level of 1.4 and then asked the captain to set the thrust. The captain adjusted the thrust until the EPR indications were at the carats (an EPR level of 2.01). At 0132:20, the controller cleared the airplane for takeoff, and the first officer, who was the pilot flying, acknowledged the clearance. (The captain was the pilot monitoring.) At 0132:44, the flight crew completed the Before Takeoff checklist. The captain recalled that, during the takeoff roll, the EGT indications for both engines were at the line between the green (normal) and the yellow (caution) ranges on the displays. (The yellow range on the EGT display indicates temperatures between 520°C and 590°C; according to the Boeing 737 Aircraft Operations Manual, the maximum continuous EGT was 540°C.) During a postaccident interview, the captain stated that he had seen that EGT position during previous takeoffs and thus considered it to be normal. According to the FDR, the engines were advanced to takeoff power starting at 0133:08, and both engines stabilized at an EPR consistent with takeoff; specifically, the No. 1 (left) engine was at 2.00 EPR, and the No. 2 (right) engine was at 1.97 EPR. According to the CVR, at 0133:13, the captain stated, “engines stable.” Between 0133:35 and 0133:46, the captain made the standard takeoff callouts, including “V1,” “rotate,” “V2” (takeoff safety speed), and “positive rate,” and the first officer made the callout “gear up.” The airplane flew a heading of 080°. At 0133:52, the CVR recorded the sound of a “thud.” Starting about 2.5 seconds later, the CVR recorded the sound of a low-frequency vibration, the first officer stating an expletive, the captain stating “lost (an) engine,” and both pilots noting that the right engine had lost power. FDR data showed that, as the airplane climbed through an altitude of about 390 ft mean sea level (all altitudes in this report are mean sea level unless stated otherwise) while the airplane was at an airspeed of 155 knots, the EPR for the right engine dropped suddenly to 1.43; the EPR for the left engine remained at a level of about 2.00. (The only engine parameter that the accident FDR recorded was EPR.) The left rudder pedal then moved to a position consistent with the application of about 5.5° of left rudder. During postaccident interviews, the crewmembers recalled that the airplane yawed to the right and that the first officer corrected the yaw with the left rudder pedal. In addition, when the loss of thrust on the right engine occurred, the airplane banked 2° to the left; immediately afterward, the airplane banked 3° to the right. About 0134:22, the captain stated, “I’ll give you flaps up,” and the first officer acknowledged this statement. During a postaccident interview, the captain stated that, after setting the flaps, he reduced thrust to maximum continuous thrust. FDR data showed that, during a 2.6-second period ending about 0134:28, the EPR for the left engine decreased from 1.96 to 1.91. The captain’s initial notification to the controller about the emergency occurred at 0134:29; at the end of that transmission, the captain stated, “stand by.” The controller responded with a routine departure instruction, after which the captain again declared an emergency and repeated “stand by.” The captain then told the first officer that the airplane should climb to and level off at 2,000 ft (the airplane was at an altitude of 1,200 ft at that time) and fly a 220° heading. At 0135:16, the controller again provided the flight crew with routine instructions. One second later, the airplane reached its maximum altitude of 2,107 ft. Also at that time, the EPR on the left engine began incrementally decreasing from 1.91 to 1.83, 1.53, and 1.23 during the next 1 minute 17 seconds. At 0135:35, the captain told the controller about the emergency for the third time, stating, “we’ve lost an engine…we are on a two twenty heading…maintaining two thousand [ft]…declaring emergency.” About that time, the airplane’s airspeed reached a maximum of about 252 knots. After this transmission, the CVR recorded the controller stating, “say again heading two four zero.” Immediately after issuing this instruction, the controller informed the captain that the heading was intended for another airplane on the same radio frequency. At 0135:55, the controller cleared the airplane for a visual approach to runway 4R at HNL and stated that the airplane could turn toward the airport. The captain responded, “we’re gonna have to run a checklist” and “we’ll let you know when we’re ready to come into the airport.” At 0136:08, the controller asked the flight crew to keep her advised, and the captain acknowledged the transmission. The exchange between the captain and the controller ended at 0136:22. While that exchange was occurring, the EPR for the left engine decreased to 1.05 (at 0135:56), which was consistent with a power level near flight idle. The EPR for the left engine remained at this level for the remainder of the flight; 8 seconds later, the EPR for the right engine began to decrease below a level of about 1.4. At 0136:20, the airplane began to descend from 2,000 ft, reaching an altitude of 1,659 ft before beginning to climb again. At 0136:34, the captain stated, “two forty heading.” About 13 seconds later, the controller requested more information about the flight, including which engine was affected, and the captain responded, “we'll give you all that in a little bit.” At 0137:06, the captain stated that the airplane should maintain an airspeed of 220 knots. During a postaccident interview, the captain stated that the 220-knot airspeed would be “easy on the running engine.” FDR data showed that, at 0137:09, the EPR for the right engine reached 1.09, which was also consistent with a power level near flight idle. At 0137:13, the captain announced his intention to take control of the airplane, which the first officer acknowledged. FDR data showed that the airplane’s altitude at the time was 1,690 ft and that its airspeed was 224 knots. At 0137:36, the captain stated, “let's trim this up at two thousand [ft]”; at that time, the airplane’s altitude was 1,878 ft and airspeed was 196 knots. Four seconds later, the captain stated, “let’s see what is the problem…which one…what’s going on with the gauges,” and “who has the E-G-T?” The first officer stated, “it looks like the number one [engine].”About that time, the EPR on the left and right engines was 1.05 and 1.12, respectively. At 0137:54, the captain asked, “number one is gone?” The first officer replied that the left engine was “gone” and that “we have number two”; at 0137:58, the captain repeated “we have number two” and stated “okay.” Between 0137:59 and 0138:10, the right EPR level (which had been slowly increasing after reaching a level of 1.09) increased quickly from 1.12 to 1.18. At 0138:16, the first officer asked, “should we head back toward the airport…before we get too far away?” The captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain recalled that he intended to climb the airplane to 2,000 ft and stay 15 miles from HNL to avoid traffic and have time to address the engine issue. He also recalled that there was no need to rush because there was no fire and an engine “was running.” The captain called for the “engine failure shutdown checklist” and then stated, “I have the radios.” At 0138:43, the captain notified the controller that the airplane could turn to the right toward the airport but that he was not yet ready to land, and the controller provided instructions for the airplane to fly a 250° heading, which the captain acknowledged. At 0138:56, the right EPR reached 1.22. Two seconds later, the first officer stated, “engine failure engine flameout or another checklist directs an engine failure.” This information was consistent with the conditions for executing the Engine Failure or Shutdown checklist (see the Organizational and Management Information section of this report.) The first officer then stated, “we’re red line here” and “we should pull the right [thrust lever] back a little bit.” At 0139:10, the captain stated that the airplane should head toward HNL, and the first officer agreed. The captain then instructed the first officer to set up the airplane for the instrument landing system approach to runway 4R. At 0139:18 and 0139:24, the captain informed the controller that the airplane was ready to proceed toward the airport and that he did not have the airport in sight, respectively. At 0139:46, the captain requested vectors straight to the airport and informed the controller that “we might lose the other engine too.” At 0139:56, the EPR on the right engine began to decrease from 1.22. At 0140:05, the first officer stated, “just have to watch this…the number two [engine].” At 0140:10, the right EPR reached 1.18. One second later, the airplane’s altitude and airspeed were 1,050 ft and 157 knots, respectively, and the CVR recorded sounds lasting 1.8 seconds that might have been associated with the stick shaker. The captain stated something similar to “what’s this” and then “we can’t keep going down,” and the first officer noted that the airplane was descending. Between 0140:12 and 0140:27, the right EPR increased from 1.18 to 1.37, the airplane’s airspeed increased to 172 knots and altitude decreased to 680 ft, and the first officer stated, “we’re descending” and “we have to climb.” At 0140:30, the captain asked the first officer to check that the airplane was “cleaned up”; at that time, the airplane began to slowly climb from 632 ft. The first officer stated that the flaps were up, and he started to report the status of the speedbrakes when the captain stated, “how is the EGT?” The first officer replied, “it’s beyond max.” The airplane’s airspeed began to drop below 170 knots, and the right EPR decreased from 1.37 to 1.33 during a 2-second period. At 0140:41, the captain stated, “we’re barely holding altitude…see what you can do in the checklist finish as much as possible.” By 0140:48, the airplane’s airspeed had decreased to 165 knots, and its altitude began to descend from 682 ft. Five seconds later, the first officer resumed the checklist by stating, “airframe vibrations abnormal engines exist.” Step 1 of the Engine Failure or Shutdown checklist prompted flight crews to determine whether they should continue with this checklist or instead use the Engine Fire or Engine Severe Damage or Separation checklist. The first officer continued, “it says do the engine shutdown only when flight conditions” but interrupted this thought to state, “we have to fly the airplane though.” At that time, the airplane’s airspeed was 159 knots and altitude was 614 ft. The captain replied, “okay.” At 0141:10, the first officer stated, “we’re losing altitude”; at that time, the airplane was at an altitude of 592 ft and an airspeed of 160 knots. Between 0141:14 and 0141:17, the right EPR increased from 1.33 to 1.36. About 3 seconds later, the controller instructed the crew to fly a heading of 050°; the first officer acknowledged this instruction at 0141:22. Starting at 0141:46, the first officer asked the captain whether the flaps 1 setting should be used, and the captain responded “not yet.” The first officer then stated that the airplane was “very slow,” to which the captain responded, “shoot…okay flaps one.” At 0141:58 and 0142:00, the CVR recorded the EGPWS annunciations “five hundred [feet above ground level]” and “too low gear,” respectively. At 0142:05, the captain told the controller, “we’ve lost [the] number one engine…we’re coming straight to the airport…we’re gonna need the fire department there’s a chance we’re gonna lose the other engine too it’s running very hot.” The captain further stated, “we’re pretty low on the speed it doesn’t look good out here…you might want to let the Coast Guard know as well.” Afterward, the captain informed the controller that the airplane had no hazardous material and about 2 hours of fuel and that he and the first officer were the only occupants aboard. In between those transmissions, the first officer stated, “fly the airplane please,” which was followed by the EGPWS annunciations “too low terrain,” “too low gear,” and “terrain terrain.” At 0142:45, the captain asked the first officer if he had the airport in sight, which was followed by the EGPWS annunciation “pull up” and the first officer’s statement, “pull up we’re low.” The EGPWS annunciations continued throughout the rest of the flight. At 0142:50, the controller asked whether the crew had the airport in sight, and the first officer stated “negative.” The controller informed the flight crew about a low-altitude alert for the airplane and asked whether the airplane was able to climb. The first officer again stated “negative.” Between 0142:58 and 0143:02, the right EPR increased from 1.33 to 1.45 and remained between 1.45 and 1.47 for the rest of the flight. Between 0143:00 and 0143:06, the controller stated that the airplane should proceed directly to the airport on a heading of 060° and cleared the airplane to land on any airport runway. At 0143:24, the captain told the controller that the airplane “cannot maintain altitude.” Between 0143:35 and 0143:41, the first officer stated, “pull back we've got a climb” and “pull back to the stick shaker,” and the captain stated, “shoot three hundred feet.” At 0143:45, the captain asked the first officer about the EGT, and he stated that it was “hot” and “way over.” At 0144:11, the controller asked if the crew wanted to land at Kalaeloa-Rodgers Airport (JRF), Kapolei, Hawaii, and the first officer responded, “we’d like the closest airport runway please.” The controller stated that JRF was 3 miles north of the airplane’s position at the time and then provided a heading of 310°. At 0144:28, the CVR recorded sounds similar to the stick shaker, which continued intermittently throughout the remainder of the flight. At 0144:52, the captain stated “you have control” twice, and the first officer responded “okay.” The captain then stated, “this is the water we [will be] in the water,” and the cockpit area microphone recorded sounds of heavy breathing. At 0145:11, the captain announced “we’re in the water” twice, and the CVR recorded sounds consistent with impact at 0145:17. FDR data showed that, at water impact, the EPR for the left engine was still 1.05 and that the EPR for the right engine was 1.46. Figure 1 shows the airplane’s flightpath along with key transmissions and events. Figure 2 shows the EPR values during the flight. Figure 3 shows the location of the EPR gauges in the cockpit of the accident airplane. The evacuation and emergency response are discussed in the Survival Aspects section of this report. Figure 1. Airplane flightpath with pertinent transmissions and events overlaid. Figure 2. Left and right EPR values during the accident flight. Note: The EPR decrease on the left engine between 0135:00 and 0136:00 (in purple) occurred between events 6 and 7 in figure 1. Figure 3. EPR gauges on the accident airplane’s center instrument panel (Source: Transair). Note: This photograph was taken in March 2016. Postaccident Interviews with Flight Crew The NTSB interviewed the accident captain and first officer a few days after the accident. The investigation subsequently determined that the left engine was capable of producing normal thrust during the accident flight; as a result, the NTSB conducted follow-up interviews with the accident flight crew 8 months later (March 2022). The captain stated that he heard a “whoosh” sound immediately after his gear-up callout. The captain also stated that he noticed that the EPR indication for each engine was “about two tick marks” below where he had set power on the EPR gauge. (One tick mark on the EPR gauge was equivalent to 0.02 EPR.) The captain thought that power had been lost on the left engine but stated that the EPR for the right engine was a “few ticks lower” than that for the left engine. The captain further stated that “the noise, the yaw and the roll, and the fact that the EPR was lower than what [he] had set, led [him] to believe that the problem [was with] number 2” when the engine issue occurred. The first officer stated that he heard a “pop” sound about the time that the landing gear retracted and that the sound emanated from the left engine area. The first officer also stated that, after the pop sound, “all the gauges on the left side, the Number 1 just dropped.” The first officer recalled “very clearly that [his] initial thought was we’ve lost the number one engine.” In addition, he recalled that the airplane was subsequently “pulling to the left,” so he thought that the left engine “wasn’t producing thrust.” The captain stated that his communications with ATC about the emergency “became a project” and that “it took a while for ATC to know what was going on.” The captain also stated that initially he had difficulty hearing radio transmissions from ATC because “everybody [was] stepping over everybody.” The captain added that ATC communications “took too much of [his] time away from the cockpit.” The captain also stated that, after setting maximum continuous thrust as the pilot monitoring, he did not move either thrust lever until after he became the pilot flying. The captain could not recall the lever positions when he took control of the airplane, but the captain noted that the first officer could adjust the thrust levers as he wanted when he was the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. The first officer also stated that, for an engine failure at V1, the procedure is to move both levers together until the affected engine is identified. The first officer further stated that “our training is [such that] we don't fly on one thrust lever until we have identified which engine. And we don't do that until after we level off.” The captain recalled that the first officer later informed him that the airplane had lost power on the left engine. The captain indicated that he trusted the first officer’s assessment because the captain had “flown with [the first officer] so many times” and “he never makes a mistake.” The captain explained that, after the first officer mentioned the left engine, he “didn't pay attention to [the] number 1 engine” because his “focus was on the engine running, which was number 2.” Further, the captain recalled that the EPR level for the left engine “was down” and “was not going to sustain flight.” The first officer stated that he got through “maybe a third or less” of the Engine Failure or Shutdown checklist because, at that point in the flight, he became concerned that the airplane was “low” and “slowing.” The first officer had also become concerned that the captain “wasn’t focused on flying the airplane.” According to the first officer, he did not get to the step in the checklist that stated, “thrust lever, affected engine, confirm close,” and he could not recall the position of the left thrust lever. The first officer further stated that he should have continued the checklist but that “the number one rule is you fly the airplane first…everything [else] comes after that.” The captain recalled that the first officer read a few lines from the Engine Failure or Shutdown checklist. The captain also stated that, when he saw that the EPR for the right engine was decreasing and that there was “nothing coming out” of the left engine, he thought that performing the checklist would be “useless” at that point. The captain explained that both engines “already shut themselves down” and that his primary focus was staying airborne and figuring out how to return to the airport “without power.” The captain added that, after he saw the EPR for the right engine and the airspeed dropping, he pushed the right thrust lever to the forward stop (where it remained for the rest of the flight), but the airspeed continued to decrease. The captain stated that he did not consider pushing the left thrust lever forward because he was “wrestling” the stick shaker and “trying to get the wings level.” In addition, both pilots stated that, after the transfer of control from the first officer to the captain (about 0137), the captain retained control of the airplane through the end of the flight. - According to postaccident medical records, the captain was placed on a ventilator after arriving at the hospital and was diagnosed with aspiration with respiratory failure. His hospital-administered urine drug screen and blood alcohol level were both negative. Toxicology testing performed by the FAA was positive for a medication given at the hospital that was related to the captain’s treatment. The captain was hospitalized for 2 days and then discharged. The first officer was diagnosed with a scalp laceration, blunt head trauma, cervical strain, and aspiration pneumonitis. His hospital-administered urine drug screen and blood alcohol level were both negative. His Department of Transportation postaccident urine drug screen, which was performed 18 hours after the accident, was negative. Toxicology testing performed by the FAA was positive for four prescription medications. The first officer was discharged from the hospital about 12 hours after he arrived. - Rhoades Aviation According to FAA documentation, in May 2012, Rhoades Aviation began operating Boeing 737 airplanes under Part 121 as a supplemental cargo-only operation doing business as Transair. At the time of the accident, Rhoades Aviation had five 737-200 airplanes and 230 employees, 24 of which were pilots. Continuous Analysis and Surveillance System According to Rhoades Aviation’s General Maintenance Manual (dated February 25, 2014), the primary function of the CASS program was to ensure that the company’s airplanes were airworthy, safe, and reliable and that the company’s maintenance and inspection programs met or exceeded all regulatory requirements. The company’s CASS program had the following primary functional areas: · monitoring a maintenance program’s effectiveness; · monitoring a maintenance program’s performance/execution; · developing and implementing corrective actions for maintenance program deficiencies identified during the surveillance, investigation, and analysis processes; and · following up to ensure that the corrective actions were effective. Monthly CASS meetings were held, and findings from the program were presented by Rhoades Aviation’s chief inspector, who was responsible for the company’s CASS program. The meetings included the FAA principal inspectors for the company. The NTSB reviewed the CASS meeting reports from July 2020 to June 2021 and found that the June 2021 CASS report included four components that had failed at least three times during the preceding month. One of these components, the right engine fuel quantity system, was first identified several months earlier. The June 2021 CASS report also showed that Rhoades Aviation was tracking maintenance issues related to the traffic collision avoidance system, right engine thrust reverser system, and left engine fuel heat valve light. The Rhoades Aviation chief inspector at the time of the accident had been hired 2 weeks before the accident. The previous chief inspector began working for the company in February 2019 as a part-time mechanic, left the company at some point later, and returned in July 2019 as the company’s chief inspector. He resigned from that position in May 2021 because of the stress associated with the position but remained with the company. In addition to managing the CASS program, his main responsibilities as chief inspector included ensuring that required inspections were performed and overseeing a records manager, records clerk, and a nondestructive testing inspector. In addition, he was helping the company with its responses to FAA inquiries about maintenance issues. The previous chief inspector stated that he did not have the staffing to effectively handle all his responsibilities and that he did not have the time or the related experience to review the CASS data and perform trend analyses. The previous chief inspector asked company management to hire a CASS manager and an additional inspector, but the positions were not filled before the chief inspector resigned because the company had difficulty finding qualified applicants. Company Manuals and Checklists Review of Rhoades Aviation’s most recent revision of its General Maintenance Manual found that several of the manual’s references and procedures no longer applied or were inaccurate. The company’s director of maintenance was responsible for the manual procedures. The Rhoades Aviation Boeing 737 Aircraft Operations Manual discussed the effect of an engine failure after V1. The manual stated the following: An engine failure at or after V1 initially affects yaw much like a crosswind effect. Vibration and noise from the affected engine may be apparent and the onset of the yaw may be rapid. The airplane heading is the best indicator of the correct rudder pedal input. To counter the thrust asymmetry due to an engine failure, stop the yaw with rudder. The manual provided the following technique for an in-flight engine shutdown: Any time an engine shutdown is required in flight, good crew coordination is essential. Airplane incidents have turned into airplane accidents as a result of the flight crew shutting down the incorrect engine. When the flight path is under complete control, the crew should proceed with a deliberate, systematic process that identifies the correct engine and ensures that the operating engine is not shut down. Do not rush through the shutdown checklist, even for a fire indication. The following technique is an example that could be used: The PF…verbally coordinates confirmation of the affected engine with the PM and then slowly retards the thrust lever of the engine that will be shutdown [sic]. Coordinate activation of the start lever as follows: • PM places a hand on and verbally identifies the start lever for the engine that will be shutdown [sic] • PF verbally confirms that the PM has identified the correct start lever • PM moves the start lever to cutoff The Rhoades Aviation Boeing 737-200C Quick Reference Handbook (QRH) provided the following guidance about non-normal checklist usage: Non-normal checklist use starts when the airplane flight path and configuration are correctly established…. Usually, time is available to assess the situation before corrective action is started. All actions must then be coordinated under the Captain’s supervision and done in a deliberate, systematic manner. The QRH included the Engine Failure or Shutdown checklist, as shown in figure 8. The QRH stated that “the word ‘Confirm’ is added to checklist items when both crewmembers must verbally agree before action is taken.” The QRH also stated that, “during an inflight non-normal situation, verbal confirmation is required” for several items, including movement of an engine thrust lever. Figure 8. Engine Failure or Shutdown checklist (Source: Rhoades Aviation). The Rhoades Aviation simulator guide, which supplemented information in the operator’s flight crew training manual, contained the most recent company guidance for training at the time of the accident. The simulator guide, which contained memory items, provided procedures to follow with an engine failure after the V1 callout. According to the simulator guide, both pilots should announce the engine failure, which (1) the pilot flying would primarily recognize from a yawing moment and the rudder input required to counteract it and (2) the pilot monitoring would primarily recognize from a yawing moment and the engine gauges. The simulator guide stated that the pilot monitoring should declare an emergency to ATC and provide “initial intentions (such as heading & altitude).” The guide also stated that, when time permits, the pilot flying should “advise ATC of level of impairment, assistance required, soulsonboard, [and] fuel-on-board (in pounds).” The simulator guide further stated that, after declaring the emergency, selecting flaps to the UP position, reducing thrust, and establishing the airplane in a climb at 210 knots, the pilot flying was to fly, navigate, and communicate, and the pilot monitoring was to “call out or reconfirm” the affected engine. The guide indicated that “the Captain, if not currently the PM, may (and most times should) elect to become the PM and run the QRH checklist.” In addition, the guide mentioned that both pilots should “be alert for aircraft yawing and changes in engine gauges & engine noise that could indicate that thrust is being reduced on the incorrect engine (operating engine).” Crew Resource Management Training According to FAA Advisory Circular 120-51E, CRM is “the application of team management concepts in the flight deck environment.” In 1998, the FAA began requiring Part 121 air carriers to provide FAA-approved initial and recurrent CRM training to flight crews. The Rhoades Aviation Aircrew Training Manual indicated that the objective of the company’s CRM training was “to increase the efficiency with which flight personnel perform by focusing on communication skills, teamwork, task allocation, and decision making.” The manual stated that the instruction methods used in the company’s CRM training included lectures, audio-visual programs, multimedia presentations, overhead projections, and printed handouts and that CRM exercises would be introduced in flight training. Rhoades Aviation’s initial CRM training consisted of 6 hours of instruction and included videos about the history of CRM, complacency, threat and error management, and four accidents that involved a lack of CRM. One of those accidents was American Airlines flight 1400, a McDonnell Douglas DC-9-82, which experienced an in-flight left engine fire during the departure climb from St. Louis Lambert International Airport, St. Louis, Missouri, in September 2007. The video for this accident explained that American Airlines’ policy was for the pilot flying to handle the radios while flying the airplane and for the pilot monitoring to execute the appropriate checklist. The flight 1400 first officer (who was the pilot monitoring) continued to control the radios while attempting to execute the engine fire checklist. The flight 1400 captain did not recognize that multiple ATC radio calls were delaying the execution of the checklist, and he directed the first officer to take control of the airplane before critical checklist steps were performed, such as cutting off fuel flow to the affected engine, causing the engine fire to continue. The video emphasized the importance of task prioritization and workload management, adherence to standard operating procedures, and good leadership when confronted with abnormal situations. The captain’s and the first officer’s initial CRM training occurred in 2019. Rhoades Aviation’s recurrent and upgrade CRM training consisted of 2 hours instruction and included topics such as current CRM-related findings, the mission of CRM training, performance markers, and team building and maintenance. The captain’s and the first officer’s most recent recurrent CRM training occurred on May 7, 2021, and August 5, 2020, respectively. Training materials and records from Rhoades Aviation showed that the captain and the first officer’s CRM training addressed the importance of CRM in abnormal situations. This training discussed thorough preparation and planning, the use of briefings, task prioritization, workload management, the use of checklists and standard operating procedures to prevent errors, and clear communications. The captain also received CRM training on the importance of effective leadership. Federal Aviation Administration Oversight FAA oversight for Rhoades Aviation was provided by a team at the Honolulu certificate management office. The team included a front-line manager and principal operations, maintenance, and avionics inspectors. The front-line manager stated that all the principal inspectors were “new to the certificate” and that the operator was “understaffed a lot of the time” and did not have “enough help to do what they need to do and to fix manuals.” Before the accident, the FAA issued several letters of investigation to Rhoades Aviation. The FAA provides letters of investigation for suspected violations of the Federal Aviation Regulations. According to the FAA, a letter of investigation “serves the dual purposes of notifying an apparent violator that he or she is under investigation for a possible violation and providing an opportunity for the apparent violator to tell his or her side of the story.” Most of the issues in the letters of investigation addressed Rhoades Aviation’s operations specifications; aircraft inspection program (the issues were unrelated to engine maintenance); maintenance manual revisions; and processes, policies, and procedures. - The Captain The captain’s first-class medical certificate included the limitation that he must wear corrective lenses, and the captain stated that he was wearing his glasses during the accident flight. The captain’s work schedule at Rhoades Aviation for the 3 days before the accident flight is shown in the table below. Table. Captain's 72-hour work history. Date Start time End time Flight time No. of legs June 29, 2021 0015 0730 3 hours 26 minutes 6 June 30, 2021 0015 1202 5 hours 17 minutes 8 July 1, 2021 0015 0723 3 hours 32 minutes 6 The captain stated that the nature of his job resulted in an unpredictable sleep pattern. The captain could not recall how much sleep he obtained in the days before the accident, but the captain reported that he obtained some sleep each day and did not feel sleep deprived when he arrived at work for the accident flight. The captain also stated that he might have obtained rest between his work shifts from June 29 to July 1. On June 29, he had a sleep opportunity between 1000 and 2000; on June 30, he had a sleep opportunity between 1500 and 2100; on July 1, he had a sleep opportunity between 1000 and 2000. The captain reported that he had experienced about five engine failures while working at Rhoades Aviation. One such failure occurred about 3 to 4 months before the accident. During that flight, the captain heard a “pow” sound while the airplane was climbing through 700 ft and noted an issue with the left engine, so he decided to immediately return to the airport. The captain reported that the company chief pilot criticized him for returning to the airport without performing the relevant abnormal checklist. The captain promised the chief pilot that he would perform the relevant checklist if he were involved in another emergency. The captain also stated that he had performed seven precautionary or emergency landings while working for the company. The First Officer The first officer was also an attorney who did legal work (when he was not flying) during weekdays and part of the day on Saturdays. The first officer did not log any flight time during the 72 hours before the accident. The first officer’s second-class medical certificate included the limitation that he must wear corrective lenses, and the first officer stated that he needed to wear a corrective lens only in his right eye and that he was wearing the corrective lens during the accident flight. The first officer reported that he normally went to sleep between 2200 and 2300 and awoke between 0600 and 0700. He thought that his sleep pattern on June 29 and 30 was consistent with his normal schedule. On June 29, he worked on manual revisions for Rhoades Aviation. On June 30 and the morning of July 1, he did legal work. The first officer then rested between 1400 and 2330 for his upcoming flight (the accident flight). He could not recall when he fell asleep but stated that his quality of sleep was good. The first officer stated that he had experienced an in-flight engine failure while working for another air carrier (from 1991 to 1995) and that the event airplane landed safely. The first officer also stated that he had not experienced another inflight engine failure until the accident flight. - Evacuation The flight crew reported that the airplane came to a quick stop after impacting the water. The captain looked out his left-side cockpit window and saw water halfway up the window. Both he and the first officer could feel the airplane sinking. The captain opened his window, and water began rushing in. The captain released his restraints (including his shoulder harnesses) and evacuated the airplane through the window. (The captain’s window was found fully open and unbroken.) The captain reported no problems releasing his restraints or opening the window. The captain left everything behind and did not reach for a flotation device because he was focused on getting out of the airplane. The captain recalled that he evacuated the airplane after the first officer. Once in the water, the captain decided to swim along the left side of the airplane to try to find structure to hold onto because waves were coming over him. The captain found nothing to hold onto, so he swam to the tail section, which was floating. The captain used the automatic direction finder antenna to hoist himself onto the right side of the vertical fin. The waves knocked him off a few times, and each time he swam back to the tail, climbed back up, and held on. The captain remembered seeing a helicopter making a few passes overhead, and the last thing that he remembered was struggling to stay afloat after a wave knocked him off the tail. His next memory was waking up in the hospital. The first officer stated that, during the impact, his upper torso moved forward as his right shoulder moved forward, downward, and to the left, causing his body to twist. The first officer’s head then moved downward (with his face turned to the left), and the top of his head struck something in front of him. The first officer opened his right-side window and had no problem releasing his restraints (including his shoulder harnesses). He evacuated the airplane through his window. (The first officer’s window was found unbroken and partially open before wreckage recovery efforts, which resulted in the window moving to the fully open position.) Once outside the cockpit, the first officer saw that the airplane had broken into two pieces, and he stayed with the nose section. The first officer saw the captain swim to the tail section but then lost sight of him. Both flight crewmembers called each other’s names and heard the other’s reply, so they both knew that the other was still above the water. The first officer recalled that the airplane nose then started to sink. About that time, he noticed a large wooden pallet nearby and climbed upon that, which enabled him to see the tail section with the captain on top. The first officer recalled hearing a helicopter and seeing it make three large circles around the wreckage area. On the fourth pass, the helicopter crew saw the first officer and shined the spotlight on him. The first officer signaled that the captain was on the tail section because he was concerned that the tail might sink. The helicopter then moved to a position over the tail to rescue the captain. A boat from HNL ARFF arrived to rescue the first officer. The first officer stated that someone in the boat bandaged his head to stop the bleeding caused by his injury. The first officer was found without a flotation device. Emergency Response About 0145 the USCG Joint Rescue Coordination Center in Honolulu received initial notification about a downed airplane 2 nautical miles south of HNL. (The USCG Joint Rescue Coordination Center was responsible for coordinating US aviation and maritime search and rescue activities in the Pacific Ocean.) Two minutes later, the USCG received the first emergency locator transmitter alert from the airplane, indicating that it was located 2 nautical miles southeast of JRF. The Joint Rescue Coordination Center notified HNL ARFF personnel (about 0147) and USCG Air Station Barbers Point personnel (about 0148) about the downed airplane. HNL ARFF launched a rescue boat about 0200, and Air Station Barbers Point launched an MH-65 Dolphin helicopter about 0218. The ARFF station was located about 2.8 nautical miles northwest of the airplane’s coordinates, and the helicopter flew to the airplane’s last known position. About 0230, personnel aboard the helicopter arrived at the accident site (which they identified by a fuel slick and debris on the water) and subsequently located both flight crewmembers on floating debris. About 0240, the HNL ARFF rescue boat arrived on scene; the boat had been delayed because of high surf and low visibility. A rescue diver aboard the helicopter was hoisted downward and assisted the captain, who was struggling to stay afloat after the tail began to sink. The diver and the captain were hoisted back to the helicopter, and then the diver entered the water again to help the first officer. The diver assessed the first officer’s condition and decided to swim with the first officer on the floating debris to the ARFF rescue boat. They reached the boat about 0251. The helicopter departed the scene about 0259, and the ARFF rescue boat departed the scene about 0302. The helicopter arrived at a local hospital with the captain about 0305. The ARFF rescue boat encountered high surf and low visibility while traveling to the HNL ARFF station dock. About 0406, the first officer was transported to the hospital by an ambulance that had been positioned at the ARFF station. Flight Crew Seats The captain’s and the first officer’s seats were manufactured by IPECO. The captain’s seat (on the left side of the cockpit) had a manufacture date of May 25, 1990, and was designed to comply with TSO-39b, Aircraft Seats and Berths, dated April 17, 1987. The first officer’s seat (on the right side of the cockpit) had a manufacture date of September 9, 1984, and was designed to comply with TSO39a, dated February 24, 1972. (The difference between these TSOs involved the incorporation of fire-blocking material that met the requirements of 14 Code of Federal Regulations 25.853(c), which became effective November 26, 1984.) Both TSO-39a and -39b required the seats to meet a static load requirement of 9 G forward and 6 G downward. The captain’s seat was intact and secured to the seat tracks, which were fastened to a box structure that attached to the floor. The box seat structure, seat cushions, and seat pan were not damaged. The bungees underneath the seat and the threaded rod and spring (which were used to adjust the seatback angle) remained intact. The storage area below the seat pan was not damaged. The first officer’s seat was intact and secured to the seat tracks. The seatback had rotated forward and collapsed, as shown in figure 7. The seat cushions and seat pan were not damaged, but the stowage compartment below the seat was damaged. The left bungee was broken with onehalf missing; the right bungee was connected, but the elastic was broken in multiple places. The threaded rod and spring were fractured at the forward end. Figure 7. First officer’s seat in cockpit after recovery. The seatback for the first officer’s seat was designed with a jackscrew mechanism that adjusted the seatback position. The jackscrew was mounted to the underside of the seat. The base of the screw was connected to the base of the seatback with a hinge pin, and a jack nut inside a housing was located on the underside of the seat pan. A compression spring and sleeve were installed over the jackscrew, and the free end of the screw was passed through the nut assembly. The spring used residual compression to push the jackscrew aft, which would cause the seatback to move forward. To move the seatback aft, the occupant would use body weight to push against the seatback, which would result in forward movement of the jackscrew. The rotation of the nut, and thus the seatback position, would become locked by a latch mechanism that could be engaged or disengaged by the seat occupant. The first officer’s seat was examined by the NTSB Materials Laboratory to determine the condition of the components that controlled the seatback position. Examination of the nut assembly revealed that the jack nut was fractured in the transverse plane between large- and small-diameter sections of the nut. The latch was found in the locked position. The latch tip showed no apparent deformation, and the nut slot (for receiving the latch) appeared to be aligned with the locking slot in the housing. Teardown of the nut assembly revealed that the jack nut had fractured in overstress. The threads on the largediameter portion of the nut (which contained the slots for engaging with the latch) exhibited a stripped appearance, whereas the threads on the small-diameter portion of the nut did not appear stripped. Examination with a stereomicroscope revealed no apparent progressive cracking features. - An aircraft performance study was performed as part of this accident investigation. The objectives of the study were to (1) quantify the Boeing 737-200 airplane’s expected climb performance capability with one engine inoperative (OEI), (2) evaluate the accident airplane’s climb performance after the rapid reduction in right EPR, and (3) determine if the accident airplane’s motion, in response to EPR changes, configuration changes, and flight control inputs, was consistent with the behavior of a nominal 737200. Boeing developed takeoff and climb performance data and OEI maximum takeoff thrust and maximum continuous thrust performance data for its 737200 Airplane Flight Manual (AFM). For this study, Boeing engineering staff calculated baseline takeoff and climb performance for a 737-200 equipped with Pratt & Whitney JT8D-9 engines and determined the OEI-expected and the accident airplane-demonstrated climb performance. The Pratt & Whitney JT8D-9A engine model was unavailable, so the JT8D9 engine model was used to support calculations for this study. The data used in the study assumed that the landing gear was retracted, the airplane was flying at a constant airspeed with a neutral control wheel, and the OEI thrust asymmetry was trimmed with rudder. According to these data, a 737200 with JT8D-9 engines would have adequate OEI performance capability to climb or maintain altitude with the accident airplane’s (1) altitude range (0 to about 2,000 ft), (2) loading conditions (a takeoff weight of 93,557 pounds), (3) flight conditions from takeoff to water impact (including a 26°C outside air temperature), and (4) flap and gear configurations. After the right engine rapid EPR reduction shortly after takeoff (with no change to the left EPR), the flight crew and the accident airplane demonstrated the ability to climb to 1,000 ft, accelerate, climb to 2,000 ft, and maintain altitude. When the left EPR was reduced below 1.2 (which occurred between 0135:52 and 0135:53), the airplane’s total engine thrust was less than the thrust required for the airplane to maintain altitude with the flight conditions, flight control inputs, EPR values for the left and right engines, and flap configurations during the remainder of the flight. (The left EPR continued to decrease, reaching 1.05 at 0135:56 and remaining at that level for the rest of the flight.) Boeing used its 737-200 integrated airplane simulation model to conduct a simulation of the accident flight. As part of this effort, Boeing modeled the following segments of the accident flight: takeoff ground roll and initial climb; right EPR rapid reduction and airplane climb and level-off; sequential left EPR reductions; the right banked turn from a heading of 240° to 260° (which began about 0138:13) followed by the left banked turn to a heading of 240° (which began about 0138:36); deceleration with flaps up; and deceleration with the flaps 1 configuration. Pratt & Whitney provided baseline JT8D-9 engine model data for each engine during the accident flight based on FDR airspeed, pressure altitude, and left and right EPR data. The following engine parameters were then calculated for each engine: N1 (speed of lowpressure spool), N2 (speed of high-pressure spool), net thrust, EGT, fuel flow, and nominal engine power lever angle. Pratt & Whitney also developed engineering models to account for (1) the engine thrust increments resulting from the installation of an AvAero hush kit (for noise abatement) on each engine in May 2004, (2) in-service engine deterioration based on data recorded during the cruise segments of preceding flights that the accident airplane accomplished, and (3) estimated thrust degradation to the right engine based on the damage observed in the recovered high- and low-pressure turbines. According to the Boeing 737-200 airframe and Pratt & Whitney JT8D-9 engine simulation models, the accident airplane’s motion (in response to EPR changes, configuration changes, and flight control inputs) was generally consistent with the behavior of the nominal 737-200 airplane/engine/flight controls simulation model and the Pratt & Whitney-calculated engine thrust profile for each engine. - The airplane’s forward fuselage section separated from the rest of the airplane near the leading edge of the wing. Most of the fuselage structure below the main cabin and cockpit floor separated from the forward fuselage. The separated structure below the floor was crushed and torn. The aft fuselage lower section was damaged, and portions of belly skin had separated from the airplane. The four cargo containers remained in the aft fuselage. Most of the cargo was waterlogged. Both wings remained attached to the fuselage, and the inboard and outboard flaps, ailerons, and spoilers remained attached to the wings. The left and right engines separated from their respective wings. The left and right main landing gear were in the retracted position when the airplane was lifted from the water after the accident. (See the Additional Information section of this report for details about the search and recovery of the wreckage.) The empennage was mostly intact with the horizontal stabilizer, elevators, and trim tabs remaining in their installed positions. The left and right elevators were undamaged. The vertical stabilizer and the rudder remained in their installed positions and were mostly undamaged. The center instrument panel showed that the EPRs for the left and right engines were about 1.0 and 1.6, respectively. The panel also showed that the EGTs for the left and right engines were 70 (indicating 700°C) and less than 0, respectively. Postaccident Examination of Left Engine The left engine showed no indications of fire, uncontainment, or case rupture. The pressure ratio bleed control valve remained installed. The turbine exhaust case EGT and EPR probes were full length. The low-pressure compressor stage 1 through 4 blades were full length. Two of the stage 5 blades had fractured; the rest were full length. Sections of the stage 5 and 6 blades were bent opposite the direction of rotation. The compressor intermediate case exhibited a deep inward dent by these blades. Most of the highpressure compressor stage 7 blades were bent opposite the direction of rotation; four of these blades were fractured and deformed. The stage 12 and 13 blades were also bent opposite the direction of rotation. The fuel pump and fuel control unit from only the left engine were examined and tested. No anomalies were found that would have prevented normal engine operation. Postaccident Examination of Right Engine The right engine showed no indications of fire, uncontainment, or case rupture. The pressure ratio bleed control valve remained attached to the engine. The turbine exhaust case EGT and EPR probes were full length. The low-pressure compressor blades in stages 2 through 6 were bent opposite the direction of rotation, as were the high-pressure compressor blades in stages 7 through 13. The high-pressure turbine disk was intact, and all stage 1 blades and blade retention rivets were secure. The outer spans of two high-pressure turbine stage 1 blades were missing. The high-pressure turbine stage 1 blades were numbered clockwise from 1 to 80, with the trailing fractured blade designated as blade No. 1 and the leading fractured blade designated as blade No. 6, as shown in figure 4. The liberated portions of the blades were not recovered. Figure 4. Fractured blades on the right engine high-pressure turbine. Blade Nos. 1 and 6 were fractured transversely about 2.4 and 2.7 inches, respectively, above the platform trailing edge. Blade Nos. 3, 4, 79, and 80 exhibited trailing-edge outer diameter impact damage toward the outer span. Other blade trailing edges showed varying damage with missing material up to 0.04 inches radially. The blade fracture surfaces were heavily coated with ocean deposits. The low-pressure turbine stage 2 and 3 blades exhibited outer span fractures. Up to 3 inches of outer span material was missing from the stage 4 blades. Metallurgical Examination of Right Engine High-Pressure Turbine Blades The two fractured high-pressure turbine blades (Nos. 1 and 6) were examined at Pratt & Whitney’s Materials and Processes Engineering Lab in East Hartford, Connecticut. The examination determined that the blades failed by stress rupture resulting from a loss of load-bearing material due to oxidation and corrosion. The oxidation occurred around the blades’ internal lightening (weight-reduction) holes and had significantly reduced each blade’s load-bearing cross-section. The fracture through the oxidized regions exhibited comparatively flat features, consistent with brittle fracture. The fracture across the remaining load-bearing blade material either exhibited a rough (intergranular) texture, which was consistent with stress rupture, or was covered by ocean deposits. In addition, the examination found microstructure changes to the blade material on four high-pressure turbine stage 2 blades, which was consistent with exposure to temperatures beyond the blades’ normal operating range. -
Analysis
Transair flight 810, a Title 14 Code of Federal Regulations Part 121 cargo flight, experienced a partial loss of power involving the right engine shortly after takeoff and a water ditching in the Pacific Ocean about 11.5 minutes later. This analysis summarizes the accident and evaluates (1) the right engine partial loss of power, (2) the captain's communications with air traffic control (ATC) and the first officer's left and right engine thrust reductions, (3) the first officer's misidentification of the affected engine and the captain's failure to verify the information, (4) checklist performance, and (5) survival factors. Maintenance was not a factor in this accident. The flight data recorder (FDR) showed that, when the initial thrust was set for takeoff, the engine pressure ratios (EPR) for the left and right engines were 2.00 and 1.97, respectively. Shortly after rotation, the cockpit voice recorder (CVR) recorded a “thud” and the sound of a lowfrequency vibration. The captain (the pilot monitoring at the time) and the first officer (the pilot flying) reported that they heard a “whoosh” and a “pop,” respectively, at that time. As the airplane climbed through an altitude of about 390 ft while at an airspeed of 155 knots, the right EPR decreased to 1.43 during a 2second period. The airplane then yawed to the right; the first officer countered the yaw with appropriate left rudder pedal inputs. The CVR showed that the captain and the first officer correctly determined that the No. 2 (right) engine had lost thrust within 5 seconds of hearing the thud sound. After moving the flaps to the UP position, the captain reduced thrust to maximum continuous thrust, causing the left EPR to decrease from 1.96 to 1.91 while the airplane was in a climb. (The right EPR remained at 1.43). The captain reported that he did not move the thrust levers again until after he became the pilot flying. The first officer stated that, after the airplane leveled off at an altitude of about 2,000 ft, he reduced thrust on both engines. FDR data showed that thrust was incrementally reduced to near flight idle (1.05 EPR on the left engine and then 1.09 EPR on the right engine) and that airspeed decreased from about 250 to 210 knots. (A decrease in airspeed to 210 knots was consistent with the operator’s simulator guide procedures for a singleengine failure after the takeoff decision speed [V1]. The simulator guide, which supplemented information in the company’s flight crew training manual, contained the most recent operator guidance for single-engine failure training at the time of the accident.) The captain was unaware of the first officer’s thrust changes because he was busy contacting the controller about the emergency. The captain told the controller, “we’ve lost an engine,” but he had declared the emergency to the controller twice before this point, as discussed later in this analysis. The captain instructed the first officer to maintain a target speed of 220 knots (which the captain thought would be “easy on the running engine”), a target altitude of 2,000 ft, and a target heading of 240°. (About 52 seconds earlier, the controller had issued the 240° heading instruction to another airplane on the same radio frequency.) About 3 minutes 14 seconds after the right engine loss of thrust occurred, the captain assumed control of the airplane; at that time, the airplane’s airspeed was 224 knots and heading was 242°, but the airplane’s altitude had decreased from about 2,100 ft (the maximum altitude that the airplane reached during the flight) to 1,690 ft. The captain increased the airplane’s pitch to 9°; the airplane’s altitude then increased to 1,878 ft, but the airspeed decreased to 196 knots. The captain subsequently stated, “let’s see what is the problem...which one...what's going on with the gauges,” and “who has the E-G-T [exhaust gas temperature]?” The first officer stated that the left engine was “gone” and “so we have number two” (the right engine), thus misidentifying the affected engine. The captain accepted the first officer’s assessment and did not take action to verify the information. Afterward, the EPR level on the right engine began to increase in response to the captain advancing the right thrust lever so that the airplane could maintain airspeed and altitude. Right EPR increased and decreased several times during the rest of the flight (coinciding with crew comments regarding the EGT on the right engine and low airspeed) while the left EPR remained near flight idle. The first officer asked the captain if they “should head back toward the airport” before the airplane traveled “too far away,” and the captain responded that the airplane would stay within 15 miles of the airport. During a postaccident interview, the captain stated that, because there was no fire and an engine “was running,” he intended to have the airplane climb to 2,000 ft and stay within 15 miles of the airport to avoid traffic and have time to address the engine issue. The captain also stated that he had been criticized by the company chief pilot for returning to the airport without completing the required abnormal checklist for a previous in-flight emergency. Although the captain’s decision resulted in the accident airplane flying farther away from the airport and farther over the ocean at night, the captain’s decision was reasonable for a single-engine failure event. The captain directed the first officer to begin the Engine Failure or Shutdown checklist and stated that he would continue handling the radios. The first officer began to read aloud the conditions for executing the Engine Failure or Shutdown checklist but then stopped to tell the captain that the right EGT was at the “red line” and that thrust should be reduced on the right engine. The captain then decided that the airplane should return to the airport and contacted the controller to request vectors. The flight crew continued to express concern about the right engine. The first officer stated, “just have to watch this though…the number two.” The captain asked the first officer to check the EGT for the right engine, and the first officer responded that it was “beyond max.” Afterward, the captain told the first officer to continue with the Engine Failure or Shutdown checklist and finish as much as possible. The first officer resumed reading aloud the conditions for performing the checklist but then stopped to state, “we have to fly the airplane though,” because the airplane was continuing to lose altitude and airspeed. The captain replied “okay.” As a result, the flight crew did not perform key steps of the checklist, including identifying, confirming, and shutting down the affected (right) engine. The first officer told the captain that the airplane was losing altitude; at that time, the airplane’s altitude was 592 ft, and its airspeed was 160 knots. The captain agreed to select flaps 1 (which the first officer had previously suggested likely because the airplane was slowing). The CVR then recorded the first enhanced ground proximity warning system (EGPWS) annunciation (500 ft above ground level); various EGPWS callouts and alerts continued to be annunciated through the remainder of the flight. The captain then told the controller that “we’ve lost number one [left] engine…there’s a chance we’re gonna lose the other engine too it’s running very hot….we’re pretty low on the speed it doesn't look good out here.” Also, the captain mentioned that the controller should notify the US Coast Guard (USCG) because he was anticipating a water ditching in the Pacific Ocean. Because of the high temperature readings on the right engine, the flight crew thought, at this point in the flight, that a dual-engine failure was imminent. During a postaccident interview, the captain stated that his priority at that time was figuring out how the airplane could stay in the air and return safely to the airport. The captain also stated that he attempted to resolve the airplane’s deteriorating energy state by advancing the right engine thrust lever. However, with the left engine remaining near flight idle, the right engine was not producing sufficient thrust to enable the airplane to maintain altitude or climb. The captain’s communication with the controller continued, and the first officer stated, “fly the airplane please.” The controller asked if the airport was in sight, and the captain then asked the first officer whether he could see the airport. The first officer responded “pull up we’re low” to the captain and “negative” to the controller; the captain was likely unable to respond to the controller because he was trying to control the airplane. The captain asked the first officer about the EGT for the right engine; the first officer replied “hot…way over.” The captain then asked about, and the controller responded by providing, the location of the closest airport. Afterward, the CVR recorded a sound similar to the stick shaker, which continued intermittently through the rest of the flight. The CVR then recorded sounds consistent with water impact. The aircraft performance study for this accident found that the airplane had adequate total engine thrust available to climb, accelerate, and maintain altitude both before and after the rapid decrease in right EPR to 1.43. However, as the left EPR decreased and remained below a level of 1.2 (which occurred about 35 seconds after the airplane leveled off at 2,000 ft and while the EPR on the right engine was about 1.4), total engine thrust decreased to the point that the airplane transitioned to and remained at a lowenergy state (that is, low total engine thrust, low airspeed, and low altitude). The flight crew relied exclusively on thrust from the damaged right engine as thrust on the left engine remained near flight idle. With this engine power configuration, the flight crew could not arrest the airplane’s descent, and the airplane was unable to maintain altitude, accelerate, or climb because the flight crew did not take the corrective action of adding left engine thrust, which was available. Right Engine Loss of Thrust and Left Engine Pressure Ratio Decrease The rotational signatures observed during postaccident examination of both engines indicated that the right engine was rotating at a much faster speed at impact than the left engine. The indications showing low rotation of the left engine core at impact were consistent with the engine operating near flight idle at that time. Postaccident examination of the left engine found no anomalies that would have caused the reduced thrust on that engine. The teardown of the right engine showed that two high-pressure turbine stage 1 blades were missing their outer spans and that both had failed from a stress rupture fracture due to oxidation and corrosion of the internal blade lightening (weight-reduction) holes, which resulted in a loss of loadbearing crosssection. The blade failures caused downstream (secondary) damage to the lowpressure turbine, resulting in a loss of thrust, which would have been presented to the flight crew as a decrease in EPR on the right engine (along with the thud sound recorded on the CVR and the yaw to the right). Postaccident examination of the high-pressure turbine stage 1 right engine blades also revealed that they had been exposed to temperatures beyond the blades’ normal operating range, resulting in microstructure changes to the blade material. According to flight crew postaccident interviews as well as CVR evidence, the right EGT was at the top of the gauge (at or above the red line). Also, the operator’s Boeing 737 Aircraft Operations Manual stated that the maximum continuous EGT for the airplane’s engines was 540°C, but the EGT gauge was found in the wreckage indicating 700°C. Thus, the overtemperature damage on the right engine blades likely occurred during the accident flight when the engine was operated at elevated temperatures. Notification to Controller About Emergency and Engine Thrust Reductions The captain first declared an emergency to the controller about 36 seconds after the CVR recorded the thud sound; he also advised the controller to stand by. The controller responded with a routine departure clearance; thus, the controller likely did not hear or understand the captain’s transmission. About 7 seconds later, the captain again declared an emergency and advised the controller to stand by. During the 30 seconds that followed, the captain reminded the first officer to fly the airplane on a heading of 220° and level off at 2,000 ft. The controller again provided routine instructions to the flight crew about 33 seconds after the captain’s second transmission about the emergency. The captain then declared an emergency (for the third time) and stated that the airplane lost an engine and was on a 220° heading. The controller responded, “say again heading two four zero.” Immediately after issuing this instruction, the controller informed the captain that the heading was intended for another airplane. The captain did not hear, understand, or remember this transmission because he later instructed the first officer to fly the airplane on a 240° heading. The controller then cleared the accident airplane for a visual approach to the airport, and the captain informed the controller that he and the first officer had to perform a checklist and would let her know when they were ready to return to the airport. The controller then asked the captain to keep her advised. The process of declaring the emergency to ATC took 1 minute 53 seconds. During a postaccident interview, the captain stated that his communications with the controller “became a project” and that “it took a while for ATC to know what was going on” regarding the emergency. The captain added that those communications “took too much of [his] time away from the cockpit.” Although frequency congestion impeded the captain’s efforts to declare an emergency to ATC, the captain could have entered squawk code 7700 (indicating an emergency situation) into the transponder and deferred further radio communications until after the first officer stabilized the airplane in level flight. In addition, about 25 seconds after the previous exchange between the controller and captain ended, the controller asked for more information about the emergency, including which engine was affected. The operator’s simulator guide stated that, after declaring an emergency involving a single-engine failure after V1, the captain could provide additional information to ATC when time permitted. Because further communication with ATC was not a priority at that time, the captain responded appropriately to the controller by stating that he would provide the information later. The simulator guide also stated that, after declaring an emergency to ATC, selecting flaps to the UP position, reducing thrust, and establishing the airplane’s climb at 210 knots, the pilot flying was to fly, navigate, and communicate, and the pilot monitoring was to “reconfirm” the failure. However, much of the captain’s time by this point in the flight was spent listening and responding to ATC transmissions. Thus, communications between the captain and controller after the onset of the emergency caused interruptions that delayed the flight crew’s efforts to address the emergency situation. While the captain was communicating with the controller, the first officer, as the pilot flying, incrementally reduced left and then right engine thrust to near flight idle so that the airplane could slow down after leveling off. The first officer stated that he had been trained in the simulator to move the thrust levers together until the crew was ready to confirm the affected engine. Thus, the first officer’s decision to independently move the left and then the right thrust lever was inappropriate. When the captain turned his attention back to the airplane after communicating with the controller, both engines were near flight idle (the EPR was 1.05 and 1.12 for the left and right engine, respectively), and the airspeed was 227 knots and decreasing. The captain commanded a speed of 220 knots and then announced that he was taking control of the airplane. FDR data indicated that the captain did not promptly increase thrust after the airspeed subsequently dropped below the 220-knot target speed. During a postaccident interview, the captain stated that he was unaware that the first officer had reduced left engine thrust to near flight idle. The captain’s lack of awareness of the first officer’s thrust reductions played a role in his handling of the inflight emergency, as discussed in the next section. Misidentification of the Affected Engine and Failure to Verify About 4 minutes elapsed between the time of the flight crew’s correct identification of the right engine as the affected engine and the first officer’s incorrect assessment about the left engine. This amount of time played a role in the first officer’s misidentification of the left engine as the affected engine. The first officer had a high workload during that time; as the pilot flying, he had to (among other things) closely monitor basic flight parameters and fly the airplane to achieve the target airspeed, altitude, and heading. The first officer was also dealing with interruptions due to the interspersing of various operational tasks. Although the first officer had previously verbalized that the right engine had lost power, the first officer’s workload demands left few opportunities for him to commit that information to memory. In addition, after the airplane had leveled off and the left and right EPR had been reduced to near flight idle, no adverse yaw (the primary cue indicating that the right engine was affected) was occurring, and the engine indications were ambiguous because both were producing low thrust (with the EPR on the left and right engines at 1.05 and 1.12, respectively). Although thrust was low on both engines, the first officer might have thought that the left engine was affected because its EPR level was lower than that for the right engine. For that to be the case, the first officer would have had to have forgotten his earlier actions of pulling back the power on the left (operational) engine and then the right (damaged) engine to reduce airspeed. The National Transportation Safety Board (NTSB) considered whether the first officer’s use of prescription medications played a role in (1) forgetting his and the captain’s initial correct diagnosis and his movement of the left thrust lever (along with the right thrust lever) to reduce airspeed and (2) asserting erroneously that the left engine was the affected engine. The NTSB's analysis of the potential side effects of these medications found that the use of these medications likely did not play a role in the accident. The NTSB also considered whether the first officer’s errors were due to fatigue. Even though the errors that the first officer made were consistent with the effects of fatigue, the evidence supporting fatigue was inconclusive. Stress is also known to degrade cognitive functions such as working memory, attention, and reasoning, and it provides an alternate explanation for the first officer’s actions. The loss of right engine thrust at a low altitude over the ocean at night was a surprising and stressful event, especially for the first officer as the pilot flying at the time of the engine event. The captain initially questioned the first officer’s assessment, stating “number one is gone?”, but then accepted the assessment and stated, “so we have number two.” At that time, no salient cue was available to indicate which engine was affected (due to the reduced thrust on both engines and the lack of adverse yaw). During a postaccident interview, the captain remembered his initial assessment that the right engine was affected but stated that he had assumed that the first officer had a better understanding of the engines’ status because he was flying the airplane when the captain was communicating the emergency to ATC. The captain had confidence in the first officer’s assessment of the affected engine based on their flight experience together; during a postaccident interview, the captain stated that the first officer “never makes a mistake.” Nevertheless, the captain did not take any action to verify the first officer’s assessment about the left engine, such as advancing the thrust lever for the left engine to determine whether an increase in thrust occurred. The operator’s simulator guide stated that pilots should be alert for changes indicating that thrust was being reduced on the incorrect (operational) engine. However, the crew did not notice the reduction in adverse yaw that resulted from the first officer’s reduction of thrust on the left engine. Subsequently, the reductions in thrust on the left and right engines (which the first officer made to reduce airspeed) meant that there would be no noticeable indications that would have reinforced the idea to the crewmembers that the left engine was affected, as they determined initially. If the captain had thought to test the thrust on the left engine by advancing the left thrust lever, the flight crew would likely have noticed an increase in left engine thrust, a yaw to the right, and engine sounds indicating that the left engine was capable of producing normal power. The captain could also have simultaneously advanced both thrust levers and observed the left engine producing more thrust. However, neither flight crewmember suggested that the captain perform these actions, and neither of these potential diagnostic steps was included in the operator’s Engine Failure or Shutdown checklist. Further, the Engine Failure and Shutdown checklist would not have helped the captain sort out the situation because the checklist appeared to assume that the airplane would be experiencing ongoing asymmetric thrust, which was not the case at this point in the accident flight. The checklist did not consider the possibility that a flight crew would need to delay checklist execution until after completing steps in an operator’s singleengine departure procedure, such as leveling off at a low altitude and reducing thrust on both engines. Because there was no longer a clear sign of which engine had failed and the crew had forgotten its earlier determination that the right engine had lost power, critical thinking was required for the crew to devise diagnostic steps to confirm the affected engine. However, each pilot’s thinking was degraded by high workload and stress. The operator’s simulator guide stated that, for a single-engine failure after V1, “the Captain, if not currently the PM [pilot monitoring], may (and most times should) elect to become the PM and run the…checklist.” Remaining in the pilot monitoring role (which was recommended but not required) would have preserved more of the captain’s mental resources to correctly diagnose and respond to the engine issue. The captain’s decision to assume the pilot flying role before reconfirming the engine issue increased his workload and decreased his ability to perceive and evaluate key information, such as the positioning of the thrust levers, the performance of the engines, and changes in the airplane’s energy state. Thus, the captain’s decision to take control of the airplane also decreased his ability to manage the crew’s response to the abnormal situation. In addition, the captain’s lack of awareness of the left engine’s low commanded thrust level, along with the subsequent deterioration of the airplane’s energy state throughout the rest of the flight, played a role in his (1) failure to verify the first officer’s (incorrect) assertion about the left engine and (2) inability to detect the crew’s misidentification of the affected engine and cognitively reframe the situation. The NTSB considered whether fatigue played a role in the captain’s errors, but the evidence was inconclusive. These errors were likely the result of the captain’s high workload and stress. Research indicates that, under conditions of high workload and stress, “crews are vulnerable to missing important cues related to their situation and are likely to experience difficulty pulling together disparate pieces of information and making sense of them,” especially when “some of that information is incomplete, ambiguous, or contradictory.” (Burian, B.K., Barshi, I., and Dismukes, K., 2005). The captain’s high workload increased further due to his decision to continue handling ATC radio communications, which occurred frequently on an ongoing basis throughout the flight. It is possible that the captain decided to maintain control of the radios based on information that he learned during the operator’s crew resource management (CRM) training. Specifically, the operator’s initial CRM training included a video that presented the circumstances of the September 2007 accident involving American Airlines flight 1400, including the distraction that radio communications caused the pilot monitoring while he attempted to execute the appropriate abnormal checklist. Thus, the captain of the Transair accident airplane might have thought that, by relieving the first officer of the responsibility of handling the radios, the first officer could focus his attention on performing the Engine Failure or Shutdown checklist (which is further discussed in the next section). The captain’s ability to properly respond to the emergency was further diminished toward the end of the flight when he thought that the airplane could have a dualengine failure, as demonstrated by his transmissions to the controller stating, “we might lose the other engine too” and, 2 minutes 19 seconds later, “there's a chance we're gonna lose the other engine too.” After the crewmembers noticed that the right engine was overheating, their attention became primarily focused on monitoring basic flight instruments and controlling the airplane. The crew’s communications and behavior during this latter portion of the flight were consistent with stress-related attentional narrowing, which restricts a person’s perceptions to the most salient cues and results in rigid thinking by reducing the number of alternatives that are considered (Stokes, A., and Kite, K.,1994). Attentional narrowing diminished the crew’s ability to understand and control the abnormal situation. As a result, the flight crew became fixated on monitoring the right EGT as well as basic flight parameters while manipulating only the right engine thrust lever. Checklist Performance The captain was aware that numerous steps in the operator’s Boeing 737-200 Engine Failure or Shutdown checklist were expected to be performed before the airplane could return to the airport. The previous criticism that the captain received from the company’s chief pilot for his handling of an earlier in-flight emergency (during which he returned to the airport without completing a required checklist) likely added pressure to the alreadydemanding situation of troubleshooting an engine issue while flying at a low altitude over the ocean at night. The Engine Failure or Shutdown checklist defined three conditions that warranted the use of that checklist: an engine failure, an engine flameout, or another checklist that directed an engine shutdown. The checklist had 11 reference items, none of which were memory items. The Engine Failure or Shutdown checklist required pilots to confirm that the thrust lever for the affected engine was selected, move that thrust lever to the idle position, and shut down the corresponding engine. However, the checklist was not designed to help the crew identify the affected engine. Further, the operator’s simulator guide stated that the primary indications of an engine failure were a yawing moment and the rudder input required to counteract it, but neither was present at the time that the checklist was initiated. Thus, the simulator guidance did not reflect realistic operational conditions because it did not account for the possibility of a partial loss of thrust or a possible need to level off and reduce thrust on both engines before completing the checklist. The captain called for the Engine Failure or Shutdown checklist about 4 minutes 26 seconds after the first indication of an engine problem. The captain’s communications with ATC after the onset of the emergency (as well as the need to assist the first officer in executing various aspects of the single-engine departure procedure) distracted the captain and precluded him from calling for the checklist sooner. The operator does not require its pilots to conduct the checklist immediately after an engine issue is detected. However, if the checklist had been started earlier in the accident sequence (that is, when adverse yaw was occurring or the EPR indications clearly showed which engine was producing lower thrust), and if fewer intervening distractions had occurred, the first officer might have recalled that he had reduced engine thrust to decrease the airplane’s speed, and both crewmembers might have recalled their initial (correct) diagnosis of the affected engine. The first officer stated that he had accomplished “maybe a third or less” of the checklist, but the CVR showed that he had only read aloud the conditions for performing the checklist. The first officer further stated that he stopped the checklist (for the first time) because of the high EGT on the right engine (which he described as “beyond max”). Afterward, the captain stated that they should head toward the airport, which the first officer suggested about 1 minute earlier (before he started reading aloud the conditions for performing the checklist). The captain then asked the first officer to set up the instrument landing system approach, and the captain contacted the controller to let her know that the airplane was ready to return. About 1 minute 35 seconds after the first officer informed the captain about the high EGT on the right engine, the captain instructed the first officer to “see what you can do in the checklist finish as much as possible.” About 15 seconds later, the first officer resumed reading aloud the conditions for performing the checklist but then stopped (for the second time) to state “we have to fly the airplane though” because the airplane was “slowing” or “low” and he thought that the captain was not focused on flying the airplane. Although the first officer likely thought that it was appropriate to focus on resolving the symptoms of the abnormal situation (the high EGT on the right engine and the airplane’s decreasing energy state) instead of performing the checklist, the first officer’s comments caused the crew’s attention to be directed away from confirming which engine was affected. After the first officer advised the captain to focus on flying the airplane, the captain stated “okay” and did not redirect the first officer to continue the checklist. During a postaccident interview, the captain stated that, when he saw that the EPR for the right engine was decreasing and that there was “nothing coming out” of the left engine, he thought that performing the checklist would be “useless” because both engines had “already shut themselves down.” It is possible that performing the checklist’s third item, “AFFECTED ENGINE…CONFIRM…CLOSE” might have prompted the crew to shut down the incorrect (left) engine, which would not have prevented this accident. However, it is also possible that performing this checklist item might have led the crew to reconsider the source of the engine issue and the correct cause of the airplane’s deteriorating energy state. Thus, as a result of the flight crewmembers’ stressrelated attention tunneling (which led to their thinking that a dualengine failure was occurring and fixation on the right EGT and basic flight parameters), they neglected to perform a checklist item that might have alerted them about their misidentification of the affected engine. The operator’s CRM training emphasized the importance of using checklists to manage abnormal situations and defend against error. During the accident flight, the captain and the first officer demonstrated ineffective CRM. Specifically, the captain did not ensure that the first officer, after his interjections while reading the conditions of the Engine Failure or Shutdown checklist, continued performing the checklist so that the affected engine could be confirmed. In addition, the captain demonstrated difficulties with task prioritization (an aspect of workload management) and leadership because, as pilotincommand, he did not ensure that the checklist was accomplished, and he was distracted by lower-priority tasks, such as communicating with ATC. As a result, the flight crew was unable to coordinate an effective response to the emergency situation. Emergency Response The controller contacted the USCG Joint Rescue Coordination Center, which was responsible for coordinating US search and rescue activities in the Pacific Ocean, to report that the accident airplane was in the water. An aircraft rescue and firefighting (ARFF) rescue boat and a USCG helicopter from Barbers Point Air Station launched about 0200 and 0218, respectively. The USCG helicopter arrived on scene about 0230 and located the accident airplane and crew. The captain was hanging onto the floating tail section of the airplane, and the first officer was on top of floating debris. The captain was struggling to stay afloat after the tail began to sink, and he was hoisted from the water to the helicopter with the assistance of a rescue diver. The diver then re-entered the water and swam with the first officer to the ARFF rescue boat, which had arrived on scene about 0240. The first officer received medical care once aboard the rescue boat. The helicopter transported the captain directly to a local hospital. The rescue boat encountered high surf and low visibility while traveling back to the ARFF station, arriving about 0406. The first officer was then taken to the hospital; his delayed arrival there did not affect the treatment of his injuries, which were minor. Thus, the search and rescue operation was timely and effective. Survival Factors The captain and the first officer were wearing their restraints, including their shoulder harnesses, at the time of the accident. According to the first officer, his upper torso moved forward during impact, and his right shoulder rolled forward, downward, and to the left, which caused his body to twist so that he was facing to the left. The first officer’s head then moved downward, and the top of his head struck something in front of him, resulting in a minor head injury that did not impede his evacuation from the airplane. Postaccident examination of the first officer’s seat found that the seatback had collapsed. Subsequent examination by the NTSB’s Materials Laboratory determined that the seatback collapse was due to the fracture of a jack nut that was part of a jackscrew assembly. The jack nut fractured in overstress due to loads that exceeded its loadbearing capacity. The accident airplane model was certificated in December 1967, and the first officer’s seat was manufactured in September 1984. The seat complied with Technical Standard Order (TSO)-C39A, which was issued in February 1972. The TSO required the seat to meet a static load requirement of 9 G forward and 6 G downward. The loads that the first officer’s seat sustained during the ditching could not be determined from the available evidence for this investigation. Newer seating systems are required to meet higher loads during certification. Specifically, crewmembers and passenger seating systems certificated under Title 14 Code of Federal Regulations Part 25 must currently meet, among other criteria, a dynamic requirement of 16 G forward and 14 G downward. These dynamic requirements apply to newly designed airplanes certificated after 1988 and all Part 25 airplanes manufactured after 2009, except for those that do not carry passengers for hire (including cargo-only airplanes, such as the accident airplane). According to the Federal Aviation Administration (FAA), four cargo 737-200 airplanes were registered in the United States as of November 2022, but the available evidence for this investigation did not indicate whether those airplanes were in active use.
Probable cause
The flight crewmembers’ misidentification of the damaged engine (after leveling off the airplane and reducing thrust) and their use of only the damaged engine for thrust during the remainder of the flight, resulting in an unintentional descent and forced ditching in the Pacific Ocean. Contributing to the accident were the flight crew’s ineffective crew resource management, high workload, and stress.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-275C
Amateur built
false
Engines
2 Turbo jet
Registration number
N810TA
Operator
RHOADES AVIATION INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
21116
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-03T00:15:35Z guid: 103407 uri: 103407 title: ERA21LA277 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103413/pdf description:
Unique identifier
103413
NTSB case number
ERA21LA277
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-04T13:52:00Z
Publication date
2023-05-24T04:00:00Z
Report type
Final
Last updated
2021-07-13T19:24:41.676Z
Event type
Accident
Location
Pottstown, Pennsylvania
Airport
HERITAGE FLD (PTW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 4, 2021, about 1252 eastern daylight time, an experimental, amateur-built RV-7A, N654C, was destroyed when it was involved in an accident near Pottstown, Pennsylvania. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner/builder of the airplane, a preflight inspection and engine run-up were normal. During the initial climb after takeoff, at 800 ft mean sea level, the engine lost all power and the pilot attempted to return to the airport; however, the airplane impacted terrain before the runway and a postcrash fire ensued. The pilot reported that, at the time of the accident, the airplane had accrued about 3.4 total flight hours. He reported that the airplane logbooks were in the airplane at the time of the accident. According to the Federal Aviation Administration inspector who responded to the accident site, only the outer portions of both wings and a portion of the tail were undamaged by the fire. The engine and cockpit sustained extensive fire damage. The electric ignition system, wiring harness, and fuel pumps were all fractured and melted. The airplane was equipped with a Subaru engine. The automotive fuel that the pilot used to fuel the airplane was stored in a bucket in the pilot’s hangar. It did not contain any water or other visible contaminants. -
Analysis
The pilot stated that, after a normal preflight inspection and engine run-up, the engine lost all power about 800 ft above ground level during takeoff. He attempted to return to the airport; however, the airplane impacted terrain before the runway and a postcrash fire ensued. Most of the airplane was destroyed by fire. The extensive thermal damage precluded examination of the engine, and the reason for the loss of engine power could not be determined.
Probable cause
A total loss of power for reasons that could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV7
Amateur built
true
Engines
1 Reciprocating
Registration number
N654C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
71046
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-13T19:24:41Z guid: 103413 uri: 103413 title: CEN21FA304 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103411/pdf description:
Unique identifier
103411
NTSB case number
CEN21FA304
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-04T18:22:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-07-14T01:20:06.564Z
Event type
Accident
Location
Killeen, Texas
Airport
Skylark Field Airport (ILE)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The German-built Focke-Wulf FWP-149D airplane was manufactured as a military trainer and was not type-certificated by the Federal Aviation Administration (FAA). The airplane operated in the United States between 1994 and 2001 with an FAA experimental exhibition airworthiness certificate before it was exported to Canada where the airplane was refurbished and operated in Canada between May 2001 and August 2019. On August 31, 2019, the airplane was flown into the United States with a Canadian registration number and experimental airworthiness certificate. On September 23, 2019, the FAA issued the current experimental exhibition airworthiness certificate with associated operating limitations, and the airplane was re-registered as N9145. At that time, the airframe total time (AFTT) and engine time since overhaul (TSOH) were 2,454.6 hours and 497.5 hours, respectively. The airplane continued to operate in the United States as an experimental exhibition airplane until the accident. Recent Maintenance According to maintenance documentation, the airplane’s last condition and 100-hour inspections were completed on September 8, 2020. At that time, the AFTT and engine TSOH were 2,512.8 hours and 557.7 hours, respectively. On October 24, 2020, the pilot annotated his flight logbook that the “chip light came on” during the flight. A review of available maintenance documentation did not reveal any associated maintenance at that time. On June 19, 2021, the pilot annotated his flight logbook that the chip light illuminated again and that there was an unspecified magneto issue. On June 21, 2021, the pilot relocated the airplane from his homebase airport (ILE) to Draughon-Miller Central Texas Regional Airport (TPL), Temple, Texas, where his aviation mechanic was based. According to a mechanic statement, maintenance invoices, and a logbook entry, the mechanic inspected the ignition system and determined the right magneto required repair. The right magneto was removed from the engine and repaired by an overhaul shop on June 29, 2021. Additional maintenance tasks at that time included changing the engine oil, repairing the oil filler neck, and installing new gaskets for the propeller governor and its adapter plate. On July 2, 2021, the mechanic installed the repaired right magneto and completed an engine run. The mechanic reported that during the engine run the amber-colored “chip detector” warning light illuminated in the airplane’s instrument panel. He shut down the engine, drained the engine oil into a clean bucket, and followed the wiring associated with the “chip detector” warning light to the engine oil filtration system housing. Disassembly of the oil filtration device revealed metal contamination inside the filter housing and on the filtration screen. The mechanic then showed the pilot the metal contamination and with the pilot present determined that the metal contamination did not stick to a magnet. The mechanic and pilot agreed that the metal contamination needed to be sent to a laboratory for additional analysis. The pilot told the mechanic that he still intended to fly the airplane back to ILE. The mechanic told the pilot that they needed to determine the source of the metal contamination before the pilot flew any trips in the airplane. The mechanic collected samples before he cleaned the filtration housing, filter screen, and bypass switch. He added new oil to the engine and performed another engine run, during which the “chip light” did not illuminate. According to last maintenance logbook entry, dated July 2, 2021, the AFTT and engine TSOH were 2,577.7 hours and 620.6 hours, respectively. Flight History Following Recent Maintenance On July 3, 2021, the pilot repositioned the airplane from TPL to ILE. The mechanic stated that the pilot completed an engine runup before the airplane departed. The mechanic stated that he believed the airplane was going to remain at ILE until the laboratory results were returned concerning the metal contamination found in the oil filter screen. According to the pilot’s flight logbook, on July 3, 2021, the flight from TPL to ILE was 0.2 hours in duration. According to ADS-B track data, on July 4, 2021, the pilot flew the airplane from ILE to New Braunfels National Airport (BAZ), New Braunfels, Texas. The airplane was airborne about 0.8 hours during the non-stop flight. After landing at BAZ, the airplane was featured in a static-display of aircraft in conjunction with the airport’s Forth-of-July airshow. The accident occurred during the pilot’s return flight to ILE after the airshow. The airplane was airborne about 0.8 hours during the accident flight. The airplane’s tachometer was destroyed during the postaccident fire and, as such, the airplane’s AFTT and engine TSOH at the time of the accident were calculated using the last maintenance logbook entry, the pilot’s online flight logbook, and ADS-B track data. Based on available information, the pilot operated the airplane at least 1.8 hours following the last maintenance that was completed on July 2, 2021, and at the time of the accident the AFTT and engine TSOH were 2,579.5 hours and 622.4 hours, respectively. Engine Oil Filtration System The airplane was equipped with an Aviation Development Corporation (ADC) oil filtration system, part number 600010-1. A review of product literature revealed that the oil filtration system was equipped with a ball-and-spring “bypass” switch, which when wired to a cockpit warning light offered a visual indication of when the filtration system was bypassing engine oil instead of flowing through the filter screen. A separate magnetic chip detector was offered as an optional feature for the oil filtration system; however, postaccident examination of the oil filtration system confirmed that the optional chip detector was not installed. Figure 5. Instrument panel warning light labeled “chip detector” (Provided by pilot’s family). - On July 4, 2021, about 1722 central daylight time, a Focke-Wulf FWP-149D experimental airplane, N9145, was destroyed when it was involved in an accident near Killeen, Texas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) track data, about 1634, the flight departed New Braunfels Regional Airport (BAZ), New Braunfels, Texas, on runway 13 and continued northbound toward Skylark Field Airport (ILE), Killeen, Texas, as shown in figure 1. Figure 1. ADS-B ground track for the entire flight. At 1714:39, when the airplane was about 12.9 nautical miles (nm) south of ILE, it entered a descent from 3,600 ft mean sea level (msl). At 1715:30, the airplane entered a left turn toward the northwest as it descended through 3,500 ft msl. About 2 minutes later, when the airplane was about 7.7 nm from ILE, it entered a right turn to join the extended centerline for runway 1 at ILE, as shown in figure 2. At 1717:50, the airplane was established on the extended runway centerline at 2,800 ft msl. Figure 2. ADS-B ground track during the landing approach. Airplane performance calculations based on ADS-B data revealed that between 1716:55 and 1718:42, the airplane decelerated from 113 knots calibrated airspeed (KCAS) to about 57 KCAS as it descended toward runway 1 at ILE, as shown in figure 3. According to the Focke-Wulf FWP-149D Flight Manual, the aerodynamic stall speed at the airplane’s maximum takeoff weight with the landing gear and flaps retracted was 61 knots (VS1), and the maximum glide distance with no engine power would be achieved at 90 knots (VG) with the landing gear and flaps retracted. During a forced landing with no wind, the airplane would glide 1.2 nm laterally for every 1,000 ft of altitude loss. At 1719:42, the airplane’s airspeed and descent rate were 57 KCAS and 655 ft per minute, respectively. About 13 seconds later, at 1719:55, the airplane’s airspeed and descent rate were 59 KCAS and 735 ft per minute. Then, during the next 1.3 minutes, the airplane’s airspeed increased to 68 KCAS and the descent rate decreased to about 450 ft/min. At 1721:39, the final ADS-B track point for the flight was at 1,141 ft msl (about 345 ft above ground level) and about 2.4 nm miles from the runway 1 displaced threshold at ILE. At that time, the airplane’s airspeed and descent rate were about 64 KCAS and 300 ft/min, respectively. The main wreckage was located about 0.5 mile north of the final ADS-B return, as shown in figure 4. Figure 3. Altitude, ground speed, true airspeed, calibrated airspeed, and vertical speed for the accident flight. Figure 4. ADS-B ground track, initial impact point, and main wreckage location. A commercial airline pilot reported hearing the pilot transmit over the aircraft emergency frequency (121.5 MHz) that he had “lost his engine” was “losing altitude” and was “trying to make it to Skylark.” The pilot subsequently stated that he “wasn’t going to make it to the airport” and to “roll the trucks.” A short time later an emergency locator transmitter (ELT) beacon was heard on the emergency frequency. A witness reported that the airplane was flying toward the airport at about “300 ft agl” and 50 to 60 knots and that the engine was “sputtering.” He saw the airplane’s wings roll left and right 2 to 3 times before the airplane “stalled” with the left wing down. The airplane then descended toward the ground. - An autopsy of the pilot was completed by Southwestern Institute of Forensic Sciences at Dallas, Dallas, Texas. According to the autopsy report, the pilot died as result of thermal and blunt force injuries, and the manner of death was accident. FAA toxicology testing did not detect any carboxyhemoglobin, ethanol, glucose, or tested-for drugs. - The main wreckage was in a level grass field with several groupings of trees. The airplane’s initial impact point was a ground scar containing fragments of red navigation light lens material, consistent with the airplane in a left-wing-low attitude at impact. The wreckage debris path was oriented on a 319° true heading and measured about 135 ft long. The main wreckage consisted of the cabin and cockpit, right wing, aft fuselage, engine, and propeller, as shown in figure 6. The main cabin and cockpit were destroyed by impact forces and the postimpact fire. All structural components and flight control surfaces were located at the accident site. All observed structural damage to the airplane was consistent with ground impact. Flight control continuity could not be established due to extensive damage but all observed flight control separations were consistent with ground impact, fire-related damage, or cuts to facilitate recovery of the wreckage. Figure 6. Main wreckage at accident site. The engine could not be rotated through the reduction gearbox using the attached propeller. Disassembly of the engine revealed the Nos. 3 and 4 connecting rods separated from their respective crankshaft journals. The Nos. 3 and 4 connecting rod beams were bent, twisted, and deformed. There was significant damage to the internal cavities of the engine crankcase, particularly along the rotational plane of the Nos. 3 and 4 connecting rods and associated rotating crankshaft components, as shown in figures 7 and 8. Figure 7. Crankcase (left side). Figure 8. Crankshaft and crankcase (right side). There was no evidence of heat distress or a lack of lubrication to the internal engine drivetrain components. The cylinder combustion chambers remained mechanically undamaged, with no evidence of foreign object ingestion or detonation. The oil sump exhibited thermal damage that included a large hole. The engine examination determined that one of the two crankshaft dynamic counterweights separated from its respective crankshaft counterweight mounting lobe at position No. 3. The crankshaft counterweight mounting lobe at position No. 3 exhibited elongated bores and a tearing/bending appearance, as shown in figures 9 and 10. Several fractured metal items were recovered from inside the crankcase, cylinder Nos. 3 and 4, and the oil sump. The recovered items included pieces of connecting caps, bolts, nuts, bearings, counterweights, counterweight mounting lobes, rollers, bushings, snap rings, and washers, as shown in figure 11. The recovered counterweight rollers exhibited fretting/galling signatures at the center bushing (crankshaft) surfaces. Figure 9. Crankshaft counterweight mounting lobe at position No. 3. Figure 10. Crankshaft counterweight mounting lobe at position No. 3. Figure 11. Metal items recovered from inside engine during the examination . The recovered items were examined at the National Transportation Safety Board (NTSB) Materials Laboratory, Washington, DC. Three of the submitted items exhibited curved surfaces, case cracking, and material composition that was consistent with type 4340 steel alloy used for crankshafts. The curved surfaces were consistent with the geometrical features of a crankshaft counterweight mounting lobe. The case cracking was consistent with nitrided type 4340 steel used for crankshafts and their counterweight mounting lobes. One crankshaft counterweight lobe piece exhibited overstress fracture features on the left side of the piece, and progressive fracture features on the right side of the piece. The remaining crankshaft counterweight lobe pieces exhibited progressive fracture features on both the left and right side of the piece, respectively. The examined crankshaft counterweight lobe pieces exhibited features consistent with progressive fatigue failure. The remaining items submitted for laboratory examination exhibited various degrees of gross plastic deformation, batter, and overstress fracture features. Additionally, the contamination collected from the oil filtration system by the mechanic on July 2, 2021, was submitted to the NTSB Materials Laboratory for identification. The particulate debris from the submitted shop cloth, collected 2 days before the accident, was analyzed using a field emission scanning electron microscope (SEM) with an energy dispersive spectrometer (EDS). The particle morphology ranged from flat plate-like to ovoid and the major dimension of the particles ranged from 0.01 inch to less than 0.001 inch. Overall, the EDS analysis revealed the following primary elements: carbon, oxygen, aluminum, iron, copper, and lead. In general, the aluminum and iron particles were flat or platelike consistent with removal via skiving or milling action. The composition of an iron particle was consistent with a chromium or chromium and molybdenum steel (the counterweights are fabricated from a chromium and molybdenum steel). Particles with high concentrations of lead and bromine were vestiges of the fuel additives in 100 octane low lead fuel (containing tetraethyllead and ethylene dibromide). The composition of the aluminum particle was consistent with an aluminum alloy with minor amounts of magnesium. -
Analysis
The pilot was conducting a cross-country flight when the airplane had a total loss of engine power while it approached the intended destination airport. Based on witness accounts, the pilot was unable to glide the airplane to the intended destination airport and entered an inadvertent aerodynamic stall at a low altitude. One witness reported that the airplane’s wings rolled left-and-right 2 to 3 times before the airplane “stalled” with the left wing down. The airplane impacted the ground in a left-wing down roll attitude and was destroyed during a postimpact fire. Postaccident examination of the engine determined that the loss of engine power was due to a fatigue failure of a crankshaft counterweight mounting lobe, which resulted in the separation of a counterweight and catastrophic secondary damage to the engine drivetrain. A couple days before the accident, an aviation mechanic found metal contamination in the engine oil filtration system after an associated warning light illuminated during a post-maintenance engine run. The mechanic and pilot discussed the metal contamination and agreed to have it submitted to a laboratory for identification. The oil filtration system was equipped with a ball-and-spring “bypass” switch, which when wired to a cockpit warning light offered a visual indication of when the filtration system was bypassing engine oil instead of flowing through the filter screen. A separate magnetic chip detector was offered as an optional feature for the oil filtration system; however, postaccident examination of the oil filtration system confirmed that the optional chip detector was not installed. As such, the warning light installed in the instrument panel was mislabeled “chip detector” instead of a label that conveyed the oil filtration system was in a bypass condition. When the mechanic saw the warning light illuminated during his post-maintenance engine run, it was a visual indication that the engine had produced enough metal contamination to restrict oil flow in the filtration system, resulting in a bypass condition. The mechanic cleaned the filtration housing, filter screen, and bypass switch. He then added new oil to the engine and performed another engine run, during which the “chip light” did not illuminate. The mechanic told the pilot not to fly the airplane until the laboratory results were returned, but he did not ground the airplane to prevent additional flights. The pilot conducted three flights, totaling at least 1.8 hours, following the maintenance. As such, it is likely he erroneously believed the airplane was safe to fly if the “chip detector” warning light was not illuminated, when, in fact, the engine was not in an airworthy condition due to the progressive failure of the crankshaft counterweight mounting lobe that likely produced the metal contamination found during the last maintenance. A review of automatic dependent surveillance-broadcast track data revealed that the pilot did not maintain the airplane’s best glide airspeed during the final minutes of the flight. Based on the published glide performance, the airplane did not have sufficient altitude to reach the runway at any point during the approach. However, had the pilot maintained best glide airspeed the airplane would have retained a safe margin above the aerodynamic stall speed and, as such, might have resulted in a less severe off-field landing.
Probable cause
The total loss of engine power due to a fatigue failure of a crankshaft counterweight mounting lobe, which resulted in a counterweight separation and catastrophic secondary damage to the engine drivetrain. Contributing to the accident was the mislabeled warning light, the pilot’s erroneous belief that the airplane was safe to operate after the metal contamination was observed in the oil filtration system, and his failure to maintain best glide airspeed during the forced landing, which resulted in the airplane exceeding its critical angle-of-attack and an inadvertent aerodynamic stall at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Focke-Wulf
Model
FWP-149D
Amateur built
false
Engines
1 Reciprocating
Registration number
N9145
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
167
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-14T01:20:06Z guid: 103411 uri: 103411 title: CEN21LA309 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103439/pdf description:
Unique identifier
103439
NTSB case number
CEN21LA309
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-06T15:45:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-07-09T01:00:12.013Z
Event type
Accident
Location
Ashtabula, Ohio
Airport
Northeast Ohio Regional (HZY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 6, 2021, about 1445 central daylight time, a Titan T-51D airplane, N15180, was substantially damaged when it was involved in an accident near Ashtabula, Ohio. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. The intent of the flight was to perform fuel flow and fuel indicator checks on the newly-built airplane while taxiing on the ground; however, they were not able to obtain full engine performance on the ground and the pilot elected to take the airplane into the air. After takeoff, while climbing through 200 ft agl, the engine lost power. The pilot reported that the engine computer circuit breaker had tripped and the engine lost power. He attempted to reset the circuit breaker and restart the engine, but the circuit breaker would not reset. The pilot nosed the airplane over to maintain an airspeed of 75 mph and landed on the remaining part of the 5,900-ft runway; however, a high sink rate developed. The airplane landed on the runway hard, and the left main landing gear collapsed. The left wing sustained substantial damage. The airplane’s owner reported that, before the flight, oxygen sensors were installed on the cylinders’ exhaust pipes to determine if the engine was running rich or lean. The sensors received their power from the engine computer. After the accident, data from the Garmin flight director showed increased electrical demand during the maintenance engine runs. During these runs, maximum engine power was never attained due to the inability to secure the airplane in place. The sensors were left installed to collect inflight engine performance information. During the initial climb, the increased engine power placed an increased electrical load on the engine’s control computer that exceeded its 15-ampere rating which tripped the circuit breaker and resulted in the loss of engine power. -
Analysis
The intent of the flight was to perform fuel flow and fuel indicator checks on the newly built airplane while taxiing on the ground; however, they were not able to obtain full engine performance on the ground and the pilot elected to take the airplane into the air. After takeoff, while climbing through 200 ft above ground level (agl), the engine lost power. The operator reported that the engine computer circuit breaker had tripped which resulted in the loss of engine power. The pilot attempted to reset the circuit breaker and restart the engine without success. The airplane landed hard on the runway and the left main landing gear collapsed. The left wing sustained substantial damage. A postaccident examination showed that the oxygen sensors used to tune the engine were left on the engine’s cylinder exhaust pipes during the flight. The sensors drew power from the engine’s control computer. During the initial climb, the increased electrical demand to run the oxygen sensors at maximum engine power exceeded the 15-ampere limit on the engine’s control computer, its circuit breaker to tripped, and the engine lost power.
Probable cause
The tripped engine control computer circuit breaker caused by an excessive electrical load on the system, which resulted in a complete loss of engine power during the initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TITAN
Model
T-51D
Amateur built
true
Engines
1 Reciprocating
Registration number
N15180
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M12HV6COHK0180
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-09T01:00:12Z guid: 103439 uri: 103439 title: ERA21LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103478/pdf description:
Unique identifier
103478
NTSB case number
ERA21LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-06T16:07:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-07-20T16:45:13.061Z
Event type
Accident
Location
Manteo, North Carolina
Airport
DARE COUNTY RGNL (MQI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 6, 2021, about 1507 eastern daylight time, a Piper PA-46-500TP, N31062, was substantially damaged when it was involved in an accident near Manteo, North Carolina. The airline transport pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the fuel tanks had been topped off with Jet-A fuel before the flight. He departed Dare County Regional Airport (MQI), Manteo, North Carolina from runway 23; however, just after he retracted the landing gear, he noted a loss of thrust from the engine. He verified that the throttle had not moved, unlocked the Manual Override (MOR), and moved it “just under halfway to full” forward in an attempt to increase engine power. Engine power did not increase, and the pilot began to prepare for a forced landing. Suddenly, the engine surged, and the pilot initiated a climb. There was a brief interruption of engine power, but the airplane continued to climb, and the pilot started a turn back to the airport. As the pilot maneuvered the airplane back toward the airport, the engine again lost power. He subsequently landed about midfield, at the intersection of runway 35 and runway 23, and was aligned about 35° off the runway heading for runway 35. The airplane continued off the paved surface and into the grass, where the nose landing gear collapsed, resulting in substantial damage to the fuselage. Examination of the propeller revealed that all blades were bent aft, opposite rotation and twisted toward low pitch with chordwise/rotational scoring in the tip region. There were no visible discrepancies noted that would prevent or degrade normal propeller operation prior to impact. All visible damage was consistent with high impact forces while rotating at low power. Examination of the electric fuel pumps on the airframe revealed they were operating within limits. Examination of the engine revealed that the reduction gearbox and the exhaust duct were unremarkable. All six of the inlet case struts were fractured. The accessory gearbox was unremarkable. The propeller shaft was manually rotated, and the power section rotated freely. The gas generator case could not be rotated manually. The compressor blades and the centrifugal impeller exhibited rotational scoring. The flow divider, fuel-to-oil heat exchanger, fuel pump, and the torque limiter were functionally tested and no anomalies were noted. The fuel control unit, overspeed governor, and propeller governor were tested and deviations that were within field adjustments were noted. The front of the compressor discharge air (P3) pneumatic line was secured to the gas generator case (See Figure 1). The rear coupling “B” nut was lockwired to the adjacent bolt. The lockwire was removed and the coupling nut was found loosely fitted (no torque) with the adjacent nipple. Figure 1. Photograph of the compressor discharge air (P3) pneumatic line. The red arrow (right) points to the front of the P3 line that was secured to the gas generator case and the red circle (left) highlights the lockwired rear coupling “B” nut. The exterior surface of the nut exhibited fretting wear from contact with the twists of the lockwire (See Figure 2). The fretting wear was observed on the conical surface of the nipple from contact with the mating surface of the tube. The fittings on the rear section of the line between the filter housing and the fuel control were lockwired and secured/torqued to their respective nipple/elbow. Both fittings were tight in the filter housing. Figure 2. Close up photograph of the P3 pneumatic line rear coupling nut with fretting wear. The red arrow indicates the fretting. Examination at higher magnification of the oval-shaped dents along the outer surface of the “B”-nut mating with the nipple showed that the damage occurred as the result of material loss and not as the result of outward material displacement, indicating that damage occurred as the result of a wear mechanism. Some evidence of directionality indicated a relative movement between the nut and the lockwire. Blackish residues were observed within the wear grooves consistent with fretting wear damage. In addition, the wear residues appeared to have accumulated predominantly towards one extremity of the oval grooves indicating that the fretting damage occurred with the nut contacting the wire and the nut attempting to move in the counterclockwise direction (in the direction loosening the nut). A review of the maintenance records could not determine when the P3 pneumatic line was most recently secured. According to the airplane flight manual, the manual override lever (MOR) “is an emergency device that may allow the crew to regain power and continue safe flight and landing following fuel control unit (FCU) malfunction or power lever control loss. The MOR is used to control fuel flow to the engine in the event a pneumatic malfunction occurs in the engine fuel control unit. A malfunction of the pneumatic signal (Py) input to the FCU will result in the fuel flow decreasing to minimum idle…. Additional effects of a Py malfunction are a loss of torque/Ng limiting functions and, Nf governor operation…To operate the MOR, lift up on the lever and slowly move it forward to take up the dead-band until the engine responds. If possible, allow engine to stabilize before advancing further.” -
Analysis
After takeoff, the pilot retracted the landing gear and the turbopropeller-powered single-engine airplane’s engine lost partial power. The pilot attempted to regain engine power using a manual override but was unsuccessful. A forced landing was made at the departure airport, during which the airplane touched down at intersecting runways and traveled through the grass before coming to a stop, resulting in substantial damage to the fuselage. with the nose gear sheared off. Examination of the airplane after the accident revealed substantial damage to the fuselage. Examination of the engine revealed that the front of the compressor discharge air (P3) pneumatic line was secured to the gas generator case. The P3 line’s rear coupling nut was lockwired to the adjacent bolt. The lockwire was removed and the coupling nut was loosely fitted (no torque) with the adjacent nipple. The exterior surface of the nut exhibited fretting wear from contact with the twists of the lockwire. The fretting wear was observed on the conical surface of the nipple from contact with the mating surface of the tube. Examination at higher magnification of the oval-shaped fretting wear along the outer surface of the “B”-nut mating with the nipple showed the fretting damage occurred due to the nut being in contact with the lockwire while the nut was attempting to move in the counterclockwise direction (in the direction loosening the nut). Since the nut would not move significantly once the lockwire was in place, it suggested that the torque at installation was low, which would have allowed the nut to loosen, thus compromising the seal of the connection. Subsequently, when the pneumatic line seal became loose, it likely resulted in the loss of P3 air pressure and the subsequent partial loss of engine power like what the pilot described. A review of the maintenance records could not determine when the P3 pneumatic line was most recently secured.
Probable cause
The improperly secured pneumatic compressor discharge air (P3) line coupling nut on the engine, which ultimately allowed the nut to back off resulting in a partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA46-500TP
Amateur built
false
Engines
1 Turbo prop
Registration number
N31062
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4697208
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-20T16:45:13Z guid: 103478 uri: 103478 title: WPR21LA268 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103465/pdf description:
Unique identifier
103465
NTSB case number
WPR21LA268
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-07T17:45:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2021-08-10T08:13:28.865Z
Event type
Accident
Location
Weed, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 7, 2021, about 1450 Pacific daylight time, a Bell 212 helicopter, N911KW, was substantially damaged when it was involved in an accident near Weed, California. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 external load flight. The pilot reported that he was supporting a US Forest Service contract involving water drop operations and that the accident flight was on approach to a lake to retrieve water using a 100-ft long line and bucket. When the helicopter was about 400 ft above ground level (agl), the pilot performed an instrument scan and noted no anomalies. The pilot added that the radar altimeter was set to 200 ft agl at the time. When the helicopter crossed the shoreline, the pilot observed that the long line and bucket were “not yet in view and still out behind [him].” Shortly afterward, he felt a “sudden onset of a significant vibration,” which he also described as once-per-minute rotation. (An inspector with the US Forest Service explained that the term “indicates an imbalance in main rotor head or main rotor blades.) The pilot scanned the instrument panel and saw no annunciator lights or indications that the engines had stopped producing power. He then glanced outside and realized that the helicopter had descended. The pilot aborted the water retrieval, made a forward cyclic input, and raised the collective, but the helicopter continued to descend. The pilot determined that he would be unable to stop the descent, and he did not want the engines or transmission to overspeed, so he performed a forced landing on water. After he leveled the helicopter and the skids touched down on the water, the pilot made a last attempt to take off, which was unsuccessful. The pilot reduced both throttle settings to idle in preparation to ditch the helicopter and applied right cyclic as the main rotors slowed. The pilot stated that the helicopter controls responded normally and that the helicopter did not yaw significantly. The helicopter rolled right, causing the main rotor blades to strike the water, and the helicopter subsequently sank into the lake. Automatic dependent surveillance-broadcast data showed that the bucket was about 35 ft above the water when the last data point was recorded. At that time, the helicopter's descent rate was about 768 ft per minute. The pilot did not jettison the long line and bucket because he thought that he would be able to fly away. The helicopter sustained substantial damage to the fuselage, main and tail rotor blades, and drive systems. Training records showed that the pilot completed six recurrent long-line training flights from May 3 to 29, 2021. On May 31, 2021, the pilot completed a helicopter pilot evaluation checkride with a US Forest Service pilot inspector and was cleared for solo external-load water bucket operations. The 240-gallon water bucket was configured to gather 90% of its total capacity, which would add an additional weight of about 1,966 pounds to the helicopter and increase its 8,150-pound gross weight to about 10,116 pounds. The bucket was recovered attached to the helicopter by a cargo hook and the long line. Postaccident examination of the bucket and engine powerpack revealed no preimpact mechanical malfunctions or failures that would have precluded normal operations. The pylon corner mounts and pylon dampers were hydraulically tested with dynamic loads and exhibited normal operational performance. The rod end bearings for the pylon dampers had tolerances that were more than the Bell 212 Maintenance Repair and Overhaul Manual tolerance of 0.004-inch radial play: the right aft damper bearing play was 0.006 inch, and the left aft damper bearing play was 0.016 inch. According to Bell Textron, the excessive radial clearance of rod end bearings reduces the amount of damper stroking to counteract vibratory motion of the pylon. Also, a flight crew in a separate event experienced a vibration that was traced back to excessive radial wear of the pylon damper rod end bearings. The helicopter’s hover out of ground effect (OGE) performance was computed using the helicopter operator’s Rotorcraft External Load Manual, which included a performance chart from Bell Helicopter’s BHT-212-MD-1 manual. According to the performance chart, at an air temperature of 35°C, heater OFF, engine rpm at 100%, skid height of 50 ft, a 15-knot headwind, and generator values of 150 amperes, the helicopter had an OGE takeoff power gross weight limitation of about 10,250 pounds. According to the Bell 212 Rotorcraft Flight Manual: Supplement Cargo Hook, at a helicopter gross weight of 8,150 pounds, an air temperature of 35°C, heater OFF, engine rpm at 100%, skid height of 60 ft, and generator values of 150 amperes, the helicopter had an OGE takeoff power limitation at a pressure altitude of about 8,000 ft and a maximum continuous power setting limitation at a pressure altitude of about 6,600 ft. The Bell Helicopters manual also showed that, at a gross weight of about 10, 116 pounds, the helicopter had an OGE takeoff power limitation at a pressure altitude of about 3,700 ft and a maximum continuous power setting limitation of 9,300 pounds. -
Analysis
The flight was on an approach to a lake to retrieve water for a water bucket drop operation. During the approach, the instruments scanned normal, and the radar altimeter was set to 200 ft above ground level to provide a buffer between the bucket and terrain. When the helicopter crossed the shoreline, the pilot visually confirmed that the 100-ft long line and bucket were slightly trailing the helicopter and had not dipped in the water. Shortly afterward, he felt a “sudden onset of a significant vibration.” The pilot aborted the water retrieval and noticed that helicopter lost altitude. He applied forward cyclic and raised the collective, but the helicopter continued to descend. The pilot realized that he would not be able to fly out of the descent, so he decided to make a forced water landing. The pilot did not jettison the long line and bucket. After he leveled the helicopter and the skids touched down on the water, he made another attempt to take off, but the helicopter settled into the lake. The pilot reduced both throttle settings to idle in preparation to ditch the helicopter and applied right cyclic as the main rotors slowed. The helicopter rolled right, and the main rotor blades struck the water, which resulted in substantial damage to the fuselage, rotor, and drive systems. Postaccident examination of the engine revealed no preimpact mechanical anomalies. The airframe examination revealed an out-of-tolerance condition of both pylon damper rod end bearings that likely caused the vibration reported by the pilot. It is likely that, after the lateral vibration, the pilot allowed the helicopter to descend while he tried to determine the source of the vibration. As the helicopter settled into the lake, the bucket filled with water. The resulting increased weight, combined with the pilot’s failure to release the water bucket, decreased the helicopter’s out-of-ground-effect performance.
Probable cause
The pilot’s failure to maintain altitude during an approach to a lake. Contributing to the accident was the pilot’s failure to release the full water bucket as the helicopter was settling, which reduced the helicopter’s out-of-ground-effect performance.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
212HP
Amateur built
false
Engines
2 Turbo shaft
Registration number
N911KW
Operator
ROGERS HELICOPTERS INC
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Firefighting
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
30592
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-10T08:13:28Z guid: 103465 uri: 103465 title: WPR21FA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103450/pdf description:
Unique identifier
103450
NTSB case number
WPR21FA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-09T21:51:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-08-24T00:06:56.166Z
Event type
Accident
Location
Albany, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
A video study was performed on the captured imagery to estimate the aircraft’s ground track, groundspeed, altitude, and roll angle. The estimated groundspeed when the aircraft initiated a left turn was 60 ± 3 mph (52 ± 3 knots). The altitude above ground level was 233 ± 10 ft at that time. The left-wing-down roll angle increased to almost 90º about 6 seconds after the turn was initiated. The aircraft impacted the ground about 9 seconds afterward. The engine speed was within its normal range, and the aircraft roll angle was increasing at a high rate. - The experimental light-sport, weight-shift-control aircraft had tricycle landing gear and a braced fabric wing. The two-place tandem cockpit frame was constructed of welded steel framing with a fiberglass cockpit fairing encompassing the frame. The wing was manufactured on December 8, 2015, and had a maximum gross weight of 1,060 pounds. The aircraft had stall speed at gross weight of 37 mph, a maximum speed of 62 mph, and a never-exceed speed of 70 mph. The aircraft’s limitations included not exceeding bank angles of 60° and pitch angles of 30°. The aircraft’s tachometer indicated the engine had a total time of 287 hours. According to the North Wing Mustang 3-15 Wing Manual, No wing on the market is totally safe. It is entirely possible to push any aircraft beyond its tolerances and damage or even break a wing. Very strong weather conditions may also cause structural failure. Aerobatics maneuvers, pitch angles beyond 30 degrees up or down, bank angles exceeding 60 degrees, aggressive stalls, and spins are maneuvers that should never be attempted under any circumstance. CAUTION The speed never to exceed for the MUSTANG 3-15 is 70 mph. The MUSTANG 3-15, even when flown in its lightest wing loading, can exceed [an] airspeed of 70 mph.” - On July 9, 2021, about 2051 Pacific daylight time, an experimental amateur-built North Wing Mustang 3 weight-shift-control trike, which was not registered, was substantially damaged when it was involved in an accident near Millersburg, Oregon. The noncertificated pilot and passenger were fatally injured. The aircraft was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to family members, the pilot and passenger departed from the pilot’s home airport in Albany, Oregon. After overflying the pilot’s home, located about 4,000 ft north of the airport, the aircraft continued northeast for about 3.3 miles. The aircraft then turned left and flew close to the passenger’s home before impacting the ground (see figure 1). Figure 1. Likely flightpath impact Several witnesses on the ground recorded the airplane’s maneuvers on their mobile phone devices. A review of those videos showed that the aircraft banked to the left in an almost 90° turn. The left wing continued to drop downward, and the aircraft descended toward the ground as the turn tightened. The aircraft impacted terrain in a left-wing-low attitude (see figure 2). Figure 2. Excerpts from a mobile phone video. - The pilot, who owned the trike, did not hold a pilot certificate, and his flight experience is unknown. - On-site examination of the aircraft, including the flight controls, structure, and engine, revealed no evidence of any mechanical anomalies. Grounds scars and the orientation of the wreckage were consistent with the aircraft impacting the ground in a nose-low attitude. No manufacturing anomalies were noted with the aircraft. The wooden propeller assembly was shattered and exhibited signatures consistent with the engine producing power at the time of impact. Individual wires were separated at the nose; the wires were examined by the National Transportation Safety Board’s Materials Laboratory, which determined that the wires had fractured in overstress. The pilot’s family stated that a postaccident engine examination found no evidence of a preimpact mechanical malfunction or failure. -
Analysis
After departure, the pilot of the weight-shift-control trike flew for about 3.3 miles. When the trike was at an altitude of about 230 ft above the ground, it banked to the left in an almost 90° turn. The left wing continued to drop down, and the aircraft descended toward the ground as the turn tightened. The aircraft impacted the ground in a nose-low attitude. Postaccident examination of the aircraft, including the flight controls, structure, and engine, revealed no evidence of any mechanical anomalies. The engine speed was within its normal range while the aircraft was banked. According to the manufacturer, the aircraft’s limitations included not exceeding bank angles of 60° and pitch angles of 30°. The manufacturer’s manual stated that flying the aircraft with a bank angle exceeding 60° “should never be attempted under any circumstance.” The pilot flew the aircraft in a manner that was not consistent with the manufacturer’s guidance and lost control of the aircraft during the low-level left turn due to the excessive bank angle.
Probable cause
The noncertificated pilot’s loss of aircraft control after a low-level turn with a bank angle that exceeded the manufacturer’s operating limitations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
North Wing
Model
Mustang
Amateur built
true
Engines
1 Reciprocating
Registration number
UNREG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
510282
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-24T00:06:56Z guid: 103450 uri: 103450 title: WPR21LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103555/pdf description:
Unique identifier
103555
NTSB case number
WPR21LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-10T08:30:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-09-14T23:49:58.844Z
Event type
Accident
Location
Chandler, Arizona
Airport
Chandler Municipal (CHD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 3 minor
Factual narrative
On July 10, 2021, about 0730 mountain standard time, a Beech A36TC, N222HC, was substantially damaged when it was involved in an accident at Chandler, Arizona. One passenger sustained serious injuries, and the pilot and two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before takeoff, he calculated the takeoff weight to be 3,794 pounds and the center of gravity (CG) to be on the forward edge of the CG envelope. The maximum certified gross weight for the airplane was 3,833 pounds. The pilot also calculated the takeoff distance to clear a 50 ft obstacle to be about 3,000 ft for an outside temperature of 90oF. The length of the runway to be used for takeoff was 4,400 ft. The pilot reported that the preflight inspection and the engine start, taxi, and pretakeoff checks were normal. The pilot further reported that the engine sound and indications were normal for the takeoff roll but that the airplane’s acceleration was “slightly slower than expected” and the ground roll was “longer than predicted.” The pilot did not abort the takeoff because “given the high OAT [outside air temperature], this was not…indicative of a problem.” He did not recall the speed for rotation but reported that it was within the range for takeoff. After liftoff, the pilot lowered the airplane’s nose to allow the airplane to accelerate. After the landing gear was retracted, the airplane did not accelerate or climb, the airspeed was getting slower, and the stall warning was activating intermittently. As the airplane was nearing the end of the runway, the pilot aborted the takeoff, and the airplane landed just beyond the departure end of the runway and into dirt. The airplane slid on its belly and subsequently collided with an airport fence. The wings were substantially damaged, and a postimpact fire ensued. Postaccident examination revealed extensive thermal damage throughout the engine. All engine accessories and the propeller hub remained attached to the engine. All engine accessories were removed along with the upper spark plugs and rocker box covers. The crankshaft was rotated by hand using the propeller. Thumb compression and suction was obtained on all six cylinders. The intake and exhaust valve rocker arms on all cylinders exhibited equal movement when the crankshaft was rotated. The turbo-charger waste gate remained attached in its installed position. The butterfly valve was in the open position. The control arm was actuated using a hand tool, and the butterfly valve opened once pressure was released. The turbine and compressor impellers spun freely by hand with no binding noted. The compressor and turbine impellers were intact with slight lateral play in the shaft between the compressor and turbine impellers along with slight rub marks on the housing. No preaccident mechanical failures or malfunctions were found that would have precluded normal operation of the engine. -
Analysis
The pilot reported that before takeoff he calculated the airplane’s takeoff weight, which he determined to be near the maximum gross takeoff weight with a center of gravity (CG) on the forward edge of the CG envelope. The takeoff calculations assumed that the airplane could sufficiently clear a 50-ft obstacle during the takeoff ground roll. During the takeoff, the pilot reported that the engine sound and indications were normal for the takeoff roll but that acceleration was slightly slower and the ground roll longer than predicted. The pilot did not abort the takeoff because he thought that the slower acceleration and longer ground roll were related to the outside air temperature, which was about 91oF. After liftoff, the pilot kept the nose lowered to build airspeed. After the landing gear was retracted, the airplane did not accelerate or climb. The airspeed was getting slower, and the stall warning was activating intermittently. As the airplane neared the end of the runway, the pilot aborted the takeoff and landed the airplane just beyond the departure end of the runway in dirt. The airplane slid on its belly and subsequently collided with an airport fence. The wings were substantially damaged, and a postimpact fire ensued. Examination of the engine revealed no preaccident mechanical failures or malfunctions that would have precluded normal operation. It is likely that the combination of a high gross airplane weight and a high outside temperature resulted in a ground roll that was longer than the pilot expected based on his takeoff calculations. By the time that the pilot aborted the takeoff, the airplane was operating at or near the stall speed and was thus not able to gain altitude.
Probable cause
The pilot’s delayed decision to abort the takeoff due to insufficient airspeed.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N222HC
Operator
B L AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
EA-259
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-14T23:49:58Z guid: 103555 uri: 103555 title: CEN21LA315 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103460/pdf description:
Unique identifier
103460
NTSB case number
CEN21LA315
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-10T09:45:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-07-14T01:20:40.705Z
Event type
Accident
Location
Longmont, Colorado
Airport
Vance Brand Airport (LMO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 4 minor
Factual narrative
On July 10, 2021, about 0845 mountain daylight time, a Cessna 421C airplane, N66NC, was substantially damaged when it was involved in an accident near Longmont, Colorado. The pilot and three passengers received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he performed the “before starting engine” and “starting engine” checklists and everything was normal. He performed an engine runup and then started his takeoff roll. The pilot reported that about halfway down the runway he sensed the airplane was not accelerating as fast as it should. He attempted to rotate; however, “the airplane mushed off the runway.” The airplane settled back onto the runway, then exited off the departure end of the runway. The airplane came to rest upright, and a post-crash fire ensued. The airplane sustained substantial damage to both wings and the fuselage. The airplane was equipped with a JPI EDM 760 engine monitor. The unit was retrieved from the airplane and the NVM (nonvolatile memory) downloaded. According to the engine manufacturer, the data indicated the airplane’s engines were operating consistent with each other at takeoff power until power was reduced for the rejected takeoff. Referring to the Cessna 421C Pilot’s Operating Handbook, for the conditions at the time of the accident, the airplane’s normal takeoff distance would have been about 2,700 ft to clear a 50 ft obstacle. Density altitude at the time of the accident was 7,170 ft. -
Analysis
The pilot reported that he performed the “before starting engine” and “starting engine” checklists and everything was normal before taking off in the twin-engine airplane. He performed an engine runup and then started his takeoff roll. The pilot reported that about halfway down the runway the airplane was not accelerating as fast as it should. He attempted to rotate the airplane; however, “the airplane mushed off the runway.” The airplane settled back onto the runway, then exited the departure end of the runway, where it sustained substantial damage to the wings and fuselage. The airplane engine monitor data indicated the airplane’s engines were operating consistent with each other at takeoff power at the time of the accident. Density altitude at the time of the accident was 7,170 ft and according to performance charts, there was adequate runway for takeoff. The reason for the loss of performance could not be determined.
Probable cause
The loss of performance for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
421C
Amateur built
false
Engines
2 Reciprocating
Registration number
N66NC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
421C0519
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-14T01:20:40Z guid: 103460 uri: 103460 title: WPR21FA266 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103452/pdf description:
Unique identifier
103452
NTSB case number
WPR21FA266
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-10T13:54:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-07-23T00:59:08.956Z
Event type
Accident
Location
Wikieup, Arizona
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane was a Beechcraft King Air C90 manufactured in 1980. It was configured in accordance with the contract for wildland fire aerial supervision. The aircraft status sheet from July 9, 2021, showed that the aircraft had 17,262.6 hours total time and 15,475 cycles. The airplane started flying under contract to the Unites States Forest Service (USFS) in April 2007, and was under contract each year since then. The airplane was only used in the aerial supervision role while under USFS contract and was not used in the lead plane role. Up through 2016, the airplane was also used under the operator’s Part 135 operation. Since then, it had only been used on contract to the USFS, for flight training, or for check rides. The airplane was used fewer than 365 hours for the USFS mission each year it was on contract, with some years fewer than 100 hours. The aerial supervision mission, as defined in the USFS contract, consisted of cruise flight from the airplane’s base to the assigned target area, a descent to the target at altitudes between 1,000 to 3,500 ft agl, circling the target in a right-hand orbit for about 3-4 hours, and returning to base. The crew for the missions consisted of a pilot provided by the contractor and 1 or 2 USFS Air Tactical Group Supervisor(s) that would coordinate the tactical use of all aircraft. The mission limits flight profiles requiring steep bank angles or increased lateral distances from the target as they may obstruct the ground view of the aerial supervisor. The mission is typically flown at speeds from 120 to 150 kts and may require higher angles of attack or flap extension. In contrast, the lead plane mission is flown by a USFS pilot in a leased airplane and involves significant maneuvering at low altitudes (below 500 ft agl) in steep mountainous terrain and turbulent conditions as they lead air tankers to their designated drop zones in the fire environment. The lead plane can perform multiple lead runs during a single flight. The airplanes used as the lead plane can be used for the aerial supervision mission, but the converse is not true. The airplane’s operator, Falcon Executive Aviation, Inc. (FEA) provided the flight logs from May 26, 2021, through July 9, 2021, to include everything up until the accident flight. The airplane accrued 42.8 hours of flight time and 17 cycles under contract to the USFS and 5 hours of flight time and 9 cycles for maintenance or flight training prior to the accident flight. Since the airplane went on contract in 2007, it had accumulated 2,997 hours and 1,359 cycles on contract and 3,507 hours and 1,877 cycles total. A review of the airplane’s maintenance records since 1990 revealed that the wing spar inspections were accomplished per Federal Aviation Administration Airworthiness Directive (AD) 89-25-10, Wing Main Spar Inspection, which became effective at the beginning of 1990 and required inspection of the wing lower forward spar attach fittings, center section, and outboard wing spar caps adjacent to the attach fitting as specified in the Beech Structural Inspection and Repair Manual (SIRM) 57-13-01. Additionally, the visual inspections of the wing spar caps for cracks and corrosion per the SIRM were accomplished. A total of 16 wing spar inspections were accomplished since the AD became effective and 6 times since the airplane went on contract to the USFS in 2007. Further, the annual spar cap visual inspection for cracks and corrosion was accomplished 16 times since 2007. During a scheduled maintenance inspection, a couple of months before the accident, AD 89-25-10 and SIRM 57-13-01 wing spar inspections were being accomplished. A third party certified commercial NDT technician conducted EC and NDT testing in March 2021. An area in the fastener hole on the left wing’s lower forward spar cap on the wing root was found to have a crack indication and was out of limits. The hole was oversized/reamed to a larger size, but the EC reinspection still produced a crack indication. FEA’s maintenance provider, Falcon Air Service (FAS), then submitted a structural damage report and service request detailing the crack indication to the Textron Aviation structures group in April 2021. Textron Aviation responded to FAS in April 2021, that the crack indication necessitated the replacement of “the center section forward spar cap, center section forward lower fittings and both outboard main spar assemblies.” The email response from Textron Aviation to FAS also included the warning below from their published instructions for wing structure inspections in the SIRM 57-13-01, (in part): WARNING: A crack in the center section lower forward spar cap necessitates the replacement of all lower forward inboard fittings, the lower forward spar cap on the center section, and both outboard forward wing panel main spar assemblies. FEA and their maintenance provider, FAS, elected to repair the wing spar instead of replacing the spars as recommended by Textron Aviation. Subsequently, the maintenance facility owner contacted a FAA DER for the design of the repair. The repair involved oversizing the affected fastener hole and installing an external doubler around the hole location. The repair was installed and signed off in May 2021, with an FAA Form 337, Major Repair and Alteration, and included FAA Form 8110-3, Statement of Compliance with Airworthiness Standards, from the DER. A FAS mechanic completed the repair in accordance with the DER’s instructions. The DER claimed no knowledge of the communications between Textron Aviation and FAS about the crack indication, though FAS claimed otherwise. Afterwards, an eddy current NDT conducted by the commercial NDT inspector, completed in May 2021, showed the repair to be successful. The inspector performing the work was current and appropriately certified as a Level II inspector in EC, Fluorescent Penetrant Inspection (FPI) inspection, in accordance with National Aerospace Standard (NAS) 410 Rev. 4. Furthermore, the inspector completed the Textron Aviation SIRM training course and held an FAA repairman certificate, issued on March 2019, that was valid for NDT inspection using liquid penetrant, magnetic particle, eddy current, and ultrasonic methods. He had a visual acuity exam performed in December 2020. The NDT inspector provided documentation of his on-the-job experience for December 2020 through July 2021. The records showed that he had performed EC and/or FPI inspections on King Air airplanes 6 times during this timeframe in addition to the inspections on the accident airplane, with 4 of those occurring prior to the inspection of the accident airplane. Further, the calibration and conformance certificates for the equipment used was current. He remembered during the last inspection of the accident airplane that the first oversize of the hole did not remove the crack and after the hole was further oversized, an additional inspection did not reveal a crack indication and there were no other crack indications on the airplane. Textron published instructions for wing structure inspections in the SIRM 57-13-01. The SIRM was first published in December 1982 and was at revision level D2 at the time of the accident. The SIRM provides inspection intervals and instructions for inspecting the wing attach fittings, center section and outboard wing spar caps, and the nacelle splice plates for cracks, corrosion, and damage. There are 11 specific items detailed for visual, magnified visual, EC, or FPI with 9 items having a recurring inspection interval of 1,000 hours or 3 years, whichever occurs first. The visual inspection of the outboard upper and lower wing spar caps for corrosion has an annual recurrence and the visual inspection of the nacelle splice plates has a 1,000-hour recurrence time. The following warning is contained in the SIRM: WARNING:A crack in the center section lower forward spar cap necessitates the replacement of all lower forward inboard fittings, the lower forward spar cap on the center section, and both outboard forward wing panel main spar assemblies. A crack in an outboard wing panel spar cap requires replacement of the outboard forward spar assembly. A crack in a center section spar fitting requires replacement of the affected fitting only. A crack in an outboard wing panel main spar fitting necessitates replacement of the entire outboard wing panel spar assembly. Textron Aviation Technical Support should be contacted for an operational safety evaluation anytime a crack is found in a wing attach fitting or spar. The introduction section of the SIRM states that “all personnel performing Non-Destructive Testing Inspections (NDT) in this manual must be qualified and Certified Level II or Level III in accordance with NAS 410, ASNT/SNT-TC-1A, or an equivalent NDT certification program in the method which they are performing.” Further it states that all personnel performing the NDT must have completed the SIRM training course. The SIRM detailed the inspections of the forward spar lower cap required where the accident wing failed. The instructions call for a bolt hole eddy current examination of the aft inboard fastener hole through the wing fitting and spar cap and a surface eddy current examination of the aft flange of the lower spar cap. An Alternate Method of Compliance (AMOC) or adjustment of the initial or repetitive compliance times that provides an equivalent level of safety, may be approved by the Manager of the assigned FAA Aircraft Certification Office (ACO). An AMOC was not sought for the crack repaired from the inspection findings. The Wichita ACO provided the following explanation on repairs allowed under the AD: “Compliance to AD 89-25-10 for a crack found in the main spar lower cap or fitting is accomplished by a repair or replacement following the Beech SIRM or FAA approved instructions provided by Beech Aircraft Corporation. For purposes of this AD, the operator can use any instructions provided by Beech that have been approved by the FAA, a designee, or a CAA under a bilateral agreement. Additionally, AD 89-25-10, Paragraph (g) allows the Wichita ACOB to approve alternative methods of compliance if it is determined that the proposed repair provides an equivalent level of safety. Note: FAA Order 8110.103B defines AMOC as providing an acceptable level of safety. In this context, the FAA uses equivalent and acceptable in the same manner.” The Wichita ACO also provided the following explanation in reference to the DER-approved repair for the crack indication performed on the accident airplane in May 2021. “A DER, acting on behalf of the FAA, approved the repair data via FAA Form 8110-3. As noted on the 8110-3, the DER approval was only for the engineering data necessary for defining and substantiating the repair, not the installation. Therefore, although the repair data was FAA approved, the instructions were not provided by Beech, so it was not done in compliance with the with the AD. However, had an AMOC been requested for this repair through the Wichita ACOB, we most likely would have approved it. The FAA has previously received requests for AMOCs for repairs in this same location and has issued approval. It is our position that an AMOC should have been requested for this repair, but we have no record of receiving such a request. Therefore, this repair appears to be more of a technical noncompliance than an airworthiness issue.” - On July 10, 2021, about 1254 mountain standard time, a Beech C-90, turbo prop airplane, N3688P, was destroyed when it was involved in an accident near Wikieup, Arizona. The pilot and Air Tactical Group supervisor were fatally injured. The airplane was operated as a public-use firefighting aircraft in support of the Bureau of Land Management conducting aerial reconnaissance and supervision. The airplane was on station for about 45 minutes over the area of the Cedar Basin fire. The ADS-B data showed the airplane had accomplished multiple orbits over the area of the fire about 2,500 ft above ground level (agl). The last ADS-B data point showed the airplane’s airspeed as 151 knots, its altitude about 2,300 ft agl, and in a descent, about 805 ft east southeast of the accident site. No distress call from the airplane was overheard on the radio. According to a witness, the airplane was observed in a steep dive towards the ground. The airplane impacted the side of a ridgeline in mountainous desert terrain. The main wreckage was mostly consumed by a post-crash fire. Debris was scattered over an area of several acres. Another witness observed the left wing falling to the ground after the aircraft had impacted the terrain. The left wing had separated outboard of the nacelle and was located about 0.79 miles northeast of the main wreckage and did not sustain thermal damage. - The Mohave County Medical Examiner Office, Lake Havasu City, Arizona, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “multiple injuries due to a plane crash.” Due to the condition of the remains the medical examiner’s office was unable to provide specimens for Toxicology testing. - No significant weather was indicated over northern Arizona at time. The nearest METAR site reported clear conditions with 10 statue mile visibility, and wind 260 at 11 knots gusting to 18 knots. The were no active AIRMETs, SIGMENTs, or PIREPs reported in the area. - The airplane was operated by Falcon Executive Aviation, Inc., as a public-use firefighting flight for the Bureau of Land Management (BLM) over the Cedar Basin fire near Wikieup. While BLM maintained operational control of the flight, the airplane was under contract to the USFS as a call-when-needed asset. Falcon Executive Aviation, Inc. (FEA) held a Part 135 Operating Certificate and maintained the airplane under an FAA Approved Aircraft Inspection Program (AAIP) that was approved on April 18, 2008. The AAIP was based on the continuous inspection program outlined in Chapter 5 of the Beech Model 90 King Air Maintenance Manual. FEA selected the 200-hour phase inspection program for the AAIP that was comprised of 4 phase inspections accomplished at 200-hour intervals. A complete inspection of the airplane under the program would be completed each 800 hours. The AAIP required all 4 phases to be completed every 24 months even if the hour requirements were not met. In January 2021, the repair station split from the FEA charter company and the repair station Falcon Air Service (FAS) was formed as a new maintenance company. The airplane was still maintained by FEA in accordance with the AAIP, but all maintenance was performed by FAS. - The pilot held an airline transport pilot certificate, airplane single and multi-engine land ratings. He also held flight instructor and ground instructor certificates, and instrument ratings. His was issued a second- class medical certificate on his FAA medical examination on May 28, 2021, At the time of the examination, he had accumulated 10,000 total hours of flight experience, of which 150 were in the last six months. - The accident site was located about 15 miles northeast of Wikieup and was situated in mountainous terrain, covered with rocks ranging in size from pebbles to boulders. The site was populated by sage brush about 3 ft in height. The main wreckage was mostly consumed by fire and was about 465 ft away from a ridgeline, with the slope gradually increasing from 15° at the main wreckage site to 30° at the end of the debris path. The main wreckage was located about N 34.8173000°, W -113.3887333°, with an elevation of about 4,510 ft. The main wreckage area contained a section of the cockpit. Wreckage debris was scattered over several acres. Most major sections of the airplane were located near the main wreckage site, with the exception of the outboard left wing. The mostly intact but separated left wing section was located about 0.79 miles northeast of the main wreckage and did not sustain thermal damage. The flap and aileron were attached, and fuel was present in the wing. Examination of the left wing revealed that the forward spar was fractured about 11 inches inboard of the outboard wing attachment point. There was an area of pre-existing fracture evident in the lower spar cap through a fastener hole. Both the upper and lower forward spar wing attach bolts remained intact and were installed. The wing attach bolts were disassembled and the fractured portions of the forward spar were sent to the National Transportation Safety Board (NTSB) Materials Laboratory for further examination. The examination revealed that the fracture of the left wing’s lower spar cap was determined to be consistent with fatigue. The upper spar cap exhibited plastic deformation adjacent to its fracture consistent with compression buckling. In contrast, the lower spar cap fracture was flat and perpendicular to the spar direction, with no gross plastic deformation at or near the fracture. Further examination of the fracture surface of the lower spar cap revealed repeated banded features consistent with crack arrest marks from progressive cracking. The examination observations were consistent with the left wing’s lower spar cap fractured from a fatigue crack that initiated at the aft inboard fastener hole through the spar cap and wing attach fitting. Additionally, the fracture surface was examined by using a scanning electron microscope. The lower cap spar fracture surface exhibited striations consistent with crack propagation. The total length of the main crack was about 2.484 inches. Additionally, there was no indication of a material defect such as a corrosion pit or inclusion. The fatigue separation was not in the same area where the repair was accomplished. The repair was inboard of the area of the wing separation. The DER-approved repaired area was not identified in the recovered wreckage and therefore could not be examined. Visual and fluorescent penetrant inspection (FPI) examinations did not reveal any additional cracks in the other left and right wing’s spar cap remnants. -
Analysis
The pilot was conducting a firefighting support flight, with an Air Tactical Group Supervisor on board the airplane. Automatic Dependent Surveillance Broadcast (ADS-B) data indicated that the airplane was on station for about 45 minutes completing multiple orbits over the area of the fire. The last ADS-B data point showed the airplane in a descent, and its airspeed was about 151 knots at an altitude of about 2,300 ft agl. According to a witness, the airplane descended in a steep dive and impacted the side of a ridgeline in mountainous desert terrain. No distress call from the airplane was overheard on the radio. Another witness observed the outboard left wing falling to the ground after the aircraft had impacted the terrain. The outboard left wing, which had separated outboard of the engine nacelle, was located about 0.79 miles northeast of the main wreckage and did not sustain thermal damage. During a scheduled maintenance inspection several months before the accident, eddy current (EC) non-destructive testing (NDT) of a left wing’s lower forward spar cap detected a crack in a fastener hole. The hole was then oversized/reamed to a larger size, but the EC reinspection still produced a crack indication. The operator then submitted a structural damage report and service request detailing the crack indication to the aircraft manufacturer. The aircraft manufacturer responded to the operator that the crack indication necessitated the replacement of “the center section forward spar cap, center section forward lower fittings and both outboard main spar assemblies.” However, the operator and their maintenance provider elected to repair the wing spar instead of replacing the spars, as indicated by the aircraft manufacturer. The maintenance facility owner contacted a Federal Aviation Administration (FAA) Designated Engineering Representative (DER) for the design of the repair. The repair involved oversizing the affected fastener hole and installing an external doubler around the hole location. The repair was installed and signed off several months before the accident. The DER claimed no knowledge of the communication between the aircraft manufacturer and the maintenance provider about the crack indication, though the maintenance provider claimed otherwise. After the repair, an eddy current inspection conducted by a commercial NDT inspector showed the wing spar repair to be successful and did not reveal a crack indication. Further, there were no other crack indications on the airplane. A postaccident examination of the spar fracture surface revealed that the left wing’s lower spar cap fractured from a fatigue crack that initiated at the aft inboard fastener hole. The fatigue crack measured 2.484 inches in length and exhibited striations consistent with crack propagation. A study comparing the crack length. striations, flight hours, and number of cycles suggests the crack was large enough to have been seen visually at the last inspection. Therefore, it is likely that the NDT inspector omitted the EC inspection of the fastener hole or missed the fatigue crack indication given its length. The fatigue separation of the lower spar cap was not in the same area where the repair was accomplished. The repaired area was inboard of where the left wing separated. The DER-approved repaired area was not identified in the recovered wreckage and therefore could not be examined. Nevertheless, the area of the wing spar fatigue crack would have been removed from the airplane if the airplane’s operator and maintenance provider had followed the procedure outlined by the aircraft manufacturer, which noted that the crack indication necessitated the replacement of the spars.
Probable cause
The failure and separation of the left wing’s outboard section due to a fatigue crack in the lower spar cap. Contributing to the accident was the operator’s decision to repair the wing spar instead of replacing it as recommended by the aircraft manufacturer. Also contributing to the accident was the failure of the Non-Destructive Testing inspector to detect the fatigue crack during inspection.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C90
Amateur built
false
Engines
2 Turbo prop
Registration number
N3688P
Operator
Falcon Executive Aviation, Inc.
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Firefighting
Commercial sightseeing flight
false
Serial number
LJ-915
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-23T00:59:08Z guid: 103452 uri: 103452 title: ERA21LA283 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103451/pdf description:
Unique identifier
103451
NTSB case number
ERA21LA283
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-10T18:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-07-14T01:33:30.142Z
Event type
Accident
Location
Charlestown, New Hampshire
Airport
Morningside Flight Park (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
On July 10, 2021, at 1730 eastern daylight time, an experimental light-sport Bailey Moyes Dragonfly, N346FL, was substantially damaged when it was involved in an accident near Charleston, New Hampshire. The pilot sustained minor injuries and the passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On the day of the accident, the commercial pilot seated in the front seat was receiving “mentoring” and airplane familiarization from the passenger in the rear seat. The passenger had been a licensed private pilot but had his airmen and medical certificates revoked in 2017. They were flying in the traffic pattern, using the northerly runway at Morningside Flight Park, a private airfield, when the accident occurred. According to the pilot, before the accident flight, both he and the passenger performed a preflight inspection together. After the inspection, the passenger flew the airplane solo and performed three touch-and-go landing maneuvers. The passenger then landed the airplane and moved to the rear seat, and the pilot sat in the front seat and performed one touch-and-go landing and one full-stop landing. During the third circuit in the traffic pattern, while on final approach, the airplane was too high and the passenger told the pilot to perform a go-around, which he did. During the downwind leg, the engine power was set at 4,200 rpm. Witnesses reported that the downwind leg was “lower and slower” than normal. According to the pilot, while near the end of the downwind leg, about 400 ft above ground level, the passenger shook the control stick “violently” and yelled “something about power.” He shook the controls again and yelled “my airplane” and assumed control of the airplane. When the airplane was abeam the runway threshold, the passenger began a turn toward the base leg of the airport traffic pattern. At that time the pilot noticed that the engine speed was about 3,200 rpm, slightly below the typical setting of 3,500 rpm for cruise flight. The pilot noted that the airplane was “low”; however, he thought the altitude was sufficient to clear the power lines. The pilot reported that a partial loss of engine power occurred about the same time the passenger turned the airplane onto the base leg. The airplane then banked “hard” to the left, pitched nose down, descended into power lines, and impacted the ground. The engine continued to operate, and the pilot attempted to shut down the engine with the magneto switches, but the engine continued to run. He then located the master switch, turned it off, and the engine stopped. The power lines were oriented north/south (5° magnetic) and located about 350 - 500 ft west of the runway, which was oriented about 14° magnetic. The utility line towers were about 350 ft apart, and the highest wire was equipped with two visibility marker balls. With the designated left traffic pattern and all takeoffs and landings to the north, a typical traffic pattern involved crossing over the power lines on the base leg. Figure 1 - Wreckage / Runway and Power line Location Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest adjacent to one of the utility towers supporting the power lines. All major components of the airplane were present at the accident site. An electrical arcing mark was present on the left wingtip. The forward fuselage was fractured aft of the front pilot station and was mostly separated from the remainder of the fuselage. The airplane was mostly intact from the rear pilot station to the tail. The aileron and rudder controls were continuous from the rear pilot station to their respective control surfaces. The elevator controls were continuous from the rear pilot station though a fracture in the elevator push-pull tube (which remained attached to its fixtures at both ends), to the elevator. The airplane was equipped with an airframe parachute, which was not deployed. The “safety pin” which prevents accidental deployment while on the ground was removed, which is appropriate for flight. The fuel tank was about 1/2 full, and a sample taken upstream of the fuel filter appeared and smelled consistent with automotive fuel, which is the engine manufacturer’s recommended fuel type. The tips of all three composite propeller blades were frayed/damaged. The engine throttle control cable was fractured in several locations. Postaccident examination of the engine revealed that the left side carburetor’s throttle arm was slightly bent, which allowed it to contact a bracket when the arm was positioned at a partial throttle setting. The impingement did not prevent moving the arm to the full throttle setting; however, it intermittently prevented the arm from returning to the idle position. No other anomalies were found that would have precluded normal operation. Toxicological samples from the passenger were tested by the FAA’s Forensic Sciences Laboratory, which detected Delta-9-THC at 11.5 ng/mL, 11-hydroxy-delta-9-THC at 3.4 ng/mL, and carboxy-delta-9-THC at 39.7 ng/mL in femoral blood. Those three substances were also detected in urine. Delta-9-THC, commonly known as THC, is the primary psychoactive chemical in cannabis and hashish, which are derived from cannabis plants. THC is commonly smoked or ingested recreationally by users seeking mind-altering effects. It may also be used medicinally to treat illness-associated nausea and appetite loss. Psychoactive effects of THC vary depending on the user, dose, and route of administration, and may include relaxation, euphoria, disinhibition, disorientation, altered perception of time and space, impaired concentration and memory, altered thought formation and expression, sedation, panic, paranoia, heightened senses, emotional lability, psychosis, and dulled attention with the illusion of increased insight. THC can impair motor coordination, reaction time, decision making, problem solving, and vigilance. According to FAA records, before the passenger’s airman and medical certificate were revoked in September 2017, he had held a private pilot certificate with a rating for airplane single-engine land. His most recent medical application date was June 7, 2016. -
Analysis
The pilot was in the airport’s traffic pattern receiving mentoring and airplane familiarization from the passenger in the rear seat, who had been a private pilot but had his airmen and medical certificates revoked about 4 years before the accident. The pilot reported that, during the third landing, the airplane was too high while on final approach and the passenger told the pilot to perform a go-around. A witness who saw the airplane on the subsequent downwind described the airplane as being “slower and lower” than normal. Near the end of the downwind leg, at an estimated altitude of 400 ft above ground level, the passenger yelled “something about power” according to the pilot and assumed control of the airplane. When abeam the runway threshold, with an engine speed about 3,200 rpm which was about 300 rpm below normal cruise speed, the passenger turned onto the base leg. The pilot later reported that although the airplane’s altitude was “low,” it seemed sufficient to clear the power lines located several hundred feet to the west of and nearly parallel to the runway. The pilot reported that a partial loss of engine power occurred about the same time the passenger turned the airplane onto the base leg. The airplane banked “hard” to the left, pitched nose down, and descended into one of the power lines. After the airplane impacted the ground, the engine continued to operate until the pilot shut it down. Because the previous pattern circuit was too high on final approach and resulted in a go-around maneuver, the pilot may have overcompensated and flown the accident pattern at too low of an altitude given the power line obstruction on the base leg. The passenger was likely concerned about the approach when he took over the controls. His subsequent turn to the base leg suggests that he intended to continue in the normal traffic pattern over the power lines. Given the low altitude at the time, this decision involved significantly greater risk than extending the downwind and correcting whatever condition(s) that caused the passenger to take control. The pilot described a partial loss of engine power about the same time the passenger made the turn to base leg, which was followed by a sharp turn to the left and a nose-down attitude just before impact with the power lines. The investigation could not determine if the reduction in engine power was due to a failure or malfunction or was intentionally commanded by the passenger in an attempt to avoid the power lines. Postaccident examination of the engine did not reveal any anomalies that would have resulted in a partial loss of engine power. Toxicology testing for the passenger, who was flying the airplane at the time of the collision with the power line, was positive for tetrahydrocannabinol (THC), the primary psychoactive chemical in cannabis and hashish and its metabolites. The levels detected may have been sufficient to cause significant impairing effects; however, they do not indicate the severity of THC-related impairment or whether such impairment contributed to the accident. Therefore, whether impairing effects of the passenger’s THC use contributed to the accident could not be determined.
Probable cause
The passenger’s decision to continue an unstable approach while at low altitude and in proximity to a known obstacle, which resulted in a collision with power lines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BAILEY N MOYES
Model
DRAGONFLY
Amateur built
false
Engines
1 Reciprocating
Registration number
N346FL
Operator
KHK MORNINGSIDE LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
034
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-14T01:33:30Z guid: 103451 uri: 103451 title: ERA21LA284 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103454/pdf description:
Unique identifier
103454
NTSB case number
ERA21LA284
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-10T21:10:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-08-30T23:22:05.404Z
Event type
Accident
Location
Elba, Alabama
Airport
Carl Folsom Airport (14J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 10, 2021, about 2010 central daylight time, a Cessna 150F, N8172S, was substantially damaged when it was involved in an accident near Elba, Alabama. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, after conducting maneuvers for about 30 minutes, they returned to Carl Folsom Airport (14J) to conduct short/soft field landings and takeoffs. After the first successful full-stop landing, they taxied back to the runway and set up for a short field takeoff and, according to the flight instructor, she applied carburetor heat during the short taxi. Shortly after rotation and liftoff, the airspeed was not increasing as they flew in ground effect. The flight instructor asked why they weren’t climbing, and the student stated, “I don’t know, you have the controls.” The flight instructor took the control of the airplane and performed a shallow right climbing turn to avoid the trees at the end of the runway. The flight instructor stated there was no time to perform any troubleshooting of the engine because they were “barely” flying, and she needed to “just fly the airplane.” The engine was operating but not producing sufficient power to maintain level flight. They were flying over the treetops as the airspeed continued to decrease and the airplane started to descend. The flight instructor pushed the nose over to avoid a stall and landed the airplane in the trees. The airplane wreckage was located about 1,000 ft west southwest of the departure end of the runway in heavy wooded terrain and brush. Postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest in a nose-down attitude and was tilted to the right. Both wings were bent aft, and the airframe sustained substantial damage. The left fuel tank was breached, and the right tank remained intact and contained fuel. The inspector was unable to examine the engine due to the airplane’s orientation and surrounding terrain. After the accident, the instructor told the FAA inspector that she had been thinking about what caused the accident and stated she thought it might be carburetor icing. The wreckage was recovered to an aviation salvage company and promptly sold. According to the salvage company that took possession of the wreckage, the engine was in excellent working condition and was subsequently sold to a private individual. A review of the local area meteorological data showed that the 1958 recorded weather observation at Shell Army Heliport (SXS) Fort Novosel, Alabama, about 12 miles southeast of the accident location, included wind from 240° at 3 knots, 9 miles visibility, clear skies, temperature 24°C, dew point 22°C; and an altimeter setting of 30.08 inches of mercury. The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, showed a probability of serious icing at glide power at the temperature and dew point reported at the time of the accident. FAA Special Airworthiness Information Bulletin (CE-09-35) – Carburetor Icing Prevention, stated that: …pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. -
Analysis
After performing flight training maneuvers for about 30 minutes, the instructor and student returned to the airport to practice short/soft field takeoffs and landings. After the first full-stop landing, the flight instructor recalled applying carburetor heat during the landing and taxi back for the next takeoff. During the student’s subsequent short field takeoff, the airspeed did not increase as expected while in ground effect and the instructor asked the student why he was not climbing. The student replied that he didn’t know and relinquished the controls to the instructor. The instructor determined that the engine was not producing enough power to maintain level flight and that they were too low to troubleshoot. As the airplane descended and the airspeed decreased, she lowered the nose and made a forced landing into trees, which resulted in substantial damage to the wings and fuselage. After the accident the flight instructor stated she thought the cause was carburetor ice. The temperature and dewpoint at the time of the accident were conducive to serious icing at glide power, and carburetor ice likely accumulated during the approach and previous landing. Although the instructor recalled applying carburetor heat during taxi there may not have been sufficient time to melt all or any accumulated carburetor ice.
Probable cause
The partial loss of engine power due to the formation of carburetor ice, which resulted in reduced climb capability and impact with trees during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N8172S
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15061772
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-30T23:22:05Z guid: 103454 uri: 103454 title: CEN21FA314 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103455/pdf description:
Unique identifier
103455
NTSB case number
CEN21FA314
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-12T09:05:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-07-12T21:43:01.05Z
Event type
Accident
Location
Seiling, Oklahoma
Airport
Fairview Municipal (6K4)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
In accordance with 14 CFR 65.81 and 14 CFR 65.85, a certificated aircraft mechanic may perform a 100-hour inspection, as well as maintenance, preventative maintenance, and alterations of aircraft. Under 14 CFR 65.95, a certificated mechanic with an inspection authorization may perform an annual inspection. - The airframe incorporated a fuselage-mounted center wing section. The left and right outboard wing sections were each mounted to the center wing section. The center-to-outboard wing attachment consisted of upper and lower fittings on the main wing spar and one fitting on the rear spar. The mating main spar fittings were secured by an expansion mandrel assembly comprising a split mandrel, tapered plug, retention bolt, washer, and castellated nut with cotter pin.   In August 2000, the airframe manufacturer issued service bulletin (SB) E/02.170/2000 requiring recurring inspections of the wing attachment fittings due to two accidents involving in-flight wing separations. In September 2000, the FAA issued airworthiness directive (AD) 2000-18-12 requiring compliance with the manufacturer’s SB for airplanes registered in the United States. For airplanes that had accumulated 3,000 hours time-in-service (TIS), the initial inspection was required to be completed within 30 days of the effective date of the AD; otherwise, the inspection was required upon reaching 3,000 hours TIS. Recurring inspections were required every 500 hours TIS or 12 calendar months.   The AD/SB required inspection of the center wing to outboard wing attachment joints for corrosion, cracks, and ovalization of the through-holes in the fitting lugs. The presence of any corrosion required a subsequent magnetic particle inspection to identify any cracks. Any corrosion was required to be removed before the airplane was returned to service, and any cracks required replacement of the fitting. Ovalization, within specific limits, could be repaired by reaming the fitting through-holes and installing a repair mandrel. Otherwise, fitting replacement was required. The SB specifically noted that there, “was no need for outboard wing removal upon expansion mandrels removal.” In accordance with the SB, the wing fittings and associated split mandrel hardware were to be coated as specified for corrosion protection after inspection and other maintenance.   Maintenance records revealed that the pilot performed the most recent annual inspection which included compliance with the previously noted AD. An FAA-certificated mechanic with airframe and powerplant ratings and an inspection authorization (A&P/IA) subsequently certified compliance with the annual inspection. The records noted compliance with the AD corresponding to each annual inspection from 2003 until the most recent annual inspection in 2021. With exception of the inspections in 2003, 2006, and 2016, each logbook endorsement related to AD/SB compliance was completed by the pilot/mechanic or the A&P/IA. Only the inspection in 2006 specifically noted the use of magnetic particle inspection. There was no indication in the maintenance records that the failed fitting had been replaced or the lug bore diameter had been machined at any time during the airplane’s service life.   The A&P/IA stated that the pilot/mechanic completed the required inspections and noted compliance with the AD. Then he, as an A&P/IA, verified that all inspections were completed and entered the annual inspection into the maintenance records under his inspection authorization. The A&P/IA confirmed that the pilot/mechanic removed the wing attachment bolts and mandrels to check for corrosion and dimensionally inspect the lugs; however, he was not certain if any non-destructive testing such as magnetic particle inspection was completed. To his knowledge, the AD was complied with by inspection; the wing lug fittings were not replaced at the last annual. He added that the pilot normally flew at reduced weights to minimize stress on the airframe.   Installation of a Honeywell TPE331 turboprop engine was completed in 2016. - On July 12, 2021, at 0805 central daylight time, a PZL Mielec M-18A “Dromader” airplane, N9310R, was destroyed when it was involved in an accident near Seiling, Oklahoma. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Airplane position data revealed that the pilot departed Fairview Municipal Airport (6K4), Fairview, Oklahoma, at 0744. He proceeded to an agricultural field about 19 miles southwest of the departure airport. The pilot then appeared to complete 11 north-south oriented application passes over the field. The final data point was recorded at 0805:42 with a corresponding approximate altitude of 1,787 ft mean sea level; about 35 ft above ground level. The final data point was at the north end of the field and at the end of an application pass. This was aligned with the point where, after the previous passes, the pilot had initiated a turn to reverse course for another pass. The airplane impacted a pasture about 0.34 mile northwest of the final data point. - The pilot held a Federal Aviation Administration (FAA) mechanic certificate with airframe and powerplant ratings. He did not hold an inspection authorization associated with that certificate. An inspection authorization was required to certify an annual inspection on the accident airplane. - Metallurgical examination determined that the fatigue crack originated on the lug bore surface about 0.12 inch from the forward face of the lower lug. The fatigue crack origin was associated with a corrosion pit on the lug bore surface. At its longest length, the fatigue crack propagated about 0.80 inch before the remaining ligament fractured in overstress. In addition, the fatigue crack surface deposits were consistent with corrosion products. Two other corrosion pits were present near the crack origin region. The bore surface exhibited significant corrosion pitting. Furthermore, corrosion deposits were prevalent on the portion of the expansion mandrel assembly in contact with the outboard lower main attachment fitting bore. Examination of the opposing upper lug portion of the lower fitting revealed fracture features consistent with upward bending of the inboard portion of the lug.   Surface deposit samples taken from the retention bolt, tapered plug, and split mandrel revealed spectra consistent with degraded or oxidized corrosion inhibiting compound. The samples from the lugs and bore of the main attachment fitting piece revealed spectra that was not a comparative match to the corrosion inhibiting compound spectrum.   The right outboard wing to center wing section main spar lower attachment fitting was also examined. The fitting was intact and did not exhibit any crack indications; however, it exhibited mechanical pits and, similarly to the failed left fitting, no positive indications of fluorescent deposits consistent with previous magnetic particle inspection. In addition, the expansion mandrel components had a brittle and crumbling brown coating, consistent with an aged or degraded corrosion inhibitor coating. - The main wreckage consisted of the fuselage, engine, right wing, and empennage. A ground impact depression, oriented toward the northwest, was located immediately adjacent to the main wreckage. The left wing had separated and was located about 120 ft northeast of the main wreckage. The flight controls remained attached to the airframe with the exception of the right aileron and the outboard portion of the left elevator; both were located at the accident site. Minor debris associated with the left wing was located about 190 yards southeast of the main wreckage. An on-scene examination indicated that the left outboard wing main and rear spars had separated from the center wing structure. Further examination revealed that the lower lug common to the left/outboard wing main spar lower lug had features consistent with fatigue fracture through approximately 90% of the lower lug cross section with the remaining lug cross section fracturing in overstress. The separated upper lug fracture surface exhibited features consistent with overstress fracture. -
Analysis
The pilot was conducting an agricultural application flight at the time of the accident. As the pilot concluded an application pass and entered a turn to return for another pass, the left outboard wing section separated from the center wing section. The airplane was destroyed when it impacted a pasture. Examination revealed that the main spar wing attachment fitting on the outboard wing section failed. Specifically, the lower lug corresponding to the lower main spar attachment failed due to fatigue. Metallurgical examination determined that the fatigue crack initiated at a corrosion pit on the surface of the wing fitting lug bore. The fatigue crack had propagated about 0.80 inch before the remaining lug cross-section was unable to support the required load and failed in overstress. The fitting lug bore surface exhibited corrosion pitting, and corrosion deposits were prevalent on the mating surfaces of the expansion mandrel assembly, which was in contact with the wing fitting bore. No indication of previous magnetic particle inspection of the lug was observed. In addition, only degraded deposits of corrosioninhibiting compound were observed on the associated attachment hardware. There was no indication that the failed wing fitting had been replaced or the lug bore diameter machined at any point during the airplane service life.   As a result of previous accidents involving wing fitting failures, the airframe manufacturer issued a service bulletin (SB) requiring recurring inspection of the wing fittings. Shortly afterward, the Federal Aviation Administration (FAA) issued an airworthiness directive (AD) requiring compliance with the SB inspection requirements for all US-registered airplanes. The AD/SB required removal of the expansion mandrels for the inspection, but the outboard wings were not required to be removed. The AD/SB specified that, if corrosion was observed, magnetic particle inspection to identify any cracks was required. Corrosion was required to be removed and any cracks required replacement of the fitting. The wing fittings and associated split mandrel hardware were to be coated for corrosion protection after inspection and other maintenance.   Maintenance records revealed that the pilot, who was also an FAA certificated mechanic (pilot/mechanic), performed the most recent inspection, which included compliance with the previously noted AD/SB. An FAA-certificated airframe and powerplant mechanic with an inspection authorization (A&P/IA) subsequently certified compliance with the annual inspection.   The A&P/IA stated that the pilot/mechanic completed the required inspections and noted compliance with the AD. Then he, as an A&P/IA, verified that all inspections were completed and entered the annual inspection into the maintenance records under the authority of his inspection authorization. The A&P/IA confirmed that the pilot/mechanic removed the wing attachment bolts and mandrels to check for corrosion and dimensionally inspected the lugs; however, he was not certain if any nondestructive testing, such as magnetic particle inspection, was completed. To his knowledge, the AD was complied with by inspection, and the wing lug fittings were not replaced at the last annual. He added that the pilot normally flew at reduced weights to minimize stress on the airframe.   A detailed visual inspection as required by the SB would likely have identified the presence of the corrosion product deposit and based on the length of the fatigue crack at failure, a subsequent magnetic particle inspection would likely have identified the fatigue crack before it had progressed to failure. In addition, the lack of corrosion inhibiting compound residue suggested that it had not been applied at the time of the most recent inspection.   The available evidence indicated that the most recent wing fitting inspection under the requirements of the AD/SB was either inadequate or not completed because the extent of corrosion on the wing fitting lug bore was significant and likely would have been visible after removal of the mandrel. Additionally, there was no evidence that a magnetic particle inspection was completed as required with the presence of corrosion. A proper magnetic particle inspection, performed by qualified personnel, would likely have detected presence of the crack before it resulted in failure of the wing fitting. Finally, the presence of only degraded corrosion inhibiting compound on the fittings suggested that corrosion inhibiting compound was not applied any time recently and certainly not at the time of the most recent annual inspection.
Probable cause
The pilot’s in-flight loss of control due to the structural failure of a wing fitting and separation of the outboard wing section. Also causal were the inadequate wing fitting inspections, which failed to detect the initial corrosion and crack before it resulted in failure of the wing fitting lug.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PZL MIELEC
Model
M18
Amateur built
false
Engines
1 Turbo prop
Registration number
N9310R
Operator
Regier Aerial LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1Z018-01
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-12T21:43:01Z guid: 103455 uri: 103455 title: WPR21FA270 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103470/pdf description:
Unique identifier
103470
NTSB case number
WPR21FA270
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-13T11:42:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-07-19T20:39:20.256Z
Event type
Accident
Location
Monterey, California
Airport
MONTEREY RGNL (MRY)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude.    The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following:   The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - The Monterey Regional Airport is a public airport operating under class-Delta airspace. The airport features multiple runways. Runway 10R, is charted with two IFR departure procedures (both requiring a climbing left turn after takeoff), elevation is 158 ft and runway dimensions are 7,175 ft x 150 ft. Figure 2: View of the Monterey Five Departure procedure. - On July 13, 2021, about 1042 Pacific daylight time (PDT), a Cessna 421C, N678SW, was destroyed when it was involved in an accident near Monterey, California. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.  Review of recorded communications from the Monterey air traffic control tower revealed that before takeoff the pilot canceled their instrument flight rules (IFR) clearance and requested a visual flight rules (VFR) on top clearance. The controller subsequently cleared the airplane to the Salinas VOR via the Monterey Five departure and to proceed VFR-ON-TOP. The controller issued a clearance for takeoff and shortly after, instructed the pilot to contact the Oakland Air Route Traffic Control Center (ARTCC). Review of recorded communications from the Oakland ARTCC revealed that the pilot established radio communication with the Oakland ARTCC controller as the airplane ascended through 1,700 ft mean sea level (msl). The controller observed on the radar display the airplane was turning in the wrong direction and issued an immediate right turn to a heading of 030° which was acknowledged by the pilot. The controller then immediately issued two low altitude alerts with no response from the pilot. No further radio communication from the pilot was received. Recorded automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that the airplane departed from runway 10R at 1738:44 and ascended to 1,075 ft msl before a right turn was initiated. The data showed that at 1740:14, the airplane continued to ascend in a right turn and reached an altitude of 2,000 ft msl before a descent began. The airplane continued in a right descending turn until ADS-B contact was lost at 1740:38, at an altitude of 775 ft msl, about 520 ft southwest of the accident site as seen in figure 1. Figure 1: View of airplane ADS-B track. A witness located near the accident site reported that he observed the accident airplane descend below the cloud layer in a nose low attitude with the landing gear retracted. The witness stated that the airplane made a right descending turn and impacted the top of a pine tree before it traveled below the tree line out of sight, followed by the sound of an explosion. - An autopsy of the pilot was performed by the Monterey County Sheriff’s Office – Coroner Division in Salinas, California. The cause of death was “multiple blunt force injuries.” Toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. - The preliminary weather for MRY reported that at 1054 PDT, wind from 280° at 7 knots, visibility of 9 statute miles, ceiling overcast at 800 ft above ground level (agl), temperature of 15°C and dew point temperature of 11°C, altimeter setting of 29.99 inches of mercury, remarks included: station with a precipitation discriminator. A High-Resolution Rapid Refresh numerical model sounding near the accident site supported cloudy conditions from about 1,100 to 1,700 ft with a freezing level at about 17,000 ft. The wind below 2,000 ft was from the west at magnitudes less than 10 knots. A temperature inversion was noted between 1,600 and 4,600 ft. A pilot on a decent to landing at MRY, in the hours leading to the accident, reported that cloud tops were near 2,000 ft msl with the bases at about 800 ft msl. - A review of the pilot’s logbook indicated that a flight review was accomplished on July 17, 2020. The flight instructor reported that during the flight, an instrument proficiency check was also conducted. However, an instrument proficiency check endorsement dated July 17, 2020 was not observed in the pilot logbook. In the 12 months preceding to the accident flight, the pilot accumulated about 0.3 hours of simulated instrument flight, 0.7 hours of actual instrument flight and no instrument approaches. - Examination of the accident site revealed that the airplane impacted trees about 1 mile south of the departure end of runway 10R. The first identifiable point of contact (FIPC) was a 50 to 75 ft tall tree that had damaged limbs near the top of the tree. The debris path was oriented on a heading of about 067° and was about 995 ft in length from the FIPC, as seen in figure 3. The main wreckage was located about 405 ft from the FIPC. Various portions of aluminum wing skin, right wing, flap, aileron, engine, propeller blades, and propeller hub were observed throughout the debris path. Additionally, several trees were damaged throughout the debris path. The fuselage came to rest upright against a residential structure at an elevation of 447 ft msl. Figure 3: View of accident site diagram. A postaccident examination of the airframe and engines revealed rotational continuity throughout both engines and no evidence of mechanical malfunctions or failures were identified that would have precluded normal operation. -
Analysis
Before taking off, the pilot canceled an instrument flight rules (IFR) flight plan that she had filed and requested a visual flight rules (VFR) on-top clearance, which the controller issued via the Monterey Five departure procedure. The departure procedure included a left turn after takeoff. The pilot took off and climbed to about 818 ft then entered a right turn. The air traffic controller noticed that the airplane was in a right-hand turn rather than a left-hand turn and issued a heading correction to continue a right-hand turn to 030o, which the pilot acknowledged. The airplane continued the climbing turn for another 925 ft then entered a descent. The controller issued two low altitude alerts with no response from the pilot. No further radio communication with the pilot was received. The airplane continued the descent until it contacted trees, terrain, and a residence about 1 mile from the departure airport. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area due to a low ceiling, with ceilings near 800 ft above ground level and tops near 2,000 ft msl. Examination of the airframe and engines did not reveal any anomalies that would have precluded normal operation. The airplane’s climbing right turn occurred shortly after the airplane entered IMC while the pilot was acknowledging a frequency change, contacting the next controller, and acknowledging the heading instruction. Track data show that as the right-hand turn continued, the airplane began descending, which was not consistent with its clearance. Review of the pilot’s logbook showed that the pilot had not met the instrument currency requirements and was likely not proficient at controlling the airplane on instruments. The pilot’s lack of recent experience operating in IMC combined with a momentary diversion of attention to manage the radio may have contributed to the development of spatial disorientation, resulting in a loss of airplane control.
Probable cause
The pilot’s failure to maintain airplane control due to spatial disorientation during an instrument departure procedure in instrument meteorological conditions which resulted in a collision with terrain. Contributing to the accident was the pilot’s lack of recent instrument flying experience.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
421C
Amateur built
false
Engines
2 Reciprocating
Registration number
N678SW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
421C1023
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-19T20:39:20Z guid: 103470 uri: 103470 title: ERA21LA291 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103491/pdf description:
Unique identifier
103491
NTSB case number
ERA21LA291
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-13T11:56:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-07-29T01:08:51.268Z
Event type
Accident
Location
Brooksville, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On July 13, 2021, about 1056 eastern daylight time, a Cessna A150K, N8412M, was substantially damaged when it was involved in an accident near Brooksville, Florida. The commercial pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he conducted a thorough preflight inspection before departing. About 25 minutes after takeoff, in cruise flight at 1,600 ft mean sea level, he noted an audible rpm reduction, followed by a vibration and a loss of engine power. During the forced landing, he “cycled the carb heat,” and verified that the mixture control was set to rich. He verified that the fuel selector was in the ON position and attempted to restart the engine. As he was unable to restart the engine, he performed a forced landing to a heavily wooded area. According to pictures provided by the Federal Aviation Administration (FAA) inspector who responded to the accident site, the engine mounts and wing spars sustained substantial damage. A postaccident examination of the engine revealed no evidence of preimpact mechanical anomalies that would have prevented normal engine operation. The propeller spinner was dented and removed prior to starting the engine to eliminate any vibration. The fuel sump was drained, and the automotive fuel looked dark in color. An external fuel tank was connected to the carburetor. The engine started and ran smoothly at various power settings with no anomalies noted. At 1053, the weather reported at Brooksville-Tampa Bay Regional Airport (BKV), about 6 miles southwest of the accident site, included a temperature of 29°C and a dew point of 24°C. The calculated relative humidity at this temperature and dewpoint was 74%. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide and cruise power." -
Analysis
About 25 minutes after takeoff, while in cruise flight at 1,600 ft mean sea level, the pilot noted an audible rpm reduction followed by a vibration and a loss of power. During the emergency descent, he “cycled the carb heat,” verified the mixture control was set to rich and that the fuel selector was in the ON position, and attempted to restart the engine. Unable to restart the engine, he performed a forced landing to a heavily wooded area, during which the airplane sustained substantial damage. A postaccident examination of the wreckage and an engine test run revealed no evidence of preimpact mechanical anomalies that would have prevented normal engine operation. Based on the temperature and dew point about the time of the accident, the conditions were favorable for carburetor icing at glide and cruise power settings. It is likely that, during the flight, carburetor ice formed, subsequently resulting in the loss of engine power.
Probable cause
A total loss of engine power as a result of carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A150K
Amateur built
false
Engines
1 Reciprocating
Registration number
N8412M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
A1500112
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-29T01:08:51Z guid: 103491 uri: 103491 title: WPR21LA271 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103486/pdf description:
Unique identifier
103486
NTSB case number
WPR21LA271
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-15T10:50:00Z
Publication date
2023-05-10T04:00:00Z
Report type
Final
Last updated
2021-07-23T01:05:55.704Z
Event type
Accident
Location
Riverside, California
Airport
RIVERSIDE MUNI (RAL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On July 15, 2021, about 0850 Pacific daylight time, an experimental amateur built RV6A, N468AC, was substantially damaged when it was involved in an accident near Riverside Municipal Airport (RAL), Riverside, California. The flight instructor sustained a serious injury, and the pilot sustained a minor injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the purpose of the flight was to conduct an airplane checkout and flight review. During a power-on stall, the engine stopped; the pilot stated that he immediately switched fuel tanks, and the engine restarted. The pilot suggested that the airplane return to RAL, and the flight instructor told him to obtain a landing clearance. The flight instructor assumed control of the airplane because the pilot had not landed the airplane before. The tower controller instructed the pilots to extend the downwind leg for landing traffic. While on final approach to land on runway 27, the engine stopped again. According to the pilot, the flight instructor thought that the airplane was not going to reach the runway. The airplane subsequently impacted terrain short of the runway and came to rest inverted on a northern heading 450 ft from the threshold of the runway. Postaccident examination of the airplane found a blue liquid, consistent with 100 low-lead fuel, draining from the lower cowling near the quick drain. About 6-7 gallons of fuel were drained from the left fuel tank, and about 16-17 gallons of fuel was drained from the right fuel tank. The engine was started and ran uneventfully for several minutes at various power settings, including full power. No evidence of any preexisting mechanical malfunction or failure was revealed that would have precluded normal operation of the engine. -
Analysis
The pilot of the experimental, amateur built airplane was undergoing an airplane checkout and flight review. The flight instructor directed the pilot to perform a power-on stall. During the maneuver, the airplane’s engine lost total power. The pilot immediately switched fuel tanks and was able to restart the engine and elected to return to the airport. The flight instructor assumed control of the airplane for the return flight. While the airplane was on short final, the engine lost total power again. The airplane subsequently impacted terrain short of the runway and came to rest inverted. Postaccident examination of the airplane found a blue liquid, consistent with 100 lowlead fuel, draining from the lower cowling. Several gallons of fuel were drained from the fuel tanks. During the engine examination, the engine was started and ran uneventfully for several minutes at various power settings, including full power. Further examination of the engine revealed no evidence of any preexisting mechanical malfunction or failure that would have precluded normal operation of the engine.
Probable cause
A total loss of engine power for reasons that could not be determined from available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
true
Engines
1 Reciprocating
Registration number
N468AC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
60573
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-23T01:05:55Z guid: 103486 uri: 103486 title: ERA21LA288 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103485/pdf description:
Unique identifier
103485
NTSB case number
ERA21LA288
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-15T11:00:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-08-03T21:14:37.846Z
Event type
Accident
Location
Lebanon, Tennessee
Airport
Fall Creek Field (TN96)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 15, 2021, about 1000 eastern daylight time, a De Havilland Canada DHC-1 Chipmunk X, N47YC, was substantially damaged when it was involved in an accident at Lebanon, Tennessee. The commercial pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he intended to fly the airplane from Fall Creek Field Airport (TN96) in Lebanon, to Lebanon Municipal Airport (M54). After uneventful ground operations, he took off on runway 18 with the fuel selector positioned to the left fuel tank, which was full. He reported that the right fuel tank was half-full. During the initial climb, at an altitude between 100 and 150 ft above the ground, the engine suddenly lost all power; however, it did not seize. The pilot was unable to return to the airport and prepared for a forced landing. He maneuvered the airplane between trees, and the airplane descended into the trees and impacted the ground. The Federal Aviation Administration inspector who responded to the accident site reported that both wings and the fuselage were substantially damaged. The leading edge of the right wing sustained impact damage that penetrated and ruptured the rubberized bladder fuel tank; no fuel remained in the tank. The left-wing fuel tank was undamaged and contained an adequate supply of fuel. The cockpit fuel selector was found in the RIGHT tank position. No contamination or obstructions were found in the fuel system. The De Havilland Gipsy Major engine was examined at an aircraft salvage facility after the accident. The engine remained attached to the airframe. There was impact damage to the propeller, engine mount, firewall, and the lower and left sides of the engine. The engine was turned through by manually rotating the propeller. The engine turned freely through 360° with no binding or unusual noise evident. The two forward cylinders did not show compression or suction when the engine was rotated. Further examination revealed impact damage to the rocker covers and internal components in the cylinder heads. A lighted borescope was then inserted inside both cylinders. The pistons moved up and down normally, and valve action was correct. There were no holes or damage to the pistons or valves. The aft two cylinders were undamaged. When the engine was rotated, compression and suction were observed on both aft cylinders. The dual engine-driven fuel pumps were removed for examination. Fuel was found inside the lines from the fuel pumps to the carburetor. The fuel strainers were opened; both strainers were full of fuel, and the screens were clean and unobstructed. The lever-action pumps functioned normally when operated by hand. The carburetor was examined on the engine. All cockpit controls were connected and exhibited full travel when manipulated by hand. The suction oil filter was removed for examination. The unit contained oil. The screen was removed, and no particulates or contamination were observed. The spark plugs were removed for examination. The electrodes were normal in wear and dark in color when compared to a Champion Check-a-Plug chart. The magnetos were removed and tested by rotating with a power drill. Both magnetos produced spark when rotated. The fixed-pitch Fairey Aviation Co. Ltd. two-bladed aluminum propeller remained securely attached to the engine. The propeller spinner was undamaged. The propeller blades exhibited minor impact damage with slight aft bending at the tips. There was no chordwise scratching on the surfaces of the blades or leading-edge damage. -
Analysis
The pilot reported that, before departure, the right tank was half full, the left tank was full, and that he took off with the fuel selector set to the left tank. The pilot reported that, during the initial climb, the airplane’s engine suddenly lost power. He maneuvered the airplane for a forced landing, and it impacted trees and terrain before coming to a stop. The airplane sustained substantial damage to the fuselage and both wings, and the pilot was seriously injured. An examination of the fuel system and engine did not reveal evidence of a preexisting mechanical malfunction or failure. The cockpit fuel selector handle was found in the right tank position. The right fuel tank was ruptured during the impact sequence and contained no fuel. The left tank, which the pilot reported that he was using at the time of the loss of engine power, held an adequate amount of fuel. Fuel was found in the line from the fuel pumps to the carburetor. The reason for the sudden loss of engine power could not be determined based on the available evidence.
Probable cause
A total loss of engine power during the initial climb for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND CANADA
Model
DHC-1 CHIPMUNK X
Amateur built
false
Engines
1 Reciprocating
Registration number
N47YC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
147X
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-03T21:14:37Z guid: 103485 uri: 103485 title: ERA21LA289 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103488/pdf description:
Unique identifier
103488
NTSB case number
ERA21LA289
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-15T12:29:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-07-29T22:48:27.897Z
Event type
Accident
Location
Easton, Maryland
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The flight instructor reported an issue with another one of the operator’s airplanes, N76NA, a Piper PA-23-160. According to the FAA airworthiness records, the airplane was modified in December 1979 in accordance with STC SA899SW, which authorized the installation of 180-horsepower Lycoming O-360-A1D engines, Hartzell HCC2YK2RBF propellers, and F7666A-2 propeller blades, resulting in a basic propeller diameter of 74 inches. The flight instructor reported that, before the accident flight, he noted that the left propeller was feathered and that it was serviced afterward. A few days later while on the ground with the throttle at idle, the left propeller feathered uncommanded. The flight instructor also reported that, 1 week before the accident, another flight instructor told him that the right propeller on the accident airplane had feathered uncommanded while on the ground. A mechanic was able to get the blades out of feather, and the airplane was flown uneventfully. The propellers from N76NA were subsequently removed, overhauled, and then reinstalled onto the accident airplane. The chief flight instructor for the operator reported that he had not experienced an uncommanded propeller feather event during his more than 13 years of flying N76NA. He did report two uncommanded feathering events in the accident airplane during landing and one that occurred during approach (not including the accident flight). The ground events involved the left and right propeller, and the in-flight event involved the right propeller. For all three cases, the feathering occurred when power was quickly reduced from an approach power setting to full idle. For both ground cases, the engines restarted normally. Maintenance could not duplicate the problem during troubleshooting after the first event. There was no entry in the provided maintenance records or in any work order regarding any inspection or testing regarding the uncommanded feathering. In addition, the flight instructor reported that the right seat “was notorious for slipping back 2 or 3 notches when the right rudder was pushed hard.” As a result, it was common practice to physically push the locking pin into the notch to keep the seat in place. The flight instructor indicated that, “as long as you don’t slam on the rudders, putting too much force against the locking pin, the seat will remain in place.” He reported that other multiengine flight instructors also had the seat slip and that they complained to maintenance, but “nothing could be done to fix it.” The chief flight instructor reported that he flew the accident airplane on a regular basis with no seat issues. - The airplane was equipped with hydraulically controlled flaps and a landing gear system that was primarily operated by an engine-driven hydraulic pump installed on the left engine. The airplane was also equipped with a hand pump in the cockpit. With an inoperative left engine, extension or retraction of the flaps and landing gear was done manually using the hand pump. According to the Owner’s Handbook for Operation and Maintenance of the Piper Apache Models PA-23 and PA-23-160 Airplanes, the landing gear required 30 to 40 pumps of the handle to be raised or lowered, and the flaps required 12 pumps of the handle to be raised or extended. The airplane was also equipped with an engine monitor that recorded parameters for both engines, including cylinder head temperature (CHT) and exhaust gas temperature (EGT). A review of the downloaded engine monitor data revealed that the left and right engine EGT and CHT were normal and showed increasing and decreasing values for both engines, consistent with airwork. From 1125:04 to 1126:28, the left engine EGT began decreasing, and the CHT for all cylinders increased. From 1126:28 to the end of the recorded data at 1128:52, the left engine EGT showed a general increase with an occasional short-term decrease in temperature, and the CHT for all left engine cylinders showed slightly increasing or steady temperatures. The end of the recorded data for the flight showed the right engine EGT between 1,097°F and 1,200°F and the right engine CHT between 281°F and 326°F (the highest value recorded). Supplemental Type Certificate (STC) SA1306SW, issued on May 4, 1971, to Apache Modification Aircraft Corporation, approved a change to the airplane type design of Piper PA-23 and Piper PA-23-160 airplanes involving the installation of 200horsepower Lycoming IO-360-C1C engines and Hartzell HC-C2YK-2 model propellers with counterweight-equipped C7666A-4 propeller blades that had a basic propeller diameter of 72 inches. With this STC, feathering of the propeller was accomplished by moving the propeller control in the cockpit to the feather position, which drained oil from the propeller back to the engine, thus allowing the air charge in the propeller cylinder and the counterweight on each blade to move the blades to the feather position. According to the airplane flight manual supplement associated with the STC, the CHT limitation was 500°F. According to the Federal Aviation Administration (FAA), the airplane was modified in May 2009 in accordance with STC SA1306SW. According to maintenance records and work orders, after the airplane made a gear-up landing in September 2020, both engines were inspected and then reinstalled on the airplane, and Aeroshell 15W50 oil was added to both engines. Hartzell HCC2YK2RBF propellers, with F7666A-2 model propeller blades, were installed. A review of the left propeller logbook revealed that the propeller was overhauled on November 3, 2020. The propeller blades did not have the counterweights required by the STC and the basic propeller diameter of 74 inches was 2 inches longer than the STC-approved propeller. According to the Propeller Owner’s Manual and Logbook, No. 115N, a note in the maintenance practices section indicated that propellers on certain aircraft and engine combinations have experienced inadvertent feathering that occurred either at the time of shutdown or at low engine rpm. The manual further stated that the feathering could be reduced or eliminated “by lowering the air charge within the propeller cylinder.” The manual showed that the air charge in the cylinder at 70°F was required to be 178 pounds per square inch (psi) ± 2 psi. Further review of the maintenance records and work orders showed that, during the airplane’s last annual inspection (about 3 months before the accident), a technician inspected the seat hardware for condition, security, and operation. The records contained no written discrepancies related to the right front seat, and there was no entry in the airframe maintenance records regarding the right front seat. - On July 15, 2021, about 1129 eastern daylight time, a Piper PA-23, N776MC, was substantially damaged when it was involved in an accident near Easton, Maryland. The flight instructor and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that, after takeoff, the pilot receiving instruction, who was also a flight instructor, completed an approach to landing stall (flaps and gear down) and reported that the throttles felt “like bungee cords.” The flight instructor then executed the same maneuver and agreed, reporting that, during recovery, the left engine spooled up “slowly.” The flight instructor told the pilot receiving instruction to perform the maneuver again, which began at 3,000 ft msl by lowering the nose while the airplane was operating at 70 mph to achieve a 500 fpm descent at 80 mph and 1,500 rpm. When the airplane was at an altitude of about 2,800 ft msl, the pilot receiving instruction initiated the stall maneuver by raising the nose and reducing engine power to idle. The airplane then descended about 100 ft before the stall buffet occurred at an airspeed of about 62 mph. During the subsequent recovery, full power was applied to both engines, but the left engine lost total power and the left propeller feathered uncommanded. At that time, the airspeed was about 57 mph, and the flight instructor stated that the airplane immediately rolled about 45° to the left into a Vmc [velocity minimum control airspeed] roll. The flight instructor immediately took control of the airplane to recover, but, as he applied full right rudder, his seat slipped back, which released pressure on the right rudder pedal. The airplane entered a second VMC roll, from which he was able to recover, but the airplane was at an altitude of about 1,200 ft msl (or about 1,100 agl) and in a descent of about 800 fpm. The pilot receiving instruction was unable to restart the left engine, and the flaps and landing gear remained extended. The airplane was below 800 ft msl and descending fast when both pilots determined that the airplane would be unable to reach an airport. The flight instructor subsequently landed the airplane in a cornfield, which resulted in substantial damage to the left wing and fuselage. - Postaccident examination of the airplane revealed that the airplane came to rest upright with both propellers feathered. The rudder was positioned partially trailing edge left, and the rudder trim tab was positioned trailing edge right (tail right). Examination of the right front seat and seat tracks revealed that the left and right seat catch plungers extended 0.442 and 0.120 inch, respectively, from their housings. The right seat catch plunger would not extend into the track hole. The seat track surrounding structure revealed no evidence of damage or deformity. The right seat tube-seat catch release had both ends bent or deformed with about 0.438 inch between them, which reduced the length of the right seat catch plunger to secure the seat into position. The forward portion of the right seat lower seat cushion was slightly deformed/wrinkled, and the seat frame and seat pan did not appear to be deformed. Examination of both wings revealed that the left main landing gear was in the down and locked position and that the right main landing gear was in the extended position; the left wing sustained substantial damage. The left fuel strainer bowl was empty while the right fuel strainer bowl had a small amount of liquid, consistent in odor and color to 100 low lead (100LL) aviation fuel. A small bubble of undetermined debris, which remained separate from the fuel, was visible at the bottom of the right fuel strainer bowl. Examination of the left and right fuel supply and vent systems revealed no evidence of preimpact failure or malfunction. Continuity of the engine controls for both engines (from the cockpit to the end fittings in each engine compartment) was confirmed. Examination of the left engine which had been removed for recovery revealed the left and right magneto to engine timing were 21° and 20° before top dead center (BTDC), respectively, while the specified timing is 20° BTDC. Examination of the fuel inlet screen of the servo fuel injector revealed evidence of previous corrosion consistent with water contamination. The engine was shipped to the manufacturer’s facility for operational testing. After arriving, inspection revealed that the left magneto timing was at 0° BTDC. A tightly secured shipping strap was over the left magneto housing which likely changed the magneto timing position. The left magneto was re-timed to the value found following recovery and impact damaged components needed for an engine run were removed and replaced. The left engine was placed in a test cell with a test propeller installed, and the idle speed was adjusted to about 700 rpm. The engine operated within the limits for full-rated power and manifold pressure. The engine was subjected to a rapid throttle movement, and the engine did not hesitate in response. The rpm drop when checking the left magneto was greater than the allowed amount. The reason for the excessive magneto drop was not determined. The propeller oil control leak test procedure was performed for both engines in accordance with Lycoming Service Instruction 1462A. The procedure specified that it was to be performed whenever the engine feathers during the landing rollout with a reduced throttle setting. The procedure specified that the engine was to be started and that the engine oil temperature should move into the green arc, but neither engine ran with those conditions. As a result, the procedure was performed on both engines while the engine oil was at ambient temperature. Testing of the left engine was performed twice at an air pressure of 40 psi, and both test results of 11 and 21 psi were within allowable limits. According to the engine manufacturer, the 21 psi is the reading obtained from a cold factory engine. Testing of the right engine using the same air pressure produced a value of 14 psi, which was also within allowable limits. Examination of the left propeller revealed that blade No. 2 was bent aft about 30° and that it exhibited leading-edge polishing and minor twisting. A chordwise paint abrasion was at the tip. The cambered side of blade No. 1 exhibited chordwise erosion on the leading edge near the tip. While on the start locks with an ambient temperature of 72°F, the air charge in the cylinder measured 175 psi. According to the Propeller Owner’s Manual and Logbook Manual, the specified air charge in the cylinder at 70°F for that model propeller and propeller blades was between 176 and 180 psi. With the use of interpolation, the pressure at 72.5°F was between 177 and 181 psi. While on the start locks, the undamaged No. 1 blade was at the specified blade angle, and the low-pitch setting was correct. Examination of the right propeller revealed that both propeller blades were in the feathered position. While on the start locks with an ambient temperature of 72°F, the air charge in the cylinder measured 169 psi. The start lock blade angle for both blades was within limits, the low-pitch blade angle for the No. 1 blade was 0.1° greater than maximum limit specified, and the No. 2 blade low-pitch blade angle was within limits. Examination and testing of both propeller governors was performed. For the left governor, a slight leak was noted at the control shaft O-ring and at the feather rod. No leakage was noted for the right governor. The relief valve and feather checks of both propeller governors were within limits, and the pump capacity for both governors was 4.4 quarts per minute (minimum specification was 5.0 quarts per minute). The high rpm check for both governors was 20 rpm higher than the high-value limit. Both governors were not subjected to an internal leakage test because the test bench did not have that capability at the time of the testing. -
Analysis
During an instructional flight, while performing a practice approach-to-landing stall with the flaps and landing gear extended, the pilot receiving instruction applied full power to both engines at the airframe buffet. While recovering, the left engine lost total power and the left propeller feathered uncommanded. At that time, the airspeed was about 57 mph and the airplane immediately rolled about 45° to the left, consistent with a Vmc roll. The flight instructor immediately took control of the airplane to recover. As he applied full right rudder, his seat slipped back, which released pressure on the right rudder pedal. The airplane entered a second Vmc roll, from which he was able to recover, but the airplane was at an altitude of about 1,100 ft agl and in a descent of about 800 ft per minute (fpm). The pilot receiving instruction was unable to restart the left engine, and the flaps and landing gear remained extended. When the airplane was flying below 700 ft agl and descending rapidly, both pilots realized that the airplane would not be able to reach the airport. The flight instructor subsequently landed the airplane with its landing gear and flaps still extended in a cornfield, during which the left wing and fuselage were substantially damaged. The airplane came to rest upright with both propellers feathered. During a postaccident test run, the left engine produced full-rated power and manifold pressure with no hesitation noted during rapid full-throttle applications. No discrepancies were noted with either engine when a propeller oil control leak test procedure was performed on each. While the installed left propeller blades had a basic diameter that was 2 inches longer than the approved propeller, the propeller was not counterweighted as specified by the applicable supplemental type certificate, and the air charge in the propeller cylinder was about 2 psi less than the lower specified limit in the Propeller Owner’s Manual and Logbook, it is unlikely that those conditions would have resulted in to the uncommanded feathering of the left propeller. The propeller governor oil pump flow rate was measured to be slightly less than the minimum specified, the reason for the lower flow rate could not be determined because the test bench was not capable of measuring the internal leakage. The investigation also could not determine if the lower flow rate was sufficient to maintain the accident propeller at a low pitch while in a low power and airspeed flight condition. Based on this information, the reason for the total loss of engine power of the left engine and the reported uncommanded feathering of the left propeller could not be determined. During the postaccident examination of the right front seat, a deformation in the tube-seat catch release was noted. That condition, which likely existed at takeoff, prevented one of the two seat catch plungers from extending into the seat track and likely allowed the seat to move back when the flight instructor applied right rudder. Given the described sequence of events provided by the flight instructor, the seat slipping directly contributed to the second Vmc roll and loss of altitude before he was able to recover. With an inoperative left engine, extension or retraction of the flaps and landing gear would have to be accomplished manually using a hand pump in the cockpit. If the seat slippage (and the subsequent loss of control and altitude) had not occurred, it is possible that either pilot would have had the time to manually retract the landing gear and flaps, and that the flight instructor could have flown with a single engine to a diversion airport.
Probable cause
A total loss of left engine power and uncommanded feathering of the left propeller for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-23
Amateur built
false
Engines
2 Reciprocating
Registration number
N776MC
Operator
Navy Annapolis Flight Center
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
23-1078
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-29T22:48:27Z guid: 103488 uri: 103488 title: WPR21FA272 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103489/pdf description:
Unique identifier
103489
NTSB case number
WPR21FA272
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-15T12:54:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-07-25T01:34:01.273Z
Event type
Accident
Location
Dinsmore, California
Airport
DINSMORE (D63)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s weight and balance records were not located. The Mooney M20J Pilot’s Operating Handbook contained a maximum performance takeoff distance chart. The chart showed that, at a takeoff weight of 2,740 pounds, a flap setting of 15°, a fuel/air mixture that was leaned for smooth operation, a temperature of 10°C, and an altitude of 2,000 ft, the ground roll would be 1,022 ft, and 1,732 ft would be required for a 50-ft obstacle clearance. At an altitude of 4,000 ft, the ground roll would be 1,309 ft, and 2,175 ft would be required for a 50-ft obstacle clearance. The calculated climb performance for the published gross weight at a density altitude of 2,500 ft would have been about 900 ft per minute with the landing gear retracted, maximum engine power, 0° flaps, and a rich fuel/air mixture. - On July 15, 2021, at 1154 Pacific daylight time, a Mooney M20J airplane, N4474H, was destroyed when it was involved in an accident near Dinsmore Airport (D63), Dinsmore, California. The pilot, pilotrated passenger, and two other passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness, who was located 0.25 miles east of the departure end of runway 9 at the airport, observed the accident airplane circling the area twice before landing on runway 27. (The witness reported that the wind was from the west.) The witness then observed the airplane travel down the runway before making a complete stop at the midpoint of the runway, at which time three people disembarked, one of whom walked around the airplane. All three people then boarded the airplane, and the airplane taxied toward runway 9. The witness observed the airplane accelerate down the runway and stated that the airplane appeared to have rotated just short of the displaced runway threshold. The witness thought that the airplane “barely cleared the fence” and that the rotation was not smooth because the pilot had suddenly “jerked” the nose of the airplane. The airplane subsequently impacted trees and then the ground about 1,600 ft from the departure end of runway 9. Two security cameras, both of which were located about 300 ft east of the departure end of runway 9 (see figure 1), captured the accident airplane during the takeoff initial climb (see figure 2 for the view from one of the cameras). Figure 1. Camera and wreckage locations. Figure 2.: Security camera image showing the accident airplane at the departure end of runway 9 during takeoff initial climb. - The wreckage was located on a magnetic heading of 126°. Examination of the accident site revealed that the airplane’s right wing impacted a tall redwood tree. Upon impact, the right wing separated and fell onto the ground underneath the tree. The airplane came to rest inverted about 120 ft from the first point of impact on a magnetic heading of 170°. Postaccident examination of the airplane revealed that the engine remained attached to the airframe by the engine mount. The engine sustained thermal and impact damage. The crankshaft rotated freely in both directions. Thumb compression was obtained on all four cylinders. The intake valve rocker arms of each cylinder moved about 40% less compared with the exhaust rocker arms. Disassembly of the engine found no evidence of heat distress on the crankshaft and its attached connecting rods. The main bearings exhibited signs of significant wear. The main bearing saddles at each crankcase exhibited significant fretting signatures. The camshaft was intact. Each exhaust cam lobe exhibited an elliptical shape, and the corresponding tappet face remained undamaged and smooth. The intake cam lobes exhibited a worn and rounded shape. The corresponding tappets for the intake cam lobes were galled. An engine monitoring unit was recovered from the wreckage. The data were subsequently downloaded. The data showed that, about 3 minutes into the recording, the engine speed increased to about 2,150 rpm and then further increased moments later to about 2,700 rpm. The manifold pressure increased to 27 inches. The recording ended about 35 seconds later with a recorded engine speed of 2,685 rpm and a manifold pressure of 27.3 inches. Other engine parameters appeared to be nominal. -
Analysis
A witness who was near the departure airport reported observing the airplane circle the area, land on the runway, and stop at the midpoint of the runway. At that time, three people disembarked from the airplane, one of whom walked around the airplane. All three people then boarded the airplane, and the airplane taxied toward the approach end of the runway. The witness observed the airplane take off and stated that the airplane appeared to have rotated just short of the displaced runway threshold. The witness stated that the airplane “barely cleared the fence” and that the rotation was not smooth. Subsequently, the airplane impacted trees just beyond the departure end of the runway, where a postimpact fire ensued. Postaccident examination of the engine revealed that the intake camlobes were worn and exhibited a rounded (instead of an elliptical) shape. The corresponding tappets for the intake cam lobes were galled. The alteration of the camlobe profile will in turn alter the amount and duration of the intake valves opening, thus negatively affecting power output. As a result, takeoff and climb performance would be directly affected. Although the extent of the degradation to the accident engine's power output could not be determined from the available evidence, the degradation was likely sufficient to cause a partial loss of engine power.
Probable cause
The airplane’s degraded engine performance due to wear to the intake cam lobes, which diminished the airplane’s takeoff and climb performance, resulting in a subsequent collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20J
Amateur built
false
Engines
1 Reciprocating
Registration number
N4474H
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-0744
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-25T01:34:01Z guid: 103489 uri: 103489 title: ERA21LA290 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103490/pdf description:
Unique identifier
103490
NTSB case number
ERA21LA290
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-15T20:45:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-07-28T16:27:11.748Z
Event type
Accident
Location
Piermont, New Hampshire
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
On July 15, 2021, about 1945 eastern daylight time, a Cameron Balloons 0-105, N2925L, was substantially damaged when it was involved in an accident near Piermont, New Hampshire. The pilot was fatally injured, one passenger received minor injuries, and three passengers were not injured. The balloon was operated as a Title 14 Code of Federal Regulations Part 91 commercial sightseeing flight. The pilot was the owner and operator of the balloon. According to a passenger, the balloon departed Post Mills Airport (2B9), Post Mills, Vermont, about 1830 with the pilot and four passengers onboard and flew northeast along the Connecticut River toward Bradford, Vermont. The balloon was aloft about 45 minutes when the pilot reported the pilot light on the burner had extinguished. He changed the propane tank, but could not locate the striker to relight the burner. The balloon started to descend while the pilot searched the balloon basket for the striker. He did not locate the original striker, but did locate the backup in a supply pocket several minutes later. The balloon had descended close to the ground by then and the pilot re-lit the pilot light; however, he could not get the balloon to climb before impacting a field. One passenger and the pilot were thrown from the basket upon impact. The balloon then started to rise, and the pilot’s foot was trapped between the balloon attach rope and the basket frame. The pilot untangled his foot, but remained hanging below the basket for an estimated 1.25 miles before falling to a field near the Connecticut River. The remaining passengers contacted the balloon ground support personnel via a handheld radio and received instructions on how to operate the balloon controls in preparation for landing. The balloon traveled about 3.45 miles from the ejection site before landing in trees. The pilot, age 72, held a commercial pilot certificate with a rating for lighter-than-air balloon and private privileges for airplane single-engine land. Additionally, he held a repairman certificate for hot air balloon and airship. Review of Federal Aviation Administration (FAA) records revealed that the pilot’s most recent third-class medical certificate was issued on May 25, 1993. At that time, he reported a total flight experience of 4,500 hours. The pilot’s logbook was not recovered. The aircraft logbooks were not recovered. Review of the FAA database revealed that the registration matched a Cameron balloon manufactured in 1984; however, the pilot had modified the balloon such that, at the time of the accident, no component of the balloon was manufactured by Cameron. The balloon was examined following its recovery to the pilot’s hangar. The examination revealed that the basket and burner were originally manufactured by Galaxy Balloons and modified by the pilot, the propane gas tanks were manufactured by Worthington, and the envelope was built by the pilot. The basket, propane tanks, and burner operated normally. The burner’s pilot light lighted without difficulty. The envelope was removed from its storage bag and laid out for examination. No preimpact anomalies were noted with the basket or envelope that would have precluded normal operation. Toxicological testing of the pilot revealed metoprolol (a beta blocker to reduce blood pressure) in blood and urine. -
Analysis
The balloon departed with the pilot and four passengers for a commercial sightseeing flight. About 45 minutes into the flight, the burner’s pilot light extinguished. The pilot told the passengers that he had to switch propane tanks; however, he could not locate the striker to relight the burner. The balloon started to descend while the pilot searched the balloon basket for the striker, and several minutes later, he located a backup striker. The balloon had descended close to the ground by the time the pilot re-lit the pilot light, and he could not get the balloon to climb before impacting a field. One passenger and the pilot were thrown from the basket upon impact. The balloon then started to rise, and the pilot’s foot was trapped between the balloon attach rope and the basket frame. The pilot untangled his foot but remained hanging below the basket for about 1 mile before falling to a field and suffering fatal injuries. The remaining passengers contacted ground support personnel via a handheld radio and received instructions on how to operate the balloon controls in preparation for landing. The balloon traveled about another 3.5 miles before landing in trees. Examination of the balloon did not reveal any preimpact anomalies that would have precluded normal operation. Had the pilot been able to relight the burner in a timely manner, it was likely that he would have been able to sufficiently arrest the balloon’s descent rate to prevent the hard landing.
Probable cause
The balloon pilot’s delay in relighting the burner, which resulted in a hard landing and his ejection from the balloon.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
CAMERON
Model
0-105
Amateur built
false
Registration number
N2925L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
true
Serial number
0-105
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-28T16:27:11Z guid: 103490 uri: 103490 title: WPR21FA273 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103492/pdf description:
Unique identifier
103492
NTSB case number
WPR21FA273
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-16T09:40:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-07-26T20:15:01.838Z
Event type
Accident
Location
Angwin, California
Airport
ANGWIN-PARRETT FLD (2O3)
Weather conditions
Visual Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
The Federal Aviation Administration’s Airplane Flying Handbook (FAA-H-8083-3C) stated in part the following about porpoising:   In a bounced landing that is improperly recovered, the airplane comes in nose first initiating a series of motions that imitate the jumps and dives of a porpoise. The problem is improper airplane attitude at touchdown, sometimes caused by inattention, not knowing where the ground is, misstrimming or forcing the airplane onto the runway…. Porpoising can also be caused by improper airspeed control. Usually, if an approach is too fast, the airplane floats and the pilot tries to force it on the runway when the airplane still wants to fly…. When pilots attempt to correct a severe porpoise with flight control and power inputs, the inputs are often untimely may increase the severity of each successive contact with the surface. These unintentional and increasing pilot-induced oscillations may lead to damage or collapse of the nose gear. When a porpoise is severe, or seems to be getting worse, the safest procedure is to execute a go-around immediately. - The airplane was equipped with a throw-over-type control column for elevator and aileron control. Figure 1 provides the description of the control column in the Beechcraft Bonanza V35, V35A, and V35B POH. Figure 1. Flight control description. (Source: Beechcraft Bonanza V35, V35A, and V35B POH). According to the POH, the balked landing procedure involved the following steps: 1. Power – FULL THROTTLE, 2700 RPM 2. Airspeed – 70 kts/81 mph until clear of obstacles, then trim to normal climb speed 3. Flaps – UP 4. Landing Gear – UP 5. Cowl Flaps - OPEN The POH showed that the final approach speed depended on the weight of the airplane (see figure 2). Due to the postaccident fire, a landing weight could not be established for the accident airplane. Figure 2. Landing speed information (Source: Beechcraft Bonanza V35, V35A, and V35B POH). - On July 16, 2021, about 0840 Pacific daylight time (PDT), a Beechcraft V35B, N112TW, was destroyed when it was involved in an accident near Angwin Airport-Parrett Field (2O3), Angwin, California. The pilot, pilot-rated passenger, and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Radar track data identified the accident airplane departing from French Valley Airport (F70), Murrieta, California, on a climbing southwest heading. The data showed that the airplane made a climbing left turn to the northwest to an altitude of about 9,000 ft msl and continued at that altitude for most of the flight. A little over two hours later, the radar track data showed the airplane descending from 9,000 ft msl as it entered a left downwind for runway 16 at 2O3. The radar track data showed that the airplane made a wide left base turn to final and overshot the final approach. The radar track data then showed the airplane reacquiring the runway heading and landing. Witnesses at 2O3 reported that the airplane cleared the first tree line at the departure end of the runway. One witness reported that, after clearing the first set of trees, the airplane began to pitch up, the left wing dropped, and the nose then dropped toward the ground. The witness lost sight of the airplane behind a hill but saw smoke shortly afterward. - The pilots’ logbooks were not recovered during the investigation. - Postaccident examination of the airplane revealed that a GoPro HERO video recording device was installed on the headliner of the accident airplane and positioned to provide an over-the-shoulder view of the front seats and most of the airplane’s instrument panel. The video recording device was sent to the National Transportation Safety Board Vehicle Recorders Division for examination. The examination revealed that the device was damaged by impact and postcrash fire but was otherwise intact. The device’s protective outer case was removed, the battery compartment was opened, and the media card was found to be in good condition. The media card was read, and the recorded video files were downloaded. The video recordings also included an associated audio track; all three occupants’ voices were recorded. The recorded video files began about 0557 and recorded the entire flight from the departure airport up until the video concluded after the airplane impacted terrain near 2O3. The recording time totaled about 2 hours 49 minutes. For most of the cross-country flight, the throw-over control column (yoke) was positioned such that the left-seat pilot (LSP) was flying. For the descent, approach, landing, and go-around attempts, the throw-over yoke was positioned such that the right-seat pilot (RSP) was flying. The flight arrived in the area about 0830; the airport was identified and a descent for landing was initiated from an altitude of about 6,200 ft msl to traffic pattern altitude to 2,725 ft msl. During the descent, the LSP lowered the landing gear and flaps, while the RSP continued to fly the airplane. The video showed the RSP indicate with his hand in a sweeping motion across the throttle quadrant. There was discussion heard on the audio as to power settings and the RSP was heard to say, “remember, you’re on the brakes honey.” The LSP stated “yup” and positioned her feet to manipulate the brakes. As the pilot completed the left base turn, he stated “high” to himself. Moments later, the left base turn rounded into a turn to final. The airplane had entered a left bank of about 30°, the airspeed indicator displayed about 150 mph, the altitude was 3,000 ft msl (1,125 ft agl), and the RSP appeared to add a notch of flaps. As the airplane rolled onto final, the LSP asked, “all the flaps?” The RSP called short final on the common traffic advisory frequency, and the runway came into view ahead of the airplane. The airplane heading was about 30° right of centerline and tracking toward runway 16. The airspeed indicator displayed a speed of about 135 mph, the altitude was 2,750 ft msl (875 ft agl), and the RSP added nose-up pitch trim and began manipulating the yoke with both hands. About this time, the RSP appeared to reduce manifold pressure to about 15 inches of mercury (inHg). The RSP manipulated the yoke with both hands while on approach and attempted to correct the airplane toward the runway centerline. The RSP continued to add nose-up pitch trim, the tachometer gauge indicated a value of about 2,300 rpm, the airplane was right of centerline for runway 16, and the airspeed indicator showed about 130 mph. Moments later, the RSP appeared to decrease the airplane’s power setting (the gauge indicated less than 15 inHg), and the engine speed was still above 2,000 rpm. The LSP stated, “gear down.” The RSP appeared to have decreased the power setting significantly as the airplane approached the runway. The airspeed indicator showed 120 mph. The video showed the airplane cross over the painted “16” on the runway, the altimeter indicated 1,850 ft msl (25 ft below ground level), and the airspeed was about 100 mph. The RSP manipulated the yoke with a two-handed grip as he attempted to round out the airplane just beyond the numbers on the runway. The airplane yawed to the left and then to the right, consistent with the airplane’s directional control not being stabilized. The airplane touched down sharply and violently with an indicated airspeed of about 85 mph. As the airplane touched down, the rear passenger grunted, and both pilots were jostled. The airplane bounced three times consistent with a porpoised landing. The video showed that each subsequent bounced increased the airplane’s pitch angle. As the airplane bounced a fourth time, the camera was jostled, and the recording became unstable. The LSP stated, “go around” as the RSP looked down and applied throttle. The manifold pressure showed an increase to about 27 inHg. When the RSP added power, he moved his hand near the other controls in this area, and it was unclear if more than just the throttle was manipulated. Flap indications on the instrument panel were not possible to conclusively resolve. The tachometer showed that the rpm’s were increasing as it passed through 2,000 rpm. The airplane settled into a brief positive pitch attitude. As the RSP looked down toward the throttle area, the airplane settled back on the runway and the airplane porpoised down the runway. The RSP stated “oh” and looked up and outside, and then back down toward the throttle area. The airspeed indicator showed about 60 mph, when the pilot commanded a positive pitch attitude with the airplane’s nose pitching up sharply. The video showed that the RSP attempted to control the airplane with both hands on the yoke and continued to make pitch changes with a nose-high attitude without lowering the airplane’s nose to allow it to accelerate. The airplane remained in a nose-high attitude but did not climb significantly and subsequently struck trees. - Examination of the accident site (see figure 3) revealed that the departure end of runway 16 was about 0.5 miles from the first identified point of contact, a 50fttall tree. The airport was not visible from the wreckage site. A portion of wing skin was found in the tree, and the left aileron was found a few feet away on the ground. The main wreckage came to rest about 500 ft downslope of the tree in a vineyard. The left-wing tip tank was found 150 ft west of the main wreckage. Recorded video showed no evidence of a pre-existing mechanical malfunction that would have precluded normal operation. Figure 3. Accident site (Source: Napa County Sheriff’s Department.) All four corners of the airplane were accounted for at the accident site. The airframe came to rest on a westerly heading with the engine separated from the firewall. The three-bladed propeller, its spinner, and its hub separated from the engine crankshaft and were located uphill and adjacent to the engine. Flight control continuity was established from the tail to the cockpit and right wing. Continuity could not be established to the left wing because it was destroyed by impact forces and postaccident fire. Numerous separations were noted within the flight control system with signatures consistent with overload separation or thermal damage. The three propeller blades exhibited s-bending, gouging along the length of the blades, and chordwise scratching. The tips of the propeller blades exhibited gouging, and one blade was missing a portion of its tip. The crankshaft was manually rotated. Compression was obtained in all cylinders. Gear and valve train continuity was established. -
Analysis
The airplane departed with visual meteorological conditions for a daytime cross-country flight. Flight track information showed the airplane descending from 9,000 ft mean sea level (msl) and entering the left downwind leg for runway 16 at the destination airport. The flight track showed a wide left base turn to final that overshot the final approach course. The airplane then reacquired the runway heading and landed. A video recording device was installed on the accident airplane, which captured the entire flight along with audio. The video showed that although the left-seat pilot was controlling the airplane during most of the cross-country portion of the flight, once the flight neared the destination airport the airplane’s throw-over yoke was moved to the right-seat pilot (the pilot), who then controlled the airplane for the rest of the flight. The pilot descended the airplane, and it entered the left downwind leg of the traffic pattern for the runway. The left base turn was then rounded to a turn to the final approach leg. The video shows that the airplane had entered a left bank of about 30°, the airspeed indicator displayed about 150 mph, and the altitude was 3,000 ft msl (1,125 feet above ground level [agl]). Throughout the approach, the pilot manipulated the yoke with both hands and attempted to correct the airplane’s flightpath toward the runway centerline. The pilot appeared to have decreased the power setting significantly as the airplane approached the runway. The video then showed the airplane crossing the runway threshold with the altimeter indicating 1,850 ft msl and the airspeed indicator showing about 100 mph. According to the airplane’s Pilot’s Operating Handbook (POH), the final approach speed should be 81 mph at the airplane’s maximum gross weight. After a hard landing, the airplane entered a series of bounces that were consistent with porpoising. Each bounce led to an increase in the airplane’s pitch angle. The left-seat pilot stated, “go around,” and the pilot applied throttle. The airplane impacted the runway again and entered another bounce. The airspeed indicator showed about 60 mph, and the pilot applied a positive pitch attitude to abort the landing. The airplane pitched nose-up sharply and remained in a nose-high attitude until it impacted a 50-ft-tall tree about 0.5 miles south of the departure end of the runway, where a postcrash fire ensued. One witness on the ramp near the departure end of the airport reported that, after clearing trees in a low spot near the airport, the airplane continued over a vineyard and then began to pitch up, the left wing dropped, and the nose then dropped toward the ground; the witness identified the airplane as having entered a stall. The witness lost sight of the airplane behind a hill but saw smoke shortly afterward. All major structural components of the airplane were located within the debris path. Postaccident examination of the airplane found no evidence of a preexisting mechanical anomaly that would have precluded normal operation. At no point during the go-around did the pilot lower the nose to allow the airplane to accelerate, which caused the airplane to exceed its critical angle of attack during the attempted go around and resulted in an aerodynamic stall at an altitude from which recovery was not possible.
Probable cause
The pilot's exceedance of the airplane’s critical angle of attack during an aborted landing after an unstabilized approach and hard landing, which resulted in an aerodynamic stall and impact with trees and terrain. Contributing to the accident was the pilot’s decision to continue the unstabilized approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
V35
Amateur built
false
Engines
1 Reciprocating
Registration number
N112TW
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-9523
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-26T20:15:01Z guid: 103492 uri: 103492 title: ERA21LA292 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103493/pdf description:
Unique identifier
103493
NTSB case number
ERA21LA292
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-16T13:20:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-08-03T21:16:06.499Z
Event type
Accident
Location
Princeton, Kentucky
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On July 16, 2021, about 1330 eastern daylight time, a Robinson R44, N512RT, was substantially damaged when it was involved in an accident near Princeton, Kentucky. The commercial pilot received serious injuries, and the pilot-rated passenger received minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the pilot, the purpose of the flight was to spray a nearby cornfield. He reported that they were having a problem with the agricultural mapping and navigation system installed in the helicopter, so the passenger, who was also an aerial application pilot, was onboard to assist with the operation of the system. They had flown two loads without incident. The pilot reported that they took off on the third load, and “after about a couple of hundred yards,” the low rotor rpm warning light illuminated. Prior to takeoff, the helicopter was filled with about 50 gallons of spraying solution. They knew it was barely overweight but felt it would be fine. After the accident, the pilot told his wife that “the helicopter just wouldn't fly, and he was getting a low rotor rpm light.” As the pilot maneuvered the helicopter for landing, the left spray boom contacted trees, and the helicopter landed hard, bounced, and rolled onto its left side. The passenger exited the helicopter and assisted the pilot in getting out. According to the pilot’s wife, after the accident, the pilot told her that before takeoff, the helicopter was filled with about 50 gallons of spraying solution. She stated that the pilot told her he “knew it was barely overweight but felt it would be fine.” She further stated that the pilot told her that “the helicopter just wouldn't fly.” Examination of the helicopter by a Federal Aviation Administration inspector revealed substantial damage to the airframe and partial separation of the tail boom. An examination was conducted on the engine and its components. No anomalies were noted during the examination. The maximum gross weight for the helicopter was 2,500 lbs. A weight and balance calculation revealed that the helicopter’s estimated weight at the time of the accident was 2,641.4 lbs. -
Analysis
Before takeoff to spray a nearby cornfield, the helicopter was filled with about 50 gallons of spraying solution and a passenger was onboard to assist the pilot with the navigation system. According to the pilot, shortly after takeoff, the low rotor rpm warning light illuminated, and the helicopter “just wouldn’t fly.” The pilot was unable to stay aloft and made a hard landing in a field. An examination of the helicopter revealed substantial damage to the airframe and partial separation of the tail boom. Examination of the engine and its components revealed no anomalies that would have resulted in a loss of power. The helicopter’s estimated takeoff weight was 2,641.4 lbs., which was 141.4 lbs. over its maximum gross weight of 2,500 lbs. After the accident, the pilot told his spouse that he knew the helicopter was “barely overweight but felt it would be fine.” Given that no mechanical anomalies were found, it is likely that the loss of rotor rpm was the result of operating the helicopter in an overweight condition.
Probable cause
The pilot’s inadequate preflight planning in that he failed to accurately determine the takeoff weight of the helicopter, which resulted in exceeding the helicopter’s maximum weight capability.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N512RT
Operator
Tomkat Aviation LLC
Second pilot present
true
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
11465
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-03T21:16:06Z guid: 103493 uri: 103493 title: CEN21LA323 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103496/pdf description:
Unique identifier
103496
NTSB case number
CEN21LA323
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-16T16:29:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-07-28T18:50:09.162Z
Event type
Accident
Location
Refugio, Texas
Airport
Rooke Field Airport (RFG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
According to the Cessna P210N Pilot Operating Handbook (POH), the airplane’s retractable landing gear is operated by an electrically-driven hydraulic power pack located behind the cockpit control pedestal. Hydraulic pressure is applied to actuator cylinders that extend or retract the landing gear and operate their respective gear down locks. A hydraulic pressure switch regulates electrical power to the pump motor to maintain the specified system pressure. During normal operation, the landing gear is retracted and held in the fully retracted position by hydraulic pressure and, as such, the hydraulic power pack will occasionally cycle on/off during flight to maintain sufficient hydraulic pressure to keep the landing gear retracted. During normal operation, the landing gear is extended into the down and locked position using hydraulic pressure supplied by the hydraulic power pack. Hydraulically actuated down locks are used to keep the main landing gear extended, and a mechanical hook is used to keep the nose gear extended. The electrical portion of the hydraulic power pack is protected by a 30-amp “pull-off” type circuit breaker located in the circuit breaker panel. The POH cautions that if for any reason the hydraulic pump continues to run after a gear cycle completion (up or down), the GEAR PUMP circuit breaker should be pulled out to shut off the hydraulic pump motor and prevent damage to the pump and motor. The hydraulic system fluid level is checked by referencing the dipstick/filler cap on the hydraulic power pack, which is accessed behind a snap-out cover panel on the right side of the control pedestal. The hydraulic fluid level should be checked at 25-hour intervals. In the event the hydraulic power pack is inoperative, or its respective circuit breaker is pulled, the landing gear can be extended using a hand-operated emergency hydraulic pump (if hydraulic system fluid has not been completely lost). The hand pump is located on the cabin floor between the front seats. The position of the landing gear is indicated by two lights (amber and green) located adjacent to the landing gear selector handle in the instrument panel. The amber landing gear position indicator illuminates when the landing gear is fully retracted. The green landing gear position indicator illuminates when the landing gear is fully extended, and their respective down locks are engaged. The green landing gear down and locked indicator light has two “push-to-test” positions: depressed halfway (with throttle retarded and master switch on), the gear warning aural alert will be heard intermittently on the airplane speaker;, depressed fully, the green light should illuminate. The amber landing gear up indicator light has one “push-to-test” function; the amber light should illuminate when fully depressed. Both landing gear position indicator assemblies can be rotated to adjust the lens dimming shutters. An inoperable bulb can be replaced in flight by using the bulb from the remaining landing gear position indicator light. The Cessna P210 series Service Manual states that a low level of hydraulic fluid can result in insufficient hydraulic system pressure and the continuous operation of the hydraulic power pack, which could result in failure of the electric motor and the inability to extend the landing gear using the hydraulic power pack. In the event of a hydraulic power pack failure, the emergency hand pump draws hydraulic fluid at a lower level in the reservoir than the power pack and, as such, the emergency hand pump remains able to extend the landing gear if there is not a total loss of hydraulic fluid in the system. - On July 16, 2021, about 1529 central daylight time, a Cessna P210N, N174R, was substantially damaged when it was involved in an accident near Refugio, Texas. The pilot was not injured and his passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The pilot reported that he departed Mustang Beach Airport (RAS), Port Aransas, Texas, on runway 12 because the winds were about 10 knots from the southeast. After takeoff, he contacted air traffic control (ATC) to obtain his instrument flight rules clearance to Addison Airport (ADS), Addison, Texas. A plot of the airplane’s ground track during the flight is depicted in figure 1. While climbing through 2,000 ft mean sea level (msl), the pilot and his passenger began to smell an odor in the cabin and eventually saw smoke emanate from the center control console. The pilot stated that at that time he did not know the source of the smoke. He subsequently declared an emergency with the air traffic controller and asked to land at the nearest airport. According to ATC documentation, about 1517, the pilot told the air traffic controller that the airplane had a mechanical failure and that he needed to land at the nearest airport. The controller told the pilot the location of Rooke Field Airport (RFG), Refugio, Texas, and cleared him to descend. According to ADS-B track data, at 1518, the airplane entered a descent from 6,500 ft msl. Figure 1 – Airplane ground track for flight About 1519, the pilot told the air traffic controller that he had RFG in sight, and he was subsequently cleared for a visual approach to the airport. The airplane flew westbound past RFG about 4 miles before it made a right turn back toward the airport, as depicted in figure 1. The airplane then entered a short left downwind leg before turning onto final approach for runway 32R at RFG, as shown in figure 2. Figure 2 – Airplane ground track during landing According to the pilot, he was unable to extend the landing gear using the landing gear hydraulic power pack. He concluded that the source of the odor and smoke was likely from a hydraulic power pack motor failure, and he proceeded to extend the landing gear using the emergency landing gear extension procedure. However, after numerous pumps, the green landing gear down and locked position indicator did not illuminate on the instrument panel. The pilot reported that both main landing gear were extended and, as such, he concluded that the nose landing gear was likely not fully extended. He decided to continue with the approach to the runway with the flaps partially extended. At 1528:41, the last ADS-B return was recorded over the displaced threshold for runway 32R at 150 ft msl (96 ft above the threshold elevation). At that time, the airplane’s calibrated airspeed and ground speed were 83 knots, 99 knots, respectively, as depicted in figure 3. The airplane’s vertical speed and flight path angle were -1,013 ft per minute and -6.8°, as depicted in figure 3 and figure 4, respectively. The airplane’s ground track and descent profile were consistent with a landing on runway 32R. The pilot reported that the airplane landed on the runway centerline and that he kept the nose landing gear off the runway as long as possible, but when the nose gear contacted the runway, the airplane veered right and off the runway. The airplane then continued to roll and skid several hundred feet until it nosed over. Figure 3 – Airplane altitude, speed, and vertical speed Figure 4 – Airplane ground track, roll angle, and flight path angle - The nearest aviation weather station was located at Aransas County Airport (RKP), Rockport, Texas, about 19.5 nautical miles southeast of the accident site. At 1453, the surface winds at RKP were 150° at 9 knots with 18 knot gusts. At 1553, the surface winds at RKP were 170° at 8 knots with 15 knot gusts. According to a High-Resolution Rapid Refresh (HRRR) atmosphere model, at 1500, the surface wind at the accident site was 168° at 13 knots. - A Federal Aviation Administration airworthiness inspector conducted an onsite examination of the airplane. Based on wheel marks observed on the runway and grass easement, the airplane veered off the right side of runway 32R about midfield with all three landing gear extended. The airplane continued about 330 ft in the grass easement before the nose landing gear strut and nose wheel separated from the nose gear casting. The airplane continued another 100 ft before it nosed over and came to rest inverted about 44 ft right of the runway edge and about 2,880 ft from the runway 32R displaced threshold. The fuselage, both wings, and empennage were substantially damaged during the accident. There was no evidence of burnt wires or insulation in the airplane cockpit, or electrical arcing or thermal damage to the wiring between the hydraulic power pack and its respective circuit breaker. The 30-amp circuit breaker labeled GEAR PUMP was found tripped/pulled. The green landing gear down and locked position indicator light did not initially illuminate when electric power was turned on. However, the green light illuminated after the bulb assembly was unscrewed and reinstalled. The airplane was recovered to the ramp where it was hoisted by a crane to test the landing gear extension/retraction system. With electrical power turned on and the circuit breaker reset, the hydraulic power pack did not function when the landing gear selector lever was cycled between gear-up and gear-down positions. Examination of the hydraulic power pack fluid reservoir revealed that the fluid level was below the ADD level as indicated by the reservoir dip stick. Further examination of the hydraulic system did not reveal any evidence of a leak. When tested, the landing gear extended into a down and locked position using the emergency landing gear extension hand pump. -
Analysis
The pilot and passenger were conducting a business cross-country flight. During cruise climb, they began to smell an odor in the cabin and eventually saw smoke emanate from the center control console. The pilot declared an emergency with the air traffic controller and asked to land at the nearest airport. While the pilot diverted to the nearest airport, he was unable to extend the landing gear using the landing gear hydraulic power pack. He concluded that the source of the odor and smoke was likely from a hydraulic power pack motor failure and proceeded to extend the landing gear using the emergency landing gear extension procedure. However, after numerous pumps, the green landing gear down and locked position indicator did not illuminate on the instrument panel. The pilot reported that both main landing gear were extended and, as such, he concluded that the nose landing gear was likely not fully extended. The pilot reported that the airplane landed on the runway centerline and that he kept the nose landing gear off the runway as long as possible, but when the nose gear contacted the runway the airplane veered right and off the runway. The airplane then continued to roll and skid several hundred feet until it nosed over. The fuselage, both wings, and empennage were substantially damaged during the accident. Based on wheel marks on the runway and grass easement and the overall distance the airplane traveled during the landing roll before the nose gear separated, it is likely the landing gear were fully extended with their respective down locks engaged during the landing roll. The nose landing gear separation was likely due to excessive forces generated while the airplane continued the landing roll in the grass easement adjacent to the runway. The circuit breaker for the hydraulic power pack was found tripped/pulled. Although the green position indicator light did not initially illuminate when electric power was turned on, it illuminated after the bulb assembly was unscrewed and reinstalled. Examination of the hydraulic power pack fluid reservoir revealed that the fluid level was below the ADD level as indicated by the reservoir dip stick. Further examination of the hydraulic system did not reveal any evidence of a leak. It is likely the electric motor that powered the hydraulic power pack overheated and failed due to its continuous operation while the hydraulic power pack attempted to maintain hydraulic system pressure with a low fluid level. When tested after the accident, the landing gear extended into a down and locked position using the emergency landing gear extension hand pump. Based on available weather data and performance calculations using automatic dependent surveillance-broadcast (ADS-B) track data, the pilot landed with a left quartering tailwind. The calculated tailwind component during landing was at least 12 knots. It is likely the pilot did not maintain directional control of the airplane during the landing roll with a tailwind. Additionally, based on the postaccident examination, although the hydraulic power pack was not working, the landing gear was likely down and locked and, thus, did not contribute to the pilot’s loss of directional control during the landing roll.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with a tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
P210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N174R
Operator
Linco Financial Services
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
P21000095
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-28T18:50:09Z guid: 103496 uri: 103496 title: CEN21LA329 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103512/pdf description:
Unique identifier
103512
NTSB case number
CEN21LA329
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-19T15:10:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-07-20T20:16:09.174Z
Event type
Accident
Location
Amana, Iowa
Airport
AMANA (C11)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 19, 2021, about 1410 central daylight time, a Grumman G-164B agricultural airplane, N8422K, was substantially damaged when it was involved in an accident near Amana, Iowa. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The airplane operator reported that the airplane’s engine lost power shortly after departure from runway 26 at the Amana Airport (C11). The accident takeoff was the 6th takeoff of the day after the engine was started about 0630. Before takeoff, the airplane was loaded with 420 gallons of fungicide and 110 gallons of fuel. The pretakeoff engine indications were normal and the airplane accelerated normally, lifted off at an airspeed of about 65 mph, and then accelerated in ground effect to about 78 mph when the engine lost power. The airplane then settled back into a cornfield about 300 ft from the end of the runway. The airplane nosed over and came to rest inverted and sustained substantial damage to the fuselage and wings. During a postaccident examination, all three propeller blades were bent aft and opposite the direction of rotation. The blades were twisted toward low pitch and chordwise/rotational scoring was visible predominately on the cambered side of the blades. Additionally, the propeller examination found no visible preimpact discrepancies that would have prevented normal propeller operation. The engine was a Honeywell model TPE331-6-252M turbo-propeller engine. It was a single-shaft engine with a two-stage centrifugal compressor, an annular combustion chamber, and a three-stage axial turbine that drives the compressor and the reduction/accessory gearbox. An attempted engine run at the manufacturer’s facility indicated low torque indicative of a discontinuity in the drive system. Subsequent disassembly of the engine confirmed that the aft end of the torsion shaft was found free and resting against the splined end of the main shaft. Further examination of the engine revealed that burnt fibrous material was found throughout the engine. No pre-impact damage was found in the engine that would have precluded normal operation. The propeller governor and fuel control unit were tested at the manufacturer’s facility. Except for slight deviations attributed to possible field adjustments, both the governor and fuel control unit operated within the manufacturer’s specifications. No anomalies were detected that would have prevented normal operation. -
Analysis
The pilot of the agricultural airplane reported that the airplane’s engine lost power shortly after takeoff. The airplane settled into the corn field off the departure end of the runway and nosed over. The airplane sustained substantial damage to its left wing and fuselage. All three propeller blades exhibited aft bending, bending opposite rotation, twisting toward low pitch and chordwise/rotational scoring predominately on the camber side which was consistent with impact at low power. Examination of the engine revealed a discontinuity in the drive system consisting of a broken torsion shaft. The broken torsion shaft is indicative of the engine operating at the time of impact. Examination of the fuel control unit and the propeller governor did not reveal any anomalies. No anomalies were found with respect to the engine, propeller, fuel control unit, or propeller governor that would explain the reported loss of engine power. Based on the results of testing and examination, the reason for the reported loss of engine power could not be determined.
Probable cause
The loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N8422K
Operator
THOMPSON AERO INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
80B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-20T20:16:09Z guid: 103512 uri: 103512 title: CEN21FA330 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103513/pdf description:
Unique identifier
103513
NTSB case number
CEN21FA330
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-19T17:00:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-07-26T16:57:17.06Z
Event type
Accident
Location
Elgin, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the Robinson R44 II Pilot Operating Handbook, the helicopter’s height was 10.75 ft. The operator stated that, during aerial application flights, the helicopter was typically flown 10 ft above the crop to ensure optimal spray disbursement. Postaccident review of available maintenance documentation revealed no unresolved maintenance tasks or issues with the helicopter. - On July 19, 2021, about 1600 central daylight time, a Robinson R44 II helicopter, N44BJ, was destroyed when it was involved in an accident near Elgin, Minnesota. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. A witness saw the helicopter completing east and west spray passes over a cornfield, with each additional spray pass progressively closer to the north end of the field. The witness saw the helicopter make two consecutive spray passes over powerlines that crossed the field, but, during the third spray pass, the helicopter flew underneath the powerlines while heading west. The witness then entered a nearby pole barn and, shortly thereafter, heard a loud “boom,” and the pole barn shook momentarily. He exited the pole barn and saw smoke rising from the cornfield. The witness and another person subsequently responded to the accident site where they found the helicopter engulfed in flames. - The Mayo Clinic, Rochester, Minnesota, performed an autopsy of the pilot. His cause of death was blunt force and thermal injuries. Toxicology testing by the FAA Forensic Sciences Laboratory detected no carboxyhemoglobin, ethanol, or tested-for drugs. - At the time of the accident, the sun’s position relative to the accident site was along a west-southwest heading (249° true) and was about 48.6° above the horizon. - The Federal Aviation Administration (FAA) revoked the pilot’s second-class medical certificate in a letter dated February 22, 2021. The pilot had been seriously injured in a forced landing accident that occurred about 11 months before this accident. The FAA sent a letter to the pilot, dated August 10, 2020, requesting a medical examination to determine if he remained qualified to hold a second-class medical certificate, but the pilot did not undergo the requested evaluation. On May 17, 2021, the pilot completed an application for a new medical certificate. On his last medical certificate application, the pilot reported 4,000 hours of total flight experience, 1,100 hours of which were flown during the previous 6 months. In addition, the pilot answered “no” when asked if his medical certificate had ever been revoked. The aviation medical examiner requested that the pilot provide information about the previous helicopter accident, but the pilot had not provided the requested records before this accident occurred. The pilot’s logbook contained only a single logbook endorsement for the required training, which was required by Special Federal Aviation Regulation 73 to act as pilotincommand of a Robinson R44 helicopter. The date of the endorsement was not provided. - The initial impact location was a multiphase power transmission line, as shown in figure 1. The transmission line consisted of 24 aluminum-conducting strands over 7 steel strands, and three lines were present. The western line remained intact, the center line was frayed, and the eastern line was severed. The frayed transmission line at the point of damage was about 28 ft above the ground. The corn crop under the transmission lines was 8 to 10 ft tall. Portions of the swashplate yoke, a blade droop tusk, the pilot’s headset, and plexiglass fragments were located under and immediately east of the power transmission lines. Figure 1. Powerlines above the cornfield with a red rectangle identifying the center powerline (main photograph) and an inset showing the frayed center powerline. The wreckage debris path, as shown in figure 2, measured 292 ft between the power transmission lines and the main wreckage. The wreckage debris path through the cornfield was on a 090° heading. The helicopter impacted terrain in a 15° descent angle. Fractured portions of the spray booms, cabin door, and plexiglass were scattered along the wreckage debris path. Figure 2. Wreckage debris path with the red circle showing the location of the wire strike. The main wreckage, as shown in figure 3, included remnants of the cabin, landing skids, cockpit, engine, main rotor transmission, main rotor head, main rotor blades, aft fuselage, sheaves, tail rotor driveshaft, tailboom, tail rotor gear box, and tail rotor blades. The product tank was relatively intact, and its support frame was located about 15 ft north of the main wreckage. Most of the cabin and cockpit were destroyed by the postimpact fire. Flight control continuity could not be established due to the extensive damage sustained during the impact and postimpact fire. Figure 3. Main wreckage at the accident site. One of the two main rotor blades remained intact but folded in half during impact. The other main rotor blade fractured about 3 ft from the blade tip and exhibited damage consistent with impact with a power transmission line, as shown in figure 4. The outboard 3 ft of the main rotor blade, as shown in figure 5, was located about 465 ft south of where the helicopter impacted the power transmission line. Figure 4. Main rotor blade fracture with damaged power transmission line. Figure 5. Outboard 3 ft of main rotor blade (Source: Helicopter operator). Postaccident examination revealed no evidence of a pre-existing mechanical malfunction or failure that would have prevented normal operation of the helicopter. -
Analysis
The pilot was conducting an aerial application flight in the helicopter. Just before the accident, a witness saw the helicopter completing east and west spray passes over a cornfield. The helicopter flew two consecutive spray passes over power transmission lines that crossed the field, but, on the third spray pass, the helicopter flew underneath the powerlines while heading west. The witness then entered a nearby barn and, shortly thereafter, heard a loud “boom,” and the barn shook momentarily. The witness exited the barn and saw smoke rising from the cornfield. The witness and another person subsequently found the helicopter engulfed in flames. According to the wreckage debris path through the cornfield, the helicopter was flying to the east when a main rotor blade impacted a powerline that crossed over the field. The powerline at the point of damage was about 28 ft above the ground. The corn crop under the transmission lines was 8 to 10 ft tall. The operator stated that, during aerial application flights, the helicopter was typically flown 10 ft above the crop to ensure optimal spray disbursement. If the 10.75 ft tall helicopter flew 10 ft above the 8 ft high corn crop, then the main rotor system would be at the same elevation as the transmission line. The position of the sun relative to the helicopter at the time of the accident would likely not have impaired the pilot’s ability to see the powerlines as the helicopter flew to the east. Postaccident examination revealed no evidence of a pre-existing mechanical malfunction or failure that would have prevented normal operation of the helicopter. Thus, it is likely that the pilot decided to intentionally fly the helicopter under the powerlines.
Probable cause
The pilot’s decision to operate the helicopter under powerlines, which resulted in a main rotor blade striking a powerline, causing the helicopter to descend from a low altitude and impact terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N44BJ
Operator
Skyhawk Aviation
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
11795
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-26T16:57:17Z guid: 103513 uri: 103513 title: ERA21LA295 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103522/pdf description:
Unique identifier
103522
NTSB case number
ERA21LA295
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-19T19:48:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-07-23T18:52:17.623Z
Event type
Accident
Location
Point Harbor, North Carolina
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On July 19, 2021, about 1848 eastern daylight time, a Robinson Helicopter Company R44 II, N4529J, was destroyed when it impacted the Albemarle Sound near Point Harbor, North Carolina. The non-certificated pilot and passenger were fatally injured. The helicopter was operated by the pilot as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Review of surveillance video at the Mecklenburg-Brunswick Regional Airport (AVC), South Hill, Virginia, showed that the helicopter landed near the fueling station about 1710. The pilot and passenger (who was the pilot’s brother) conducted refueling activities together. A fuel receipt showed about 32 gallons of 100-low lead were added. At 1722 the pilot and passenger boarded the helicopter, a hover taxi was initiated to runway 19, and the helicopter departed southbound from runway 19 at 1726. Review of Federal Aviation Administration (FAA) automatic dependent surveillance- broadcast (ADS-B) data found that data was received for the first 2 minutes of the flight. The flight track headed southbound from runway 19, and then about 1.5 miles south of AVC, the flight track turned southeast and ended at 1728:52. No further radar or track data was located for the remainder of the flight. A friend of the pilot reported that he received a FaceTime video call from the pilot shortly after the takeoff from AVC. The pilot told him he had just refueled and they would arrive at Manteo Airport [Dare County Regional Airport (MQI), Manteo, North Carolina] in 1 hour. The friend reported that everything seemed normal, and the pilot did not mention anything about weather conditions or the helicopter. According to a witness located on the northwest side of the Albemarle Sound in Hertford, North Carolina, about 1830 she and her husband heard the sound of a low flying small helicopter. She observed a blue helicopter land in an open field that was about ½ mile from the shoreline. The witness reported that she and her husband got in their car to see if any assistance was needed; however, when they were about 50 ft from the helicopter it took off. She reported that the takeoff was quick, it sounded like a normal helicopter, and it flew toward the Albemarle Sound in a southeast direction where it eventually exited out of view over the water. She added that the weather conditions over the water were low overcast clouds, it was misty, and you could not see the land across the Sound, which was something you could see on a nice day. According to the United States Coast Guard incident commander, about 1940 they were notified of an overdue helicopter destined for MQI. A search was initiated over the Albemarle Sound based upon the last known position of cell phone data from pilot and passenger. The day after the accident, fragments of the helicopter were located floating on the surface of the Sound near 36.029491°, -75.991991° which was consistent with the general area of the cell phone position data. The pilot and passenger were found the next day and had sustained fatal injuries. Figure 1 shows the cell phone position data from 1816 to the final reported position at 1848. In addition, the figure shows the location of the off airport landing, the general debris area, and unidentified primary radar targets recorded around the presumed accident time. It is not known which radar targets may have belonged to the helicopter. Figure 1: Overview of the cell phone location data, last known takeoff position, general debris area, and planned route of flight. A limited number of small fragments of the helicopter were recovered. The pieces included seat cushions and fragments of the airframe in the area of the fuel tank. The debris displayed evidence of significant tearing and crushing. The limited amount of wreckage found precluded examining the helicopter for any evidence of preimpact mechanical malfunctions or failures. An NTSB weather study found that weather radar and satellite imagery about the time of the accident over the debris area revealed areas of widespread light to heavy precipitation and areas of low clouds and visibility. According to Leidos Flight Service and ForeFlight, there was no record that the pilot requested an online weather briefing or called flight service. Thunderstorms and instrument flight rules conditions were forecasted for the accident area at the time of the accident. Figure 2 shows radar imagery about the time of the accident over the debris area. Figure 2: Radar reflectivity at 1848 and the accident area as denoted by the purple circle. Review of FAA airman certification records found that the pilot did not hold a student pilot certificate nor any medical certificate. Records showed that the pilot applied for a third class medical on January 29, 2021; however, the issuance decision was differed by the Aviation Medical Examiner due to the number of driving under the influence (DUI) infractions. According to the flight instructor, the accident pilot began flight training with him in February 2021, 1 month after the accident pilot purchased the helicopter. The pilot based the helicopter at William M. Tuck Airport (W78), South Boston, Virginia. The flight instructor estimated that he provided about 20 hours of dual flight instruction to the pilot. The flight instructor reported that the pilot had received instruction from another flight instructor within his first 20 hours of training. In early May 2021, the flight instructor signed the student off for supervised and local solo flight and the instructor estimated that he completed about 6 hours of solo flight under his supervision. The flight instructor said that during their course of training the accident pilot “implied” to him that he possessed a medical certificate; however, he never saw a copy of the medical certificate or a student pilot certificate. The pilot’s logbooks were not recovered. On June 30, 2021, the accident pilot informed the flight instructor that he had relocated the helicopter’s base from W78 to his private residence in Glade Hill, Virginia, despite not having the proper endorsements or authorization from the flight instructor. The last dual flight training conducted was on May 28, 2021. The flight instructor provided copies of text messages between he and the accident pilot from the afternoon of the accident. The pilot informed the flight instructor that he was going to fly through W78 for a fuel stop, and then down to “OBX for a fishing trip.” The flight instructor responded in part that fuel service was not operable at W78, and the pilot responded that he might try AVC instead. The flight instructor reported that the accident pilot did not hold endorsements for any cross-country flights, and they had performed limited cross-country training. The flight instructor reported that it was his impression that the accident pilot “knew what the rules were” and further stated that “some people don’t always play by the rules.” A friend of the pilot reported that about 1 month before the accident, the accident pilot shared with him that he was now “good to go on his own” but said that he needed more hours to get his “actual license.” The pilot informed him that he could not fly passengers for hire. The friend reported that he was unsure of whether the pilot understood that he could not fly passengers under any circumstances. The East Carolina University Brody School of Medicine, Department of Pathology and Laboratory Medicine, Division of Forensic Pathology performed the pilot’s autopsy, at the request of the North Carolina Office of the Chief Medical Examiner. According to the autopsy report, the cause of death was multiple traumatic injuries. No thermal injury or airway soot was described. Changes associated with prolonged water immersion were noted. The autopsy did not identify significant natural disease. The North Carolina Office of the Chief Medical Examiner performed toxicological testing of postmortem specimens from the pilot. This testing detected ethanol at 0.08 g/dL in cavity blood. The testing did not include measurement of carboxyhemoglobin. The FAA Forensic Sciences Laboratory also tested postmortem specimens from the pilot. Ethanol was detected at 0.093 g/dL in cavity blood, 0.097 g/dL in muscle, and 0.148 g/dL in brain. N-propanol was detected in cavity blood, muscle, and brain. N-butanol was detected in brain. The carboxyhemoglobin level in cavity blood was measured to be elevated at 19%. Of note, no specimen was available for carboxyhemoglobin testing of the passenger in this accident. According to the Pilot’s Operating Handbook, visual flight rules (VFR) day and night operations were approved; however, flight into instrument meteorological conditions (IMC) was not. According to 14 CFR § 61.23 and 61.87, a student pilot certificate and at least a 3rd class medical certificate were one of multiple requirements to solo the helicopter. Carrying passengers was also prohibited. -
Analysis
The noncertificated pilot, who was the owner of the helicopter, originated the afternoon flight from a private residence, completed a brief fuel stop at an uncontrolled airport, and then continued toward the destination. Shortly after takeoff following the fuel stop, the pilot called a friend near the destination via video chat and informed him that he would arrive in an hour. The friend reported that everything seemed normal with the pilot, and he did not mention any concerns pertaining to the weather or helicopter. About an hour later, 27 miles northwest of the destination, a witness saw the helicopter land in a field. The helicopter remained on the ground for a few minutes and when the witness approached the helicopter in their car, the helicopter quickly took off toward a large body of water and continued a flight path that was consistent with a direction to the planned destination. About an hour after the helicopter was last seen by this witness, family members alerted the United States Coast Guard (USCG) that the helicopter had not arrived at the destination. The USCG conducted a search for the helicopter based upon cellphone location data and the next day small fragments of wreckage were located on the surface of the large body of water. The pilot and passenger were also recovered, and both had sustained fatal injuries. The small fragments of wreckage located were consistent with an impact at high velocity. Based upon planned route of flight data collected from a flight planning application, cellphone location data, and the debris area, it is likely that after the brief off-airport landing, the pilot continued the flight toward the destination. A witness described conditions at the time as low clouds, misty, with restricted visibility across the water. An NTSB weather study found that near the location of where debris was found, about the presumed time of the accident, widespread light to heavy precipitation, low clouds, and reduced visibility were present. There was no record that the pilot received an online or telephone weather briefing. Had the pilot received a weather briefing, forecasts would have alerted him of possible instrument meteorological conditions (IMC) and precipitation along his route. Given that the pilot informed his friend shortly after takeoff that he would arrive in 1 hour, and made no mention of the weather, it is likely that he was not aware of the IMC and precipitation. It is likely that the pilot performed an unplanned off-airport landing due to the weather conditions ahead, and instead of terminating the flight, he chose to continue in what had become IMC. The pilot’s attempted flight under visual flight rules in those conditions would have increased his likelihood of losing control of the helicopter due to spatial disorientation with no clear separation between the water surface and low clouds and obscuration of the horizon. The pilot was not qualified to operate the helicopter in IMC, the helicopter was not approved for flight into IMC, and in addition, he possessed limited training to operate the helicopter in general. These findings make a mechanical problem with the helicopter an unlikely factor in the accident, however, the limited amount of wreckage found precluded the investigation from examining the helicopter for any evidence of preimpact mechanical malfunctions or failures. The pilot’s flight instructor was aware of the accident cross-country flight; however, the pilot was not issued any of the required endorsements or prerequisite training to conduct the flight. The flight instructor reported that this was not the first flight the pilot conducted in which he was not properly endorsed or authorized for. The investigation was unable to determine if the pilot understood that he was not legally authorized to conduct solo cross-country flights or carry passengers. The flight instructor had authorized the pilot to perform solo flights, despite the student not holding the required student pilot and medical certificate. This deviation from regulations by the flight instructor likely contributed to the pilot’s subsequent deviations from regulations and his decision to conduct the accident flight despite not being properly trained or endorsed for the accident flight. Based on the pilot’s toxicology results, at least some of the detected ethanol was likely from sources other than consumption. Whether ethanol effects contributed to the accident cannot be determined from available evidence. Based on available medical and operational evidence, postmortem carbon monoxide production during prolonged water immersion likely increased the carboxyhemoglobin level in the pilot’s cavity blood after his death. It is unlikely that carbon monoxide effects contributed to the accident.
Probable cause
The noncertificated pilot’s decision to continue visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation over a large body of water and a high velocity impact with the water. Contributing to the accident was the flight instructor’s inadequate oversight during their initial training and improperly signing off the student for solo flight when he lacked the proper student pilot and medical certificate.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N4529J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12683
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-07-23T18:52:17Z guid: 103522 uri: 103522 title: ERA21LA298 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103546/pdf description:
Unique identifier
103546
NTSB case number
ERA21LA298
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-21T17:44:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-08-05T16:50:22.759Z
Event type
Accident
Location
Rockwell, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 21, 2021, at 1644 eastern daylight time, an experimental, amateur-built STOL CH 750, N750RS was substantially damaged when it was involved in an accident near Rockwell, North Carolina. The private pilot was not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. About 30 minutes into the flight the engine “burped” and then progressively lost power as it ran more roughly, and the airplane descended. The pilot switched fuel tanks but described no other remedial actions before the engine lost all power. The pilot selected an open field adjacent to roadway for the forced landing. According to the pilot the airplane was in the landing flare, about 5 ft above the ground, when the “airplane stalled and dropped out from under me.” The airplane eventually nosed over and came to rest inverted. Examination of photographs revealed damage to the wings and fuselage and substantial damage to the rudder/vertical stabilizer. One of three propeller blades was fractured at its root. The responding police officer released the airplane to the owner, who removed the wings, drained the fuel from the wings, and hired a local wrecking service to recover the airplane from the scene. An aircraft recovery service then recovered the airplane to their facility. Once there, recovery personnel drained about 1/2 pint of automotive gasoline from the gascolator. They replaced the propeller, cleared the intake of sod from the accident site, plumbed a fuel can of aviation gasoline into the fuel supply line at the left-wing root, and attempted an engine start. The engine started immediately, accelerated smoothly, and ran continuously without interruption through several power changes. Both a magneto and carburetor heat check were performed satisfactorily. Atmospheric conditions at the time of the accident were conducive to “serious icing at glide power.” Federal Aviation Administration (FAA) Technical Center testing indicated that carburetor icing will occur in less time and at higher ambient temperatures with automotive gasoline than with aviation gasoline. The pilot reported to the FAA inspector that he did not apply carburetor heat during the accident flight. -
Analysis
About 30 minutes into the flight the engine “burped” then progressively lost power. The pilot switched fuel tanks but described no other remedial actions before the engine lost all power. The pilot selected an open field adjacent to a roadway for a forced landing where the airplane nosed over and came to rest inverted, sustaining substantial damage. Atmospheric conditions at the time of the accident were conducive to carburetor icing, and the airplane was fueled with automotive gasoline, which increased its likelihood. After the accident, a fuel can of aviation gasoline was plumbed into the fuel supply line at the left-wing root, and an engine start was attempted. The engine started immediately, accelerated smoothly, and ran continuously without interruption through several power changes. Both a magneto and carburetor heat check were performed satisfactorily. The pilot reported that he did not apply carburetor heat during the accident flight.
Probable cause
The total loss of engine power due to carburetor ice. Also causal was the pilot’s failure to apply carburetor heat at any time during the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CARPENTER
Model
STOL CH750
Amateur built
true
Engines
1 Reciprocating
Registration number
N750RS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-8221
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-05T16:50:22Z guid: 103546 uri: 103546 title: ERA21LA297 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103540/pdf description:
Unique identifier
103540
NTSB case number
ERA21LA297
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-23T19:30:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-07-28T19:09:24.819Z
Event type
Accident
Location
Arden, North Carolina
Airport
ASHEVILLE RGNL (AVL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 23, 2021, about 1830 eastern daylight time, a Cessna 150F, N3059X, was substantially damaged when it was involved in an accident near Arden, North Carolina. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed Asheville Regional Airport (AVL), Asheville, North Carolina, and was climbing through 5,100 feet mean sea level when the engine “went to idle.” The pilot attempted to adjust the throttle setting; however, the tachometer continued to indicate 740 rpm. The pilot established best glide speed, declared an emergency, and turned back toward AVL. When he determined that he could not reach the airport, he performed a forced landing into a coal ash pit; during the landing roll, the airplane nosed over. Examination of the accident site by a Federal Aviation Administration inspector revealed substantial damage to the airplane’s left wing, rudder, and fuselage. The engine throttle cable was separated from the carburetor throttle control lever. The securing hardware (bolt/washer/cotter pin) was not found and there was no evidence of impact damage to the lever or carburetor. Examination of the carburetor after the airplane was recovered revealed that the throttle control lever was in the full forward (or wide-open) position, which matched the position of the cockpit control. The throttle control cable was separated from the intact throttle control lever. Further examination of the throttle control lever revealed that there was no spring installed. Review of maintenance records and the tachometer revealed that the accident occurred 15 hours after the airplane’s most recent annual inspection. -
Analysis
The student pilot was climbing through 5,100 feet mean sea level when the engine “went to idle.” He attempted to adjust the throttle setting; however, the tachometer continued to indicate 740 rpm. The pilot established best glide speed, declared an emergency, and performed a forced landing into a coal ash pit, during which the airplane nosed over, resulting in substantial damage. Examination of the engine revealed that the throttle control cable had separated from the throttle control lever and there was no spring installed. The securing hardware (bolt/washer/cotter pin) was not found. It is likely that the absence of the cotter pin was not noted during the annual inspection 15 hours before the accident, which allowed the bolt holding the throttle cable to the throttle control lever to loosen and depart during flight, resulting in an engine power reduction to idle.
Probable cause
The inadequate inspection of the throttle control cable assembly, which resulted in a partial loss of engine power during cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N3059X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15064459
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-28T19:09:24Z guid: 103540 uri: 103540 title: CEN21FA334 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103535/pdf description:
Unique identifier
103535
NTSB case number
CEN21FA334
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-25T08:45:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-08-02T18:55:32.117Z
Event type
Accident
Location
Benoit, Mississippi
Airport
Private Grass Airstrip (None)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the AT-802/802A takeoff ground roll distance chart, the airplane’s total ground roll distance with a weight of 13,630 pounds, a field elevation of 128 ft above ground level, and a temperature of 27°C would have been 2,050 ft on a paved runway. According to the airframe manufacturer, for a takeoff on a turf, a runway factor of 1.2 [based on Federal Aviation Administration (FAA) Advisory Circular 23-8C, paragraph 23.45(c)] is added to the calculation. Thus, the accident airplane’s takeoff ground roll distance would have been 2,460 ft. - On July 25, 2021, about 0745 central daylight time, an Air Tractor 802 airplane, N363BG, was substantially damaged when it was involved in an accident near Benoit, Mississippi. The commercial pilot sustained fatal injuries. The airplane was operated under Title 14 Code of Federal Regulations Part 137 as an aerial application flight. The intent of the flight was to apply product to a bean field located about 3.5 miles southwest of Benoit, Mississippi. According to the operator, the airplane had 225 gallons of Jet A fuel and 635 gallons of product before takeoff. The airplane was operating from a private grass strip that was 2,164 ft long and 100 ft wide that was oriented on a magnetic heading of about 230°. Witnesses stated that they observed a normal takeoff roll but that, at the departure end of the runway, the airplane struck an embankment, nosed over, and came to rest inverted in the field. - The Bolivar County, Mississippi, Medical Examiner performed an autopsy of the pilot. His cause of death was multiple traumatic head and neck injuries. The autopsy identified no significant natural disease. Toxicology testing by the FAA Forensic Sciences Laboratory detected .189 g/dL of ethanol in blood specimens, .252 g/dL of ethanol in vitreous fluid specimens, and .141 g/dL of ethanol in urine specimens. Ethanol is a type of alcohol that, if consumed in beer, wine, and liquor, can impair judgment, psychomotor performance, cognition, and vigilance. Ethanol, even in small amounts, can impair performance, and the number and severity of pilot errors tend to increase with increased blood ethanol levels. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting the piloting of civil aircraft with a blood ethanol level of 0.04 g/dL or greater. The following prescription medications were also found in the pilot’s heart and urine specimens: gabapentin, doxepin (and its metabolite nordoxepin), rosuvastatin, triamterene, amlodipine, fexofenadine (and its metabolite azacyclonol), and carvedilol. The nonprescription medications acetaminophen and ibuprofen were also detected. Gabapentin is used to treat nerve pain and certain types of seizures. Gabapentin can cause sedation and dizziness and can impair coordination and performance of tasks such as driving and operating heavy machinery. Gabapentin typically carries a warning that the drug may interact with alcohol or other sedating medications to worsen sleepiness and dizziness. Doxepin is an antidepressant medication that can have sedating effects and cause psychomotor impairment. Doxepin typically carries a warning that effects of alcohol or other sedating medications may be heightened by the drug. The FAA considers both gabapentin and doxepin to be “Do Not Issue/Do Not Fly” medications. Regular use of either drug for any reason is disqualifying for pilot medical certification. - The pilot’s last aviation medical examination was on December 18, 2020. At that time, he reported no medication use and no active medical conditions. He was issued a second-class medical certificate limited by a requirement to wear lenses for distant vision and have glasses for near vision. - The airplane was located in a soybean field southwest of the airstrip. The airplane came to rest inverted on its nose, cockpit, vertical stabilizer, and rudder. The airplane’s forward fuselage, cowling, and firewall were crushed aft and bent upward. The forward cockpit was crushed inward and aft. The windscreen and cockpit windows were broken and fragmented. The tops of the vertical stabilizer and rudder were bent and broken aft. The left wing was crushed aft from the tip inboard about 5 ft. The engine and propeller were separated from the airplane and came to rest along a 150ft path from the initial impact point to the location where the airplane’s main wreckage came to rest. The engine was broken into two sections, the reduction gearbox/exhaust section and the engine power module. The upstream side of the firststage power turbine vane baffle exhibited circumferential rubbing and deformation. The downstream side of the secondstage power turbine vane ring showed circumferential rubbing on the outer shroud. The secondstage power turbine disk showed that one-fourth of the blades separated just above the blade platform. The remaining blades were fractured in the airfoil at roughly the same height. The propeller was fractured at the flange. All five propeller blades showed bending and twisting toward high pitch. Two of the blades showed S-bending. Four of the five blades showed chordwise rotational abrasions on the back of the blades. No preaccident mechanical failures or malfunctions were found that would have precluded normal operation of the airplane. -
Analysis
The agricultural airplane was operating from a private grass airstrip that was 2,164 ft long and 100 ft wide. The airplane had just been fueled with 225 gallons of fuel and loaded with 635 gallons of chemicals before takeoff. Witnesses stated that the takeoff roll was normal but that, at the departure end of the runway, the airplane struck an embankment, nosed over, and came to rest inverted in a field. The airplane sustained substantial damaged to both wings, the empennage, and fuselage. A postaccident examination of the airplane showed no preaccident mechanical failures or malfunctions that would have precluded normal operation. Based on the airplane’s weight, the field elevation, the field type (turf), and the weather conditions at the time of the accident, the airplane’s planned takeoff ground roll would have been about 2,460 ft, which exceeded the length of the airstrip. Neither witness reported observations consistent with the pilot attempting to abort the takeoff. Thus, the pilot exceeded the airplane’s performance limitations during the takeoff. Toxicology testing detected ethanol at .189 g/dL in the pilot’s blood, .252 g/dL in his vitreous fluid, and .141 g/dL in his urine. Based on available medical evidence, it is likely that the pilot had consumed ethanol. The extent to which measured ethanol levels were affected by postmortem ethanol production is unknown, preventing reliable estimation of the pilot’s blood ethanol level at the time of the crash. Toxicology testing also found gabapentin and doxepin in the pilot’s specimens, both of which can cause impairment, especially when combined with ethanol. The evidence was not sufficient to determine whether doxepin was exerting some effects during the accident flight. However, given the concentration of gabapentin in the pilot’s blood and urine specimens, gabapentin was likely exerting some performanceimpairing effects, such as sedation and dizziness, which would have been more likely to occur in the presence of ethanol. Thus, the pilot was most likely impaired by the effects of the combined substances in his system.
Probable cause
The pilot’s exceedance of the airplane’s takeoff performance capabilities and his failure to abort the takeoff in a timely manner. Contributing to the accident was the pilot’s impairment due to his use of ethanol and prohibited medications.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-802
Amateur built
false
Engines
1 Turbo prop
Registration number
N363BG
Operator
OLD RIVER FLYING SERVICE LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
802-0478
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-02T18:55:32Z guid: 103535 uri: 103535 title: ERA21LA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103553/pdf description:
Unique identifier
103553
NTSB case number
ERA21LA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-26T10:00:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-07-27T16:56:22.541Z
Event type
Accident
Location
Murfreesboro, Tennessee
Airport
MURFREESBORO MUNI (MBT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 26, 2021, about 0900 central daylight time, a Cessna 140, N72129, was substantially damaged when it was involved in an accident near Murfreesboro Municipal Airport (MBT), Murfreesboro, Tennessee. The airline transport pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot completed a preflight inspection with no anomalies noted, and reported that the airplane contained about 14 gallons of fuel. After flying for about half an hour, the pilot entered the MBT traffic pattern. During the initial climb after the second touch-and-go landing, about 100 ft above ground level, the engine “sputtered,” lost total power, and the propeller continued to windmill. The pilot performed a forced landing onto a road, during which the airplane struck a wire, pitched downward, and impacted the road. The airplane slid about 300 ft and came to rest upright, resulting in substantial damage to the fuselage and wing struts. The pilot reported that during landing, he typically had the carburetor heat ON until the airplane was on short final. Then, he would turn the carburetor heat OFF and perform the landing. He stated that he had a “similar” situation occur previously, during which the engine lost total power during an idle check while on the ground. After the power loss, he was able to restart the engine, and subsequently had the engine examined with no anomalies noted. Since that issue could not be duplicated, he “concluded it was carb[uretor] icing.” An examination of the engine was performed by a mechanic under the supervision of an Federal Aviation Administration (FAA) inspector. There were no mechanical malfunctions or failures found that would have precluded normal engine operation. The reported weather about the time of the accident included a temperature of 27°C and a dew point of 23°C. The calculated relative humidity was 80 percent. Review of the carburetor icing probability chart contained within FAA Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." -
Analysis
After flying for about 30 minutes, the pilot entered the airport traffic pattern and performed touch-and-go takeoffs and landings. On the initial climb after the second touch-and-go, about 100 ft above ground level, the engine “sputtered,” lost total power, and the propeller continued to windmill. The pilot performed a forced landing to a nearby road, during which the airplane struck a wire, pitched downward, and impacted the road, resulting in substantial damage to the fuselage and wing struts. Examination of the engine revealed no malfunctions or failures that would have precluded normal operation. The pilot reported that he typically conducted the approach to landing with the carburetor heat on until the airplane was on short final, then he would turn it off. He also described a previous situation during which the engine had lost total power in a similar way while on the ground. After the engine was examined following that event, the pilot concluded that the loss of power was a result of carburetor icing. The temperature and dew point on the day of the accident were favorable to the development of serious carburetor icing at a glide power setting. Given the pilot’s previous experience with the engine’s susceptibility to carburetor icing, the absence of mechanical anomalies found with the engine, and the pilot’s routine practice of turning the carburetor heat off before landing, it is likely that the loss of engine power was the result of carburetor icing.
Probable cause
A total loss of engine power as a result of carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N72129
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
9296
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-27T16:56:22Z guid: 103553 uri: 103553 title: WPR21FA286 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103554/pdf description:
Unique identifier
103554
NTSB case number
WPR21FA286
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-26T14:18:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2021-08-12T19:24:03.886Z
Event type
Accident
Location
Truckee, California
Airport
TRUCKEE-TAHOE (TRK)
Weather conditions
Visual Meteorological Conditions
Injuries
6 fatal, 0 serious, 0 minor
Factual narrative
NTSB Safety Alert SA-084, Circling Approaches: Know the Risks, cautions that circling approaches can be riskier than other types of approaches. Specifically, circling approaches often require maneuvering at low altitude and low airspeed during the final segment of the approach, increasing the opportunity for loss of control or collision with terrain. These risks are heightened when conducting circling approaches in marginal or reduced visibility conditions. - Flight Management System The airplane was equipped with a triple FMS, including three control display units in the cockpit, and three flight management computer (FMC) units in the underfloor avionics equipment bay. The flight crew used the control display units to input, modify, and execute flight plans; calculate airplane performance; and determine the airplane’s approach speeds (including Vref), maximum landing weight, and landing field length. The year before the accident, a maintenance facility serviced the airplane’s FMC units to comply with a scheduled battery replacement. Servicing the FMC units involved removing the FMCs from the aircraft, sending them to a third-party repair facility, and subsequently reinstalling them in the aircraft. Bombardier’s (the airplane manufacturer’s) maintenance manual instructed owners to “make sure that the default values and BOW value are appropriate for the aircraft” after reinstalling the FMC. According to the maintenance facility, it reinstalled the FMCs and the required databases, which included the approach speeds and performance databases, but did not input the BOW specific to the accident airplane. During subsequent testing, the manufacturer of the FMS confirmed that the BOW defaults to 24,000 lbs after battery replacement and reinstallation of the databases. The FMC manufacturer also confirmed that the installation of the databases did not prompt the user to enter a BOW. Flight Spoilers The airplane was equipped with flight spoilers that provided lift dumping and speed control while airborne. A flight spoiler control lever on the center pedestal allows the pilot to select variable amounts of flight spoiler deployment up to a maximum of 40°. An amber caution message is posted on the engine indicating and crew alerting system if the flight spoilers are deployed in flight and another condition is met, such as an altitude between 10 and 300 ft above ground level (agl); the left or right N1 is greater than 79%; or, if radio altitude is not available, any time the landing gear is extended. Stall Protection System According to a technical memorandum prepared by Bombardier, the natural stall characteristics of its Challenger 600 series airplanes (including the Challenger 605) include an abrupt load factor reduction and uncontrollable roll at the instant of stall with no pre-stall warning. The memorandum notes that these natural stall characteristics are not certifiable to 14 CFR Part 25 Transport Category Airworthiness standards. Consequently, Challenger airplanes incorporate an SPS that provides certifiable stall characteristics (most critically, a stall warning and pitch down at the point of stall) by mechanical means. To provide a stall warning, which is absent in the natural stall, Challenger control columns have stick shakers that engage when the airplane AOA increases above a predefined threshold (the shaker firing angle). To obtain certifiable stall characteristics if the AOA increases further, a stick pusher device abruptly commands full nose-down elevator once the AOA crosses a second higher threshold (the pusher firing angle). This nose-down elevator produces a nose- down pitching moment and pitch response similar to the pitch response associated with certifiable natural stall characteristics. The nose-down motion reduces the AOA and wing lift. The pusher firing angle defines the airplane stall AOA for certification purposes and is tailored to provide stick pusher engagement and AOA recovery without encountering the natural stall. The pusher firing angle also accounts for higher pitch rates and consequent AOA overshoots beyond that point. The shaker firing angle is offset to a lower AOA than the pusher firing angle to provide the stall warning margin required by certification standards. Bombardier programmed the shaker firing angle assuming that a crew experiencing the stick shaker will lower the nose and recover AOA promptly and thus avoid the stall AOA defined by the pusher firing angle. Two AOA vanes mounted on the left and right sides of the forward fuselage provide the AOA signals for the SPS. If either AOA signal exceeds the shaker firing angle, the stick shaker on the corresponding control column will engage (and both columns will shake because they are mechanically connected). If one AOA signal exceeds the pusher firing angle, it will trigger an aural stall warning and flashing red STALL warning lights in the cockpit. If both AOA signals exceed the pusher firing angle, the stick pusher will engage, applying about 80 lbs of forward force to the control columns. The accident airplane’s FDR data showed a difference between the recorded left and right AOA vane data of about 0.5° to 0.75° during the cruise portion of the accident flight and 1.5° toward the end of the flight. Bombardier stated that some difference was not unusual, and 0.5° was the “normally expected maximum” difference. Bombardier noted that comparing AOA vane differences during the approach segment of a flight is more difficult due to turbulence and maneuvering. An NTSB aircraft performance study for this accident considered the effect of this AOA vane split on the SPS system’s performance (see the Tests and Research section below) and concurred with Bombardier’s conclusion that “the pusher did fire well before any natural stall in the first stall warning event, and the system did recover the aircraft, indicating that any effect of a split in delaying pusher response was not large or significant.” Engines Both engines were colocated with the main wreckage. A review of the FDR engine data revealed that both N1 and core speeds remained stable and were about matched while the airplane was in cruise flight. During this time, both engines’ inter-turbine temperatures and fuel flows were stable and consistent. Engine performance for both engines remained consistent during the 30-minute descent and the approach to landing as both engines decreased normally in response to the changes in thrust demand. During the final 6 seconds before the FDR recording ceased, the data showed that both engines started to increase thrust from a low setting consistent with the accelerating fan and core speeds at the time, which happened about the same time as the initial stick shaker and stick pusher engagements. - TRK had two intersecting runways, in 02/20 and 11/29 configurations with lengths of 4,654 and 7,001 ft respectively. Aids to Navigation The published circling minimums provided obstacle clearance when pilots remained within the appropriate area of protection. Pilots would determine the category of airplane for the approach based on the approach speed of the airplane, which in turn would determine the minimum descent altitude and visibility requirements for the circle-to-land approach as depicted on the approach chart. In addition, according to the “Landing Minima Categories” of the Flight Standardization Board, the accident airplane “is considered category C aircraft for the purposes of determining ‘straight-in landing minima.’” The published minimums for a category C aircraft to circle-to-land from the runway 20 RNAV (GPS) approach at TRK included an airspeed less than 140 kts, a minimum decision height of 7,700 ft msl (1,796 ft agl) and a 3 nm radius from the airport. This approach listed ALVVA as an IAF and AWEGA as an intermediate fix with a published hold. - The CVR was a Fairchild FA2100-1020 and captured 2 hours, 4 minutes, 15 seconds of audio for each of its four channels: captain, FO, observer, and cockpit area microphone. Examination of the CVR’s interior case and memory board showed no significant heat or structural damage. The FDR was a Fairchild FA2100 that contained about 409 hours of data and included parameters related to the airplane’s pitch, roll, autopilot, and engines. Examination of the FDR’s interior case and memory board showed no heat or structural damage. - On July 26, 2021, about 1318 Pacific daylight time, a Bombardier Inc. Challenger 605, N605TR, was destroyed when it was involved in an accident near TruckeeTahoe Airport (TRK), Truckee, California. The captain, FO, and four passengers were fatally injured. The airplane was operated as a Part 91 personal flight. According to automatic dependent surveillancebroadcast (ADS-B) data, the nonrevenue flight operating under instrument flight rules departed Coeur d'Alene Airport - Pappy Boyington Field (COE), Coeur d’Alene, Idaho, about 1145 for TRK. (All times in this report are referenced to the airplane’s FDR clock unless otherwise indicated. The ADS-B clock was 1.625 seconds behind the FDR clock and has been shifted by 1.625 seconds in this report.) CVR data indicated that about 1155, ATC cleared the flight to 37,000 ft mean sea level (msl) where it remained for the rest of the cruise phase of the flight. About 1220, the captain started the approach briefing for the RNAV (GPS) approach for runway 11 at TRK with the FO. At 1248, ATC began issuing descent instructions for the airplane’s approach into TRK. At 1249:31, the FO received the updated weather observations for 1251 from the AWOS at TRK, which included an advisory of “visibility may be different than what is shown on AWOS due to heavy smoke in the area.” However, when the FO subsequently relayed the weather to the captain, he did not include the smoke advisory. At 1251:22, the FO informed the captain, “New numbers are sent… eighteen, twenty-nine, forty-five” (referring to a Vref speed of 118 kts, approach climb speed of 129 kts, final segment speed of 145 kts). During this time, the CVR recorded the captain asking the FO for the descent checklist twice before the FO initiated the checklist. The flight crew stated they had completed the approach briefing for the RNAV (GPS) approach for runway 11 about 1252. At 1255, the FO asked ATC if they could proceed direct to the waypoint ALANT for the RNAV (GPS) approach for runway 11 at TRK and the controller cleared them as requested. About 1258, as the airplane descended below 26,000 ft msl, ATC informed the flight crew that they could expect the RNAV (GPS) runway 20 approach at TRK. The captain informed the FO that runway 20 was too short and that they “cannot accept that,” and added that the runway 20 approach would require them “to circle to land” for runway 11. The FO then computed the required landing distance and concluded that runway 20 was “4,655” ft long (4,654 ft according to the TRK airport chart) and they required a minimum landing distance of 4,600 ft. The captain noted that the margin was “too tight,” and the FO agreed. At 1259:57, the captain told the FO they could make the approach into runway 20 and circle to land. Fifteen seconds later, the FO informed ATC that they could take the runway 20 approach but would need to circle to runway 11 because they needed the longer runway. The controller approved their request and told them to plan on the circling approach, then told them to expect some delays. The flight crew did not brief the new approach, which was required by the descent checklist because the flight crew had changed their approach after briefing the original approach. At 1302:54, the FO asked the controller if they should enter the published hold at AWEGA waypoint, but the controller instructed the flight crew to expect a hold at waypoint ALVVA, an initial approach fix (IAF) west of AWEGA. The FO then asked for and was given a clearance and instructions to hold at ALVAA. When the airplane was about 11 nm southeast of waypoint ALVVA, the FO told the captain he would start the turn for him toward the waypoint and did so. The FO then helped the captain program the hold into the FMS. At 1311:43, ATC cleared the flight for the RNAV (GPS) runway 20 approach. After the FO asked and the captain confirmed that he was ready for the approach, the FO provided an abbreviated readback of the clearance. At 1312:13, the FO asked the captain, “Are you gonna be able to get down?” According to the ADS-B data, the airplane was at an altitude of 15,725 ft msl at the time and the first altitude of the approach was 12,000 ft msl at AWEGA, about 3.5 nm away. At 1312:39, the FO then stated to the captain, “We’ve got a ways to go,” and added, “You got plenty of time.” About this time, FDR data showed the airplane’s indicated airspeed was at 241 kts. At 1313:24 the FO said, “We gotta get this thing slowed down,” then asked if the captain wanted “a right three sixty [degree turn],” but the captain declined. The airplane was about 3 nm south of AWEGA, heading toward OSTIE waypoint at an airspeed of about 252 kts (OSTIE is about 2 nm north of LUMMO, the final approach fix [FAF]) (see the locations of flight crew comments and waypoints in figure 1 below). Figure 1. Airplane flightpath and crew discussion on runway 20 approach At 1313:41 the captain instructed the FO, “Now just below two fifty give me flaps twenty please”; however, the FO responded, “Below two-fifty? how about below two-thirty?” (consistent with the published flap speeds of 231 kts in the manufacturer’s operating manual that were also placarded in the airplane), and the captain agreed. The FO then stated again that they should start slowing down the airplane. A few seconds later, the controller terminated radar services and asked the flight crew to contact Truckee tower. At 1314:15, when the airspeed was about 228 kts, the captain again asked the FO to deploy flaps 20°, which the FO stated had been selected (and FDR data showed the flaps setting was selected 4 seconds later). About the same time, the FO contacted Truckee tower and informed them that they were passing the FAF inbound (which ADS-B data confirmed) and would circle to runway 11. The tower acknowledged the communication and asked them to report when the airport was in sight. The captain asked the FO to deploy the landing gear, then the FO responded, “… You came off… what are you… ah nevermind,” and then said, “How ‘bout gear down flaps thirty before landing checklist.” The captain then asked the FO again to deploy the landing gear. At 1315:20, the flaps were at 30° and the landing gear was down when the captain asked for “flaps, thirty please” and the FO responded, “No, we’re at flaps thirty, gear down.” The captain then immediately restated, “Flaps thirty.” About 15 seconds later, the captain asked the FO to confirm the airport’s location on the left. The FO confirmed the airport's location then added, “We’re gonna have to make a right hand turn to get to it,” and the captain acknowledged him. At 1315:55, the FO stated the airport was 5 miles away. At 1316:20, the FO deployed full flaps (45°) after confirming with the captain. A second later (near YAKYU waypoint), the FO said, “There’s the airport,” told the captain to make a 90° right turn, and contacted Truckee tower, which cleared the airplane to land. The FO attempted to point out the airport to the captain, and the captain asked “where?” twice. At 1316:43, the FO told the captain to roll out (level the wings, stopping the turn) and turn the autopilot off. The airplane was at the beginning of the downwind leg turn (about 213° magnetic) when the FO told the captain to roll out, and the airplane rolled out on a heading of about 233°. Figure 2 depicts the turns taken by the airplane in the approach and the maximum circling radius of 3 nm allowed for category C aircraft at TRK in the airport’s approach charts (the airplane was at least 1.3 nm from that maximum circling radius). Figure 2. The airplane’s downwind leg and allowed circling radius. At 1316:53, the FO told the captain, “I’m gonna get your speed under control for you.” FDR data indicated the airplane’s airspeed was about 162 kts at this time. FDR data showed that the airplane began to slow after the FO made this statement. At 1316:56, the captain stated, “Oh I see the runway,” when the airplane had already started the circling approach to runway 11. Two seconds later, the FO told the captain that he could start descending, and the captain replied, “’Kay, full flaps.” The FO replied, “You do have full flaps,” and then stated, “Patience patience patience you got all the time in the world”; 13 seconds later, he stated, “You are looking very good my friend.” At 1317:24, the airspeed was about 123 kts and the airplane was on a west heading about 1.5 nm from the approach end of runway 11 when the FO told the captain to “bring that turn around,” then the airplane began a left turn toward the runway. At 1317:46, as the airplane was turning through a heading of 188°, the FO made the first of several requests for control of the airplane, asking the captain, “Let me see the airplane for a second.” Eight seconds later, the FO told the captain, “We’re gonna go through it [the runway centerline] and come back [to the centerline] okay?” and the captain acknowledged the FO. About 1317:59, when the airplane flew through the runway 11 extended centerline about 0.8 nm from the runway threshold, FDR data showed that the flight spoilers were fully deployed (40°). At the time, the airspeed was 135 kts, and the N1 had reduced from about 60% rpm to about 28% rpm. At 1318:01, the FO said, “We are very high” (the airplane was about 6,390 ft msl, or about 489 ft above the runway 11 threshold elevation of 5,901 ft msl). At 1317:59, the airplane began a left turn that reached a bank angle of 36° about 4 seconds later. According to the CVR data, the stick shaker engaged at 1318:04, then the captain asked, “What are you doing,” which was followed by a stall warning sound. The airplane was on a south heading about 0.75 nm from the runway threshold as it continued to turn back toward the extended runway centerline (see figure 3). The stick pusher engaged about 1318:05. (For more information about the stick shaker and stick pusher, see the section below about the SPS.) The captain again asked the FO, “What are you doing?” and the FO then asked the captain three times over 2 seconds to “let me have the airplane.” The stick pusher disengaged at 1318:07 followed immediately by the stick shaker disengaging. At 1318:09, the stick shaker engaged again followed immediately by the stick pusher engaging, and the airplane was about 6,075 ft msl on a southeasterly heading when it entered a rapid left roll. The airplane was in a 111° leftwinglow bank angle at 1318:11 and 1 second later it was in a 146° rightwinglow bank angle and an approximate 30° noselow attitude, just before the airplane impacted terrain and a postcrash fire ensued. Figure 3. Accident airplane’s flightpath during final approach after crossing the runway centerline. Surveillance video from a business located along the airport perimeter captured the airplane in its final moments. At 1318:09 (according to the time captured by the recording device), the airplane was in a descending left turn on a southeasterly heading at a low altitude. About 1318:12, it entered a rapid left roll and disappeared below the tree line, and smoke appeared in the same location 5 seconds later. - Toxicology testing performed by the FAA Forensic Sciences Laboratory detected ethanol in the FO’s muscle and kidney tissue concentrations approximately equivalent to 0.059 grams per deciliter and at 0.028 grams per deciliter, respectively. FAA toxicology testing also detected npropanol, another form of alcohol, in his muscle tissue. FAA toxicology testing of the captain’s muscle tissue was negative for ethanol and other testedfor drugs. Ethanol detected in postmortem specimens may result from ethanol production by microbes in a person’s body tissues after death. - The weather observations at TRK for 1245 were captured by an AWOS at the airport and showed visibility of 4 statute miles, ceiling broken at 2,300 ft agl, and variable visibility between 3.5 and 5 miles from smoke in the area, with a density altitude of 8,997 ft. (The CVR captured that the FO received the weather observations for 1251 from the AWOS at TRK and relayed most of those observations to the captain.) Imagery data from a geostationary operational environmental satellite for 1316 depicted smoke near the surface with a band of cumulus to cumulus congestus clouds immediately west of the accident site and to the east and southeast of the accident site. Images from the National Aeronautics and Space Administration’s Moderate Resolution Imaging Spectroradiometer revealed the presence of smoke from nearby forest fires over the accident site. At the time of the accident, the National Weather Service had an AIRMET advisory current for instrument flight rules conditions due to smoke over the area and a center weather advisory for developing thunderstorms. The flight plan filed by the crew for the accident flight reported two passengers on the flight; however, according to the operator, the two additional passengers were added to the flight at the last minute. The flight crew did not update the flight plan to reflect the additional passengers. NTSB investigators on scene were eventually able to confirm the correct number of individuals on the airplane after consultation with law enforcement on scene. - According to FAA Advisory Circular 120-12A (dated April 24, 1986) a flight must be conducted under Parts 135 or 121 when it “holds itself out” to the public or a segment of the public as willing to furnish transportation and is defined by four elements: “(1) a holding out of a willingness to (2) transport persons or property (3) from place to place (4) for compensation.” According to the operator, Aeolus Air Charter Inc., the accident flight was a personal flight and not conducted or held out to the public for compensation or hire. A review of documents related to the airplane’s registration showed that on the day of the accident, the operator applied to the FAA flight standards district office in Fargo, North Dakota, to amend the company’s operation specification and add the accident airplane to the company’s Part 135 air carrier operating certificate. At the time of the accident, the operator had one airplane from its fleet on its Part 135 operations specification. Approach Briefing The manufacturer’s operating manual included the approach briefing in section 5 of the descent checklist. According to the procedure: The approach briefing should be accomplished well before entering the terminal control zone. The pilot-flying shall conduct the briefing and review and/or outline the operational aspects of the expected approach, which should include the following: (a)Type of approach (b)Runway in use (c)Landing minima (d)Review of Vref and N1 values (e)Altitudes (MSA [minimum safe altitude], Field elevation, Threshold elevation, Descent crossing altitudes) (f)Outbound and procedure turn courses (g)Final inbound course (h)Decision Height (DH) or Minimum Descent Altitude (MDA) (i)Missed approach point (non-precision) (j)Missed approach procedure (k)NAV equipment set-up (l)Any questions or clarifications and other pertinent details. Weight and Balance Title 14 CFR 135.185 states that multiengine aircraft must have a current empty weight and balance based on actually weighing the aircraft within the preceding 36 months. In addition, the operator’s general operations manual stated that its aircraft are weighed every 36 months. The accident airplane’s operator, owner, and previous maintenance facility were unable to provide a 36-month certified weight of the airplane. According to the operator’s GOM, its director of maintenance was responsible for “ensuring weight and balance of Aeolus Air Charter, Inc. aircraft comply with 14 CFR Part 135.185.” The operator’s chief pilot stated that the operator’s procedures were the same for flying and conducting a weight and balance for its Part 91 and Part 135 flights. Circling Approaches The manufacturer’s operating manual for the accident airplane model directs pilots performing a circling approach to fly the downwind leg parallel to the runway about 1.5 miles away from the runway. The operating manual also directs pilots performing a circling approach to maintain flaps 30° at the “Flaps 30° speed + 10 KIAS [kts indicated airspeed]” and landing gear down from the FAF to the beginning of the turn towards final approach. However, the manufacturer also noted that, although the circling approach procedure in its operating manual calls for maintaining flaps 30°, a flight crew is not prohibited from a flaps 45° configuration if the approach remains within the limitations of the airplane’s flight manual. According to Bombardier, the operating manuals of older Challenger models included flaps 20° and flaps 30° as approved approach climb configurations, and the “Flaps 30° speed” referred to the flaps 30° approach climb configuration. Bombardier removed the approach climb speed data for a flaps 30° configuration when it introduced the Challenger 604. However, some references to “Flaps 30° speed” remained in the normal procedures section of the Challenger 604 operating manual, so at the time of the accident, the operating manual referred to an undefined “Flaps 30° speed.” Bombardier stated that the appropriate speeds for approaches that refer to the “Flaps 30° speed” are taught in training, and that it would review and adjust the operating manual for consistency with the airplane’s flight manual. The operator’s GOM included procedures for the PF to conduct an approach briefing before starting any approach, which included the following items (among others): 1.Approach to be flown and backup approach, if available. 2.Special procedures during the approach, such as circling approach, interception of a radial from an arc, VDP [visual descent point], etc. 3.Altitudes of IAF, FAF, step-downs, sector altitudes, and obstacles. 4.Minimums (DH, MDA), HAT [height above touchdown], HAA [height above airport], and radio altimeter setting Based on the estimated actual weight and balance information, the Vref for the airplane at the time of the accident was 124 kts. According to 14 CFR 97.3, an airplane with Vref between 121 and 141 kts is a category C aircraft. The FAA’s Instrument Procedures Handbook urges caution when attempting a circle-to-land maneuver, particularly for category C aircraft: Circling approaches are one of the most challenging flight maneuvers in the NAS [National Airspace System], especially for pilots of Category C and Category D turbine-powered transport category airplanes. The maneuvers are conducted at low altitude, day and night, and often with precipitation present affecting visibility, depth perception, and the ability to adequately assess the descent profile to the landing runway… Circling approaches conducted at faster-than-normal, straight-in approach speeds require a pilot to consider a larger circling approach area. The operator’s GOM included procedures to complete a positive transfer of controls. According to these procedures: A normal, non-emergency transfer of control with the autopilot not engaged will follow the protocol below: 1.PF will state, “You have the controls.” 2.The new PF will place his hands on the yoke and state, “I have the controls.” 3.The new PM will release the controls. Transfer of aircraft control when the autopilot is engaged will follow the protocol below: 1.The PF will verbalize the current course/heading and altitude assignment and state, “You have the aircraft.” 2.The new PF will state, “I have the aircraft.” When a positive transfer of controls is completed, the former PF should advise the new PF of the current course/heading and altitude assignment. Stabilized Approach Criteria The operator’s GOM included criteria for stabilized approaches: G.Approaches in VMC must be stabilized by no later than 500 ft AFE [above field elevation] and 1000 ft AFE in IMC [instrument meteorological conditions]. A stabilized approach is defined as: 1.Aircraft in landing configuration. 2.Aircraft in a position for a normal descent to the runway. 3.Airspeed on target (IMC) or approaching target (VMC). 4.Airspeed on target (VMC) by 500 feet AFE. H.Go-around initiation may be made by either the PF or the PM. The operator’s GOM’s recommendations and standardized procedures also state that the PM makes call outs for going around at the missed approach point. Crew Resource Management The FAA’s Risk Management Handbook defines CRM as “[t]he application of team management concepts in the flight deck environment.” The handbook also states that CRM concepts can include situation awareness, communication skills, and teamwork, among others. - Captain The captain, who had signed an employment contract with the operator but was not yet an employee at the time of the accident, was operating the flight under contract to the operator until he could be onboarded. A review of training records from the captain’s training provider showed that the captain, who was the PF and PIC during the accident, completed his most recent proficiency training as PIC in a Challenger 605 simulator 10 days before the accident flight. This most recent ground training included CRM training, and the captain’s overall rating for ground training was proficient. Records showed that the captain passed his checkride, which included a nonprecision approach, stall prevention, and a goaround/rejected landing; however, the instructor comments for the practice simulator sessions noted that he rushed checklists, needed to slow down and read the checklist requirements, and needed to setup approach procedures without PM prompts. The captain also enrolled online for the accident flight operator’s basic indoctrination training, which included instruction on the flight operator’s GOM, 12 days before the accident flight. Federal regulations do not require any leadership and command training for Part 91 or Part 135 operations, and the captain had not taken any leadership training. However, according to both 14 CFR 91.3(a) and the flight operator’s GOM, the captain as PIC would have been “directly responsible for, and is the final authority as to, the operation of” the accident airplane. First Officer The FO, who was the PM and second-in-command during the accident flight, was not the accident operator’s employee at the time of the accident and had been hired as a contract pilot for the accident flight. The flight was the first pairing of this crew with the operator. A review of training records from the FO’s training provider showed that the FO completed a simulator session in a Challenger 604 in May 2021 and completed Challenger 604 recurrent training as PIC in June 2021. The recurrent training program included 15 hours of ground training and 8 hours of simulator training, which were split evenly as the PF and PM with five nonprecision approaches and one circletoland approach. The simulator training sessions included CRM, in which the FO was rated proficient. The FO’s training was not specific to the operator’s policies and procedures and the FO did not receive training on the operator’s GOM. According to Federal Aviation Administration (FAA) Order 8900.1, Volume 5, Chapter 2, Section 19, the accident airplane, a Challenger 605, was under the same type rating designation as the Challenger 604. - Aircraft Performance Study The NTSB conducted an aircraft performance study to define the accident airplane’s position and orientation during the relevant portions of the accident flight and to determine the airplane’s response to control inputs, external disturbances, and other factors that could affect its flight. The study used ADS-B, FDR, CVR, video, and weather data, along with the wreckage location and output from aircraft performance analysis programs and simulations. The study determined that as the airplane was circling to land on runway 11, the left wing exceeded the natural stall AOA and stalled. Immediately following the first stick shaker and stick pusher engagements, the elevators moved to 10° trailing edge down, which decreased the AOA below the stick shaker and stick pusher firing angles, which disengaged the shaker and pusher. However, the elevators then moved about 18° trailing edge up, which increased the AOA above the natural stall AOA (engaging the stick shaker and stick pusher again). At 1318:09.4, the normal load factor (NLF) dropped suddenly from 1.62 to 1.29 g over 1/8 of a second. At the same time, the roll rate increased dramatically as the airplane abruptly rolled to the left from 27° to 147° in 2.3 seconds, consistent with the left wing stalling and the known natural stall characteristics of the accident airplane type and model. The airplane continued to roll to the left and impacted the ground. The results of the study suggested that the FMS’s erroneous airplane empty weight did not affect the sequence of events significantly. As noted above, the airplane empty weight programmed into the FMS was most likely the factorydefault weight of 24,000 lbs, about 3,000 lbs lighter than the estimated actual airplane empty weight. With that discrepancy, the FMS would have computed a landing weight of about 28,300 lbs and a corresponding Vref of 118 kts. A review of the flight crew’s ForeFlight accounts (a mobile application that can be used for flight planning among other purposes) showed that the captain and FO calculated landing weights of 31,540 lbs and 29,951 lbs respectively. According to FDR data, the airplane had 3,392 lbs of fuel before impact. Bombardier used data from the airplane’s December 2007 aircraft weight and balance report and FDR data of fuel quantities and stabilizer position to estimate the airplane’s weight and balance information at the time of the accident, including a BOW of 27,034 lbs. Bombardier further validated through simulation analysis that the stabilizer position at various points in the accident flight was consistent with the estimated weight. The NTSB calculated that with the estimated BOW, the landing weight would have been 31,294 lbs with a corresponding Vref of 124 kts. After adding 10 kts to Vref for maneuvering, the target speed during the circling maneuver using the FMS weight would have been 128 kts, and the target speed using the estimated correct weight would have been 134 kts. The performance study determined that the calibrated airspeed when the stick shaker was first recorded was about 130 kts. Because that airspeed was 6 kts above the correct Vref (124 kts), the erroneous FMS weight did not contribute to the airplane operating with a significantly reduced AOA margin to the stick shaker during the final maneuver. The study determined that the full spoiler deployment (before the airplane turned left toward the runway centerline) resulted in a noticeable reduction in maneuvering capability during the final left bank turn and significantly reduced the AOA margin to the stick shaker, stick pusher, and natural stall. About 1318:04.4, before the stall and loss of control, the left vane AOA was high enough to engage the stick shaker at an airspeed of 130 kts, a left bank angle of 36°, and an NLF of 1.23 g. Stick shaker engagement would not normally be expected in these circumstances, but the full deployment of the flight spoilers as the airplane was crossing the extended runway centerline reduced the lift (and therefore NLF) capability of the airplane, contributing to the stick shaker engagement. If the spoilers had been stowed at the same airspeed, the stick shaker would not have engaged until an NLF of 1.54 g and a bank angle of about 50°, and the stick pusher would not have engaged until an NLF of 1.75 g and a bank angle of 55°. - The airplane came to rest on a slope between a golf course fairway and a residential street. Most of the airplane was consumed by postcrash fire, but all the airplane’s primary flight control surfaces were identified at the accident site. A debris path, which measured about 225 ft long and 85 ft wide, was marked by several broken trees and was oriented on an easterly heading. The initial point of impact was identified by a severed tree that stood about 70 ft tall, located about 120 ft west of the main wreckage. Portions of the right and left wings and control surfaces were found fragmented along the debris path. Additional airframe fragments were separated from the main wreckage, which included both engines, the empennage, and fuselage remnants. Most of the airplane’s secondary flight control surfaces were identified at the accident site except the inboard left flap. However, the NTSB did not observe any parts or fragments from the airplane on the ground when a portion of the airplane’s flightpath was surveyed. -
Analysis
The captain and first officer (FO) departed on a non-revenue flight operating under instrument flight rules with four passengers bound for Truckee, California. Most of the flight was uneventful. During the descent, air traffic control (ATC) told the flight crew to expect the area navigation (RNAV [GPS]) approach for runway 20. The captain (pilot flying [PF]) stated and the FO (pilot monitoring [PM]) calculated and confirmed that runway 20 was too short for the landing distance required by the airplane at its expected landing weight. Instead of making a request to ATC for the straight-in approach to runway 11 (the longer runway), the captain told the FO they could take the runway 20 approach and circle to land on runway 11, and the FO relayed this information to ATC. ATC approved, and the flight crew accepted the circletoland approach. Although the descent checklist required that the flight crew brief the new circletoland approach, and the flight crew’s acceptance of the new approach invalidated the previous straight-in approach brief, they failed to brief the new approach. ATC instructed the flight crew to hold, but the captain was slow in complying with this instruction, so the FO started the turn to enter the holding pattern and then informed ATC once they were established in the hold. About 20 seconds later, ATC cleared them for the approach. Before the FO confirmed the clearance, he asked the captain if he was ready for the approach, and the captain stated that he was. The FO subsequently commented that they had too much airspeed at the beginning of the approach and then suggested a 360° turn to the captain, but the captain never acknowledged the excessive airspeed and refused the 360° turn. After the FO visually identified the airport, he told the captain to make a 90° right turn to put the airplane on an approximate heading of 290°, which was parallel to runway 11 and consistent with the manufacturer’s operating manual procedures for the downwind leg of the circling approach. However, the FO instructed the captain to roll out of the turn prematurely, and the captain stopped the turn on a heading of about 233° magnetic, which placed the airplane at an angle 57° left of the downwind course parallel with runway 11. As a result of the early roll-out, the flight crew established a course that required an unnecessarily tight turning radius. When they started the turn to final, the airplane was still about 1.3 nautical miles (nm) from the maximum circling radius that was established for the airplane’s approach category. The FO also deployed flaps 45° after confirming with the captain (the manufacturer’s operating manual procedures for the downwind leg called for a flaps setting of 30°, but the manufacturer stated that a flight crew is not prohibited from a flaps 45° configuration if the approach remains within the limitations of the airplane’s flight manual). The airplane’s airspeed was 44 kts above the landing reference speed (Vref) of 118 kts that the flight crew had calculated earlier in the flight; the FO told the captain, “I’m gonna get your speed under control for you.” The FO likely reduced the throttles after he made this statement, as the engine fan speeds (N1) began to decrease from about 88% to about 28%, and the airplane began to slow from 162 kts. After the FO repeatedly attempted to point out the airport to the captain, the captain identified the runway; the captain's difficulty in finding the runway might have been the result of reduced visibility in the area due to smoke. The FO continuously reassured and instructed the captain throughout the circletoland portion of the approach. On the base leg to the runway and about 25 seconds before impact with the ground, the FO started to repeatedly ask for control of the airplane, but neither flight crewmember verbalized a positive transfer of control as required by the operator’s general operating manual (GOM); we could not determine who had control of the airplane following these requests. As the airplane crossed the runway extended centerline while maneuvering toward the runway, the FO noted that the airplane was too high. One of the pilots (recorded flight data did not indicate which) fully deployed the flight spoilers, likely to increase the airplane's sink rate. (The flight spoilers are deployed using a single control lever accessible to both pilots.) The airspeed at the time was 135 kts, 17 kts above the Vref based on the erroneous basic operating weight (BOW) programmed into the airplane’s flight management system (FMS). About 7 seconds later, the left bank became steeper, and the stall protection system (SPS) stick shaker and stick pusher engaged. The captain asked the FO, “What are you doing,” and the FO again asked the captain multiple times to “let [him] have the airplane.” The stick shaker and stick pusher then briefly disengaged before engaging again. The airplane then entered a rapid left roll, consistent with a left-wing stall, and impacted terrain. A postcrash fire consumed most of the wreckage. Analysis of data retrieved from the flight data recorder (FDR) indicated that the engines were functioning normally at the time of impact and there were no indications of a flight control or system malfunction. Most of the wreckage was consumed by postcrash fire, and the flight control linkages were destroyed either by high energy impact forces or the postcrash fire, which precluded a complete examination of the wreckage. Examination of the primary flight control surfaces did not reveal any preimpact mechanical anomalies. Engine data from the accident flight did not show any interruptions in power or suggest any mechanical anomalies with the power production capabilities of either engine. Flight Crew Performance The captain and FO were appropriately qualified to perform their respective duties as pilotincommand (PIC) and secondincommand of the accident flight, which was the first pairing of this crew for the operator. A review of operator documentation revealed that the flight complied with the requirements of Title 14 Code of Federal Regulations (CFR) Part 91, General Operating and Flight Rules, and was not conducted under the operator’s 14 CFR Part 135 certificate. Although toxicology testing detected ethanol in the FO’s tissue, given the different concentrations of ethanol, the presence of npropanol, and the state in which the body was found, it is likely that the identified ethanol was from sources other than ingestion. The flight crew elected to conduct a circling approach to runway 11 and never asked ATC for the straightin RNAV (GPS) approach to the desired runway. The crew also failed to brief the new circling approach after previously briefing the anticipated straightin approach. The flight crew’s failure to brief the circling approach prevented them from sharing a mental model for how the approach should have been conducted and points to poor crew resource management (CRM) because they failed to prepare for adverse situations and contingencies, such as a missed approach. Because of their lack of preparation, they made critical errors on the approach that reduced the safety margin, which included: oflying the circling approach at a higher airspeed than the upper limit specified for the airplane’s category C approach category; ofailing to establish the airplane on the downwind leg of the circletoland approach; and ofailing to visually identify the runway early in the approach, likely due to obscuration by smoke. The airplane’s higher airspeed reduced the flight crew’s time to configure the airplane, assess their position relative to the runway, and make corrections to their trajectory, which further reduced the safety margin. During the approach, the FO made several announcements to the captain that the airplane was fast. The captain rejected the FO’s suggestion to take a 360° turn early in the approach, which would have provided additional time and distance for speed control. The circling approach maneuver began at 160 kts, which was 20 kts higher than the upper limit of the circletoland approach speed established for this airplane’s approach category (category C) and did not drop below the category C maximum speed until the flight crew was preparing to start their base leg turn. The captain’s failure to establish the airplane on the downwind leg and the airplane’s proximity to the airport during the approach also reduced the safety margin by limiting the space available to align the airplane with the runway centerline. The captain did not establish the airplane on a downwind leg parallel to the destination runway, as depicted in the manufacturer’s operating manual, but instead flew a downwind leg that converged on the runway centerline. This tightened the pattern and resulted in an overshoot of the runway centerline only 0.8 nm from the runway threshold during the base-to-final turn, limiting the flight crew’s ability to properly align the airplane with the runway centerline for final approach. The FO received updated weather information from an automated weather observation system (AWOS) early in the approach, which included an advisory of reduced visibility due to heavy smoke in the area, but he did not relay this visibility advisory to the captain, further reducing the safety margin. The smoke likely made it more difficult for the captain to visually identify the airport. The FO reassured the captain throughout the approach about needing to be patient and having plenty of time (despite the time constraints resulting from the fast and tight circling maneuver). These reassurances demonstrated that the FO was aware of the adverse effects of self-induced pressure to perform; however, he exhibited self-induced pressure to salvage a deteriorating approach. In addition, despite the captain not properly setting up the approach, he failed to ask for more time in the holding pattern and rejected the FO’s suggestion to use a 360° turn to slow the airplane. Without any external pressure to land immediately, the captain’s actions indicated a self-induced pressure to perform without being corrected. Following the turn to the base leg, the airplane was not in a position from which it could align with the runway without overshooting the centerline, nor could the pilots execute a normal descent to the runway. Further, the airspeed was not on target or approaching the flight crew’s target Vref of 118 kts. The stabilized approach criteria in the operator’s GOM required that the airplane be in a position to execute a normal descent to the runway and that the airspeed be on target or approaching target no later than 500 ft above field elevation in visual meteorological conditions (VMC). The accident approach did not meet those criteria and was therefore unstabilized. Once the approach became unstabilized, the crew should have abandoned the approach and gone around but did not. The operator’s GOM empowered both pilots to perform a goaround, and the circumstances of the approach did not preclude a goaround; there was no time- or fuelrelated pressure to land. Even so, the flight crew never announced a goaround, and the FO did not make callouts for going around as required in his role as PM (as the PM, it would have been the FO’s duty to call for a goaround once the operator’s stabilized approach criteria were violated). The flight crew’s choice to continue the unstabilized approach rather than go around was consistent with selfinduced pressure to perform and degraded decisionmaking. About 8 seconds after the FO asked for control of the airplane the first time, he said, “We’re gonna go through it and come back okay?”, likely referring to the runway centerline, and indicating an intent to salvage the unstable approach. As the airplane crossed the centerline, the captain said, “It’s here” (also likely referring to the centerline), and the FO responded, “Yes yes it’s here we are very high,” indicating that he was aware that the airplane was not in a position to make a normal descent to the runway. At the same time, the spoilers were deployed. Given the FO’s stated intent to overshoot the runway centerline and then return to it and his recognition that they were high, it is likely that the FO deployed the spoilers in an attempt to descend quickly toward a nominal glidepath to the runway. Once the airplane crossed the extended runway centerline, it approached a stall and the stick shaker engaged; the FO again requested control of the airplane multiple times, likely motivated by a desire to continue the approach. However, the cockpit voice recorder (CVR) did not record a positive transfer of control or any indication that the captain had relinquished control to the FO. The FO had acted as an instructor to the captain throughout the flight; seeing himself in this role might have driven his desire to take the controls in the final moments of the flight. Given the FO’s clear motivation to continue the approach and his multiple requests for control of the airplane, it is likely that he improperly attempted to take control of the aircraft without permission from the captain and increased the bank angle of the left turn, which contributed to the left wing’s stall. In his leadership position as PIC, the captain should have taken decisive action to exercise his authority to ensure airplane control when the FO likely improperly attempted to take control; however, he failed to do so. In addition, both the FO’s decision to attempt to salvage the unstabilized approach and the captain’s failure to intervene demonstrated degraded performance and vigilance. Further, during the final 10 seconds of the flight, the CVR captured reactive statements from both crewmembers, including the FO’s multiple requests for control of the airplane, that suggest they were not working together. The captain's lack of assertiveness in exercising his authority, each flight crewmember’s failure to recognize their own psychological stresses, and the flight crew's disregard for safety while attempting to salvage the approach all point to improper CRM in the final moments of the accident flight. Failures in CRM generally describe a lack of clear communication and a failure to recognize degraded performance and vigilance in the cockpit. In this case, poor CRM contributed to the flight crew’s degraded performance and competition for control of the airplane, ultimately resulting in a stall. Airplane Performance Examination of paperwork for previous maintenance done on the airplane established that the weight and balance information was incorrect in the airplane’s FMS. About 10 months before the accident, a maintenance facility serviced the airplane’s FMS units to comply with a scheduled battery replacement. Although the maintenance facility reinstalled the required databases, which included the approach speeds and performance databases, it did not input a weight specific to the accident airplane. As a result, the airplane had likely been operating with an incorrect empty weight since the maintenance; the operator reported flying the airplane for four flights since the operator took possession of it in May 2021. The default empty weight in the FMS was about 3,000 lbs lighter than the estimated actual airplane empty weight for the accident flight. Because of the inaccurate empty weight, the FMS had computed for the flight crew an erroneous Vref of 118 kts, which was 6 kts slower than the correct reference landing speed of 124 kts. Although this oversight showed a lack of attention to detail by the operator, an airplane performance study determined that the weight and balance discrepancy did not contribute to the stall because the airplane was flying several kts above the correct reference speed in its final moments. The performance study and accident data revealed that the full deployment of the flight spoilers about 12 seconds before the accident had a significant effect on the stall margin of the airplane in the final moments before impact. Performance analysis showed that the airplane would have been at a bank angle of about 36° when the stick shaker engaged at a calibrated airspeed of 130 kts. Had the flight spoilers been stowed at this airspeed, the stick shaker would not have engaged until the airplane reached a calculated bank angle of about 50°. Therefore, the airplane’s stall margin was significantly reduced by the deployment of the flight spoilers. As discussed above, the CVR evidence suggests that the FO most likely deployed the spoilers. We were unable to determine if any of the statements recorded by the CVR at the time of spoiler deployment were specifically related to that action. For example, the CVR captured the captain questioning an action taken by the FO just before the stall warning; it was unclear whether this statement might have been in response to a specific control input made by the FO or to the FO’s continued and repeated requests to take control of the airplane in general. Although the stall warning disengaged briefly, this was likely the result of the stick pusher providing angle of attack (AOA) recovery rather than a timely response of the flight crew to the stall warning; in any case, the stall warning subsequently re-engaged. The combination of the FO’s improper deployment of the flight spoilers and the airplane’s bank angle and airspeed at the time resulted in the airplane exceeding the critical AOA, followed by an asymmetric stall (of the left wing), a rapid left roll, and impact with terrain.
Probable cause
The first officer’s (FO’s) improper decision to attempt to salvage an unstabilized approach by executing a steep left turn to realign the airplane with the runway centerline, and the captain’s failure to intervene after recognizing the FO’s erroneous action, while both ignored stall protection system warnings, which resulted in a left-wing stall and an impact with terrain. Contributing to the accident was the FO's improper deployment of the flight spoilers, which decreased the airplane's stall margin; the captain’s improper setup of the circling approach; and the flight crew’s self-induced pressure to perform and poor crew resource management, which degraded their decision-making.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOMBARDIER INC
Model
CL-600-2B16
Amateur built
false
Engines
2 Turbo fan
Registration number
N605TR
Operator
AEOLUS AIR CHARTER
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
5715
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-12T19:24:03Z guid: 103554 uri: 103554 title: ANC21FA065 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103564/pdf description:
Unique identifier
103564
NTSB case number
ANC21FA065
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-26T14:20:00Z
Publication date
2023-04-12T04:00:00Z
Report type
Final
Last updated
2021-07-28T22:43:35.912Z
Event type
Accident
Location
Eagle River, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On July 26, 2021, about 1320 Alaska daylight time (AKDT), a Cessna 172P airplane, N65698, was substantially damaged when it was involved in an accident near Eagle River, Alaska. The flight instructor and private pilot received fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight, operated by Angel Aviation Inc., Anchorage, Alaska, originated from Merrill Field Airport (MRI), Anchorage, Alaska, about 1215. The flight, reserved as a “discovery flight,” was scheduled to last from 1200 until 1400. After departing MRI, the airplane proceeded northbound near Palmer, Alaska, before turning towards the Knik Glacier. When the airplane did not arrive back at MRI, a concerned family member referenced a tracking application which showed the airplane had stopped moving in the area of the Eagle River Valley, and notified authorities. About 1700, an alert notice (ALNOT) was issued and a search was initiated, and the wreckage was located about 2245 in an area of steep, rising glacial terrain at an elevation of about 3,100 ft mean sea level (msl). Although the ALNOT listed a destination of Girdwood, Alaska, the flight had been planned to return to MRI. The reason for the listing of Girdwood could not be determined. - At the time of the accident, the flight instructor was wearing an Apple Watch, which recorded pulse data. The last recorded pulse data recovered from the watch were from between 1500 to 1600 on the day of the accident. The level of accuracy of the pulse recording was unknown. - The National Weather Service, Ted Stevens Anchorage International Airport (PANC) 1600 sounding depicted a lifted condensation level (LCL) and level of free convection at 3,294 ft above ground level (agl), with a convective condensation level at 4,623 ft agl, which supported few to scattered clouds at the LCL at about 2,700 ft agl and a broken layer about 4,600 ft agl. The freezing level was identified above 8,000 ft. The sounding indicated several temperature inversions below 10,000 ft, with the atmosphere characterized as stable with a lifted index of 3.4, and the precipitable water content of 0.79 inches. The sounding supported a moderate to severe risk of carburetor type icing from the surface through 7,000 ft, based on the temperature and relative humidity profiles. Figure 1 is a carburetor icing probability chart depicting the potential for carburetor icing given the conditions reported at Birchwood Airport at the time of the accident, which were similar to the conditions reported at PANC, Elmendorf Air Force Base, and Palmer Airport. The chart indicated a moderate risk of serious carburetor icing (green) conditions at cruise power and severe at glide power and bordered the severe category (blue) for serious icing at any power setting. Figure 1: Carburetor Icing Probability Chart - The airplane was equipped with an Ameri-King Corporation AK-451-2 emergency locator transmitter (ELT) marked certified in accordance with technical standards order (TSO) C-126 and C091(a). The ELT remained secure in its cradle and the wires and antenna remained attached. During the search, no signals were received from the 406MHz or 121.5MHz system. The day after the accident, when there were no personnel near the wreckage, the ELT began emitting a signal, which was received by the Alaska Rescue Coordination Center. During a postaccident examination of the ELT, when in the “ON” mode, the ELT activated and transmitted on both 121.5 and 406MHz. When tested in the “ARMED” mode, the ELT transmitted only once out of numerous tests. In 2015, the FAA determined Ameri-King Corp., manufactured, sold, or distributed parts and articles for installation on FAA type certificated aircraft which did not conform to an approved design, but were represented as FAA-approved. On December 28, 2015, the FAA issued an emergency cease-and-desist order to Ameri-King Corp., terminating their technical standard order authorization (TSOA) and parts manufacturer approval (PMA). The emergency cease and desist order required Ameri-King Corp. to immediately cease and desist manufacturing, selling, and distributing any parts and articles for installation on FAA type-certificated aircraft. Prohibited activities also included advertising, repairing, rebuilding, and altering any articles intended for installation on type certificated products. According to the FAA, based on the investigation that led to the issuance of the emergency cease-and-desist order, the FAA was not confident parts and articles manufactured by Ameri-King Corp. prior to December 28, 2015, were manufactured in accordance with approved design. Following the cease-and-desist order, the FAA subsequently issued an unapproved parts notification and airworthiness directive (AD), which applied to the ELT installed on the airplane at the time of the accident. AD-17-16-01 stated, in part: “This AD was prompted by multiple reports of ELT failure. This AD was also prompted by a report of noncompliance to quality standards and manufacturer processes related to Ameri-King Corporation ELTs. Failure to adhere to these standards and processes could result in ELTs that do not function. We are issuing this AD to detect and correct nonfunctioning ELTs, which, if not corrected, could delay or impede the rescue of the flightcrew and passengers after an emergency landing.” As part of the AD, a testing process was developed that was to be completed within 12 months of the issuance of the AD, and repeated at intervals not to exceed 12 months. A review of the aircraft maintenance records, specifically the AD compliance sheet, revealed an entry showing compliance with AD-17-16-01 on January 3, 2020. A maintenance entry dated January 3, 2020, stated, “Replaced ELT with Artex ELT 1000 P/N A3-06-2749-1 battery due 12/2026.” The next entry, dated January 22, 2021, stated “Tested ELT IAW 91.207(d), ELT battery due 12/2026. AD compliance sheet verified and up to date.” - The airplane sustained substantial damage to the fuselage and left wing. A post-accident examination revealed that all major components remained attached at their respective attach points. The propeller remained attached at the crankshaft and each blade was missing about 2 inches of the blade tip and exhibited leading-edge gouging, torsional twisting, chordwise striations across the cambered surface and trailing edge “S” bending. Flight control continuity was established from all control surfaces to the cockpit. Internal engine continuity was confirmed through rotation of the propeller. The carburetor, induction system, and airbox remained free of pre-impact obstructions to airflow. The carburetor “heat valve” was observed to be in the ON/HOT position and was “captured” in this position due to the deformation of the surrounding heat box material due to impact. -
Analysis
The pilot and flight instructor departed on a 2-hour discovery flight and did not return. The wreckage was subsequently located nearly 9 hours after the airplane’s scheduled return time in an area of rocky, mountainous terrain. The airplane sustained substantial damage to the fuselage and left wing. No pre-accident engine or airframe mechanical malfunctions or anomalies were found that would have precluded normal operation. The carburetor “heat valve” was observed in the ON/HOT position, and was captured in this position due to the deformation of the surrounding heat box material, consistent with the absorption of impact energy. The propeller remained attached at the crankshaft. Each blade was missing about 2 inches of the blade tip and exhibited leading-edge gouging and torsional twisting, chordwise striations across the cambered surface, and trailing edge “S” bending, all of which is consistent with rotation under power at the time of impact. The temperature and dewpoint in the area of the accident site around the time of the accident were consistent with a moderate risk of serious carburetor icing at cruise power settings and severe icing at glide power settings. Although the airplane’s emergency locator transmitter (ELT) emitted a signal the day after the accident, which was detected by search and rescue personnel, no signal was detected immediately after the accident. During postaccident examination of the ELT, when in the ON mode, the ELT activated and transmitted on both 121.5 and 406MHz. When tested in the ARMED mode, the ELT transmitted only once out of numerous tests. The ELT installed in the airplane was an AmeriKing AK-451 ELT that was the subject of a Federal Aviation Administration (FAA) airworthiness directive (AD) which required annual testing as a result of an unapproved parts investigation. The AD was prompted by multiple reports of ELT failures and a report of noncompliance to quality standards and manufacturer processes. The AD further stated that failure to adhere to the standards and processes could result in ELTs that would not function, similar to the circumstances in this accident. A review of the airplane’s maintenance records revealed an entry showing compliance with the AD about 19 months before the accident. An entry with the same date indicated that the ELT was replaced with a different make and model. An entry dated about 6 months before the accident indicated that the ELT was tested in accordance with 91.207(d) and the AD compliance sheet was up-to-date. Since the maintenance records indicated that the AD-affected ELT had been removed and replaced with a unit not affected by the AD, the required testing was likely not accomplished; therefore, the faults with the ELT were not discovered. Had the ELT functioned as designed, emergency personnel would have been alerted to the accident, even if the company did not report it overdue. Similarly, had the AD-affected ELT been removed and replaced with a functional unit as was noted in the maintenance records, the search and rescue response likely would have been faster; however, whether faster location of the wreckage would have prevented a fatal outcome could not be determined.
Probable cause
An inflight collision with terrain under unknown circumstances. Contributing to the delayed rescue response was the failure of the emergency locator transmitter (ELT) to activate as designed, and the mechanic’s failure to ensure the correct ELT was installed and all applicable airworthiness directives complied with in accordance with federal regulations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N65698
Operator
ANGEL AVIATION INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17275822
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-07-28T22:43:35Z guid: 103564 uri: 103564 title: ERA21LA316 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103631/pdf description:
Unique identifier
103631
NTSB case number
ERA21LA316
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-27T12:05:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-08-20T06:16:26.897Z
Event type
Accident
Location
Mount Pleasant, South Carolina
Airport
MT PLEASANT RGNL-FAISON FLD (LRO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 27, 2021, about 1105 eastern daylight time, a Socata TBM-700 C2, N48UM, was substantially damaged when it was involved in an accident at Mount Pleasant Regional Airport-Faison Field (LRO) Mount Pleasant, South Carolina. The private pilot and five passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, his visual approach was “uncomfortably fast.” The airplane crossed over the threshold of the 3,700-ft-long runway at 125 to 130 knots and touched down on “the first 1/3 to the middle 1/3 of the runway.” He applied brakes, but the runway was wet and slick. Unable to stop on the remaining runway, the pilot attempted to move the throttle from beta to full to abort the landing, but the throttle “stuck.” The airplane subsequently came to rest about 325 ft past the end of the runway. According to the Federal Aviation Administration inspector who responded to the accident site and conducted an initial examination of the wreckage, the engine mounts and left wing sustained substantial damage. The flaps were found in the “TAKEOFF” position. All engine and flight controls were intact from the cockpit controls to their respective control surfaces and functioned normally. In addition, examination of the brakes revealed no anomalies. The throttle lever had no binding and operated smoothly through its full range of motion. A pilot’s abbreviated checklist, a quick reference performance guide, and a laminated checklist were located on the airplane, but no Pilot’s Information Manual (PIM) was on board the airplane. According to the PIM, with the flaps in the landing position, the landing distance on a wet runway would have been about 2,700 ft; the PIM recommended an approach speed of 80 knots and a touchdown speed of 65 knots. The pilot’s reported approach speed was about 30 to 40 knots over the PIM recommended approach speed. The pilot reported in the "Operator/Owner Safety Recommendation" section of the Pilot/Operator Aircraft Accident/Incident Report (NTSB form 6120.1/2) that "when it was apparent that the approach was not stabilized, I should have performed a go-around.” -
Analysis
The pilot stated his visual approach to landing was “uncomfortably fast.” The airplane crossed over the threshold about 30 to 40 knots above the approach speed recommended in the Pilot’s Information Manual (PIM). He applied brakes, but the runway was wet and slick. Unable to stop on the remaining runway, the pilot attempted to abort the landing by moving the throttle from beta to full, but the throttle “stuck.” The airplane subsequently overran the runway and came to rest about 325 ft past the end of the runway. The engine mounts and left wing sustained substantial damage. Examination of the airplane revealed all engine and flight controls were intact from the cockpit controls to their respective control surfaces and functioned normally. In addition, examination of the brakes revealed no anomalies. The throttle lever had no binding and operated smoothly through its full range of motion. The flaps were found in the takeoff position, not in the landing position as they should have been for landing. Postaccident examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. According to the PIM, when configured correctly and using the recommended approach speed of 80 knots, the landing distance on a wet runway would have been about 2,700 ft of the 3,700 ft available.
Probable cause
The pilot’s decision to continue an unstable approach, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SOCATA
Model
TBM-700 C2
Amateur built
false
Engines
1 Turbo prop
Registration number
N48UM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
299
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-20T06:16:26Z guid: 103631 uri: 103631 title: ERA21LA305 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103575/pdf description:
Unique identifier
103575
NTSB case number
ERA21LA305
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-27T20:00:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-09-21T21:39:37.068Z
Event type
Accident
Location
Unionville, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On July 27, 2021, about 1900 central daylight time, an experimental, amateur-built Twin weight-shift control aircraft, N327TT, was substantially damaged when it was involved in an accident near Unionville, Tennessee. The pilot received serious injuries, and the passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was on a local flight with a friend. After departure, he was climbing through 500 ft above ground level when the engine momentarily lost all power. After leveling off, engine power was regained, and he conducted a precautionary landing in a field. The landing was uneventful, but when he applied the brakes, he mistakenly applied the foot throttle. The aircraft accelerated, and he lost directional control. The aircraft collided with a fence post and sustained substantial damage to the airframe. Additionally, the engine sustained impact damage and its fuel lines were destroyed. The aircraft was recovered, and during the examination of the engine, the source of the brief loss of engine power could not be determined. -
Analysis
According to the pilot, during climb out, the engine of the weight-shift control aircraft momentarily lost all power. After leveling off, the engine regained power, and he performed a precautionary landing in a field. The landing was uneventful, but when he applied the brakes, he mistakenly applied the foot throttle. The aircraft accelerated, and he lost directional control. The aircraft impacted a fence post and sustained substantial damage to the airframe. An examination of the engine did not reveal the source of the momentary loss of engine power.
Probable cause
The loss of directional control during a precautionary landing, which resulted in a collision with a fence post.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
TUCKER
Model
Twin
Amateur built
true
Engines
1 Reciprocating
Registration number
N327TT
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17092
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T21:39:37Z guid: 103575 uri: 103575 title: ERA21LA304 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103572/pdf description:
Unique identifier
103572
NTSB case number
ERA21LA304
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-28T09:20:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2021-08-09T22:49:20.708Z
Event type
Accident
Location
Lexington, Kentucky
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On July 28, 2021, about 0820 eastern daylight time, a Boeing B75N1, N1720B, was substantially damaged when it was involved in an accident near Lexington, Kentucky. The private pilot sustained minor injuries and the passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot he departed with 46 gallons of fuel, after flying for 20 minutes, he was at 1,500 ft mean sea level when the airplane began to descend, and he was unable to maintain altitude. The pilot added full power, full mixture, and carburetor heat, but was still unable to maintain altitude. The pilot performed a forced landing to a private driveway. The airplane impacted a telephone pole just prior to touchdown. According to the Federal Aviation Administration (FAA) inspector who responded to the accident site, initial examination of the airplane revealed that the wings sustained substantial damage. All engine and flight controls functioned normally and were verified from the cockpit controls to their respective control surfaces. The magneto switch was jammed in the BOTH position. The inspector was able to manually rotate the propeller with no binding in the engine. The engine was examined on the airframe at a salvage facility by an FAA inspector. The engine was prepped for a field test run and fuel was plumbed into the engine, it started after a few tries, and then ran smoothly with no anomalies noted. At 0854, the weather reported at Blue Grass Airport (LEX), about 11 miles northwest of the accident site, included a temperature of 22°C and a dew point 19°C. The calculated relative humidity at this temperature and dewpoint was 83%. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." According to FAA Advisory Circular 20-113, "To prevent accident due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system." The circular recommended that when operating in conditions where the relative humidity is greater than 50 percent, "…apply carburetor heat briefly immediately before takeoff, particularly with float type carburetors, to remove any ice which may have been accumulated during taxi and runup." It also stated, "Remain alert for indications of induction system icing during takeoff and climb-out, especially when the relative humidity is above 50 percent, or when visible moisture is present in the atmosphere." -
Analysis
The private pilot and passenger were on a local area personal flight in the single-engine airplane. The pilot reported after flying for 20 minutes, he was at 1,500 ft mean sea level when the airplane began to lose engine power and he was unable to maintain altitude. The pilot added full power, full mixture, and carburetor heat, but was still unable to maintain altitude. The pilot subsequently performed a forced landing to a private driveway. A postaccident examination of the wreckage revealed no evidence of preimpact mechanical anomalies that would have prevented normal engine operation. In addition, fuel was plumbed into the engine and the engine ran without anomaly. Although the weather conditions at the time of the accident were conducive to the accumulation of carburetor icing at glide power, the pilot reported that he used carburetor heat, which would have prevented the accumulation of ice.
Probable cause
A loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
B75N1
Amateur built
false
Engines
1 Reciprocating
Registration number
N1720B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-6017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-09T22:49:20Z guid: 103572 uri: 103572 title: ERA21FA308 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103582/pdf description:
Unique identifier
103582
NTSB case number
ERA21FA308
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-29T15:28:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-08-11T00:19:57.278Z
Event type
Accident
Location
Pensacola, Florida
Airport
FERGUSON (82J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On July 29, 2021, about 1428 eastern daylight time, a Ryan Navion A, N114ST, was substantially damaged when it was involved in an accident near Pensacola, Florida. The airline transport pilot and two passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner of the airplane, the airplane departed from his home base, Ferguson Airport (82J), Pensacola, Florida, and he planned to fly to Executive Airport (ORL), Orlando, Florida (about 350 nautical miles away). The pilot stated the airplane was 180 pounds under maximum gross weight (with a useful load of 876 pounds) and that the temperature was “at least 94°F” (the postaccident-computed density altitude was about 2,300 ft). The preflight inspection, engine runup, and associated magneto checks yielded normal results, and the flight control checks were accomplished without any anomalies detected. The pilot calculated that the airplane would need between 2,000 and 2,500 ft of runway to take off. The pilot stated that, during the takeoff roll, the airplane’s acceleration appeared to be “okay” and that the takeoff roll was longer than normal, as he expected. All engine indications and temperatures appeared in the normal operating range. After rotation and initial climb, the pilot retracted the landing gear. According to the pilot, once the gear was up, the engine rpm started decreasing from 2,600 to about 2,300 rpm; the manifold pressure remained normal. When the airplane was at an altitude of about 200 ft mean sea level, the airplane could no longer maintain level flight and descended. The pilot made a right turn to attempt a forced landing on a school’s running track. At the completion of the turn, the pilot realized that the airplane would not make it to the track and told his passengers to brace for impact. The pilot left the landing gear retracted so that he could maintain the airplane’s airspeed. The airplane impacted a tree and a 6-ft-tall chain-link security fence before impacting the school’s parking lot and coming to rest there. A postimpact fire ensued immediately after impact. Witnesses at 82J stated that during the takeoff roll, the airplane engine sounded “rough” and appeared slow. They had previously observed the airplane taking off before but this time it used nearly the entire length of the 3,325 ft runway before becoming airborne. Security camera video from the school showed the airplane from left to right during its initial climb, before the airplane was no longer visible on the video. About 45 seconds later, the video showed the airplane from right to left on the school property. The airplane was in a nose-high pitch attitude and its wings were level during impact. Another on-site security camera captured the postimpact fire. The video showed that the postimpact fire burned for about 10 minutes before being extinguished. The trees and a chain-link security fence were at an elevation of 28 ft and on a heading of about 305°. The paved school parking lot was about 3/4-mile southwest from the departure end of runway 18 at 82J. Wreckage debris and broken tree limbs were scattered along a path that was about 100 ft long and oriented on a magnetic heading of about 310°. The wreckage site was compact, and the engine, airframe structural components, and flight control surfaces were accounted for at the scene. Flight control continuity was confirmed from all flight control surfaces to the cockpit. The fuel tanks were breached during impact. The postimpact fire consumed the inboard half of the right wing, the cockpit, including the instrument panel; and sections of the aft right side of the engine compartment. The accessory section of the engine was extensively heat damaged. Both propeller blades showed little evidence of polishing or chordwise scraping. The propeller spinner was slightly damaged on one side and exhibited little rotational damage. The spark plugs showed no anomalous damage or degradation when compared with the Champion Aviation Check-A-Plug chart. Both left and right magnetos showed impact and thermal damaged, and the internal components exhibited grinding when manually rotated. All internal components appeared to be well lubricated. The oil filter was cut open, which revealed that the pleats were burned, but no ferrous material or other foreign debris was discovered. No metal or material was discovered in the oil sump or engine case. Examination of the airframe and engine revealed no indication of a preimpact mechanical failure or anomaly that would preclude normal operation. -
Analysis
The airline transport pilot and two passengers were departing from the pilot’s home airport for a cross-country flight. According to the pilot, the weather was hot, so he was expecting the takeoff roll to be longer than normal, about 2,000 to 2,500 ft of the 3,225ft runway. The density altitude was computed to be about 2,300 ft, and the airport elevation was 32 ft. After the preflight inspection and engine runup, which the pilot stated were normal, he commenced the takeoff roll. The pilot stated that shortly after rotating, beginning the initial climb, and retracting the landing gear, the engine rpm decreased from about 2,600 to 2,300 rpm, and the airplane was unable to maintain altitude in level flight. As a result, he maneuvered for an off-airport forced landing, during which the airplane impacted a tree and a security fence. A postcrash fire ensued, resulting in significant thermal damage to the engine and its components. Witnesses described that during the takeoff the airplane appeared slow, used more runway than normal for takeoff, and lifted off near the end of the runway. Additionally, a witness reported that the engine sounded “a little rough.” Postaccident examination of the wreckage, which included a complete engine disassembly, revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. As a result, the reason for the partial loss of engine power could not be determined from the available evidence.
Probable cause
A partial loss of engine power during the initial climb, which resulted in a forced, off-airport landing and impact with trees and a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RYAN
Model
NAVION
Amateur built
false
Engines
1 Reciprocating
Registration number
N114ST
Operator
ANTHEM TOWELS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
NAV-4-2021
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-11T00:19:57Z guid: 103582 uri: 103582 title: WPR21LA299 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103594/pdf description:
Unique identifier
103594
NTSB case number
WPR21LA299
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-30T15:23:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-08-16T20:10:15.543Z
Event type
Accident
Location
Tracy, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 30, 2021, about 1423 Pacific daylight time, a Grumman G-164B airplane, N3629F, was substantially damaged when it was involved in an accident near Tracy, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was just beginning his 8th pass over a hay field that was located beneath high-tension power lines. He planned to repeat his previous passes by flying south below the high-tension power lines, which ran diagonally across the field (northeast to southwest) and the flightpath. When the pilot was about midway through the spray pass, he experienced a total loss of engine power accompanied by a vibration; however, the pilot could not recall if the vibration occurred before or after the power loss. The pilot stated that his airspeed was about 130 mph at the time of the power loss but was decaying rapidly. He was unable to enter a climb due to the power lines located overhead. The pilot flew about 10-15 ft above ground level under another set of power lines at the south end of the field to an adjacent field. He then began a shallow right tun to orient the airplane parallel to a series of raised dirt beds. However, during the turn the airplane contacted the ground and several trees. The wings and fuselage were substantially damaged. In a subsequent statement the pilot reported that he was likely running the engine at 70-80% of full power as he was nearing the end of the load at the time and did not require a high power setting. The pilot could not recall the exact position of the power lever. Engine Examination Postaccident examination of the engine revealed that the engine’s rotating group rotated with some resistance but was free to rotate after the planetary gear assembly was removed from the nose cone assembly. Continuity of the direct drive fuel control drive train was confirmed from the fuel control drive shaft to the power shaft. Additionally, evidence of rotational scoring was observed in several locations including the propeller shaft, first stage compressor impeller, second stage compressor impeller, and to the entire turbine rotating group. Compressor shroud metal spray deposits were observed in several locations of the first, second, and third stage turbine rotor blades, and on the first, second, and third stage turbine rotor vanes. Accessory Testing Testing of the fuel control showed that the unit operated outside the manufacturer’s specifications in several areas including fuel flow, the flight idle setting, and various test points. However, according to the manufacturer, none of the tests that were beyond specifications would have been contributing factors in a loss of power event. Testing of the fuel pump also did not reveal any anomalies. The propeller governor was tested, and both the maximum rpm and minimum rpm were beyond their normal limitations. Additionally, the arm travel range was out of limits. According to the manufacturer, the test data were the results of typical adjustments made to the propeller governor in the field and the operational testing showed that the unit was functioning properly at the time of the accident. Fuel Solenoid Shutoff Valve with Manual Override The engine was equipped with a fuel solenoid valve to introduce fuel to the engine when the speed switch is actuated during engine start and to cease fuel delivery when the stop switch is actuated. When the valve is open, fuel passes through a ball valve and out to the fuel atomizers. The manual override lever and shaft at the upper end of the valve is connected to the manual stop and feather lever in the cockpit. The valve can be opened and closed electrically but cannot be opened manually. An examination of the valve revealed that the scribe mark on the end of the override shaft was positioned at the top of the valve, consistent with an OPEN position. Low pressure air was applied to the fuel inlet port of the valve, which did not pass through the valve, consistent with the ball valve being in the CLOSED position. According to the manufacturer, the CLOSED position of the ball valve would prevent fuel flow to the engine fuel nozzles. The manufacturer noted that the closed position of the ball valve is inconsistent with the findings of metal spray in the turbine section, which indicates the engine was rotating and fuel was being delivered to the engine to generate a flame at the time of impact. However, according to the manufacturer, these opposing findings can only exist if the fuel shutoff valve closed at impact, either through pilot intervention, an electrical short, or inertial movement during the impact sequence. Removal of the beta tube required 18 – 18.5 turns, which was consistent with the turns required in another propeller/engine configuration and consistent with normal alignment. Propeller According to the propeller manufacturer, no visible discrepancies were noted that would have degraded normal operation prior to impact. The blades remained in their respective clamps and no slippage was noted. All three pilot tubes were intact and minimal blade-to-hub contact marks were observed. Some deformation was observed on one of the drive dowel holes in the direction of rotation. All three propeller blades exhibited chordwise/rotational scoring on the camber-side near the tip. Blade No. 2 displayed some S-bend characteristics and an approximately 3-inch-long tip fracture, which was not recovered. Blade Nos. 2 and 3 exhibited some bending opposite the direction of rotation and twisting towards the low pitch. Some scuffing and abrasions were present on each of the blade faces with no evidence of rotational scoring. Maintenance records showed that the propeller’s most recent overhaul took place in 2012. A work order from that overhaul showed that the blade angles were set to 30 inches radius, and the manufacturer noted this angle was consistent with published guidance. Lock Brackets, Start Lock Plates, and Piston All three start lock brackets were fractured and the start lock plates displayed signatures consistent with forceful impact with the start lock pin. According to the propeller manufacturer, the counterweight puncture in the spinner dome was consistent with a low blade angle when the spinner impacted terrain and the signatures on the start lock bracket indicated forceful contact in the high pitch direction. The start lock pins were actuated by a hand tool and when the blade/clamp assemblies were rotated only blade No. 2 would intermittently lock near the start lock angle. Both the blade No. 1 and blade No. 2 start lock plates passed by the displaced pin/bracket without locking. Marks on the piston/cylinder showed a mark about 1.85 inches from the bottom of the piston consistent with an approximate blade angle of -1° and a start lock angle of about 2.0°. Another mark located about 2.35 inches from the bottom of the piston was consistent with an estimated blade angle of about 15.6°. Finally, a mark about 1.9 inches from the top of the cylinder was consistent with an approximate blade angle of -1° to 0.7° and corresponded with the piston marks and the blade damage and near the start lock angle. -
Analysis
The pilot reported that he was performing a low-level agricultural pesticide application on a hay field when the engine suddenly lost all power. Although the airplane was at a high airspeed at the time, the pilot was unable to climb due to the presence of high-tension powerlines above him in his flightpath. During the subsequent descent, he flew beneath a set of powerlines, turned, and landed in a field after his airspeed had decreased. During the landing, the airplane contacted the ground and trees, which resulted in substantial damage to the fuselage and wings. Postaccident examination of the engine and accessories did not reveal any mechanical anomalies that could have precluded normal operation. Evidence of rotational scoring and metal spray deposits in the engine indicate that it was operating at the time of impact. The fuel solenoid shutoff valve was in the CLOSED position, which would have prevented fuel flow to the engine. However, due to the overwhelming evidence that the engine was rotating at the time of impact, it is likely that the shutoff valve moved to the CLOSED position as a result of the impact. Propeller signatures indicated that the blades impacted the ground while rotating at low power. An examination of the propeller did not reveal any visible discrepancies that would have affected performance prior to impact. The damage to the start lock brackets, start lock plates, and a contact mark on the internal surface of the piston suggest the propeller was on or below the start lock angle at impact. This was likely the result of impact forces, as the pilot stated that he did not reduce throttle input or attempt to feather blades before impact. Previous maintenance indicated that the blade radius was properly set. The pilot did not recall the power lever position at the time of the power loss and the investigation did not reveal any evidence of preimpact mechanical malfunctions or failures. Therefore, the reason for the pilot’s reported loss of power could not be determined.
Probable cause
A loss of thrust during a low-level agricultural application flight, which resulted in a descent and impact with terrain. The reason for the loss of thrust could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SCHWEIZER AIRCRAFT CORP
Model
G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N3629F
Operator
Haley's Flying Service
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
745B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-16T20:10:15Z guid: 103594 uri: 103594 title: CEN21LA346 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103600/pdf description:
Unique identifier
103600
NTSB case number
CEN21LA346
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-30T15:40:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-08-04T17:10:29.652Z
Event type
Accident
Location
Briggs, Texas
Airport
FLF Gliderport (TX23)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On April 23, 2012, the glider manufacturer issued Service Bulletin No. G304C-06a_R01, applicable for glider models G304C, G304CZ and G304CZ17. The service bulletin did not apply to the accident glider model (304S) despite it having a similar vertical stabilizer and elevator control design. The service bulletin described the possibility of water intrusion into the elevator control tube resulting in corrosion and failure. The corrective actions were, in part, to verify if the elevator control tube had a drainage hole and, if not, to conduct a pull test, every 12 months, to determine if the control tube required replacement. Additionally, if the glider had a rubber sealing boot at the top of the vertical stabilizer, the elevator control tube was to be replaced no later than December 31, 2012. If the glider did not have a rubber sealing boot, the control tube was to be replaced no later than December 31, 2013. After the accident, on October 5, 2021, the glider manufacturer issued Service Bulletin No. G304S-12b for glider models G304S (accident glider), G304MS, and G304eS. The corrective actions are similar, but not identical, to the service bulletin issued in April 2012. Service Bulletin No. G304S-12b requires, in part, a pull test on the control tube, regardless of the presence of a drain hole condition, and to replace the control tube if there is any change in length. Additionally, the service bulletin requires a visual check for a drain hole at the clevis end of the control tube and to check throughput of the drainage hole. If no drainage hole is present, a borescope should be used to inspect the inner surface of the control tube by entering through the top threaded hole. If the borescope inspection reveals internal corrosion, the control tube is to be replaced within one month. If no corrosion is observed, the inspection is to be repeated every 12 months until the tube is replaced. The service bulletin stipulated that the elevator control tube be replaced no later than December 21, 2022. Additionally, Service Bulletin No. G304S-12b required a surface sealing and corrosion prevention compound be inserted inside the control tube when installing a new control tube with a drainage hole at the clevis fitting or when an existing control tube is modified with a drainage hole, the installation of shrink tubing to cover the witness hole at the upper end of the control tube, and to trim the rubber sealing boot to prevent water accumulation. - According to the maintenance logbook, on July 6, 2021, the glider was inspected and found to be in an airworthy condition. The aviation mechanic with inspector authorization noted in the corresponding logbook entry that he had “checked controls” and that the condition inspection had been completed in accordance with Federal Aviation Regulations Part 43, Appendix D. - On July 30, 2021, about 1440 central daylight time, a HpH, Spol. S.R.O Glasflügel 304S experimental glider, N304AB, was substantially damaged when it was involved in an accident near Briggs, Texas. The pilot was seriously injured. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot of the tow plane, shortly after takeoff and while the tow plane was about 300 ft above the runway, the glider unexpectedly released from the towline. The glider entered a left turn and landed in a wings-level attitude. The tailboom separated from the aft fuselage during the landing. The tow airplane and the towline were not damaged during the event. - The experimental glider was equipped with a T-tail empennage. The elevator is controlled, in part, by a steel control tube, part number 304S-46-12, installed inside the vertical stabilizer in a vertical orientation. The upper end of the control tube terminates with a rod end bearing and the lower end of the control tube terminates with a clevis fitting. A rubber sealing boot is installed over the control tube at the upper end. Postaccident examination revealed the elevator control tube fractured about 0.75 inch above the clevis fitting located at the lower end of the control tube, and there was a large longitudinal fracture/hole near the upper end of the control tube. The elevator control tube was further examined by the National Transportation Safety Board Materials Laboratory, Washington, D.C. The control tube fractured in the circumferential direction at two locations at the lower end adjacent to the clevis fitting, as shown in figure 1 and figure 2. The fractures were coplanar with the upper and lower faces of a plug of corrosion product that had filled most of the inner cavity and measured between 0.35 inch and 0.60 inch in length. The fracture surfaces exhibited features consistent with overstress and loss of wall thickness due to corrosion. There was no evidence of a drain hole in the clevis fitting at the lower end of the control tube, as shown in figure 3. Figure. Fracture of elevator control tube near the clevis fitting. Figure 2. Fracture of elevator control tube near the clevis fitting. Figure 3. Clevis fitting without drain hole. The control tube was also fractured in the longitudinal direction near the upper end of the rod, as shown in figure 4 and figure 5. The midpoint of the fracture was about 2.2 inch from the upper end of the tube and it extended about 1.6 inch in the longitudinal direction. The fracture surfaces were corroded as was the inner surface of the tube and the surrounding paint was bubbled and stained. The tube material bulged outward on either side of the fracture. The fracture features were consistent with internal corrosion and an overstress fracture. The outside of the tube above the longitudinal fracture exhibited a dark stain over a length of about 0.87 inch, as shown in figure 6, consistent with contact with the collar of the rubber sealing boot. The stain extended just above the level of the witness hole. Internal corrosion was observed along the entire length of the rod, as shown in figure 7 and figure 8. Figure 4. Fracture of control tube near the upper end. Figure 5. Fracture of control tube near the upper end. Figure 6. Upper end of control tube. Figure 7. Inner surface of control tube near the clevis fitting fracture. Figure 8. Inner surface of control tube about midspan. -
Analysis
The pilot was departing on a local flight in the experimental glider when the glider unexpectedly separated from the towline shortly after liftoff. The glider then entered a left turn and landed in a wings-level attitude. The tailboom was substantially damaged during landing. The tow airplane and the towline were not damaged during the event. Postaccident examination determined that the elevator control tube installed in the vertical stabilizer was corroded along the entire length of its inner surface, reducing its wall thickness. Water likely entered the control rod, either through a witness hole near the upper end of the control tube or as moisture carried in by humid air. There was no drain hole at the bottom end of the control tube and, as a result, there was no way for liquid water to drain out of the control tube. The wall thickness eventually thinned sufficiently to cause the tube to burst in the longitudinal direction near its upper end. After the control tube burst, the resulting hole on the side of the tube allowed for the easy ingress of water that made its way past the boot seal. The corrosion product and standing water at the base of the tube eventually reduced the tube wall thickness to a point where it could no longer withstand the typical operational loads and subsequently fractured in overstress near the clevis fitting during the accident flight. The overstress failure of the control tube prevented the pilot’s control of the elevator during the accident flight. The last condition inspection of the glider was completed 24 days before the accident. The corresponding logbook entry noted that the flight controls were inspected, and that the glider was in an airworthy condition. The longitudinal fracture near the upper end of the elevator control tube would have been readily visible with the rubber boot removed and, as such, it is likely the mechanic did not remove the rubber boot to adequately inspect the elevator control tube during the last condition inspection.
Probable cause
The overstress fracture of the elevator control tube due to reduced wall thickness from water intrusion and subsequent corrosion. Contributing to the accident was the lack of a drain hole at the bottom of the elevator control tube, which allowed the tube to collect water, and the mechanic’s inadequate inspection of the elevator control system during the recent condition inspection.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
HpH, Spol. S.R.O.
Model
Glasflügel 304S
Amateur built
false
Engines
1 Turbo jet
Registration number
N304AB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
004-S
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-04T17:10:29Z guid: 103600 uri: 103600 title: ERA21LA309 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103595/pdf description:
Unique identifier
103595
NTSB case number
ERA21LA309
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-30T17:25:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-08-06T16:59:43.733Z
Event type
Accident
Location
Colchester, Vermont
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 30, 2021, about 1625 eastern daylight time, an Enstrom 280FX helicopter, N36DK, was destroyed when it was involved in an accident near Colchester, Vermont. The commercial pilot sustained serious injuries. The helicopter was operated by Beta Air LLC as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed for a proficiency flight from Plattsburgh International Airport (PGB), Plattsburgh, New York, to Burlington International Airport (BTV), Burlington, Vermont. While enroute to BTV, the pilot “noticed something burning” and then “observed smoke in the cockpit.” He also observed a rapidly rising exhaust gas temperature despite moving the mixture to full rich and initiated a precautionary landing during which the helicopter lost partial and then total engine power. The pilot subsequently completed an autorotation landing on the Lake Champlain Causeway, striking trees before coming to rest on the road and rocks that lined the causeway. The pilot stated that, once he exited the helicopter, he saw flames and smoke coming from the engine compartment. He did not observe any fuel leaking onto the ground. According to a witness who was walking along the causeway, she heard something that sounded like a car accident and saw that the helicopter had impacted the causeway. She observed smoke emanating from the rear of the helicopter and saw the pilot evacuate from the wreckage. She helped the pilot move farther away from the helicopter and, shortly thereafter, saw fire consuming the helicopter (see the figure below). Figure. Helicopter fire (Source: social media site). Postaccident examination of the engine revealed significant soot and thermal damage. The heaviest area of thermal damage was located around the No. 3 cylinder near the turbocharger. The outer portion of the turbocharger displayed significant thermal damage. The turbocharger exhaust and inlet clamps were intact and remained tightly installed with safety wires present. The turbocharger was partially disassembled, and the interior displayed no evidence of thermal damage. The flexible fuel and oil lines displayed significant thermal damage, and some were destroyed by fire. It was not possible to evaluate the lines for possible leakage due to the extensive thermal damage. The metal fuel lines were found securely connected to their respective attach points. Several oil lines were located near fire damage in the forward left portion of the engine compartment, where the thermal damage was most severe. Maintenance records revealed that, on March 12, 2021, the helicopter’s engine was replaced, and all fuel and oil hoses were replaced with new hoses. The helicopter had flown about 200 hours since this maintenance. On May 13, 2021, an annual inspection was completed, and the engine was found to be in an airworthy condition. -
Analysis
The commercial pilot reported that while enroute he smelled and then observed smoke in the cockpit. He also observed a rapidly rising exhaust gas temperature despite moving the mixture to full rich. The pilot initiated a precautionary landing during which the helicopter experienced a partial and then total loss of engine power. During the final segment of the autorotation, the helicopter impacted trees and landed hard on a causeway. Postaccident examination of the engine found significant soot and thermal damage, which precluded a determination of the specific source of the in-flight engine fire. However, one cause of the fire could be eliminated. Specifically, the heaviest area of thermal damage was located around the No. 3 cylinder near the turbocharger. The outer portion of the turbocharger displayed significant thermal damage, but the turbocharger exhaust and inlet clamps were intact and remained tightly installed with safety wires present. Therefore, leakage of exhaust gases from the turbocharger was not the cause of the in-flight fire. The external damage to the turbocharger indicated that its high temperature surfaces were possible ignition sources for an ignitable liquid, such as lubricating oil or fuel. The flexible fuel and oil lines all displayed significant thermal damage, and some were destroyed by fire. Several oil lines were located near the thermal damage in the forward left portion of the engine compartment. Therefore, lubricating oil from these lines was a possible fuel source for the fire. In addition, because the flexible fuel lines were either damaged or destroyed, fuel from these lines could not be eliminated as a source of fuel for the in-flight fire.
Probable cause
An in-flight fire originating in the engine compartment near the turbocharger from a source that could not be determined, which resulted in a loss of engine power and led to an autorotation and a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ENSTROM
Model
280
Amateur built
false
Engines
1 Reciprocating
Registration number
N36DK
Operator
BETA AIR LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2003
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-06T16:59:43Z guid: 103595 uri: 103595 title: ERA21LA310 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103598/pdf description:
Unique identifier
103598
NTSB case number
ERA21LA310
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-31T10:53:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-08-02T16:46:42.617Z
Event type
Accident
Location
Middletown, New York
Airport
RANDALL (06N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 31, 2021, about 0953 eastern daylight time, a Liteflite PTY LTD Dragonfly Model C airplane, N799HG, was substantially damaged when it was involved in an accident near Middletown, New York. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 glider tow flight. According to the tow pilot, the first flight of the day to check for convective activity at Randall Airport (06N), Middletown, New York, was uneventful. He parked the airplane; a hang glider was hooked up and he performed a normal takeoff. At about 50 ft above ground level, the engine lost total power. He immediately lowered the airplane’s nose; however, “there was too much drag from the tow line and the airplane stalled and pancaked to the ground.” After the airplane struck the ground, the engine regained power, and the airplane then ground looped and struck a snowplow parked on the ramp. The pilot of the hang glider being towed reported that as the tow line went slack, the airplane appeared as though it was stalling, and he then disconnected the tow line and landed safely. The owner of the airplane witnessed the accident and reported that during the climbout, the engine sputtered, the airplane "stalled," and full engine power was restored before the airplane struck the ground. An initial examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the fuselage boom tube sustained substantial damage. However, the inspector reported that the airplane had previously been partially dissembled by the operator without authorization, prior to his initial examination. The engine was subsequently examined under the supervision of an FAA inspector. When the inspector reached over the top of the engine to verify the engine serial number, the right side carburetor (one of two) fell out of its mounting. The inspector noted a loose securing clamp and a disconnected anti-vibration spring, and the carburetor was being held up by the throttle cable. The engine displayed no indications of excessive leakage of oil or fuel. The electric fuel pump was found disconnected. The spark plugs were removed and visually examined. The upper and lower spark plugs of cylinder Nos. 1 and 3 revealed rich fuel mixture, all spark plugs were found to be overtorqued without lubrication on threads and the upper spark plug terminal of the cylinder No. 1 was found bent after removal of the spark plug wire. Compression and suction were achieved on all cylinders. -
Analysis
The tow pilot reported that the first flight of the day was to check for convective activity and was uneventful. After a hang glider was hooked up to the airplane, the pilot performed a normal takeoff. During the initial climb, the engine lost total power about 50 ft above ground level and although the pilot immediately lowered the airplane’s nose, he stated that “there was too much drag from the tow line and the airplane stalled and pancaked to the ground.” The hang glider pilot reported that when he noticed slack in the town line, he disconnected, and landed safely. The engine subsequently regained power and the airplane impacted the ground and was substantially damaged during the subsequent ground loop and impact with a parked snowplow. A postaccident examination of the engine revealed that a clamp securing one of the two carburetors was loose, and its anti-vibration spring was found disconnected. This condition may have led to erratic engine performance including sputtering, surging, and loss of power. No other mechanical discrepancies were discovered during the examination. Based on this information, it is likely that the loss of engine power was due to the discrepancies noted with the carburetor.
Probable cause
The improper installation of the carburetor, which resulted in a momentary total loss of engine power during initial climb. Contributing was the pilot’s failure to maintain control of the airplane following the initial power loss.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LITEFLITE PTY LTD
Model
DRAGONFLY MODEL C
Amateur built
false
Engines
1 Reciprocating
Registration number
N799HG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Glider tow
Commercial sightseeing flight
false
Serial number
099
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-02T16:46:42Z guid: 103598 uri: 103598 title: CEN21FA345 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103599/pdf description:
Unique identifier
103599
NTSB case number
CEN21FA345
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-07-31T12:30:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-08-04T23:48:11.857Z
Event type
Accident
Location
Hartford, Wisconsin
Airport
HARTFORD MUNI (HXF)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On July 31, 2021, about 1130 central daylight time, a Piper J3C-65 airplane, N42522, was substantially damaged when it was involved in an accident near Hartford, Wisconsin. The flight instructor was fatally injured and the pilot receiving instruction was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot receiving instruction reported that they were practicing takeoffs and landings from runway 27 at the Hartford Municipal Airport (HXF) and had performed about 10 before the accident occurred. On the accident takeoff, when the airplane reached 400-500 ft agl, the instructor said, “engine failure, turn around for 09”. The instructor did not state if it was an actual or simulated engine failure. Both pilots were on the controls at this time and started a turn for runway 9 when the airplane entered a “graveyard spin.” He remembered about 1 to 2 seconds of the spin and had no further recollection of the accident. The airplane impacted a bean field about 1,100 ft west of the departure end of runway 27. Based on airframe damage signatures, the airplane impacted in a left-wing low, nose low attitude, with the airplane coming to rest about 35 ft west of the initial impact point. A postaccident examination of the airplane confirmed flight control system continuity from the cockpit controls to all control surfaces. There were no separations in any of the flight control cables. The left-wing spars were broken at the wing root, but the remainder of the wing was predominately intact. Both left lift struts were bent and remained attached at the fuselage and wing. The right wing remained attached to the fuselage with little damage. Both right lift struts were bent and remained attached to the fuselage and wing. The forward lower fuselage at the firewall was pushed rearward. The engine remained attached to the fuselage. One propeller blade was bent aft and under the engine, and the crankshaft was partially separated just aft of the propeller flange. Examination of the engine confirmed internal continuity, and both magnetos provided a spark on all spark plug leads. All spark plugs were examined, and no anomalies were noted. The front of the cabin area was crushed rearward and upward at the firewall, but the deformation was limited to the area where the front pilot would have placed their feet. The top of the instrument panel was bent forward, consistent with the front pilot impacting it during the accident sequence. The flight instructor in the front seat suffered fatal injuries attributed to blunt force trauma to the head by the medical examiner. The student pilot in the rear seat sustained serious head and torso injuries, including loss of consciousness, lumbar and rib fractures, and broken ulna and radius. When originally manufactured, the airplane was equipped with lap seat belts but did not have shoulder harnesses installed and no shoulder harnesses had been retrofitted to the airplane. A National Transportation Safety Board survival factors specialist used anthropometric data, photographic evidence, manufacturer drawings, and measurements taken from the accident scene to determine the occupant trajectories in the event of an accident both with and without shoulder harnesses installed. The study showed that both occupants were likely to impact their head and upper torso on structures located within the airplane’s cabin when restrained only by a lap belt. The addition of an upper torso restraint (shoulder harness) would likely have lessened the severity of the injuries by altering the body trajectories such that impact forces with objects within the cabin were eliminated or lessened. Effective July 18, 1977, Section 23.785 of 14 CFR Part 23 required all normal aircraft, for which application for type certificate was made on or after July 18, 1977, to have approved upper torso harnesses for each front seat. Section 14 CFR Part 91.205(b)(14) required all small civil airplanes manufactured after December 12, 1986, to have an approved upper torso harness for all seats. However, aircraft that were manufactured before that date were not required to have an upper torso restraint installed. In 1981 the NTSB initiated a multi-part general aviation crashworthiness program (NTSB Safety Report SR8301). The NTSB examined accidents and their effects on the occupants and airplane structure for the purpose of upgrading occupant protection design standards. In the second report in this program (NTSB Safety Report SR8501), the NTSB found that 20 percent of the fatally injured occupants in those accidents could have survived with upper torso harnesses (assuming the seatbelts were fastened properly) and 88 percent of the serious injuries could have significantly less severe injuries with the use of upper torso harnesses. The NTSB concluded that upper torso harness use was the most effective way of reducing fatalities and serious injuries in general aviation accidents. As a result of the program the NTSB issued safety recommendation A-85-124 recommending the FAA issue an advisory circular to provide information on crash survivability aspects of small aircraft. In March 1987, Technical Standard Order (TSO) C114, “Torso Restraint Systems,” was issued by the FAA. The TSO prescribed the minimum performance standards that upper torso harness restraint systems must meet to be identified with a TSO marking. Then on September 19, 2000, the FAA issued policy statement number ACE-00-23.561-01, “Methods of Approval of Retrofit Shoulder Harness Installation in Small Airplanes.” This provided guidance to make it easier to retrofit shoulder harnesses in certificated aircraft by making it a “minor change” if the following criteria were met: The aircraft was manufactured before July 19, 1978, for front seats and Dec. 12, 1986, for rear seats. TSO-C114 belts were used. No drilling or welding had been performed. The mechanic doing the install consulted Advisory Circular 43.13-2A, Chapter 9, for information on restraint systems, effective restraint angles, attachment methods, and other details of installation. The installing mechanic made an entry in the aircraft's maintenance log. If drilling or welding was required, then a supplemental type certificate or field approval was required to make the modification. At the time of this accident several manufacturers offered shoulder harness kits that could be retrofit to the accident airplane under supplemental type certificate. -
Analysis
The pilot receiving instruction reported that they had performed about 10 practice takeoffs and landings before the accident takeoff. On the accident takeoff, when the airplane reached an altitude of 400-500 ft above ground level (agl), the instructor said, “engine failure, turn around for 09”. The pilot receiving instruction later reported that it was unclear from the instructor’s statement whether it was an actual or a simulated engine failure. Both pilots were on the flight controls at the time and started a turn when the airplane entered a “graveyard spin”. The pilot receiving instruction remembered about 1 to 2 seconds of the spin and had no further recollection of the accident. Examination of the flight controls and engine did not reveal any preimpact anomalies that would preclude normal operation. Based on the surviving pilot’s description and the airplane damage signatures, the airplane was in a nose-low, left-wing low attitude at impact. It is likely that the airplane entered an inadvertent stall/spin when the critical angle of attack was exceeded. The surviving pilot was not sure if the airplane’s engine had actually lost power or if the flight instructor was simulating an engine emergency. The lack of engine-related mechanical anomalies and the pilot training purpose of the flight suggest that it was likely a simulated emergency scenario initiated by the flight instructor. The airplane was not equipped with shoulder harnesses and only lap seat belts were installed. Regulations did not require shoulder harnesses to be installed at the time it was manufactured. However, at the time of the accident, several manufacturers offered shoulder harnesses kits that could be retrofitted to the airplane under supplemental type certificate. The investigation determined that the injuries to the occupants were consistent with the use of only lap seat belts. The availability of shoulder harnesses would likely have reduced the severity of the injuries.
Probable cause
The flight crew’s exceedance of the airplane’s critical angle of attack during a simulated engine failure during initial climb after takeoff, which led to an aerodynamic stall/spin and loss of control. Contributing to the severity of the occupants’ injuries was the airplane’s lack of shoulder harnesses.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N42522
Operator
Cub Air Flight LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
14795
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-04T23:48:11Z guid: 103599 uri: 103599 title: WPR21FA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103602/pdf description:
Unique identifier
103602
NTSB case number
WPR21FA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-01T13:51:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-08-11T00:15:19.935Z
Event type
Accident
Location
Colusa, California
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
The FAA’s Helicopter Flying Handbook describes low-G conditions and mast bumping, stating in part the following: Helicopters with two-bladed teetering rotors rely entirely on the tilt of the thrust vector for control. Therefore, low-G conditions can be catastrophic for two-bladed helicopters.… Abrupt forward cyclic input or pushover in a two-bladed helicopter can be dangerous and must be avoided, particularly at higher speeds. During a pushover from moderate or high airspeed, as the helicopter noses over, it enters a low-G condition. Thrust is reduced, and the pilot has lost control of fuselage attitude but may not immediately realize it. Tail rotor thrust or other aerodynamic factors will often induce a roll. The pilot still has control of the rotor disk, and may instinctively try to correct the roll, but the fuselage does not respond due to the lack of thrust. If the fuselage is rolling right, and the pilot puts in left cyclic to correct, the combination of fuselage angle to the right and rotor disk angle to the left becomes quite large and may exceed the clearances built into the rotor hub. This results in the hub contacting the rotor mast, which is known as mast bumping…and the energy and inertia in the rotor system can sever the mast or allow rotor blades to strike the tail or other portions of the helicopter. The handbook included an illustration that depicted the hub contacting the rotor mast, as a result of improper corrective action in a low-G condition (figure 6). Figure 6. Result of improper corrective action in a low-G condition - Review of the helicopter’s airframe and engine logbooks revealed that, at the time of the most recent annual inspection, the helicopter had a Hobbs meter time, an airframe total time, and an engine total time of 378.2 hours. The helicopter was not equipped with any onboard devices that would have recorded airspeed, altitude, yaw, pitch, roll, or flight control positions. - On August 1, 2021, about 1251 Pacific daylight time, a Robinson Helicopter Company R66, N7000J, was substantially damaged when it was involved in an accident near Colusa, California. The pilot and three passengers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Recorded automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that, about 1207, the helicopter departed Willows, California, and flew toward the foothills that bordered the western edge of the valley. The ADS-B data also showed that the helicopter turned south while over Elk Creek, California, and overflew Lodoga and Stonyford, California, before turning to the east. The helicopter continued an easterly heading for about 12 minutes and then turned to a southeasterly heading. The helicopter remained on a southeasterly heading for about 2 minutes and then initiated a left turn to an easterly heading when the helicopter was about 0.7 miles west of the accident site, as shown in figure 1. The last recorded data point showed that the helicopter was about 392 ft west of the accident site. The ADS-B data contained no altitude data for the entire flight. Figure 1. ADS-B flight track for the accident flight. A witness, who was driving south on a highway about 0.5 miles east of the accident site, reported that he noticed a helicopter flying on an easterly heading about 50 to 100 ft above ground level. The witness stated that the helicopter was initially straight and level but then suddenly made a sharp left turn. The witness briefly lost sight of the helicopter due to trees; when he re-established visual contact, he observed the helicopter “sharply diving,” and the helicopter then impacted terrain. - Examination of the accident site revealed that the helicopter impacted a tomato field. Wreckage debris was scattered among an area that measured 360 ft by 392 ft, as depicted in figure 2. Figure 2. Wreckage diagram of debris area. A portion of the main rotor blade was located on the western edge of the debris area. The right door was located about 161 ft southeast of the main rotor blade portion. About 112 ft south of the right door, the outboard portion of one blade was found. A ground impression that was about 16 ft long, 8 inches wide, and in a “U” shape was located about 8 ft east of the outboard section of the main rotor blade. The main rotor gearbox and main rotor assembly were located about 5 ft east of the ground impression. The forward left and right control tubes along with their respective servos and the servo mount structure were located about 3 ft west of the main wreckage. The engine was separated from the fuselage and located adjacent to the fuselage. Examination of the airframe revealed that the lower windshield frame on the forward lower right area of the fuselage exhibited a dent at the separation edge that was consistent with the size and shape of the leading edge of a main rotor blade. The aft section of the fuselage exhibited buckling, compression, and crushing. The cabin area was separated behind the forward seatbacks and was tethered by various wires. The tailcone was separated at the forward end. The empennage was separated from the tail cone. The driveshaft from the engine to the gearbox was separated near the engine and exhibited twisting with tortional fractures. Cyclic and collective control continuity was established, but multiple separations consistent with overload were observed throughout the systems. The forward left and right control tube attachment hardware at the nonrotating swashplate was not located at the accident site or within the recovered wreckage. All three control tubes from the servo to the swashplate remained intact with some slight bends and scratches, as shown in figure 3. Figure 3. Nonrotating swashplate area and both upper areas of the left and right control tubes. The tail rotor controls were separated in multiple areas. All areas of separation were consistent with impact damage and/or overload separation. The main rotor blades exhibited varying degrees of damage and were fractured in various areas, as shown in figure 4. Figure 4. Red and blue main rotor blades. The engine was separated from the airframe. The turbine module and fuel control unit were fractured and separated from the gearbox. N1 and N2 rotated freely by hand. The upper magnetic chip detector was free of ferrous debris. The lower magnetic chip detector was not located. The turbine module was disassembled for examination. The gas generator turbine turned freely by hand. The power turbine remained locked in position due to impact damage. The second, third, and fourth stage turbine air foils were intact and undamaged. The engine monitoring unit was located within the wreckage, and all stored data were downloaded. The data showed that the engine was operating at the time of the accident, which can be seen in figure 5. Figure 5. Downloaded engine data for the accident flight. No evidence of any pre-existing mechanical anomalies were noted with the engine. The main rotor mast assembly, swashplate assembly, flight control servos, flight control upper push-pull tube assemblies, and mast fairing ribs were sent to the NTSB Materials Laboratory for further examination. The main rotor mast was bent aft, and the pitch change links were fractured on slant planes consistent with ductile overstress fracture. The tube assembly attached to the mast fairing upper rib was separated at the riveted joint just above the mast fairing rib. The rivets on the forward side of the tube assembly were sheared, and the tube portion above the fractured joint was rotated aft. The left and right upper flight control push-pull tubes were bent, and fasteners attaching the left and right control tubes to the lower swashplate assembly were missing. On the control servos, pieces of the lower flight control push-pull tubes were attached at the lower end with fractures on slant planes consistent with ductile overstress fracture. Mounting frame pieces on the control servos also had fractures on slant fracture planes consistent with ductile overstress fracture. The mast fairing ribs were deformed, and contact damage was observed at the edges of through-holes for the flight control upper push-pull tubes. The forward left and right control attachment lugs on the swashplate were cleaned and examined. No substantial thread imprints were observed on the bores of the attachment holes on the lugs. Remnants shaved from the attachment bolt were located on the lower forward half of the lug at the left side of the hole, and the area between the bolt remnants was rubbed. The lower portion of the lug with the attachment bolt remnants was examined using a scanning electron microscope. The lower portion of the bolt remnant exhibited dimple features consistent with ductile overstress fracture. -
Analysis
The pilot was conducting a personal flight during daytime visual flight rules conditions with three passengers aboard. A witness who was driving on a nearby highway observed the helicopter flying on an easterly heading about 50 to 100 ft above ground level. The witness stated that the helicopter was initially straight and level but had suddenly made a sharp left turn. The witness briefly lost sight of the helicopter due to trees; when he reestablished visual contact, he observed the helicopter descend and impact terrain. Postaccident examination of the helicopter revealed no evidence of any pre-existing mechanical malfunction that would have precluded normal operation. The forward left and right control tube attachment bolts at the nonrotating swashplate were not located at the accident site or within the recovered wreckage. The flight control bolts most likely separated during the accident sequence as a result of an overstress fracture. No evidence of preexisting loosening of the attachment nuts, such as substantial thread imprints in the lug bores, was observed. This damage was consistent with the blade grips contacting the mast, commonly referred to as mast bumping, which occurs due to excessive flapping motion of rotor blades (specifically, up-and-down motion of the blade tips). It is likely that, during the flight, the pilot made an abrupt flight control input that resulted in a main rotor blade contacting the tailboom and a subsequent in-flight breakup. The reason for the pilot’s abrupt control inputs could not be determined.
Probable cause
The pilot’s abrupt flight control input that led to mast bumping and a subsequent in-flight breakup.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER CO
Model
R66
Amateur built
false
Engines
1 Turbo shaft
Registration number
N7000J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0411
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-11T00:15:19Z guid: 103602 uri: 103602 title: WPR21LA301 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103608/pdf description:
Unique identifier
103608
NTSB case number
WPR21LA301
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-02T10:30:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-08-11T21:17:05.513Z
Event type
Accident
Location
Amado, Arizona
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 2, 2021, about 0930 mountain standard time, a Piper PA-28-140 airplane, N44245, was substantially damaged when it was involved in an accident near Amado, Arizona. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while in level cruise flight, about 6,000 ft mean sea level, the airplane suddenly started vibrating. He checked the magneto switch and looked over the instruments for any cylinder anomalies and found none. He decided to shut down the engine to stop the vibrations. Soon after shutting down the engine, he said that he was committed to force land in a nearby field. He stated that, while preparing for the forced landing, he was too fast and tried to make it to the next field that was situated over the next tree line and fence. During the landing, he impacted a tree with the right wing and subsequently landed hard in a muddy field. The airplane’s nose landing gear collapsed during the landing, and the pilot and pilot-rated passenger were able to exit without injury. Examination of the accident site photos revealed that the right wing remained attached to the rear spar, separated at the main spar near the wing root and was bent upwards. The outboard right wing was buckled, and the leading edge had circular impact damage. The fuselage was buckled near the firewall and near the empennage. One of the propeller blades was separated about 5 inches outboard of the blade root. The separated propeller blade portion was not found during the investigation. The remaining propeller blade section was retained for further examination. Review of the propeller logbooks revealed that the propeller was installed on the accident airplane on March 17, 2020, with 116.1 hours of operation since overhaul. The last annual inspection was completed on April 10, 2021. At the time of the accident, the propeller had about 245 hours of operation since overhaul. Examination of the propeller blade section by the National Transportation Safety Board Materials Laboratory revealed that the propeller exhibited a fatigue crack that initiated near the trailing edge of the blade. Red transfer marks were found near the trailing edge of the blade. The fatigue crack initiated at multiple sites along the blade face surface adjacent to the trailing edge. The edge area exhibited indications of copper, as well as iron and manganese. These indicate material transfer from an alloy dissimilar to that of the blade’s material. -
Analysis
The pilot reported that during the flight, the airplane suddenly started vibrating. After checking the magneto switch and looking over the instruments for any cylinder anomalies, he shut down the engine. The pilot initiated a forced landing to a field during which the right wing impacted a tree. The airplane landed hard in a muddy field, collapsing the nose landing gear. Postaccident examination of the airplane revealed a portion of the propeller blade had separated in flight. Examination of the propeller revealed that the propeller blade exhibited a fatigue crack that initiated near the trailing edge of the blade. Metal transfer from an alloy dissimilar to that of the blade’s material likely resulted from an object that impacted the blade face near the trailing edge. The red transfer marks on the blade were likely impact marks from contacting the engine cowling during the accident sequence.
Probable cause
The inflight separation of a section of a propeller blade due to a fatigue crack, which resulted in a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N44245
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-7425397
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-11T21:17:05Z guid: 103608 uri: 103608 title: ERA21LA313 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103613/pdf description:
Unique identifier
103613
NTSB case number
ERA21LA313
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-02T13:59:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-09-06T19:11:24.592Z
Event type
Accident
Location
Waxhaw, North Carolina
Airport
JAARS-TOWNSEND (N52)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
Density Altitude When aircraft operate in a nonstandard atmosphere, the term density altitude is used for correlating aerodynamic performance in the nonstandard atmosphere. According to the Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25C), density altitude is the vertical distance above sea level in the standard atmosphere at which a given density is to be found. The density of air has significant effects on the aircraft’s performance because as air becomes less dense, it reduces: • Power because the engine takes in less air • Thrust because a propeller is less efficient in thin air • Lift because the thin air exerts less force on the airfoils Density altitude is pressure altitude corrected for nonstandard temperature. As the density of the air increases (lower density altitude), aircraft performance increases; conversely as air density decreases (higher density altitude), aircraft performance decreases. A decrease in air density means a high-density altitude; an increase in air density means a lower density altitude. Density altitude is used in calculating aircraft performance because under standard atmospheric conditions, air at each level in the atmosphere not only has a specific density, its pressure altitude and density altitude identify the same level. The computation of density altitude involves consideration of pressure (pressure altitude) and temperature. Since aircraft performance data at any level is based upon air density under standard day conditions, such performance data apply to air density levels that may not be identical with altimeter indications. Under conditions higher or lower than standard, these levels cannot be determined directly from the altimeter. Density altitude is determined by first finding pressure altitude, and then correcting this altitude for nonstandard temperature variations. Since density varies directly with pressure and inversely with temperature, a given pressure altitude may exist for a wide range of temperatures by allowing the density to vary. However, a known density occurs for any one temperature and pressure altitude. The density of the air has a pronounced effect on aircraft and engine performance. Regardless of the actual altitude of the aircraft, it will perform as though it were operating at an altitude equal to the existing density altitude. Air density is affected by changes in altitude, temperature, and humidity. High density altitude refers to thin air, while low density altitude refers to dense air. The conditions that result in a high-density altitude are high elevations, low atmospheric pressures, high temperatures, high humidity, or some combination of these factors. Lower elevations, high atmospheric pressure, low temperatures, and low humidity are more indicative of low-density altitude. Carburetor Heat According to the Aviation Maintenance Technician Handbook – Powerplant (FAA-H-8083-32B), carburetor heat is used in aircraft to prevent the formation of ice in the carburetor and carburetor normal flow air is admitted at the lower front nose cowling below the propeller spinner and is passed through an air filter into air ducts leading to the carburetor. A carburetor heat air valve is located below the carburetor for selecting an alternate warm air source (carburetor heat) to prevent carburetor icing. Carburetor icing occurs when the temperature is lowered in the throat of the carburetor and enough moisture is present to freeze and block the flow of air to the engine. The carburetor heat valve admits air from the outside air scoop for normal operation, and it admits warm air from the engine compartment for operation during icing conditions. The carburetor heat is operated by a push-pull control in the flight deck. The carburetor air ducts consist of a fixed duct riveted to the nose cowling and a flexible duct between the fixed duct and the carburetor air valve housing. The carburetor air ducts normally provide a passage for outside air to the carburetor. Applying carburetor heat to an operating engine decreases the density of the air. Air enters the system through the ram-air intake. The intake opening is in the slipstream, so the air is forced into the induction system giving a ram effect to the incoming airflow. The air passes through the air ducts to the carburetor. The carburetor meters the fuel in proportion to the air and mixes the air with the correct amount of fuel. The throttle plate of the carburetor can be controlled from the flight deck to regulate the flow of air (manifold pressure), and in this way, power output of the engine can be controlled. Improper or careless use of carburetor heat can be just as dangerous as the most advanced stage of induction system ice. Increasing the temperature of the air causes it to expand and decrease in density. This action reduces the weight of the charge delivered to the cylinder and causes a noticeable loss in power because of decreased volumetric efficiency. If icing is not present when carburetor heat or induction system anti-icing is applied and the throttle setting does not change, the mixture will become richer. In addition, high intake air temperature may cause detonation and engine failure, especially during takeoff and high-power operation. Therefore, during all phases of engine operation, the carburetor temperature must afford the greatest protection against icing and detonation. Corrective Actions To increase safety, JAARS Inc. made the following changes: o The pilot received remedial academic and flight training at the JAARS Aviation Training Center, focused on abort point philosophy and how to apply abort points considering ambiguities introduced by variable surface conditions, poorly marked runways, or when flying airplanes that only have pilot operating handbook performance numbers available. o The JAARS Aviation Fixed and Rotor Wing Knowledge, Skills, and Attributes (KSAs) document based on the International Air Transport Association/International Civil Aviation Organization Professional Pilot Competency format, modified for single pilot crew operations, was used during the remedial academic and flight training. o JAARS Waxhaw Flight Operations Manual (FOM) Chapter 11 was developed to address flight camps. The FOM contains the standard operating procedures and the organizational detail needed to determine lines of authority and responsibilities. Operational authority will remain with JAARS. o JAARS CrossVenture|Aero was developed to bring youth aviation camps in-house. o Daily pilot briefings are now conducted following a standard format. as shown in a slide presentation. o Abort points are now printed and distributed as part of the flight briefings. o Abort point markers (double orange cones) are now placed next to the runway on the right side for better instructor pilot visibility to mark the takeoff/landing abort points for each runway. o A pilot application process is now in place. Instructor pilot qualifications are now checked, and standardization is completed in accordance with standardization documents and flight sheets. o JAARS purchased dedicated aircraft for use in their CrossVenture/Aero youth aviation camps and a volunteered aircraft application process is also now in place to assure that aircraft that are not owned by JAARS which are to be used for flight camps, are subjected to an aircraft records inspection, followed by a physical aircraft inspection using aircraft inspection documents. o The JAARS Waxhaw flight department Safety Management System (SMS) is now also used to manage, safety risk and assure the effectiveness of safety risk controls for the youth aviation camps. It includes systematic procedures, practices, and policies for the management of safety risk. To promote safety at the JAARS Townsend Airport, JAARS Inc. invited Wings Over Waxhaw to participate in the JAARS SMS through mutual use of their reporting process. - Review of occupant weights and airplane weight and balance records indicated that the airplane was within weight and balance limitations during the takeoff. - On August 2, 2021, about 1259 eastern standard time, a Cessna 172E, N3090U, was substantially damaged when it was involved in an accident in Waxhaw, North Carolina. The pilot and two passengers received minor injuries. The airplane was being operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The accident occurred during an aviation youth camp while taking off from runway 4, at JAARS-Townsend Airport (N52), Waxhaw, North Carolina. After rotation, just past the windsock located on the fence of the airport, the airplane became airborne and gained about 50 ft. The pilot maintained best rate of climb speed (80 mph), but the airplane failed to climb. He momentarily decreased the airspeed towards best angle of climb speed (65 mph), to see if the airplane would respond, but it did not, so he returned to the best rate of climb speed. He heard no abnormal sounds from the engine or any decrease in rpm during the takeoff run. Sensing that the airplane would not clear the trees beyond the departure end of the runway, he momentarily reduced power to idle to land on the remaining runway and overrun area. However, to avoid hitting the chain-link fence, he elected to add power and land on a lawn just beyond the airport. After adding enough power to reach the lawn, he reduced power to idle and touched down before the wooded area. On rollout, the airplane traveled towards a gap in the trees. The pilot turned left to avoid the trees, the airplane nosed over and came to rest nose down, leaning against a tree. The pilot realized that he and the front seat passenger were hanging from their seatbelts, and he was concerned about the fuel that was leaking from the airplane. The rear seat passenger easily egressed and assisted the front seat passenger. The pilot’s pant leg was snagged between his seat and the instrument panel, so he grabbed the fabric and ripped it until he felt he was free, at which point he was able to egress. He then directed some campers away from the accident site, and a few minutes later returned to the airplane, to ensure that the master switch was off. To do so, he pulled the windscreen the rest of the way off the airplane. According to witnesses, during the takeoff the angle of climb was much less than expected and the airplane never climbed above 10 to 20 ft above the runway. One of the witnesses reported the engine did not sound right. Several of the witnesses reported seeing the airplane bank to the right before they lost sight of it. One stated the airplane pitched down and rolled to the right, then pitched up and rolled to the left before impact. - The recorded weather at Lancaster County Airport-McWhorter Field, located about 11 miles southwest of N52, at 1255, included: calm winds, 10 miles visibility, clear skies, temperature 29° C, dew point 18° C, and an altimeter setting of 30.03 inches of mercury. Density altitude under these conditions was approximately 2,347 ft above mean sea level. - Takeoff Video Video of the previous takeoff, which occurred about 2 hours before the accident with similar loading, revealed that there was enough imagery to determine where the individual that was recording the video was standing and was usable to gain some indication of performance. Abort Points There were two hard-takeoff abort points designated in the briefing for the event, one for each runway. The briefing for the abort points was a bullet point presentation followed by a verbal description. The performance charts indicated that the airplane would need about 950 ft for the ground roll and about 1,680 ft to clear a 50-ft obstacle. The location of the hard-abort point for runway 4 was 830 ft from the beginning of the runway. The other hard-abort point (for runway 22) was 1,300 ft from the beginning of runway 4. - On-Scene Examination On-scene examination by a Federal Aviation Administration inspector revealed that the airplane touched down off the airport property on a gravel driveway, and a grassy area before an opening in the wooded area and then traveled about 600 ft before it had come to rest leaning against a tree, supported by the right wing (which was leaking fuel) in a nose-down, inverted position. A debris path that started with the right wingtip led up to the main wreckage. The airplane’s left wingtip was found in a tree. The left horizontal stabilizer and elevator were separated from the fuselage, the aft fuselage was buckled, and small parts from the airplane were spread throughout the debris path, leading up to the main wreckage. The nose landing gear displayed impact damage, one propeller blade was undamaged, and the other propeller blade was bent aft. The engine mounts were broken, the engine had shifted from its normal mounting position, and the fuel strainer was loose. The flight control cables were broken and parted. National Transportation Safety Board (NTSB) Examination Examination of the wreckage by the NTSB did not reveal any preimpact failures or malfunctions that would have precluded normal operation. Examination of the cockpit revealed that the mixture control was in the full rich position, the throttle was in the full throttle position, and the carburetor heat control knob was not fully closed. Examination of the carburetor heat door also revealed that it was open. -
Analysis
The accident occurred while the flight was taking off during an aviation youth camp. The pilot reported the airplane became airborne and climbed in ground effect to an altitude of about 50 ft above ground level (agl). He stated the airplane climb rate seemed sluggish, so he transitioned the airspeed from the best rate of climb to the best angle of climb, but he still did not get the climb performance he expected. The pilot momentarily reduced the power to land, then realized there were trees and a fence off the end of the runway, so he added power to land on a lawn just beyond the airport. The pilot applied rudder during the landing roll to avoid trees and in doing so, the airplane nosed over and came to rest nose down, leaning up against a tree. During the impact sequence, the airplane was substantially damaged. The pilot and the two passengers received minor injuries. According to witnesses, during the takeoff the angle of climb was much less than expected and the airplane never climbed above 10 to 20 ft above the runway. One witness reported the engine sounded sluggish. Several of the witnesses reported seeing the airplane bank to the right before they lost sight of it. One stated the airplane pitched down and rolled to the right, then pitched up and rolled to the left before impact. Review of weight and balance information revealed that the airplane was within the weight and balance envelope during the flight. Examination of the wreckage did not reveal evidence of any preimpact failures or malfunctions that would have precluded normal operation. However, the carburetor heat control knob was found to not be fully closed and the carburetor heat door was found to be open. The airplane’s performance charts indicated that the airplane would need a 950-ft ground roll for takeoff and 1,680 ft to clear a 50-ft obstacle. The takeoff was being conducted from a runway that was 3,309 ft long. There were two takeoff abort points designated in the briefing for the event, one for each runway. The pilot confused the abort points and was using the abort point designated for the opposite direction runway. The abort point for he should have used was 830 ft from the beginning of the runway, while the abort point he actually used was 1,300 ft from the beginning of the runway. This confusion regarding abort points reduced the amount of available runway remaining for the pilot to stop the airplane once he realized the airplane was not going to clear the trees at the end of the runway. Based on the available evidence, a loss of engine performance likely occurred during the takeoff because the carburetor heat control knob was not fully closed. This loss of power would also have been compounded by the elevated density altitude, which also would have decreased the airplane’s takeoff performance. The pilot’s delay in aborting the takeoff left the airplane airborne but with insufficient distance and performance to clear the tree line.
Probable cause
The pilot’s failure to abort the takeoff in sufficient time to stop the airplane on the runway remaining. Contributing to the accident was the lack of airplane takeoff performance due to the pilot’s failure to assure that the carburetor heat control was in the off position and the elevated density altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N3090U
Operator
JAARS Inc.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17250690
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-06T19:11:24Z guid: 103613 uri: 103613 title: CEN21FA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103632/pdf description:
Unique identifier
103632
NTSB case number
CEN21FA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-04T16:20:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-08-11T20:23:25.663Z
Event type
Accident
Location
Starkville, Mississippi
Airport
OKTIBBEHA (M51)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On August 4, 2021, about 1520 central daylight time, a North American T6G airplane, N7197C, was destroyed when it was involved in an accident near Starkville, Mississippi. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of air traffic control (ATC) radar track data revealed that the airplane departed runway 36 at McCharen Field Airport (M83), West Point, Mississippi; continued toward the southsouthwest; and performed a series of maneuvers near the accident site. The final radar return was recorded about 1518; at that time, the airplane was located about 0.15 miles west of the accident site. The pilot was not in contact with an ATC facility during the flight. A witness saw the airplane operating overhead at a low altitude. The witness stated that the airplane made three passes and was “low” over trees. The witness’ boyfriend, who was at the same location, recorded two video clips of the airplane. A review of the video clips showed the airplane briefly as it passed overhead at a low altitude (just above the trees). The video clips also showed that the airplane was trailing smoke from an installed smoke system. - The Mississippi State Medical Examiner’s Office, Pearl, Mississippi, performed an autopsy of the pilot. His cause of death was blunt force injuries. The Federal Aviation Administration Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot. Ethanol was detected at 0.046 g/dL in his cavity blood but not in his vitreous specimens. Detected ethanol can be the result of consumption or postmortem microbial ethanol production. - Damage to the airplane at the accident site was consistent with the airplane striking the trees at a steep angle before impacting terrain. The main wreckage was located near the airplane’s initial impact point, which was on a heading of about 105°. The wreckage was confined to an area near the impact point. The on-site examination was limited due to impact damage to the airplane. The engine separated from the airframe and, along with the propeller, was partially buried under dirt. Both wings displayed accordion crushing along their wingspan. Cable continuity was confirmed from the empennage to the cockpit. However, control tubes beneath the front and rear cockpit areas were heavily damaged from the impact. Postaccident examination of the airframe and engines revealed no mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The pilot was conducting a series of low-level maneuvers when the accident occurred. The airplane subsequently impacted trees and terrain. A postaccident examination revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Although ethanol was detected in the pilot’s cavity blood, no ethanol was detected in the pilot’s vitreous specimens. Because vitreous specimens are generally less susceptible to contamination and postmortem microbial ethanol production than other specimen types, the absence of detectable ethanol in the pilot’s vitreous specimens indicated that the detected ethanol in the pilot’s cavity blood was likely from sources other than consumption and was thus not a factor in the accident.
Probable cause
The pilot’s failure to maintain clearance from trees while maneuvering at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
T-6G
Amateur built
false
Engines
1 Reciprocating
Registration number
N7197C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
49-2897
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-11T20:23:25Z guid: 103632 uri: 103632 title: ERA21LA321 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103674/pdf description:
Unique identifier
103674
NTSB case number
ERA21LA321
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-06T17:20:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-09-13T21:06:10.048Z
Event type
Accident
Location
Springfield, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 6, 2021, about 1620 central daylight time, an experimental Cubcrafters Inc., CC11-160, N825ME, was substantially damaged when it was involved in an accident near Springfield, Tennessee. The airline transport pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that after refueling with 18 gallons of aviation fuel, the pilot and a passenger took off from Springfield Robertson County Airport (M91) Springfield, Tennessee, and flew to a private airport about 7 nautical miles east. The airplane was performing well and there were no anomalies observed during the flight. After landing and coming to a full stop at the airport, they conducted another takeoff, flew a normal traffic pattern, and conducted a touch-and-go landing. During the subsequent climb, when about 400 ft above ground level, the engine suddenly stopped producing power. The pilot further described that, “there was no sputter or indication, it just stopped.” There was little time to troubleshoot as the airplane was descending quickly and the pilot performed a forced landing in a field. Upon landing, the airplane struck a fence and the landing gear collapsed before the airplane came to rest to rest. Postaccident examination of the airframe and engine revealed that the fuselage was fractured and dented in several locations and the leading edge of the right wing was damaged. The fuel tank contained aviation fuel that was clean and free of debris. There was oil in the engine reservoir and no debris or metallic material in the oil filter. The electronic ignition system produced spark on all spark plug electrodes. A download of the Garmin G3X Electronic Flight Instrument System was conducted. The download revealed that at an altitude of about 1,000 ft mean sea level, while climbing about 1,000 ft per minute at a groundspeed of 80 kts, the engine rpm, oil pressure, and exhaust gas temperatures suddenly decreased, followed rapidly by a decrease in fuel flow. There were no associated crew-alerting system alerts recorded during the flight and a review of the most recent maintenance records did not reveal any past irregularity or other anomalous behavior from the engine or other systems. A further examination of the engine and airframe was conducted by a mechanic under the oversight of a Federal Aviation Administration inspector. During the examination and subsequent engine test runs in various configurations the engine operated normally with no anomalous behavior noted. During the engine run, the circuit breakers from the main power supply were disengaged and the right ignition switch was turned off, which resulted in a loss of engine power due to low voltage on the back up battery. A leaking fuel valve was discovered in the fuel system during the examination. At 1532, the weather reported at Outlaw Field Airport (CKV), Clarksville, Tennessee, which was located about 24 nautical miles west of the accident site, included a temperature of 29°C and a dew point 17°C. The calculated relative humidity at this temperature and dewpoint was 48 percent. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." -
Analysis
The pilot stated that the engine suddenly stopped producing power while climbing at an altitude of about 400 ft above ground level after a touch-and-go landing. With no time to troubleshoot the reason for the loss of power, the pilot performed a forced landing to a field, where the airplane contacted a fence and the fuselage and right wing were substantially damaged. Weather conditions in the area at the time of the accident flight were conducive to serious carburetor icing at glide power; however, the description of the partial loss of engine power and the phase of flight at which it occurred were not consistent with carburetor icing. A postaccident examination and test run revealed that the engine was able to operate normally. During the examination it was noted that a fuel valve was leaking, though it is likely that this was due to damage sustained during the accident. Additionally, the electronic ignition system backup battery voltage was low. During the engine test run when the main ignition system circuit breakers were deactivated, and with the right side backup ignition selected, the engine lost power (and appropriate annunciations were illuminated on the instrument panel). Given that the pilot did not report any ignition system issues or annunciations, it is unlikely that the voltage issue noted with the backup system played a role in the reported loss of engine power. Based on this information, a reason for the loss of engine power could not be determined.
Probable cause
A loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUBCRAFTERS INC
Model
CC11-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N825ME
Operator
PLANE COMPANY LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CC11-00372
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-13T21:06:10Z guid: 103674 uri: 103674 title: ERA21FA317 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103652/pdf description:
Unique identifier
103652
NTSB case number
ERA21FA317
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-07T19:00:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-08-12T17:17:26.826Z
Event type
Accident
Location
Argyle, New York
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On August 7, 2021, about 1800 eastern daylight time, an experimental amateur-built Rotorway Exec 162F, N162KJ, was destroyed when it was involved in an accident in Argyle, New York. The pilot and passenger were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   A witness located about 1/2 mile north of the accident site observed the helicopter flying southbound at an estimated altitude of 50 to 75 ft above ground level. The witness stated that he thought that the helicopter was “having issues, as the helicopter could not stay up in the air.” The witness stated that it seemed “almost like [the helicopter] was bouncing” as it flew across a field. Just after the helicopter flew over a tree line, the witness heard a “loud sound” and “watched the [rotor] just stop.” The helicopter then “fell straight down.” A postimpact fire ensued. The pilot did not possess a rotorcraft-helicopter rating. His logbook included two 90-day endorsements for solo flight, the latest of which expired in June 2004. His most recent valid medical certificate was issued in 2000. In 2016, the Federal Aviation Administration (FAA) denied his application for medical certification due to medical history, which included bipolar disorder and depression. The pilot completed the build of the helicopter in May 2003.   Postaccident examination of the accident scene revealed a debris path that was about 400 ft long and oriented on a magnetic heading of 210°. The debris path began in an open field of 4-ft-tall grass with a 4 inch-by-4 inch fractured piece of aluminum skin from the right side of the tailboom, just forward of the tail rotor arc. The right horizontal stabilizer was located 156 ft along the wreckage path, 70 ft left of the path centerline. The left horizontal stabilizer was located about 10 ft farther along the debris path and 205 ft left of the path centerline.   A 4-ft-long section of the aft end of the tailboom, including the vertical stabilizer and the tail rotor gearbox (with one tail rotor blade attached), was located 30 ft farther down the path, 10 ft left of centerline, just after the path transitioned from the grass field to the tree line and into a wooded area. An impact mark on the right side of the tailboom section, near the fractured forward end, was consistent in size and shape with the profile of the main rotor blade. The wreckage path continued for another 200 ft through the woods and down a steep hill, with numerous fragments of clear plastic canopy along and to the left and right of the path.   The main wreckage, which was located at the end of the path, came to rest on its right side and top, almost completely inverted. The wreckage was largely consumed by the postimpact fire. Molten aluminum remnants were present at several locations beneath the main wreckage. No ground scars were observed leading up to the main wreckage, and the trees and foliage along the wreckage path were not damaged, except for some broken branches directly above, and immediately surrounding, the main wreckage.   Control continuity was established from the anti-torque pedals to the tail rotor through breaks in the push-pull cable. Continuity from the cockpit controls to the teetering main rotor head was partially established; several components in the push-pull cable system were not found.   Both main rotor blades were intact and attached to the blade grips, and both blades exhibited downward bending damage in several locations. The teetering hinge attach points were fractured on both sides of the bub plate. One rotor blade had leading-edge damage and gouging about 1 to 2 ft inboard of the blade tip. Both pitch change links were fractured at their upper (blade end) rod ends, and both links remained attached to fractured segments of their lower control horns. The inboard ends of both lower blade grips were bent upward, and each had semicircular deformation consistent with the diameter of the rotor mast, as shown in figure 1. “A” blade grip bottom half, with semicircular deformation “B” blade grip bottom half, with semicircular deformation Figure 1 - Damage to blade grips. Toxicology testing by the FAA Forensic Sciences Laboratory detected ethanol in the pilot’s blood; no ethanol was detected in his urine. N-propanol (a microbial product) was detected in his blood. Diphenhydramine, trazodone, and 7-aminoclonazepam (the inactive metabolite of clonazepam) were detected in his blood and urine. Delta-9-tetrahydocannabinol (THC), 11-hydroxy-delta-9-THC, and carboxy-delta-9-tetrahydrocannabinol were also detected in the pilot’s blood and urine. According to the FAA, diphenhydramine and trazodone (used to treat depression, anxiety, and insomnia) are both sedating but can be acceptable for use if taken with sufficient waiting periods before flying; trazodone is disqualifying if used to treat bipolar disorder. Clonazepam is disqualifying due to the underlying condition it treats (panic disorders). The use of marijuana is addressed by 14 Code of Federal Regulations 91.17(a)(3), which states that “no person may act or attempt to act as a crewmember of a civil aircraft…while using any drug that affects the person’s faculties in any way contrary to safety.”. The FAA’s Helicopter Flying Handbook describes low-G conditions and mast bumping, stating in part the following: Helicopters with two-bladed teetering rotors rely entirely on the tilt of the thrust vector for control. Therefore, low-G conditions can be catastrophic for two-bladed helicopters.… Abrupt forward cyclic input or pushover in a two-bladed helicopter can be dangerous and must be avoided, particularly at higher speeds. During a pushover from moderate or high airspeed, as the helicopter noses over, it enters a low-G condition. Thrust is reduced, and the pilot has lost control of fuselage attitude but may not immediately realize it. Tail rotor thrust or other aerodynamic factors will often induce a roll. The pilot still has control of the rotor disk, and may instinctively try to correct the roll, but the fuselage does not respond due to the lack of thrust. If the fuselage is rolling right, and the pilot puts in left cyclic to correct, the combination of fuselage angle to the right and rotor disk angle to the left becomes quite large and may exceed the clearances built into the rotor hub. This results in the hub contacting the rotor mast, which is known as mast bumping…and the energy and inertia in the rotor system can sever the mast or allow rotor blades to strike the tail or other portions of the helicopter. The handbook included an illustration that depicted the hub contacting the rotor mast, as a result of improper corrective action in a low-G condition (figure 2). Figure 2. Mast bumping illustration (Source: FAA Helicopter Flying Handbook). -
Analysis
A witness reported observing the helicopter flying southbound at an altitude of about 50 to 75 ft above ground level. The witness stated that the helicopter was “having issues” and “could not stay up in the air.” The witness further stated that the helicopter seemed as if it were “bouncing” as it flew across a field. Just after the helicopter flew over a tree line, the witness heard a “loud sound” and “watched the [rotor] just stop.” The helicopter then “fell straight down.” Examination of the wreckage revealed that the lower inboard ends of the main rotor blade grips were bent upward and that both had semicircular indentations with the same diameter as the rotor mast. This damage was consistent with the blade grips contacting the mast, commonly referred to as mast bumping, which occurs due to excessive flapping motion of rotor blades (specifically, up-and-down motion of the blade tips). The aft tailboom was separated from the helicopter and found about halfway along the 400-ft-long wreckage path. An impact mark consistent with the shape of the main rotor blade was found at the forward end of the separated section, consistent with a main rotor blade severing the tailboom. Teetering rotor systems, such as the one on the accident helicopter, are particularly susceptible to mast bumping during low-G conditions, which can result from abrupt forward (nose-down) cyclic inputs. The witness’s description of the helicopter appearing to bounce as it was flying is consistent with repeated abrupt control inputs resulting in oscillating low-G conditions. These inputs likely led to the mast bumping and excessive blade flapping, which resulted in a main rotor blade contacting the tailboom. The reason for the pilot’s abrupt control inputs could not be determined. Toxicology testing of the pilot’s specimens detected ethanol and npropanol, diphenhydramine), trazadone, and a metabolite of clonazepam. The ethanol was detected in the pilot’s blood at low levels (below those considered to be impairing) and was not detected in his urine. That information, along with the presence of n-propanol in the pilot’s blood, suggested that the ethanol was from sources other than ingestion and that it likely was not a factor in the accident. The diphenhydramine results were also below the therapeutic level; therefore, that medication was not likely a factor. The pilot had been denied a Federal Aviation Administration medical certificate due to his medical history, which included bipolar disorder and depression. The detection of trazadone (which was well below therapeutic levels) and a metabolite of clonazepam indicated that he had been taking these medications to treat diagnosed conditions. However, the toxicological results suggested that the pilot’s use of these medications was likely not a factor in the accident. Toxicology testing also detected Delta-9-tetrahydocannabinol (THC), which showed that the pilot had used cannabis. Although the effects of THC can last a few hours, THC can be detected in the body for days or weeks. Thus, the investigation could not determine if the pilot’s use of cannabis could have been impairing and influenced his behavior during the accident flight.
Probable cause
The pilot’s abrupt control inputs, which resulted in a lowG condition, main rotor mast bumping, and the subsequent severing of the tail boom by a main rotor blade.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROTORWAY
Model
Exec 162F
Amateur built
true
Engines
1 Reciprocating
Registration number
N162KJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6692
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-12T17:17:26Z guid: 103652 uri: 103652 title: CEN21FA364 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103660/pdf description:
Unique identifier
103660
NTSB case number
CEN21FA364
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-09T12:15:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-08-12T18:42:57.694Z
Event type
Accident
Location
Melbourne, Arkansas
Airport
MELBOURNE MUNI - JOHN E MILLER FLD (42A)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
After the accident, 42A installed radio transmission recording capability on its UNICOM frequency. - According to the Cessna Turbo-System Centurion Owner’s Manual, at a gross weight of 3,400 pounds (maximum gross weight), the airplane’s stall speed at 0° of bank with the landing gear down and the flaps retracted was 74 mph. With the landing gear down and the flaps fully down (30o), the stall speed was 63 mph. With 30o of bank, the gear down, and the flaps fully down, the stall speed was 68 mph. With 60o of bank, the gear down, and the flaps fully down, the stall speed was 89 mph. The before takeoff checklist stated that flaps should be set between 0 o (flaps up) and 20o (maximum performance takeoff configuration). The takeoff discussion does not reference any flap setting greater than 20o. The owner’s manual stated that, for a balked landing (go-around) climb, the flaps should be reduced to 20o immediately after full power is applied. The manual also stated that, after all obstacles are cleared and a safe altitude and airspeed are obtained, the flaps should be retracted. The owner’s manual only cited two uses for full flaps (30o): shortfield landings and the emergency landing procedure with a defective nose gear. The field elevation at 42A was 734 ft. Runway 21 was 4,003 ft long. The temperature was 89.6oF (32oC), the dew point was 75oF (24oC), and the altimeter was 30.01 inches. On the basis of this information, at 3,400 pounds and with 20o of flaps and no headwind, the airplane would have a takeoff ground run of about 920 ft, and the distance needed to clear a 50ft obstacle would be 1,708 ft. - On August 9, 2021, about 1115 central daylight time, a Cessna 210H airplane, N5940F, was destroyed when it was involved in an accident near Melbourne, Arkansas. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot intended to fly the airplane from Melbourne Municipal Airport (42A), Melbourne, Arkansas, to his home airport 60 miles away in Heber Springs, Arkansas. A witness, who was at the departure airport, reported observing the pilot conduct a preflight of the airplane and taxi to runway 21 for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll, and then he observed the airplane lift off near the departure end of the runway. No radio or distress calls were heard from the pilot. At the time of the accident, the departure airport’s UNICOM radio receiver was not staffed and did not have the capability to record. - An autopsy of the pilot was performed by the State Crime Lab, Medical Examiner Division, Little Rock, Arkansas. His cause of death was multiple blunt force injuries. Toxicology testing by the Federal Aviation Administration Forensic Sciences Laboratory identified no tested-for drugs. The pilot’s glucose (sugar) was 144 mg/dL in vitreous specimens and 195 mg/dl in urine specimens. The pilot’s hemoglobin A1C (HbA1c) blood level was 7.2%. The FAA considers glucose levels in vitreous and urine specimens to be abnormal if above 125 and 100 mg/dL, respectively. HbA1c is an indirect measure of a person’s average blood sugar during the preceding 3 months. Generally, an HbA1c of 6.5% or higher indicates diabetes, and an HbA1c of less than 7% indicates control of diabetes. - The accident site was located about 3,500 ft from the departure end of the runway on a magnetic heading of 188°, as shown in the figure below. Figure. Accident site location in relation to 42A. Examination of the wreckage showed that the airplane impacted several large 80-ft-tall trees before it came to rest on the ground. Pieces of the right elevator and right horizontal stabilizer were found embedded in tree branches about 20 ft above the ground. The fuselage, wings, and engine were laying on the ground adjacent to a large tree. Most of the airframe was consumed by the postimpact fire. The engine was found separated from the fuselage about 4 ft from the main wreckage. The engine was mostly intact and had minor fire damage. Several cut branches observed in the trees were consistent with propeller blade strikes. The propeller remained attached to the engine at the flange. All three blades showed S-bending, chordwise rubs and scratches, and leading-edge nicks. Flight control continuity was confirmed from all control surfaces to the cockpit. Further examination of the airframe showed that the flap actuator was in the fully extended position (30°). The elevator trim actuator was measured at a 2inch extension, which was consistent with a 20° nose-down position. The engine was examined, and no pre-impact anomalies were found. -
Analysis
The pilot was conducting a personal flight to his home airport. A witness at the departure airport reported observing the pilot conduct a preflight examination of the airplane and then taxi the airplane to the runway for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll and that the airplane lifted off near the departure end of the runway. Witnesses who were located beyond the departure end of the runway reported that the airplane was flying low and seemed to be turning just before it crashed. The airplane impacted trees and terrain. A postcrash fire ensued and destroyed the airplane. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operations. The flap actuator was found in the fully extended position (30°). The elevator trim actuator was measured at a 2-inch extension, which was consistent with a 20° nose-down position. With the flaps fully extended, the airplane’s ability to climb and maneuver was significantly degraded. As a result, the pilot was unable to maintain airplane control while making a turn at a low altitude after liftoff. Postmortem toxicology testing showed that the pilot’s hemoglobin A1C level was 7.2%, which indicated the pilot’s diabetes was uncontrolled (but not severely) during the months before the accident. His elevated glucose (sugar) level placed him at risk for fatigue, dehydration, and blurred vision. The investigation could not determine whether the pilot’s uncontrolled diabetes impaired his ability to properly monitor the airplane’s configuration and safely perform the takeoff and climb.
Probable cause
The pilot’s failure to maintain control of the airplane with full flaps during the takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210H
Amateur built
false
Engines
1 Reciprocating
Registration number
N5940F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21058940
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-12T18:42:57Z guid: 103660 uri: 103660 title: ERA21FA318 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103662/pdf description:
Unique identifier
103662
NTSB case number
ERA21FA318
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-09T17:56:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-08-13T00:37:56.832Z
Event type
Accident
Location
Ocklawaha, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On August 9, 2021, about 1656 eastern daylight time, an experimental amateur-built Pitts Model 12, N112JH, was substantially damaged when it was involved in an accident near Ocklawaha, Florida. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot was conducting a local aerobatic flight. According to flight track data, the airplane completed three loops and then entered a climb and descent, at which point the data ended. Multiple witnesses reported seeing the airplane “spiraling” toward the water, but none reported seeing the airplane before that point. One witness recorded cell phone video of the airplane that showed the airplane in an inverted flat spin, which was followed by a nose-down spin and contact with the lake. The video also recorded the sound of the engine operating continuously until the airplane impacted the water. The pilot and passenger were wearing parachutes, and the pilot was observed jumping from the airplane at a low altitude. The video did not capture the pilot’s parachute deploying before water contact, but witnesses stated that the parachute was open and floating in the water. Furthermore, the sound of the engine was continuous until the airplane impacted the water. Multiple witness reported seeing the airplane spiraling towards the water, but none reported seeing the airplane prior to that. PILOT INFORMATION The pilot’s personal logbook was not located. According to a ferry pilot, the pilot bought the airplane about 1 year before the accident, and he hired the ferry pilot to help him move the airplane to his home airport at that time. The ferry pilot provided a statement that detailed the time that he and the accident pilot spent in the airplane. The ferry pilot stated that the accident pilot was “all over with the rudder during the takeoff.” They performed two landings at the destination airport before completing the flight. The ferry pilot offered to provide flight instruction, but the accident pilot declined and said, “I know how to fly an airplane and you are too expensive.” The ferry pilot thought that the accident flight was the first time that the pilot had flown the airplane with a passenger. WRECKAGE AND IMPACT INFORMATION Postaccident examination of the wreckage revealed that the wood and fabric wings were destroyed by the impact with the water. The fuselage remained intact and was impact damaged. The rudder and elevator remained attached to the fuselage. The left elevator was displaced 90° down. Flight control continuity was established from the rudder and elevator to the control stick in the cockpit. The throttle control was full forward, and the propeller control was mid-range. About 6 ft of the upper wing was impact damaged but remained attached by cables, the aileron remained attached to the wing, and the control rod was fractured. Other wing pieces were found floating in the large debris field in the water.   The engine was impact damaged but remained attached to the airframe by cables and wires. The front spark plugs in the radial engine were fractured; the rear spark plugs were removed and showed normal wear signatures. Several push rods were impact separated. The rear accessory case was impact damaged, and several components were separated. The propeller remained attached to the engine, but all three propeller blades were separated at the hub. The engine rotated smoothly by hand at the propeller flange, and continuity was established throughout the engine. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot and pilot-rated passenger departed on a local flight and were performing aerobatic maneuvers over a lake. Flight track data indicated that the pilot performed at least three loops; the data ended as the airplane was climbing and beginning a descent. Witnesses report seeing the airplane in a spiral as it entered the lake. Recorded video of the accident showed the airplane in an inverted flat spin, which was followed by a nose-down spin to water contact. The engine was heard continuously operating throughout the video until water impact. Postaccident examination of the wreckage revealed no evidence of a preaccident malfunction or failure that would have prevented normal operation. Overall, the flight track data, witness observations, and video indicated that the pilot lost control of the airplane while he was likely attempting another aerobatic maneuver. Furthermore, a pilot who flew with the accident pilot when he first purchased the airplane (1 year before the accident) offered to provide flight training to the accident pilot, but the pilot declined, stating that the training was too expensive and that he knew how to fly an airplane. Because the pilot’s logbook was not found, the investigation was unable to determine the pilot’s total flight experience in the airplane make and model and whether that played a role in the accident.
Probable cause
The pilot’s failure to maintain airplane control while performing aerobatic maneuvers, which resulted in an inverted flat spin from which he was unable to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PITTS
Model
12
Amateur built
true
Engines
1 Reciprocating
Registration number
N112JH
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
109
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-13T00:37:56Z guid: 103662 uri: 103662 title: CEN21LA371 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103685/pdf description:
Unique identifier
103685
NTSB case number
CEN21LA371
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-10T16:45:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-08-13T20:51:36.473Z
Event type
Accident
Location
West Fargo, North Dakota
Airport
WEST FARGO MUNI (D54)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On August 10, 2021, about 1545 central daylight time, a Cessna 210D airplane, N3944Y, was substantially damaged when it was involved in an accident near West Fargo, North Dakota. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Witnesses stated that the pilot performed a go-around after an attempt to land on runway 18. During the go-around, the airplane banked right and the engine “cut out.” The airplane impacted a field west of the runway and sustained substantial damage to the fuselage, wings, and empennage. An on-scene examination of the airplane by a Federal Aviation Administration inspector revealed that the fuel selector was in the left tank position. There was about 8 gallons of fuel in the left wing fuel tank and no useable fuel in the right wing fuel tank. The right wing sustained impact damage, but there was no evidence of fuel on the ground at the accident site. There was no evidence of a fuel leak or fuel staining on the airplane. A subsequent examination of the engine and fuel system revealed no anomalies that would have precluded normal operation. Examination of the fuel system found about 1/8 ounce of fuel in the fuel system forward of the fuel selector. The fuel system lines and components were intact, secure, and did not exhibit any evidence of leakage. The fuel vent system was unobstructed. The fuel selector operated through its detents without anomaly. An ohmmeter was used to check resistances of both fuel senders when their float arms were positioned at the top and bottom mechanical stops. The approximate resistance values for the left fuel sender bottom stop was 28 ohms, the right fuel sender bottom stop was 38 ohms. According to the aircraft manufacturer, the fuel senders’ minimum resistance value should be 33.5 ohms +/- 2 ohms. -
Analysis
The pilot was performing a go-around at the destination airport when the airplane lost total engine power and subsequently impacted terrain. Postaccident examination revealed useable fuel in the left-wing fuel tank, and no useable fuel in the right fuel tank. The fuel selector was positioned to the left-wing fuel tank. The fuel vent system was unobstructed. The examination revealed little fuel in the fuel system from the fuel selector to the engine, which was consistent with fuel starvation. The fuel sender resistance values for the left-wing tank indicated that erroneous fuel quantity values would have been displayed at the cockpit fuel gauges. There were no anomalies that would have precluded normal engine operation. Based on the available information, it is likely that the loss of engine power was the result of fuel starvation when the pilot exhausted the fuel supply in the right-wing tank. Although the fuel selector was found selected to the tank that contained fuel, it is likely that the pilot switched fuel tanks following the loss of engine power.
Probable cause
A total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210D
Amateur built
false
Engines
1 Reciprocating
Registration number
N3944Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21058444
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-13T20:51:36Z guid: 103685 uri: 103685 title: WPR21LA313 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103681/pdf description:
Unique identifier
103681
NTSB case number
WPR21LA313
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-11T10:00:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-08-20T03:09:31.065Z
Event type
Accident
Location
Helena, Montana
Airport
HELENA RGNL (HLN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On August 11, 2021, about 0900 mountain daylight time, a Cessna 425 Conquest 1, N783MB, sustained substantial damage when it was involved in an accident near Helena, Montana. The pilot and two passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight.   The pilot stated that on the morning of the accident he refueled the airplane to full wing tanks by adding an additional 207 gallons of Jet A. Shortly thereafter, he departed from his home airport in Faribault, Minnesota and continued to his destination at a cruise altitude of 24,000 ft mean sea level.   Air Traffic Control transmissions and automatic dependent surveillance-broadcast data indicate that, while en route at 0847:35, the pilot reported to an air traffic controller that the airplane had an engine [left engine] flame-out and requested a descent. The pilot opted to divert from the originally planned destination and contacted Helena approach control. He stated that the airplane was 16 miles from Helena and descending through 19,000 ft, advising the controller that he may need to lose altitude to land on runway 27. The controller responded that the pilot could maneuver north of the airport to align with the right base leg of the traffic pattern to the runway.   At 0852:59 the pilot reported to the air traffic controller that he had an hour and a half of fuel on board and about 3 minutes later the airplane made a right turn to the north. At 0857:15, with the airplane about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power (see Figure 1 below). At 0859:02, the pilot reported the airplane was going to collide with trees. The airplane came to rest with the right wing and empennage severed from the fuselage. There was fuel onboard the airplane at the time of impact, the quantity is unknown due to the fuel tanks being breached. The pilot estimated there was about 400 pounds in each tank at the time of the occurrence. Figure 1: Flight Track Plot The pilot noted that the airplane had undergone an annual inspection about 5 months before the accident, in March 2021. The airplane had accumulated about 20 flight hours since that inspection. During the examination of both the left and right engines, no evidence of a failure or anomaly was found. The left engine's compressor section showed the ability to rotate the first stage compressor wheel by hand, but the power section, specifically the propeller shaft, could not be manually rotated. The reduction gearbox had no damage to the case, but the propeller shaft was broken and the propeller flange was missing. Buckling was observed in the exhaust duct. The gas generator case, accessory gearbox, inlet case, and inlet screen were undamaged. The fuel control unit’s (FCU) connecting arm moved freely, but the reversing lever guide pin was bent and the carbon block was missing. The pneumatic lines, oil and fuel filters, power turbine (PT) blades, and first stage blades in the compressor section were intact and without damage. In the right engine, similar findings were observed with intact components in the compressor section, reduction gearbox, gas generator case, accessory gearbox, inlet case, and inlet screen. The power control linkage and reversing linkage were properly connected with intact hardware and safety mechanisms. The pneumatic lines, oil and fuel filters, PT blades, first stage blades in the compressor section, propeller shaft, and propeller retention bolts were undamaged. The controls and accessories, including the FCU, fuel pump, ignition system, fuel nozzles, flow divider, air system's bleed valve, propeller governor, and torque transducer, were all undamaged. Both fuel pumps were inspected, and no contamination was detected in the removed filters. A partial amount of fuel was found in both filter bowls. A complete examination of the fuel system could not be completed due to the damage incurred to the airplane at impact. According to the engine manufacturer, if an engine flames out in flight due to fuel starvation, it does not leave behind unique evidence different than a normal engine shut down. He added that both engines flaming out within a short time is not consistent with any dual-engine aircraft systemic design behaviors that could have occurred other than a fuel supply or delivery issue. -
Analysis
The pilot stated that on the morning of the accident he filled both wing fuel tanks to full. After takeoff, he climbed to his planned cruise altitude of 24,000 ft mean sea level (msl). While en route to his destination, the pilot reported that the left engine experienced a flame-out. The pilot opted to divert from the originally planned destination and descended. When the airplane was about 7,900 ft msl, the pilot reported that the right engine experienced a loss of power and that he was not going to be able to make it to the airport. Shortly thereafter, the airplane collided with trees and the airplane came to rest with the right wing and empennage severed from the fuselage. There was fuel in the wing tanks at the time of the impact. Postaccident examination of the wreckage did not reveal any anomalies. A partial amount of fuel was found in both of the filter bowls, but it is unknown if fuel was able to reach the engines. A complete examination of the fuel system could not be completed due to the damage incurred to the airplane at impact. Both engines flaming out within a short time of one another is likely indicative of a fuel supply or delivery issue; however, the nature of the problem could not be identified during postaccident examination.
Probable cause
A flameout of both engines due to fuel starvation for reasons that could not be determined due to the airplane’s damage.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
425
Amateur built
false
Engines
2 Turbo prop
Registration number
N783MB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
425-0103
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-20T03:09:31Z guid: 103681 uri: 103681 title: ANC21LA074 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103736/pdf description:
Unique identifier
103736
NTSB case number
ANC21LA074
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-13T16:55:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-08-23T04:00:26.403Z
Event type
Accident
Location
Soldotna, Alaska
Airport
Soldotna Airport (SXQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 13, 2021, about 1555 Alaska daylight time, a Cessna 180 airplane, N3467Y, was substantially damaged when it was involved in an accident at Soldotna Airport (SXQ), Soldotna, Alaska. The flight instructor and the pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that he and the pilot receiving instruction were practicing landings in the tailwheel-equipped airplane. The purpose of the flight was to complete the requirements for a tailwheel endorsement. The pilot receiving instruction had successfully completed a series of touch-and-go landings on runway 25 at SXQ and was conducting another landing. The flight instructor stated that, as the airplane touched down on the paved runway, he heard a “loud thud” just as the pilot receiving instruction applied full takeoff engine power. The airplane began to veer to the left, and the pilot receiving instruction applied full right rudder to correct the veer, but the airplane continued to veer. The flight instructor took control of the airplane, and the pilot receiving instruction stated “we’ve lost the left gear.” The airplane continued off the left side of the runway and entered an area of rough, grass-covered terrain before colliding with a taxiway sign. The airplane’s left main landing gear collapsed, and the airplane came to an abrupt stop next to the runway. The airplane sustained substantial damage to the left wing, fuselage, and empennage. A witness to the accident reported that the right wingtip dragged on the ground as the airplane veered to the left and that the left gear impacted a sign along the taxiway. Another witness reported that the right wing was dragging on the runway for about 200 to 300 ft and that the airplane departed the runway and impacted taxiway lights, which was followed by a gear collapse. A postaccident examination of the runway environment revealed that the airplane touched down about 361 ft from the runway threshold. Ground scars, impact signatures, and tire skid marks on the runway were consistent with simultaneous contact of the right-wing tip and the right main landing gear tire. The airplane continued to veer to the left, for an additional 218 ft from the touchdown point before departing the left side of the runway. The airplane then veered slightly to the right, momentarily reentering the runway surface, but then veered to the left again. The airplane subsequently collided with a taxiway light, a sign, and a runway “wigwag” airfield light system before becoming airborne momentarily again. During the second touchdown, the airplane collided with another runway sign. The airplane wreckage came to rest in an area of rough and uneven grass-covered terrain on the left side of the runway, about 1,249 ft from the initial touchdown point. The right wing had abrasion damage on the wing tip fairing that matched witness marks on the runway. The left main landing gear leg was folded under the fuselage. The entire gearbox structure of the left main landing gear was torn from the fuselage, and the structure remained attached to the upper portion of the spring steel landing gear leg assembly. The airplane examination found no preaccident mechanical anomalies that would have precluded normal operations. -
Analysis
The flight instructor reported that he and the pilot receiving instruction were practicing landings in the tailwheel-equipped airplane. Upon touchdown on the dry, paved runway, the airplane veered to the left and departed the runway. The airplane impacted a taxiway light, a taxiway sign, and a runway light system, causing the airplane’s left landing gear to collapse. The airplane sustained substantial damage to the left wing, fuselage, and empennage. A witness reported that the right wingtip dragged on the ground as the airplane veered to the left. A postaccident examination of the runway surface revealed ground scars and impact signatures on the runway surface that were consistent with simultaneous contact of the right-wing tip and right main landing gear tire on initial touchdown. Examination of the airplane found no preaccident mechanical anomalies that would have precluded normal operations. Given the physical evidence found on the runway surface and the damage sustained to the airplane’s right wingtip, which indicate an unstable landing that was not corrected by the instructor before touchdown, it is likely that the flight instructor’s inadequate supervision resulted in the pilot receiving instruction’s loss of control while landing on the paved runway.
Probable cause
The flight instructor's inadequate supervision of the pilot receiving instruction, which resulted in a loss of control during the landing touchdown and a left main landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180H
Amateur built
false
Engines
1 Reciprocating
Registration number
N3467Y
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
18051967
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-23T04:00:26Z guid: 103736 uri: 103736 title: CEN21LA375 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103729/pdf description:
Unique identifier
103729
NTSB case number
CEN21LA375
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-14T14:30:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-08-31T18:04:02.631Z
Event type
Accident
Location
Waller, Texas
Airport
Dry Creek Airport (TS07)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 14, 2021, about 1330 central daylight time, a Haley Highlander, N100GH, was substantially damaged when it was involved in an accident near Waller, Texas. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while in cruise flight, about 800 ft above ground level, the engine began to surge and lost power. In an effort to restore power, the pilot turned on the auxiliary fuel pump, but the engine did not restart. During a forced landing to a dirt road, the airplane touched down short of the road in a corn field, which resulted in substantial damage to the right wing. The engine was subsequently removed for repair and the airplane was disassembled before the National Transportation Safety Board (NTSB) could conduct a detailed examination. When asked if the engine repair facility determined a cause for the loss of engine power, the pilot stated “No, the reason was lack of fuel in one tank which made the engine lose power and start surging.” The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. -
Analysis
The pilot reported that while in cruise flight, about 800 ft above ground level, the engine began to surge and lost power. In an effort to restore power, the pilot turned on the auxiliary fuel pump, but the engine did not restart. During a forced landing to a dirt road, the airplane touched down short of the road in a corn field, which resulted in substantial damage to the right wing. The engine was subsequently removed for repair and the airplane was disassembled before the National Transportation Safety Board (NTSB) could conduct a detailed examination. When asked if the engine repair facility determined a cause for the loss of engine power, the pilot stated “No, the reason was lack of fuel in one tank which made the engine lose power and start surging.” The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
A loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HALEY
Model
Highlander
Amateur built
true
Engines
1 Reciprocating
Registration number
N100GH
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
JA186-08-09
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-31T18:04:02Z guid: 103729 uri: 103729 title: PLD21FR003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103697/pdf description:
Unique identifier
103697
NTSB case number
PLD21FR003
Transportation mode
Pipeline
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-15T06:29:00Z
Publication date
2023-05-09T04:00:00Z
Report type
Final
Last updated
2023-04-27T04:00:00Z
Event type
Accident
Location
Coolidge, Arizona
Injuries
2 fatal, 1 serious, 0 minor
Pipeline operator
Kinder Morgan
Pipeline type
Gas Transmission - Regulated
Regulator type
Pipeline and Hazardous Materials Safety Administration
Probable cause
The National Transportation Safety Board determines that the probable cause of the August 15, 2021, pipeline rupture in Coolidge, Arizona, was tented tape wrap leading to stress corrosion cracking, a fracture at a longitudinal seam weld, and subsequent rupture of the pipe. Contributing to the rupture was Kinder Morgan’s failure to record the correct coating type used for this segment of pipeline, leading to a risk assessment that did not fully identify the risk of stress corrosion cracking.
Has safety recommendations
false

Vehicle 1

Findings
creator: NTSB last-modified: 2023-04-27T04:00:00Z guid: 103697 uri: 103697 title: CEN21LA372 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103715/pdf description:
Unique identifier
103715
NTSB case number
CEN21LA372
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-15T17:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-08-18T20:15:15.265Z
Event type
Accident
Location
Augusta, Kansas
Airport
N/A (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On August 15, 2021, about 1630 central daylight time, a Flying K Enterprises Sky Raider airplane, N56179 was substantially damaged when it was involved in an accident near Augusta, Kansas. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported the preflight inspection, engine start, taxi runs, and run-up were normal. The takeoff ground run was about 250 ft, and the pilot established an initial climb at 50 mph. Shortly afterward, the engine speed dropped from 6,000 rpm to about 5,000 rpm. He lowered the nose and entered a shallow turn toward a field, the engine speed dropped to “almost nothing” but it did not quit altogether. About 150 ft above ground level, the pilot lowered the nose further but was only able to gain sufficient airspeed to “flatten the descent” before impact. The airplane came to rest upright in an open field. Both main landing gear collapsed, and the lower fuselage was damaged resulting in substantial damage to the airplane. A postaccident engine examination did not identify any anomalies consistent with an inability to produce rated power. The engine had been removed from the airframe, and the wings removed from the fuselage to facilitate recovery from the accident site and initial repairs. As a result, a comprehensive examination of the airframe fuel system could not be conducted. The engine utilized dual, slide-type carburetors which are unlikely to accumulate ice. -
Analysis
The pilot reported that the engine power decreased about 1,000 rpm during initial climb after takeoff. Shortly afterward, the engine speed decreased to “almost nothing” but the engine did not quit altogether. The pilot lowered the nose but was only able to gain sufficient airspeed to “flatten the descent” before impact. The airplane came to rest upright in an open field with damage to the lower fuselage. A postrecovery engine examination did not identify any anomalies consistent with an inability to produce rated power. The engine had been removed from the airframe, and the wings removed from the fuselage to facilitate recovery from the accident site and initial repairs. As a result, a comprehensive examination of the airframe fuel system could not be conducted. The engine utilized dual, slide-type carburetors, which are unlikely to accumulate ice.
Probable cause
A partial loss of engine power for reasons that could not determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Flying K Enterprises
Model
Sky Raider
Amateur built
true
Engines
1 Reciprocating
Registration number
N56179
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
74
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-18T20:15:15Z guid: 103715 uri: 103715 title: ANC21LA073 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103719/pdf description:
Unique identifier
103719
NTSB case number
ANC21LA073
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-16T15:52:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-08-25T20:24:52.707Z
Event type
Accident
Location
Fairbanks, Alaska
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 16, 2021, about 1452 Alaska daylight time, a Cessna 208B, N97HA, was substantially damaged when it was involved in an accident near Fairbanks, Alaska. The pilot and eight passengers were not injured. The airplane was operated as a Title 14 CFR Part 135 scheduled commuter flight. According to the pilot, Wright Air Service flight 440 departed about 1424 from the Fairbanks International Airport (FAI), destined for Huslia, Alaska (HLA), located about 220 miles west-northwest of FAI. The pilot reported that after departure, she climbed the airplane to her assigned altitude of 10,000 ft msl, where she encountered “light rime” icing conditions. To exit the icing conditions, she requested and was assigned a block altitude from 10,000 to 12,000 ft msl. She subsequently climbed the airplane to 10,500 ft msl. She was unable to exit the icing condition and elected to begin a gradual descent back to 10,000 ft msl. She added that instrument meteorological conditions prevailed and that the autopilot was engaged. The pilot also noted that while en route, the airplane’s deicing boots and heated propeller were operating normally by removing ice accumulations. She reported that while in a gradual descent from 10,500 ft msl to 10,000 ft msl, the autopilot suddenly disengaged without warning, and the airplane entered an abrupt uncommanded right bank followed by a steep, nose-down, spiraling descent. The pilot said that during the upset, it felt as if the aileron controls were jammed as she tried to regain control of the airplane. After regaining control of the airplane, she declared an emergency to air traffic control and subsequently made an emergency landing at FAI. Flight track data revealed that after departing FAI, the flight proceeded to the west-northwest for about 47 nautical miles cruising at an altitude of about 10,000 ft msl. Before the upset, a climb was initiated, and the flight reached an altitude of about 10,700 ft msl before descending to about 10,300 ft msl followed by an inflight upset with abrupt changes to altitude and speed. (See figure – Flight track.) Figure - Flight track. The Fairbanks upper air soundings indicated cloud cover was likely from 3,000 ft msl through 18,000 ft msl with moderate icing above 9,500 ft msl and the freezing level around 6,440 ft msl. The NWS Fairbanks/Pedro Dome (PAPD) weather radar depicted light to moderate precipitation moving southwest to northeast across the flight path throughout the accident flight with very light precipitation located near the accident location at the accident time. Experimental satellite cross section information further supplemented the Fairbanks sounding icing data, indicating supercooled liquid water located within the clouds from 7,000 ft msl through 13,000 ft msl between 1447 and 1500. Both the NWS Forecast Icing Product (FIP) and the NWS Current Icing Product (CIP) indicated a 30% to 60% chance of trace to moderate icing in the accident region; the CIP indicated an unknown probability of SLD between 8,000 ft msl and 11,000 ft msl at 1500. Additional information received from the National Center for Atmospheric Research indicated favorable conditions for SLD. Several passengers on the flight provided their observations about the weather conditions. One of the passengers stated that around the time of the upset, the airplane felt like it was getting “slammed with ice” and in turbulence; this passenger viewed chunks or sheets of ice flying past the airframe while in descent after the initial upset. Another passenger stated that before the upset, there was ice built up on the front windshield, and they noticed “heavy moisture” on the strut throughout the entire flight. A third passenger stated that they observed snow and ice building up on their side window before the upset and that the accumulation was thick enough that they could not see through it. A postflight examination of the airplane revealed substantial damage to the wings and right aileron. The examination revealed no evidence of preaccident mechanical malfunctions or anomalies with the airplane that would have precluded normal operation. Flight control continuity was confirmed from the cockpit to all control surfaces. Additionally, testing of the autopilot and deice systems did not reveal any anomalies. A review of the airplane’s pilot operating handbook (POH) and applicable supplements revealed that flight in freezing rain, freezing drizzle, mixed conditions, or conditions defined as severe were prohibited. In addition, the minimum speed for flight in icing conditions with the flaps up was 130 knots indicated airspeed with a maximum weight of 8,550 lbs. The POH further stated, “the autopilot must be disconnected once every 10 minutes in icing conditions to check for any out-of-trim conditions caused by ice buildup.” Data obtained from the Garmin GFC 600 autopilot revealed that the autopilot was not disconnected every 10 minutes through the course of the flight as required. The indicated air speed was consistently below 130 knots, and it was below 100 knots in the seconds preceding the upset. The low airspeed alert activated at 107 kts about 16 minutes, 5 minutes and 2 1/2 minutes before the upset, respectively. A review of the data did not identify any unexpected operation of the autopilot. According to the weight and balance information for the airplane dated February 3, 2021, the basic empty weight of the airplane in the seating configuration of the accident flight was 5,202.5 lbs with a center of gravity of 188.2 inches. At the airplane’s maximum takeoff gross weight of 9,062 lbs, the center of gravity range was 200.23 inches to 204.35 inches. At the airplane’s maximum takeoff gross weight for flight into known icing conditions of 8,550 lbs, the center of gravity range was 197 inches to 204 inches. The airplane’s weight and balance at the time of the accident was estimated using the weight of the pilot from her most recent FAA medical examination (115 lbs) and the weights provided by the operator for the passengers and their baggage (1,606 lbs and 832 lbs, respectively). The pilot stated that the airplane departed with about 1,900 lbs of fuel. Assuming an average fuel burn of about 360 lbs/hr, about 30 minutes of flight time before the upset, and allowing for additional fuel burned during takeoff and initial climb, fuel onboard at the time of the accident was about 1,700 lbs. The gross weight of the airplane at the time of the accident, without accounting for the weight of any ice accumulation, was about 9,420 lbs, and the center of gravity was about 199.8 inches. Previous Related Recommendations During its investigation of this accident, the NTSB determined that the airplane encountered SLD. The pilot stated that before the accident flight, she reviewed weather information from several sources, including “multiple pages” on the NWS Alaska Aviation Weather Unit (AAWU) website. The NWS Aviation Weather Center (AWC) produces graphical forecast products (the CIP and the FIP)that depict the potential for significant icing, including SLD conditions, for the contiguous United States. However, a product depicting SLD was not available for the state of Alaska, and if it had been, the accident may have been avoided. As a result, the NTSB issued the following recommendations: Safety Recommendation A-22-21 asked the FAA, in collaboration with the NWS, to develop a graphical forecast showing the potential for SLD icing conditions in Alaska and make this information available to pilots. Safety Recommendation A-22-22 asked the NWS to work with the FAA to develop a graphical forecast depicting potential areas of SLD icing conditions in Alaska and make this information available to pilots. Although neither Part 135 nor Wright Air Service’s Operations Specifications required the operator to physically document the weight and balance for any flights conducted in the company's single-engine airplanes, 14 CFR 135.63 requires that operators using multiengine aircraft are "responsible for the preparation and accuracy of a load manifest in duplicate containing information concerning the loading of the aircraft." This load manifest must be prepared before each flight and include, among other items, the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the center of gravity location of the loaded aircraft. Further, one copy of the load manifest is to be carried in the airplane, and the operator is required to keep the records for at least 30 days. The NTSB attempted to address this exclusion with the issuance of Safety Recommendations A-89-135, A-99-61 and A-15-029, which asked the FAA to amend the record-keeping requirements of 14 CFR 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action, and the NTSB classified Safety Recommendations A-89-135, A-99-61, and A-15-029 "Closed—Unacceptable Action" in 1990, 2014, and 2021, respectively. -
Analysis
After departure, the pilot climbed the airplane with the autopilot engaged to her assigned altitude of 10,000 ft mean sea level (msl), where she encountered instrument meteorological conditions and “light rime” icing conditions. To exit the icing conditions, she climbed the airplane to 10,500 ft msl. However, she was unable to exit the icing conditions and began a gradual descent back to 10,000 ft msl. She noted that while en route, the airplane’s deicing boots, and heated propeller were operating normally by removing ice accumulations. While in a gradual descent from 10,500 ft msl to 10,000 ft msl, the autopilot disengaged without warning, and the airplane entered an abrupt uncommand right bank followed by a steep, nose-down, spiraling descent. The pilot stated that during the upset, it felt as if the aileron controls were jammed as she tried to regain control of the airplane. After regaining control of the airplane, she declared an emergency and made an emergency landing back at the departure airport. The airplane sustained substantial damage to the wings and the right aileron during the upset. Postaccident examination revealed no evidence of preaccident mechanical malfunctions or anomalies with the airplane that would have precluded normal operation. Flight control continuity was confirmed from the cockpit to all control surfaces. Additionally, testing of the autopilot and deice systems did not reveal any anomalies. Weather soundings, forecasts, and experimental weather products indicated a 30% to 60% chance of light to moderate icing in the accident region with supercooled liquid water in the clouds from 7,000 ft to 13,000 ft and favorable conditions for supercooled large droplets (SLD). It is likely the airplane encountered SLD conditions that degraded the airplane’s performance, which resulted in the upset. Graphical aviation forecast information that showed areas of icing (trace to severe/heavy) was available in Alaska. However, that information did not depict areas with potential SLD icing. If a product that included SLD icing information for Alaska had been available, the accident may have been avoided. As a result, the National Transportation Safety Board (NTSB) issued recommendations to the Federal Aviation Administration (FAA) and the National Weather Service (NWS) to collaborate in the development of a graphical forecast showing the potential for SLD icing conditions in Alaska and to make this information available to pilots (Safety Recommendations A-22-21 and -22). Although the airplane was equipped for flight into known icing conditions, the pilot’s operating handbook (POH) and applicable supplements contained information that flight in freezing rain, freezing drizzle, mixed conditions, or conditions defined as severe were prohibited. In addition, the minimum speed for flight in icing conditions with the flaps up was 130 knots indicated airspeed with a maximum weight of 8,550 lbs. The POH further required that the autopilot be disconnected once every 10 minutes in icing conditions to check for any out-of-trim conditions caused by ice buildup. Data obtained from the autopilot revealed that it was not disconnected every 10 minutes through the course of the flight as required. The indicated air speed was consistently below 130 knots, and it was below 100 knots in the seconds preceding the upset. Furthermore, the low airspeed alert activated at 107 kts about 16 minutes, 5 minutes and 2 1/2 minutes before the upset, respectively. Additionally, the estimated gross weight of the airplane at the time of the accident was about 293.5 lbs over its maximum approved gross weight and 805.5 lbs over its approved maximum gross weight for flight in known icing conditions. For each flight in multiengine operations, Title 14 Code of Federal Regulations (CFR) 135.63(c) requires the preparation of a load manifest that includes, among other items the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the center of gravity location of the loaded aircraft; one copy of the load manifest should be carried in the airplane, and the operator is required to keep the records for at least 30 days. Single-engine operations, such as the accident flight, are excluded from this requirement. Had the pilot been required to compute and record a weight and balance calculation, she may have been more aware of the airplane’s limitations for flight in known icing conditions and its overweight condition. The NTSB previously attempted to address this exclusion with the issuance of Safety Recommendations A-89-135, A-99-61, and A-15-29, which asked the FAA to amend the record-keeping requirements of 14 CFR 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action, and the NTSB classified Safety Recommendations A-89-135, A-99-61, and A-15-29 "Closed—Unacceptable Action" in 1990, 2014, and 2021, respectively.
Probable cause
The pilot’s unexpected encounter with supercooled liquid droplets (SLD), which resulted in a loss of control due to ice accumulation. Contributing to the accident were: (1) the pilot’s failure to maintain the minimum airspeed for flight in icing conditions, (2) the pilot’s failure to disconnect the autopilot every 10 minutes to check for ice buildup, (3) the overweight airplane, (4) the lack of an SLD forecast product for the state of Alaska, and (5) the Federal Aviation Administration's failure to require weight and balance documentation for each flight in Title 14 Code of Federal Regulations Part 135 single-engine operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
208
Amateur built
false
Engines
1 Turbo prop
Registration number
N97HA
Operator
WRIGHT AIR SERVICE INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
208B0610
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-25T20:24:52Z guid: 103719 uri: 103719 title: ERA21LA328 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103717/pdf description:
Unique identifier
103717
NTSB case number
ERA21LA328
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-16T21:32:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-09-06T21:56:39.087Z
Event type
Accident
Location
Orlando, Florida
Airport
EXEC (ORL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On August 16, 2021, about 2032 eastern standard time, a Piper PA-28-140, N98304, operated by Airline Training Academy Inc., dba ATA Flight School, was substantially damaged when it was involved in an accident in Orlando, Florida. The private pilot was seriously injured, and the flight instructor received minor injuries. The airplane was being operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. According to the flight instructor, the purpose of the flight was so that the private pilot could accrue flight time to meet the requirements for a commercial pilot certificate. The flight departed North Perry Airport (HWO), Hollywood, Florida, about 1855, destined for Orlando Executive Airport (ORL), Orlando, Florida. During the accident flight, the private pilot was in the left seat and the flight instructor was in the right seat and was “acting as safety pilot.” Prior to departing HWO, they completed the preflight checklist, added oil to the engine and assured that the fuel tanks were full. They planned to fly to ORL, land, and later return to HWO. About 30 miles from ORL, the flight instructor requested visual flight rules flight following services from air traffic control. He received a weather update and was asked to remain outside the Orlando Class B airspace. As a result, they had to fly around weather that was in the area, and then were eventually handed off to ORL tower at approximately 2020. As they were approaching the airport, the private pilot was flying the airplane. He switched fuel tanks and, about 700 feet msl, he determined that the throttle was not responding to his commands. He then alerted the flight instructor and handed over control of the airplane to him. Once the flight instructor confirmed that the throttle was not responsive, the private pilot went through the emergency checklist while the flight instructor pitched the nose of the airplane up to decrease the rate of descent. The flight instructor radioed ORL tower and declared an emergency and then conducted a forced landing. When the airplane came to rest, the flight instructor observed that the private pilot was not conscious. He then tried to wake him up and began to remove him from the airplane. At some point the private pilot regained some level of consciousness and the flight instructor assisted him to an urgent care center that was located about 100 yards from the accident site. They both received medical attention at the urgent care center and were then transported to a hospital. After the accident, the flight instructor stated to an Orange County Sheriff’s officer that there had been prior issues with the airplane. According to an FAA inspector, the pilots had advised that the engine stoppage had occurred when they switched fuel tanks. During the recovery, 5 gallons of fuel were drained from the left wing fuel tank, and 10 gallons of fuel were drained from the right wing fuel tank. Examination of the wreckage by the NTSB revealed that the fuselage exhibited impact damage to its firewall and cockpit belly skin. Downward deformation was observed at the tail cone area. The nose gear was impact-separated and the engine cowlings exhibited impact damage. All control cables remained attached to their respective attach points and control continuity was established. Two Hobbs meters were installed each showing different times. The carburetor heat control was in the OFF position. The wing flap lever was in the up (0°) position. The manual primer was stowed and the electric fuel pump switch was in the ON position. The pilot and copilot seats where the pilot and flight instructor were seated remained attached to their respective mounts. The pilot and copilot seats were in poor condition displaying torn fabric with missing and protruding cushion material. Their lap belt restraints remained attached to their respective attach points. The rear bench seat remained attached to its mounts. The bench seat’s inboard seat belt latches were not installed. Examination of the fuel selector and fuel selector valve revealed that the fuel selector valve cover was not installed per manufacturer’s guidance. Instead, it had been installed directly to the interior side panel with oversize screws, which interfered with the movement of the selector handle. Further examination also revealed that the cover was not in the correct mounting orientation/clocked position; no selector cover attach bracket was installed, nor was the spring-loaded metal stop. The fuel selector was observed between the L TANK (left fuel tank) and FUEL OFF position. Prior to verification of the fuel selector position, fuel line continuity could not be established with low pressure air from the left or right wing root fuel lines to the gascolator. Removal of the cover confirmed the valve was positioned between the left fuel tank and fuel off positions. Detents in the fuel selector valve were confirmed. Fuel line continuity was confirmed with low pressure air when the selector was placed in the left fuel tank and right fuel tank positions, respectively. The interior of the left wing also displayed an area where high-expansion foam was visible through the breaks in the wing. A residual amount of blue liquid consistent in color and odor to that of aviation type gasoline was observed within the fuel tank. Fuel line continuity was established from the wing root to the fuel tank with low pressure air. The fuel cap was not attached to its receptacle and was not located within the recovered wreckage. The engine remained attached to the impact damaged mount. The induction air box was impact damaged and the carburetor heat was observed in the “off/filtered air” position. No anomalies were noted to the heat muff, and the exhaust tailpipe was crushed at its lower area. The induction air filter assembly exhibited impact damage and no obstructions were observed. Examination of the induction air hose/duct revealed it was not a Piper part/correct hose. The induction Scat type hose exhibited impact damage. The electric fuel pump’s filter was clear of debris and fuel was observed during the examination. The gascolator exhibited impact damage and its filter was clear of debris. The aluminum two-bladed fixed pitch propeller remained attached to the engine. Both propeller blades were deformed aft about mid-span with no leading-edge damage observed. The propeller spinner remained attach to the propeller with leading edge impact or recovery damage noted. The engine was subsequently prepared for a ground test run. Both propeller blades were cut inboard of their bent areas. The gascolator was bypassed with a fuel line due to impact damage of the gascolator. A fuel supply was attached to the aircraft’s fuel line at the right wing root and the fuel selector was placed in the right fuel tank position. The engine was then started and ran to about 100° of oil temperature; about 80 psi of oil pressure, and about 6 psi of fuel pressure were observed. The magneto drop was observed about 400 RPM between the left and right magnetos. The engine was then run to 2,500 rpm with no anomalies noted. The engine was shut down via mixture control and the fuel supply tank was then attached to the fuel line at the leftwing root area. The fuel selector was then placed in the left fuel tank position. The engine was then started and ran to 2,500 rpm with no anomalies noted. On July 27, 2021 (20 days prior to the accident), the individual who listed himself as the operator on an NTSB Form 6120 Pilot/Operator Accident/Incident Report, certified in the airplane maintenance records “that this aircraft was inspected with accordance with a 100hr Inspection was determined to be in airworthy condition.” Review of State of Florida records at the time indicate that he was the Registered Agent for Airline Training Academy Inc., which was a Florida Profit Corporation. On August 03, 2021 (13 days prior to the accident), an FAA inspector performed a ramp inspection on airplanes that were being operated at HWO. During the inspection of the accident airplane, the inspector identified 42 discrepancies with the airplane including that the fuel selector valve handle should be painted red and visible from normal viewing angles, and the installed fuel tank selector placard was unsatisfactory. After discussing the condition of the airplane with one of the owners, the inspector was advised that they were not going to use the airplane at the flight school. On August 8, 2021 (8 days prior to the accident), a mechanic “Installed customer supplied fuel selector valve cover” and certified that “all work was accomplished in accordance with Piper PA28-140 service manual section 2, 4, and 8.” None of these sections, however, addressed installation of the fuel selector valve or fuel selector valve cover. The company name that was listed on the maintenance entry was Aviation Maintenance Technologies Inc. Review of publicly available business information indicated that the president of Aviation Maintenance Technologies Inc. was also the same individual listed on the bill of sale for the accident airplane under “purchaser” when it was purchased by Florida General Aviation Corporation. A comparison of FAA registration records to a Florida Profit Corporation Annual Report filed with the Florida Secretary of State, also indicated that the president of Florida General Aviation Corporation was also the president of the Airline Training Academy Inc. According to Title 14 CFR 91.403 (a), the owner or operator of an aircraft is primarily responsible for maintaining that aircraft in an airworthy condition, and a review of published Piper Aircraft guidance documents indicated that documentation was available for proper installation and inspection of the fuel selector valve and fuel selector valve cover. -
Analysis
The purpose of the cross-country flight was so that the private pilot could accrue flight time to meet the requirements for a commercial pilot certificate. During the flight, the private pilot was in the left seat and a flight instructor was in the right seat. During the descent to their destination airport, the private pilot switched fuel tanks and, about 700 feet above mean sea level (msl), there was a loss of engine power. The flight instructor assumed control of the airplane, declared an emergency and conducted a forced landing. During the forced landing, the airplane was substantially damaged, and the private pilot was seriously injured. During recovery of the wreckage form the accident site, 5 gallons of fuel were drained from the left wing fuel tank and 10 gallons of fuel were drained from the right wing fuel tank. Examination of the wreckage revealed that the fuel selector and fuel selector valve cover were not installed per the manufacturer’s guidance. The selector valve cover had been improperly installed directly to the interior side panel with oversize screws, which interfered with the movement of the selector handle. The cover was not in the correct mounting orientation, the selector cover attach bracket was not installed, nor was the spring-loaded metal stop (which would keep the fuel selector valve from inadvertently being placed in the FUEL OFF position). The fuel selector was observed between the L TANK (left fuel tank) and FUEL OFF position. Prior to verification of the fuel selector position, fuel line continuity could not be established with low pressure air from the left or right wing root fuel lines to the gascolator. Removal of the cover also confirmed that the fuel selector valve was positioned between the left fuel tank and fuel off positions. Detents in the fuel selector valve were also confirmed, but the fuel selector valve cover selector position labeling did not align with the detent positions as the fuel selector valve cover had not been properly indexed. After the examination, when the fuel selector valve was placed in either the correct left fuel tank or right fuel tank positions, the engine was able to be run without any anomalies. Based on this information, the loss of engine power was most likely the result of fuel starvation, after the flight crew inadvertently placed the fuel selector into a position between the left fuel tank and off positions. Maintenance records indicated that the airplane had undergone a 100-hour inspection 20 days before the accident. However, 13 days before the accident, a Federal Aviation Administration (FAA) inspector performed an inspection of the airplane and identified 42 discrepancies, including that the fuel selector valve handle should be painted red and that the installed fuel tank selector placard was unsatisfactory. After discussing the condition of the airplane with one of the owners, the inspector was advised that they were not going to use the aircraft at the flight school. Maintenance records indicated that 8 days before the accident, a mechanic installed a fuel selector valve cover and certified that all work was accomplished in accordance with the manufacturer’s maintenance manual. None of the sections explicitly listed in the maintenance log entry, however, addressed the installation of the fuel selector valve or fuel selector valve cover. Based on this information, the improper installation of the fuel selector valve cover, which was accomplished at the direction of the operator/owner, likely directly contributed to the flight crew’s incorrection positioning of the fuel selector valve.
Probable cause
A total loss of engine power due to fuel starvation that resulted from improper maintenance of the fuel selector valve and fuel selector valve cover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N98304
Operator
Airline Training Academy
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-26161
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-06T21:56:39Z guid: 103717 uri: 103717 title: ERA21LA335 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103738/pdf description:
Unique identifier
103738
NTSB case number
ERA21LA335
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-18T19:50:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-30T20:45:59.282Z
Event type
Accident
Location
Livingston, Tennessee
Airport
Livingston Municipal Airport (8A3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 18, 2021, about 1850 central daylight time, an experimental, amateur-built Hummer 260L helicopter, N777TC, was substantially damaged when it was involved in an accident near Livingston, Tennessee. The private pilot and the pilot-rated passenger were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot/owner stated that the flight was initiated from Livingston Municipal Airport (8A3) with an adequate supply of fuel. After warming the engine, he lifted the helicopter to a hover, hover taxied, ground taxied, and practiced setting down and lifting-up to a hover for about 10 to 15 minutes with no engine issues noted. He then intended to takeoff and fly in the airport traffic pattern. The pilot reported that the auxiliary fuel pump was on for the takeoff. He started to takeoff, and between 100 to 150 ft above ground level (agl) while passing through effective translational lift at an airspeed between 40 and 50 knots, the helicopter experienced a sudden complete loss of engine power. The pilot lowered the collective, made a partial throttle reduction, and entered an autorotation. When the helicopter was at 70 to 75 ft agl and 50 knots, the engine power increased. The pilot increased the throttle, and the engine power increased to full rpm; but as he increased collective, the engine again lost total power. According to the pilot, the helicopter was operating in the shaded area of the helicopter’s height/velocity diagram, and although he rapidly lowered the collective to gain energy in the main rotor blades, there was not enough inertia in them for a normal autorotative landing. The helicopter impacted hard on soft, wet, and slightly sloped terrain, and the landing gear wheels became buried and separated. The helicopter then rolled onto its right side, and the main rotor blades contacted the ground. The pilot stated that during recovery of the helicopter, fuel drained from a depressed fuel tank sump drain valve. After recovering the helicopter and elevating it, an additional 4 to 5 gallons of fuel were drained, which emptied the fuel tank; no fuel contamination was reported. One of four 4130 steel tubes that structurally secured the tailboom was cracked and deformed. The fuel shut-off valve was in the open position. Examination of the engine following recovery revealed that all fuel hoses were installed correctly and tight. Residual fuel was present in each hose. Residual fuel and some debris was present in the airframe fuel strainer; the debris was sand-like in particle size. The inlet screen of the controller, or servo fuel injector, was clean. There were no discrepancies found with the engine controls, the air induction, exhaust, and ignition systems, or the auxiliary fuel pump, which was electrically tested. Crankshaft, camshaft, and valve train continuity were confirmed. Borescope inspection of each cylinder revealed no discrepancies with the valves or pistons. Operational testing of the fuel injector nozzles revealed an equal amount flowed from five of the six fuel injector nozzles; the No. 3 nozzle’s flow was about two-thirds that of the others. The controller was retained and sent to the manufacturer’s facility for operational testing, which revealed no evidence of preimpact failure or malfunction. The unit was operationally tested with airflow and found to flow nearly identical to the values that were recorded when it was manufactured in 2012. According to the Federal Aviation Administration’s Helicopter Flying Handbook, the height/velocity (H/V) diagram shows the combinations of airspeed and height above the ground that will allow an average pilot to successfully complete a landing after an engine failure. The handbook states that operation of the helicopter in the shaded area of the diagram may not allow sufficient time or altitude to enter a stabilized autorotative descent. It further states that “in the simplest explanation, the H/V diagram is a diagram in which the shaded areas should be avoided, as the pilot may be unable to complete an autorotation landing without damage.” -
Analysis
The pilot initiated takeoff in the helicopter, and when passing through effective translational lift, with an airspeed between 40 and 50 knots, and about 100 to 150 ft above ground level (agl), the engine experienced a sudden complete loss of power. He lowered the collective, made a partial throttle reduction, and entered an autorotation, but engine power increased when the helicopter was at 70 to 75 ft agl and 50 knots. He increased the throttle, and the engine power increased to full rpm. As he increased collective, the engine “sputtered and quit instantly.” The helicopter was operating in the shaded area of the helicopter’s height/velocity diagram, which, according to guidance, may not allow sufficient time or altitude to enter a stabilized autorotative descent. Although the pilot rapidly lowered the collective to gain energy in the main rotor blades, there was not enough inertia in them for a normal autorotative landing. The helicopter landed hard on soft wet terrain resulting in structural damage to one of the steel tubes that attached the tailboom. During postaccident examination of the helicopter and its engine, one fuel injector nozzle flowed slightly less than the other five; however, it likely did not contribute to the twice-repeated total loss of engine power. The examination of the engine and its systems revealed no other evidence of preimpact failure or malfunction. The reason for the twice-repeated total loss of engine power could not be determined based on the available evidence.
Probable cause
A total loss of engine power for reasons that could not be determined. Contributing to the accident was the pilot’s operation of the helicopter in a flight regime that would not allow for a successful autorotative landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Hummer
Model
260L
Amateur built
true
Engines
1 Reciprocating
Registration number
N777TC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0834
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T20:45:59Z guid: 103738 uri: 103738 title: ERA21FA333 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103731/pdf description:
Unique identifier
103731
NTSB case number
ERA21FA333
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-20T11:13:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-08-24T21:16:34.608Z
Event type
Accident
Location
Wadesboro, North Carolina
Airport
Anson County Airport (AFP)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The maintenance logbooks were not recovered during the investigation. - On August 20, 2021, about 1013 eastern daylight time, a Piper PA-24-250, N8262P, was destroyed when it was involved in an accident near Wadesboro, North Carolina. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the previous owner of the airplane, he sold the airplane to the accident pilot on August 4, 2021. The pilot drove from his home in Florida to Darr Field Airport (NC03), High Point, North Carolina, where the airplane was based at the time. The pilot, who also held a mechanic certificate with airframe and powerplant ratings, as well as an inspection authorization, planned to complete repairs, perform an annual inspection, and fly the airplane to LaBelle Municipal Airport (X14), LaBelle, Florida. The repairs included replacing hoses, rebuilding a jammed fuel selector valve, repairing a corroded fuel line, and removing and checking one magneto. On the day of the accident, the pilot made an uneventful flight in the airplane from NC03 to Anson County Airport (AFP), Wadesboro, North Carolina. Before the day of the accident, the airplane had not been flown for about 15 years. The pilot purchased 51 gallons of fuel at AFP and departed for X14. According to witnesses, during startup, the engine sputtered and backfired. Shortly after takeoff, the engine sputtered and backfired again. The airplane then turned left and descended nose down into wooded terrain, where a postcrash fire ensued. - An autopsy of the pilot was performed by the Mecklenburg County Medical Examiners’ Office, Charlotte, North Carolina. The cause of death was blunt force injuries. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory identified ethanol in the pilot’s muscle (0.08 gm/hg) and brain (0.029 gm/hg). In addition, N-propanol and N-butanol were found in the pilot’s muscle. Ethanol is primarily a social drug with a powerful central nervous system depressant. After ingestion, ethanol is quickly distributed throughout the body’s tissues and fluids. Ethanol may also be produced in body tissues postmortem. N propanol and N-butanol are additional types of alcohol that are formed in tissues postmortem tissues. Meclizine was found in the pilot’s liver, and amlodipine was found in his liver and muscle tissues. Meclizine is an antiemetic available over the counter and by prescription; it is often used to treat motion sickness. It carries these warnings about performance: “do not exceed recommended dosage; drowsiness may occur; avoid alcoholic drinks; alcohol, sedatives, and tranquilizers may increase drowsiness; be careful when driving a motor vehicle or operating machinery.” Amlodipine is a blood pressure medication that is generally considered not to be impairing. - The pilot’s logbook was not recovered during the investigation. On an insurance application for a September 30, 2020, policy renewal, the pilot reported a total flight experience of 800 hours, of which 100 hours were accumulated during the preceding 12 months. The application was for a different make and model airplane than the accident airplane. The pilot’s experience in the accident airplane make and model could not be determined from the available evidence. - The wreckage came to rest inverted, oriented to the east with no debris path observed, and located about 0.5 miles north-northwest of the runway 34 departure end. The cockpit and cabin were partially consumed by fire. The throttle mixture and propeller levers were observed in their fully forward position. Both magnetos were selected, and the electric fuel pump switch was in the on position. The fuel selector valve, which exhibited thermal damage, had separated and was positioned to the left main fuel tank. Measurement of the flap actuator jackscrew corresponded to the flaps’ retracted setting, and measurement of the landing gear actuator cable corresponded to the landing gear retracted position. Flight control continuity was established from the cockpit area (through cable impact and recovery separations) to the respective flight control surfaces (ailerons, rudder, stabilator, and stabilator trim.) The engine came to rest inverted. One propeller blade remained attached to the propeller hub, and the other blade had separated and was located underneath the engine. Both blades exhibited tip curling, and the blade that remained attached exhibited leading-edge damage. The engine sustained front impact damage; as a result, the crankshaft could be rotated by hand only about 90°. Camshaft and crankshaft continuity were confirmed to the rear accessory section of the engine. Holes were drilled into the top of the engine crankcase to facilitate visual and borescope examination. Additionally, because fire consumed the oil sump and a portion of the lower crankcase, visual and borescope examination could also be accomplished from the underside of the engine. Visual and borescope examination of the cylinders and crankcase revealed no preimpact mechanical malfunctions. The carburetor had separated from the engine due to impact and sustained thermal damage. Disassembly of the carburetor revealed that the two floats were present at the bottom of the bowl and that all seals were destroyed. The carburetor fuel inlet screen had no debris. The engine-driven fuel pump remained attached to the engine but was destroyed. All fuel and oil hoses were destroyed by fire. Both magnetos remained attached to the engine and exhibited thermal damage. The right magneto was rotated by hand, but no spark was produced. The left magneto could not be rotated by hand. Fire damage precluded testing of the carburetor and magnetos. Testing of the airport fuel supply did not reveal any anomalies, and no issues were reported with other airplanes that received airport fuel that day. -
Analysis
According to the previous owner of the airplane, he sold it to the pilot about 2 weeks before the accident. The pilot, who held and mechanic certificate and an inspection authorization, planned to complete repairs, perform an annual inspection, and fly the airplane to his home airport. The repairs included replacing hoses, rebuilding a jammed fuel selector valve, repairing a corroded fuel line, and removing and checking a magneto. On the day of the accident, the pilot flew the airplane uneventfully for about 30 minutes, from the location where the airplane had been based to an airport along the route home, to purchase fuel. Witnesses reported that, during startup, the engine sputtered and backfired and that, shortly after takeoff, the engine sputtered and backfired again. The airplane then turned left back toward the airport and descended nose down into wooded terrain, where a postcrash fire ensued. The wreckage came to rest in a compact area, about 0.5 miles from the runway departure end, with no debris path observed, consistent with an aerodynamic stall and relatively low-energy impact. One propeller blade remained attached to the propeller hub, and the other blade had separated and was located underneath the engine. Both blades exhibited tip curling and leading-edge damage. Examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures. Fire damage precluded testing of the carburetor and magnetos. Testing of the airport fuel supply revealed no anomalies, and no issues were reported with other airplanes that received airport fuel that day. The engine sputtering and backfiring reported by the witnesses, as well as the signatures observed on the propeller blade, was consistent with a partial loss of engine power. The reason that the engine lost partial power could not be determined based on the available evidence. Toxicological testing of the pilot identified ethanol in his muscle and brain specimens; however, the difference in the levels of ethanol and the presence of two other alcohols (both primarily produced postmortem) indicated that the ethanol was most likely from postmortem production rather than ingestion. Meclizine, which is often used to treat motion sickness, was found in the pilot’s liver specimens. Although meclizine can cause drowsiness, it likely did not play a role in this accident given that the airplane was observed maneuvering during the final moments of the flight.
Probable cause
A partial loss of engine power during takeoff for reasons that could not be determined. Contributing was the pilot’s loss of airplane control, resulting in an aerodynamic stall and impact with trees and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA24
Amateur built
false
Engines
1 Reciprocating
Registration number
N8262P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-3515
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-24T21:16:34Z guid: 103731 uri: 103731 title: ERA21FA334 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103732/pdf description:
Unique identifier
103732
NTSB case number
ERA21FA334
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-20T13:36:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Last updated
2021-09-03T15:55:59.568Z
Event type
Accident
Location
Wilkes-Barre, Pennsylvania
Airport
WILKES-BARRE/SCRANTON INTL (AVP)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Portable GPS During the examination of the wreckage, a Garmin Aera 660 Portable GPS was recovered. An external examination revealed the device was missing its touch display and had sustained impact and moisture damage, rendering it inoperable. The nonvolatile memory chip was removed and read out was attempted; however, the chip was unresponsive using multiple read out and recovery methods and no data was recovered. Fuel Facility Records Review of fuel facility records indicated that the airplane had been fueled before the accident flight with 56.2 gallons of 100LL aviation gasoline. Further review of the fuel facility records indicated that the facility had completed all the required checks satisfactorily prior to dispensing fuel on the day of the accident. Airplane Weight and Balance Review of weight and balance information indicated that the airplane was within weight and balance limitations. Break Out According to the Formation Pilots Knowledge Guide, the purpose of a break out is to ensure immediate separation and to avoid a mid-air collision. A wingman must break out of the formation if: - He loses sight of his reference aircraft - He is unable to rejoin or stay in formation without crossing directly under or in front of Lead - He feels his presence in the formation constitutes a hazard. - When directed to do so by Lead The guidance continues that if a pilot has lost sight of the reference aircraft, clear, then break in the safest direction away from the last known position or flight path of Lead and other aircraft. One technique—look for blue sky and pull--is appropriate for many situations, but there may be conditions where a pilot would actually pull toward the ground, depending on the airplane’s attitude and relative location to the rest of the flight. Aerodynamic Stalls The Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25C), says in part, that an aerodynamic stall results from a rapid decrease in lift caused by the separation of airflow from the wing’s surface brought on by exceeding the critical angle of attack (AOA). A stall can occur at any pitch attitude or airspeed. The Handbook also states that: Low speed is not necessary to produce a stall. The wing can be brought into an excessive AOA at any speed… The stalling speed of an aircraft is also higher in a turn than in straight-and-level flight. Centrifugal force is added to the aircraft’s weight and the wing must produce sufficient additional lift to counterbalance the load imposed by the combination of centrifugal force and weight. In a turn, the necessary additional lift is acquired by applying back pressure to the elevator control. This increases the wing’s AOA and results in increased lift. The AOA must increase as the bank angle increases to counteract the increasing load caused by centrifugal force. If at any time during a turn the AOA becomes excessive, the aircraft stalls. The accident airplane’s wings-level stall speed was around 74 mph with the wing flaps and landing gear retracted (referred to as a “clean” configuration). Review of a stall speed and load factor chart indicated that: - At 45° of bank, the stall speed would have increased about 20% (About 89 mph). - At 60° of bank, the stall speed would have increased about 40% (About 104 mph, which was above the wings-level clean stall speed). - At 75° of bank, the stall speed would have increased about 95% (About 144 mph, which was above the 140 mph climb speed). - At bank angles exceeding 75°, the stall speed would have increased to 100% or more (148 mph or more). Magnetos The airplane was equipped with two magnetos, which were driven by the engine and operated independently from the electrical system. In a magneto, a spinning magnet induces a large current and small voltage in the primary winding of a coil. A secondary winding then develops a small current and a large voltage which is then routed to the spark plugs. Even if the airplane electrical system fails, there should always be reliable ignition. A way to shut off each of the magnetos is required. This is done through the P-leads on each magneto. The "P" in P-lead comes from the primary winding in the magneto's coil. To deactivate a magneto, the primary winding is grounded. An ignition (magneto) switch in the cockpit would open and close the P-lead circuits to a suitable ground. The ignition switch had positions for “OFF” (off), “R” (right), “L” (left), and “BOTH” (both), to make the required connections: When selected to “OFF”, both left and right P-leads were grounded and both magnetos were off. When selected to the “L” position, the right P-lead was grounded. When selected to the “R” position, the left P-lead was grounded. When selected to the “BOTH” position, both P-lead circuits were open, and both magnetos were on. Preaccident Troubleshooting According to the airplane operator’s Director of Maintenance (DOM), on August 19, 2021, the accident airplane arrived at AVP late due to weather. The pilot made a logbook entry after landing and performed a magneto check, stating that the engine was “banging” on the left magneto. On the day of the accident, the DOM asked one of the other pilots to run the airplane for him so he could observe how the engine was running from outside the airplane. During the magneto check, the engine was “popping and banging” in the “L” position. The DOM then asked the pilot to shut down the engine. While at idle, the pilot conducted a P-lead check, as is the company’s standard operating procedure during engine shut-down. During the P-lead check, he observed that the engine seemed to turn off while passing though the “L” position on the way to the off position. The DOM then asked the pilot to run the engine again so they could verify the left magneto position. The DOM climbed onto the airplane’s wing and observed the engine stop running while passing through the “L” magneto switch position. The DOM switched back and forth numerous times through the “OFF,” “L,” “R,” and “BOTH” positions, and verified that in the left magneto position the engine reacted identically to the OFF position. Then they shut down the engine. Upon visual inspection of the back of the left magneto, the DOM discovered that the P-lead spring, located at the end of the P-lead insulator, was fully compressed, allowing the internal grounding spring, which grounds the magneto when the P-lead is removed, to make contact with the case of the magneto. He observed no other physical anomalies in the rear section of the magneto. The DOM then unscrewed the P-lead and removed the insulator and P-lead spring. He checked for continuity of the wire to the switch with a multimeter, and for proper operation of the switch. Both functioned properly. He then replaced P-lead spring with a new one, re-installed the P-lead insulator back into the magneto, screwed down the cap, and connected the safety clip. The DOM verified that it applied ample pressure to move the internal grounding spring away from the case, then reattached the rear cover. After finding the P-lead spring compressed on the left side, he decided to remove the cover for the right magneto to visually check the condition of the springs. The P-lead spring was extended and was pushing the internal grounding spring away from the case. The rear cover of the right magneto was then closed and secured. The DOM subsequently started the engine and performed an engine run-up and magneto check, which revealed no anomalies. The DOM stated that, before the accident, the team’s engine start was uneventful, and engine run-ups and power checks were performed with no anomalies reported from any of the pilots before takeoff. Pratt & Whitney Troubleshooting Guidance According to the Pratt & Whitney Wasp (R-1340) Maintenance Manual (Chapter 5…Trouble Shooting), items listed in the published troubleshooting chart were presented with consideration given to frequency of occurrence. Under the section on “Rough Running,” “Ignition” was the first item on the troubleshooting chart. The chart then listed the probable causes which could contribute to a rough running engine, such as: Defective spark plugs Dirty or glazed breaker points Breaker out of adjustment Fouled spark plugs due to prolonged idling Moisture or oil in the magneto and/or distributor Water in the ignition harness Improper magneto timing Faulty magneto internally Defective ignition manifold Defective sparkplug lead connectors Magneto ground to cockpit switch connection partially grounded The corrected action to be taken was listed in bold italics as “Apply continuity test.” Under the section on “Engine Stops,” ignition was once again the first item on the troubleshooting chart and listed, “Short in the system” as a possible cause, in addition to the master switch or magneto switch being inadvertently shut off. The corrected action to be taken was listed in bold italics as, “Check all wiring for security, breaks or chafing” and to, “Check all system components.” Postaccident Testing of the Left Magneto The input drive of left magneto would not rotate. The points looked serviceable with a gap of “8.” The coil was tested and found to be within operating limits of 5,100 ohms. The condenser was visibly damaged but tested serviceable. Examination of the left magneto by the NTSB Materials Laboratory also revealed a crack in the threaded socket for the P-lead fitting, which was part of the aluminum upper case half casting. The crack ran from the top surface of the socket toward the interior and passed through a transverse hole near the top of the socket. The crack continued past the transverse hole further into the threaded socket. At the top surface of the threaded socket, just above the transverse hole, an indentation was present which was co-located with the crack. The indentation was consistent with impact-related damage. The top surface of the threaded socket exhibited an imprint consistent with the hexagonal shape of the P-lead fitting. This imprint was pressed into the top of the threaded socket. The interior surfaces of the threaded socket exhibited pulled and deformed thread crests, as well as areas where the threads were almost entirely missing. The fracture surfaces of the crack exhibited voids and an area with a cold shut casting defect in the aluminum. These features on the fracture surface were consistent with a low-quality casting, but were not indicative of a preimpact malfunction or failure. Postaccident Testing of the Right Magneto The right magneto rotated easily, indicative of weak magnetism. When the magneto was put on a test stand, the magneto would not perform at low rpm and would not fire on all points until it reached 180 rpm. Review of airplane maintenance records did not reveal when the magneto was installed on the engine. - The accident airplane was a low-wing monoplane of conventional metal construction. It was equipped with retractable landing gear, wing flaps, and a two-blade, constant speed propeller. It was powered by a 600-horsepower, Pratt & Whitney R-1340-AN-1, 9-cylinder, air cooled, radial engine. According to the Federal Aviation Administration (FAA) and airplane maintenance records, the airplane was manufactured in 1943, and had been modified from its original configuration by multiple alterations and additions, including conversion from a two-seat tandem configuration to a single-seat configuration, with a smoke oil tank taking the place of the rear seat. The airplane’s most recent annual inspection was completed on February 4, 2021. At the time of the inspection, the airplane had accrued about 6,911 total hours of operation, and the engine had accrued about 439 hours of operation since its last overhaul. - AVP was a public use, tower-controlled airport located 5 miles southwest of Scranton, Pennsylvania. There were two runways oriented in an 4/22 and 10/28 configuration. Runway 4 (the departure runway) measured 7,502 ft long and 150 ft wide. Runway 28 (the crosswind runway) measured 4,300 ft long and 150 ft wide. - On August 20, 2021, about 1236 eastern standard time, a North American SNJ-2, N52900, was destroyed when it was involved in an accident in Wilkes-Barre, Pennsylvania. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 air show flight. The accident airplane was operated as part of the Geico Skytypers Air Show Team, which was comprised of six North American SNJ-2 airplanes. The accident occurred during a practice flight for the Great Pocono Raceway Airshow. The flight was initiated with a formation takeoff, which consisted of three, two-airplane elements (sections) with each element taking off at 15-second intervals. The accident pilot was leading the 2nd element, and the accident airplane was the No. 3 airplane in the formation. All communications were conducted for the flight by the flight leader in the No. 1 airplane, using the call sign “SKYTYPE 1.” At 1234:43, ATC cleared SKYTYPE 1 for takeoff from Runway 4. At 12:35:45, SKYTYPE 1 reported that they would be rolling momentarily. At 1237:44, SKYTYPE 1 advised the tower controller that they were coming around to land on Runway 4. ATC acknowledged SKYTYPE 1 and advised them they were cleared to land on any runway. At 1238:03, SKYTYPE1 advised the controller that they had an aircraft down at the departure end of runway 4. According to the flight leader, after takeoff, about 100 feet above ground level, the No. 3 airplane made a left turn, the nose went down, and the airplane departed controlled flight. The smoke system then turned on, and the airplane impacted the ground. According to the pilot in the No. 4 airplane, who was the accident pilot’s wingman in the 2nd section, they had just taken off, and he was sliding into position on the right side of the No. 3 airplane. Normally at that point, the accident pilot would look at him to check that his landing gear was up; but he did not. The pilot in the No. 4 airplane noted that the accident airplane’s landing gear was retracting and the airplane was starting to decelerate. He also heard, over the radio frequency that they used for communication between the airplanes, the accident pilot transmit, “Three’s got an emergency.” The No. 3 airplane turned to the left, and as it rolled through about 20° of bank, the airplane slowed further, and the bank continued to increase as the airplane descended. The smoke system then came on, the airplane impacted the ground, and a post-impact fire ensued. A video provided by a witness on the ground captured popping noises similar to back-firing of the engine before the airplane turned left and pitched down to ground contact. No black smoke was observed emanating from the airplane before the accident. - An autopsy was performed on the pilot by Forensic Associates of Northeastern Pennsylvania. Cause of death was multiple traumatic injuries secondary to airplane crash. Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens from the pilot were negative for carbon monoxide, basic, acidic, and neutral drugs. - At the time of the accident, the pilot was employed as a first officer for a 14 CFR Part 121 air carrier. The pilot was a graduate of the United States Air Force Academy and had served in the United States Air Force (USAF). During his time in the USAF, he flew the T-34C, T-6 (Texan II), C-5, C-21, and MC-12. He held type ratings for several transport category airplanes and also held a flight instructor certificate with ratings for airplane single and multiengine, instrument airplane, and glider. His most recent FAA first-class medical certificate was issued on January 4, 2021. On that date, he reported that he had accrued 7,006 total flight hours. - The airplane contacted the ground with its left wingtip first, then the nose, followed by the right wing. On impact, the airplane rotated to the left and came to rest on a 120° magnetic heading, just off the west side of taxiway B, about 185 ft south of intersection B5. The airplane was severely fire damaged. During the impact sequence, the engine separated from its mounting location, was displaced to the right, and came to rest against the inboard right wing leading edge. The empennage had separated from the aft fuselage, the left outer wing panel had separated from its mounting location (the wing center section), and both the left and right ailerons were separated from their mounting locations. The landing gear and wing flaps were up, and the pitot tube was clear of obstruction. Both fuel tanks were breached, and the top of the smoke oil tank was broken and melted away. The majority of the cockpit had been burned away. The hydraulic filter and hydraulic power control had separated from their mounting locations. The throttle and mixture controls were in the approximately mid-range position, and the propeller control was almost full forward. The engine control lock was burned away. The flight control lock was unlocked. The latching mechanism for the pilot’s five-point harness was in the closed and latched position. Examination of the two-blade propeller revealed that one blade was bent back about 10° about 12 inches outboard of the blade root; the rest of the propeller blade was almost completely straight. The other propeller blade was partially curled aft starting about mid-span. Both blades displayed minimal leading-edge gouging and chordwise scratching. Examination of the engine revealed that the starter motor was separated from its mounting location. The engine oil tank was also separated from its mounting location and was breached during the impact sequence. Trace amounts of oil remained within the tank. The oil cooler, though impact damaged, appeared functional, and the oil “Y” drain valve was separated from its mounting location. The spin-on oil filter was intact and contained engine oil; there was no metallic debris in the pleats of the internal filter material. The hand fuel pump had also been separated from its mounting location. Internal examination revealed that its screen was clear of contaminants. The air chamber mixing gate was open. Some oil remained within the crankcase. Drivetrain continuity and thumb compression and suction were established on cylinder Nos. 2, 4, 5, and 9. Thumb compression and suction could not be established on cylinder Nos. 1, 6, 7, and 8 due to impact damage. No oil was observed leaking from the blower, nor was any present in the intake or exhaust stacks. The carburetor was unremarkable; the carburetor floats were functional and were not leaking. The fuel pump was also functional. -
Analysis
The accident airplane was one in a flight of six other airplanes departing on a practice flight in preparation for an airshow routine. The accident pilot’s wingman stated that they had just taken off, and that the accident pilot did not look over at him to check that his landing gear was up as he normally did. The wingman noted that the accident airplane’s landing gear was retracting, that the airplane began decelerating, and that he heard the accident pilot transmit over the radio that he had an emergency. The accident airplane turned to the left, and as its angle of bank increased past about 20°, the airplane slowed further, the bank continued to increase, and the airplane began descending. The airplane’s smoke system then came on, the airplane impacted the ground, and a post-impact fire ensued. A video provided by a witness on the ground captured popping noises similar to back-firing of the engine before the airplane turned left and pitched down to ground contact. No black smoke was observed emanating from the airplane before the accident. Postaccident examination of the airplane revealed that it was severely fire damaged. No evidence of any preimpact failures or malfunctions of the airframe or engine that would have precluded normal operation were identified. Examination of the propeller revealed signatures consistent with low power at the time of impact. Given this physical evidence, the pilot’s report of an inflight emergency, and the witness video that depicted abnormal engine sounds, it is likely that the engine at least partially lost power during the initial climb, which precipitated the pilot’s break out from the formation. On the day before the accident, the accident pilot arrived at the airport late due to weather. He reported that the engine was “banging” while operating on the left magneto during a magneto check. Troubleshooting by the director of maintenance (DOM) revealed that the engine was “popping and banging” while operating on the left magneto, and during the idle-power P-lead check for proper grounding of the magnetos, when the magneto switch was passed through the left magneto position on the way to the off position, the engine seemed to be shutting down as if the magneto switch had been placed in the off position. The DOM discovered that the left magneto P-lead spring at the end of the P-lead insulator was fully compressed, allowing the internal grounding spring to contact the magneto case. Inspection of the right magneto revealed that its P-lead spring was extended normally. The DOM replaced the left magneto P-lead spring and performed an engine run-up, magneto check, and P-lead check, which revealed no anomalies. Additionally, the pilot did not report any anomalies during the engine run-up before takeoff on the accident flight. Postaccident examination revealed that the left magneto could not be fully rotated due to impact damage. Its points looked serviceable, and the coil, when tested, was within operating limits. The condenser was damaged but tested serviceable. The right magneto would rotate easily, consistent with poor magnetism, would not perform at low rpm, and would not fire on all points until it reached 180 rpm. Review of maintenance records did not reveal any entries related to the installation of the right magneto on the engine; therefore, its service history could not be determined. According to the engine manufacturer’s troubleshooting guidance, there were 11 ignition system-related items that could cause the engine to run rough, and listed the corrective action to be taken as “apply continuity test.” Under the section on “Engine Stops,” it listed “short in the system” as a possible cause, in addition to the master switch or magneto switch being inadvertently cut off. The manual stated, “Check all wiring for security, breaks or chafing” and “Check all systems components.” Based on the lack of anomalies found during the postaccident engine examination, it is possible that the loss of engine power occurred due to an additional undiagnosed fault with the ignition system, which could have been compounded by the poor-performing right magneto; however, the extent of the post-impact fire damage precluded a thorough examination of the ignition system wiring and components. While breaking out from the formation, the accident pilot entered a steep left turn, which may have been an attempt to land on the crosswind runway, but also would have significantly increased the airplane’s stall speed due to the increased load factor imposed by the turn. The pilot’s exceedance of the airplane’s critical angle of attack during this turn resulted in an aerodynamic stall and the loss of control.
Probable cause
A partial loss of engine power for undetermined reasons. Also causal was the pilot’s exceedance of the airplane’s critical angle of attack while maneuvering for a forced landing following the loss of engine power, which resulted in an aerodynamic stall and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
SNJ-2
Amateur built
false
Engines
1 Reciprocating
Registration number
N52900
Operator
SNJ-2 CORP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Air race/show
Commercial sightseeing flight
false
Serial number
2010
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-09-03T15:55:59Z guid: 103732 uri: 103732 title: ANC21LA094 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103927/pdf description:
Unique identifier
103927
NTSB case number
ANC21LA094
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-21T14:25:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-09-21T22:30:54.947Z
Event type
Accident
Location
Bettles, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 21, 2021, about 1325 Alaska daylight time, a float-equipped de Havilland DHC-3 Otter airplane, N560TR, sustained substantial damage when it was involved in an accident near Bettles, Alaska. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 commercial flight. The pilot reported that, while on the base leg approach for a landing at a remote lake, he heard a “loud bang,” and the engine lost total power. The pilot determined that the airplane would not be able to reach its intended destination, so he turned the airplane into the wind and made a forced landing onto an area with tundra-covered terrain, which resulted in substantial damage to the fuselage. A review of the airplane’s maintenance records was unremarkable, and no evidence of regulatory noncompliance was found. Postaccident disassembly and examination of the engine found that it had seized and that the propeller spline had fractured into two pieces. A substantial amount of metal fragmentation was found in the oil screen. The engine was subsequently examined using a lighted borescope, and fragments of broken internal engine pieces were visible, preventing the removal of the aft accessory wall. -
Analysis
The pilot reported that, while on the base leg approach, he heard a “loud bang,” and the engine lost total power. The pilot determined that the airplane would not be able to reach its intended destination, so he turned the airplane into the wind and made a forced landing on tundra-covered terrain, which resulted in substantial damage to the fuselage. The airplane’s maintenance records were unremarkable. Postaccident examination of the engine revealed that it had seized and sheared the propeller spline into two pieces. The accessory wall could not be removed because of the extensive internal damage to the engine. As a result, the investigation was unable to determine the reason that the engine seized during the flight.
Probable cause
The seizure of the engine during flight for undetermined reasons, which led to a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
DHC-3
Amateur built
false
Engines
1 Reciprocating
Registration number
N560TR
Operator
Sourdough Air Service, Inc.
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
141
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T22:30:54Z guid: 103927 uri: 103927 title: ERA21LA339 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103759/pdf description:
Unique identifier
103759
NTSB case number
ERA21LA339
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-21T14:30:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-08-31T15:25:37.496Z
Event type
Accident
Location
Port Orange, Florida
Airport
SPRUCE CREEK (7FL6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 21, 2021, about 1330 eastern daylight time, an Enstrom 280C, N9285, was substantially damaged when it was involved in an accident in Daytona Beach, Florida. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91personal flight. According to the pilot, he conducted a local flight around Spruce Creek Airport (7FL6), Daytona Beach, Florida, and was approaching to land. Just prior to touchdown, the helicopter made an uncommanded climb and started to spin to the right. The pilot applied full left pedal, but the helicopter continued to spin to the right. He lowered the collective and the helicopter landed hard on the skids. The left skid was damaged during, fuselage frame, and the tail rotor blades were damaged during the landing. Postaccident examination of the helicopter revealed that the tail rotor driveshaft was free to spin inside the coupling and not connected by a through bolt. The coupling and a section of the drive shaft were forwarded to the National Transportation Safety Board’s Material Laboratory for further examination. The examination revealed that the bolt holes in the drive shaft tube were mechanically distorted consistent with the presence of an axially applied torsional shear-stress in the drive shaft tube in the clockwise direction. Macroscopically, the fracture surface in the drive shaft tube was consistent with overstress due to torsionally applied shear stress (for more information, see Materials Laboratory Factual Report in the public docket for this investigation). -
Analysis
The pilot was conducting a local flight when just prior to touchdown, the helicopter began to spin to the right and made an uncommanded climb and spin to the right. The pilot applied full left rudder pedal, but the helicopter continued to spin to the right. He lowered the collective and landed hard on the skids, which resulted in substantial damage to the fuselage. Postaccident examination of the helicopter revealed the tail rotor driveshaft was separated and free to spin inside the coupling. Metallurgical examination of the driveshaft revealed the bolt holes in the driveshaft were distorted, consistent with torsional shear-stress in the clockwise direction.
Probable cause
The failure of the tail rotor drive shaft at the coupling due to torsionally applied shear stress.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ENSTROM
Model
280
Amateur built
false
Engines
1 Reciprocating
Registration number
N9285
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1003
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-31T15:25:37Z guid: 103759 uri: 103759 title: ERA21LA336 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103739/pdf description:
Unique identifier
103739
NTSB case number
ERA21LA336
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-21T14:40:00Z
Publication date
2023-05-10T04:00:00Z
Report type
Final
Last updated
2021-08-27T22:51:50.29Z
Event type
Accident
Location
Fort Lauderdale, Florida
Airport
FORT LAUDERDALE EXECUTIVE (FXE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 21, 2021, about 1340 eastern daylight time, a Gulfstream Aerospace G-IV airplane, N277GM, was substantially damaged when it was involved in an accident at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The 4 crewmembers and 10 passengers were not injured. The airplane was operated by the pilot in command (PIC) as a Title 14 Code of Federal Regulations Part 91 personal flight. The PIC reported that after a routine taxi to the runway, he initiated the takeoff on runway 9. As the takeoff roll progressed the airplane accelerated as expected, normal callouts were made, and nothing was abnormal until the airplane reached about 100 to 110 knots, at which point he felt a “terrible shimmy” that progressively got “worse and worse.” He then recalled that it felt that as if the tires blew because the forward “deck angle” became lower. He initiated an immediate aborted takeoff with braking and thrust reversers and it seemed that the airplane was slowing; however, the airplane veered off the runway and the right wing and right main landing gear struck a concrete slab holding approach lighting equipment. The airplane came to a stop shortly after impacting the concrete slab. The second-in-command (SIC) pilot reported that the taxi and initial takeoff roll were normal. As the airplane passed through 80 knots, he recalled feeling a “slight shimmy” and “a little rattle” between the rudder pedals, which “intensified dramatically.” Once the shimmy intensified, the PIC aborted the takeoff. During the abort procedure, it became apparent that “the nose gear collapsed.” After the airplane came to rest, he immediately got up, opened the main cabin door, and assisted the passengers in the emergency evacuation. A third non-type rated observer pilot seated in the jumpseat reported a similar account of the takeoff and abort sequence. Examination of the runway environment and accident site revealed that the airplane came to rest in a sandy grass area about 200 ft to the right of the runway 9 centerline. The left main landing gear did not collapse; however, the right main landing gear had punctured upward into the inboard aft section of the right wing, which resulted in substantial damage. All major components of the nose landing gear (NLG), which had sheared from the airplane, were located on or near runway 9. The first item located on the runway, farthest from the main wreckage, was the NLG pip pin (upper torque link pin). It was found about 2,215 ft from the main wreckage. The bulk of the NLG came to rest near the runway centerline about 900 ft farther down the runway from the pip pin. The safety pin that was normally installed through the pip pin was found intact still attached to the separated NLG by its lanyard cord. Figure 1 shows a still image captured by the FXE Airport Authority drone shortly after the accident. Additional photographs have been added to the drone image to show the location of swivel tire marks and where components were located on the runway as noted with the red circles. Figure 1: Overview of the main wreckage and runway environment (Source: FXE Airport Authority) Nose Landing Gear Pins and Operation According to Gulfstream Technical Publications, the NLG was equipped with a removable pip pin that enabled the upper torque link arm (or upper scissor linkage) to be disconnected from the steering collar for additional steering movement for towing operations. The pip pin incorporated a plunger button that when depressed retracted a set of locking balls on the opposite end of the pin to enable the removal of the pin. When the plunger button was released, the balls locked in an extended position, which physically prevented pin movement through the steering collar receptacle. The pin retention system incorporated two additional safety features. The first was a lanyard cable with a smaller safety pin that was to be inserted into its respective hole in the end of the pip pin once the plunger button was fully retracted. The second was an additional lanyard with a clip that attached to a handle on the plunger end of the pip pin. According to Gulfstream representatives, the primary purpose of the second lanyard was to ensure that the pip pin remained with the NLG when it was removed during towing operations; it served no purpose in ensuring that the pip pin remained secured when it was installed through the upper torque link arm. Figure 2 shows the accident NLG, the pip pin, and the safety pin installed during postaccident examination and testing. The NLG and pip pin as found did not possess the second lanyard, safety clip, or handle that was called for in the Gulfstream Technical Publications. Figure 2: View of the NLG and pip pin installed during postaccident examination testing Detailed instructions were provided in the airplane’s handling handbook on how to release and re-install the pip pin for towing. The instructions stated in part, that the pip pin should be inspected to “ensure locking balls work freely when plunger is depressed” and to “ensure locking balls cannot be moved when plunger is released”. The handbook further stated to discard pip pins that failed this inspection and cautioned that: DEFECTIVE OR IMPROPERLY INSTALLED PIP PIN CAN CAUSE EXTENSIVE DAMAGE TO AIRCRAFT. According to the Gulfstream G-IV pilot’s preflight checklist, the NLG and wheel area must be checked and the “torque link” must be “PINNED / SAFETIED.” Examination of the Nose Landing Gear and Pins Postaccident examination and testing of the separated NLG and its pins revealed no anomalies. The pip pin displayed some exterior damage due to its impact with the runway. It could be inserted into position and the plunger and locking balls operated without issue. With the plunger and locking balls released, the safety pin was inserted into the pip pin without issue. Attempts were made to remove the pip pin by hand, with the locking balls released, but as designed, the balls prevented the pin from being removed from the upper torque link arm; the pip pin could not be removed either with or without the safety pin installed. The NLG and pip pin as found did not possess the second lanyard, safety clip, or handle that is normally attached. Details of the Towing and Preflight The ground personnel involved in towing the airplane to the fixed-base-operator (FBO) ramp were interviewed. Two ramp personnel reported that they used an electric tow cart to move the airplane a few hours before departure. When they arrived at the airplane, the three landing gear tow pins were inserted on the nose and main landing gear, and the NLG upper torque link arm was already disconnected with the pip pin installed in the steering collar. After an uneventful tow, one ramp crewmember removed the pip pin without issue, however, he noticed that the locking balls and plunger button were stuck in (depressed). He reported that the “the button was stuck in” and all of the locking balls were stuck in. He reported that he was familiar with this type of pin device but had never experienced this type of issue before. The ground personnel attempted to release the plunger button by shaking the pin, and they “tapped” on the pin with a wooden chock, however, the locking balls and plunger would not release. The ground personnel reported that they took no further actions to get the plunger unstuck and that they re-inserted the pip pin in the steering collar with the upper torque link arm attached. They attempted to insert the safety pin hanging from a lanyard connected to the NLG; however, one ramp crewmember reported that he knew that if the plunger button and locking balls remained depressed, the safety pin could not be inserted due to its design. The safety pin was left hanging on the right side of the NLG. The ground personnel alerted their ramp supervisor to the issue with the NLG pip pin as the flight crew had not yet arrived at the airplane. According to the ramp supervisor, he told the first crewmember who arrived at the airplane, “per tow team, check your nose pin.” Surveillance video captured the ramp personnel’s troubleshooting of the pin, the flight crew’s preflight, and the airplane’s taxi from the ramp toward the runway. The ramp supervisor reviewed the surveillance video and identified the observer pilot as the flight crewmember he reportedly told to check the pip pin. At the time, he believed that this flight crewmember was “probably the co-pilot” rather than the PIC. The ground personnel reported that they did not discuss the pip pin issue with the other pilots who arrived after the observer pilot. The observer pilot reported that he had received permission from the PIC to join the flight as an observer for general pilot development, as he had just finished ground school training for the G-IV. He was in training to become a first officer with a Part 135 charter operator run by the PIC. He reported that prior to the other pilots’ arrival, he removed the three gear tow pins and placed them on the airstairs. The observer pilot further reported that he was on the telephone with a friend when ramp personnel approached him. He asked the ramp personnel for ice and newspapers, and the ramp personnel asked him if he needed anything else, such as fuel, to which the observer pilot said he was not sure and he was waiting for the other pilots to arrive. The observer pilot stated that none of the ramp personnel informed him to check the NLG pip pin or “anything related to the aircraft.” He reported that the SIC arrived, and they did a full preflight and walkaround. The observer pilot recalled that the SIC reviewed the NLG in detail, and they both observed that the “really big pin [pip pin]” was installed. The pin appeared to be flush and was “all the way in.” He stated that, “I can tell you 200 percent that he was pointing at that [pip] pin.” The SIC further explained to him that the NLG will not be steerable without this pin, and it was the “most important pin.” He could not recall if the smaller safety pin was also installed into the larger pip pin. The SIC reported that during his preflight inspection of the NLG, the pip pin was installed and “flush”. He could not recall whether the safety pin was also installed; however, he did not see any safety pin dangling on the NLG. He reported that it was his understanding that a visual inspection is required of the pip pin, and he did not have the “authority” to insert the pip pin if it was not in place. He believed the pins should be inserted by maintenance or ramp personnel. He reported that neither the ground personnel nor the observer pilot informed him of any issue with the pip pin. The PIC reported that prior to taxi, the SIC performed a “complete walkaround.” This was his first time flying with the SIC. He added that it is his standard practice to do a “final look” to ensure the pip pin is installed and that the fuel cap doors and chocks are closed/ removed. He did not recall seeing any safety pin dangling next to the pip pin. He reported that over the years of flying the G-IV, once or twice, he experienced a situation in which the safety pin was found not installed prior to taxi. Concerning the accident flight, he reported that neither the ramp personnel nor the SIC or observer pilot informed him that there was an issue with the pip pin. The SIC reported that he had not attended formal ground school or taken a practical examination to obtain his G-IV “SIC Privileges Only” type rating. He received a logbook endorsement from a type-rated captain he had previously flown with per Part 61.55(d)(1). He reported that he was “limited in what I know with the aircraft.” The cockpit voice recorder (CVR) and flight data recorder (FDR) were downloaded and reviewed at the National Transportation Safety Board Vehicle Recorders Laboratory in Washington, DC. Both the FDR and CVR simultaneously stopped recording before the runway excursion. The high-amplitude shimmy present in the nose gear likely created enough of a moment in the tail where the G switch was located to stop the recorders. Prior to the end of data, a normal accelerating takeoff was observed, with a peak airspeed of 122 knots reached. Additional Information Following the accident, the FBO reported that they updated standard operating procedures for ground personnel to ensure that the PIC, or SIC in the event the PIC is unavailable, is made aware of anomalies or damage to the aircraft. -
Analysis
The flight crew, which consisted of the pilot- and second-in-command (PIC and SIC), and a non-type-rated observer pilot, reported that during takeoff near 100 knots a violent shimmy developed at the nose landing gear (NLG). The PIC aborted the takeoff and during the abort procedure, the NLG separated. The airplane veered off the runway, and the right wing and right main landing gear struck approach lights, which resulted in substantial damage to the fuselage and right wing. The passengers and flight crew evacuated the airplane without incident through the main cabin door. Postaccident interviews revealed that following towing operations prior to the flight crew’s arrival, ground personnel were unable to get the plunger button and locking balls of the NLG’s removable pip pin to release normally. Following a brief troubleshooting effort by the ground crew, the pip pin’s plunger button remained stuck fully inward, and the locking balls remained retracted. The ground crew re-installed the pip pin through the steering collar with the upper torque link arm connected. However, with the locking balls in the retracted position, the pin was not secured in position as it should have been. Further, the ground personnel could not install the safety pin through the pip pin because the pin’s design prevented the safety pin from being inserted if the locking balls and plunger were not released. The ground personnel left the safety pin hanging from its lanyard on the right side of the NLG. The ground personnel subsequently informed their ramp supervisor of the anomaly. The supervisor reported that he informed the first arriving crewmember at the airplane (the observer pilot) that the nose pin needed to be checked. However, all three pilots reported that no ground crewmember told them about any issues with the NLG or pins. Examination of the runway environment revealed that the first item of debris located on the runway was the pip pin. Shortly after this location, tire swivel marks were located near the runway centerline, which were followed by large scrape and tire marks, leading to the separated NLG. The safety pin remained attached to the NLG via its lanyard and was undamaged. Postaccident examination and testing of the NLG and its pins revealed no evidence of preimpact mechanical malfunctions or failures. The sticking of the pip pin plunger button that the ground crew reported experiencing could not be duplicated during postaccident testing. When installed on the NLG, the locking ball mechanism worked as intended, and the pip pin could not be removed by hand. Although the airplane’s preflight checklist called for a visual check of the NLG’s torque link to ensure that it was connected to the steering collar by the pip pin and that the safety pin was installed, it is likely that none of the pilots noticed that the pip pin did not have its safety pin installed during preflight. Subsequently, during the takeoff roll, without the locking balls extended, the pip pin likely moved outward and fell from its position holding the upper torque link arm. This allowed the upper torque link arm to move freely, which resulted in the violent shimmy and NLG separation. The location of the debris on the runway, tire marks, and postaccident examination and testing support this likely chain of events. Contributing to the PIC and SIC’s omission during preflight was the ground crew’s failure to directly inform the PIC or SIC that there was a problem with the NLG pip pin. The ground crew also failed to discard the malfunctioning pip pin per the airplane’s ground handling procedures and instead re-installed the pip pin. Although the observer pilot was reportedly informed of an issue with a nose gear pin, he was not qualified to act as a required flight crewmember for the airplane and was on his cell phone when he was reportedly informed of the issue by the ramp supervisor. These factors likely contributed to the miscommunication and the PIC’s and SIC’s subsequent lack of awareness of the NLG issue.
Probable cause
The pilot-in-command’s (PIC) and second-in-command’s (SIC) failure during preflight inspection to ensure that the nose landing gear’s pip pin was properly installed, which resulted in separation of the pip pin during takeoff. Contributing to the accident was the ground crew supervisor’s failure to inform the PIC or SIC of the anomaly concerning the pip pin following a towing operation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AEROSPACE
Model
G-IV
Amateur built
false
Engines
2 Turbo jet
Registration number
N277GM
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1124
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-27T22:51:50Z guid: 103739 uri: 103739 title: CEN21LA384 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103750/pdf description:
Unique identifier
103750
NTSB case number
CEN21LA384
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-24T19:58:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-08-25T16:54:04.777Z
Event type
Accident
Location
Lansing, Michigan
Airport
Capital Region International (LAN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The airplane was equipped with retractable, tricycle landing gear. The nose landing gear was a full castoring configuration, and independent nose wheel steering was not available. During taxi, takeoff roll, and landing rollout, directional control was maintained through differential braking of the main landing gear. With sufficient airspeed, the ruddervators become effective and also provide directional control. The main landing gear brake assemblies were hydraulically operated and individually activated by floor-mounted toe pedals located at both pilot stations. The brakes were not equipped with an anti-skid/anti-lock functionality. The airplane flight manual (AFM) specified a maximum 10-knot tailwind for takeoff or landing. Review of the AFM determined that at the airplane accident weight of 5,756 lbs (obtained from recoverable data module [RDM] data), the expected takeoff ground roll with a calm wind was 2,885 ft, and with a 10-knot tailwind was 4,090 ft. - On August 24, 2021, at 1858 eastern daylight time, a Cirrus Design Corp. SF50 “Vision Jet” airplane, N1GG, was destroyed when it was involved in an accident near Lansing, Michigan. The pilot and 3 passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. The flight was departing from Capital Region International Airport (LAN). At 1854:51, the pilot was cleared to taxi to runway 28L. Shortly afterward, the tower controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R, the opposite direction runway. The controller advised that the wind was from 280° at 7 knots at the time, and the pilot accepted runway 10R for departure. At 1856:13, the controller informed the pilot that information Oscar was current and added, “we got some new weather on this one.” The pilot acknowledged, “we’ll get Oscar” and “we’re ready to go when we get to the end . . . before the storm comes.” At 1856:26, the pilot was cleared for takeoff, and data indicated the accident takeoff began about 1857:15. At 1857:19, the controller advised the pilot of a windshear alert of plus 20 kts at a 1-mile final for runway 28L. The pilot acknowledged the alert. The pilot stated that departing from an 8,000 ft long runway with a 7-knot tailwind was within the operating and performance limitations of the airplane. The pilot noted after a ground roll of about 4,000 ft that “the left rudder didn’t seem to be functioning properly” and that he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He subsequently used minimal braking to control the airplane. The airplane ultimately overran the runway, impacted the chain link airport perimeter fence, and encountered a ditch before it came to a rest. An examination of the runway revealed skid marks beginning about 4,700 ft from the arrival end of runway 10R which were about 300 ft long. The skid marks resumed about 300 ft further down the runway and continued about 3,200 ft until they departed the left side of the pavement near the departure threshold. The skid marks associated with the left tire were pronounced and appeared consistent with heavy braking from the left main landing gear. The skid marks associated with the right tire were defined but faint and appeared consistent with light braking from the right main landing gear. - At 1755, a convective significant meteorological information (SIGMET) was issued for an area of severe thunderstorms with tops to flight level 450 and the possibility of 1-inch diameter hail and 60-knot wind gusts. The area included the accident location and was moving from 250° at 25 kts. Terminal aerodrome forecasts (TAF) for the airport, issued at 1813 and valid for the accident time, noted the possibility of thunderstorms in the vicinity. A TAF issued at 1840 forecast the potential for a west wind from 290° with gusts to 38 for a period beginning a few minutes after the accident time. At 1853, the automated surface observing system (ASOS), located about 6,100 ft east-northeast of the runway 10R approach threshold, recorded the wind from 250° at 8 kts. At 1855, the ASOS recorded an increase in the wind gust magnitude from 10 kts to 21 kts. About 1857, the low-level windshear alert system (LLWAS) station located about 4,400 ft east-southeast of the runway 10R approach threshold recorded an increase of the 2-minute averaged wind speed from 290° magnetic at 8 kts, to 310° magnetic at 16 kts with 30-knot gusts. At 1858, the LLWAS alert system display located in the tower presented numerous wind shear alerts applicable to the east side of the airport, notably an alert for an area about 6,600 ft southeast of the runway 10R departure threshold. At 1908, the ASOS recorded the wind from 290° at 17 kts with gusts to 30 kts. - The pilot completed a Cirrus Aircraft SF50 recurrent training course on July 30, 2021. This met the requirement for a pilot proficiency check under 14 CFR 61.58 and a flight review under 14 CFR 61.56. - The airplane impacted an airport perimeter fence off the end of runway 10R and a postimpact fire consumed portions of the airplane. An examination of the airframe did not reveal any anomalies; however, the extent of the postimpact fire damage limited the scope of the examination. The airplane was equipped with an RDM that recorded multiple flight and system parameters. According to that data, about 1857:08, the thrust lever angle (TLA) increased from idle to takeoff, and the engine fan (N1) and core speeds (N2) responded as commanded by 1857:15. As the airplane began to accelerate, the airspeed lagged the ground speed consistent with a tailwind condition at the time. About 1857:50, the heading began to oscillate but generally began drifting left with respect to the easterly takeoff direction. The true airspeed reached 106 kts and stagnated as the ground speed continued to increase consistent with a tailwind gust encounter. About 1857:56, the TLA was reduced from takeoff to idle, consistent with a rejected takeoff. At that time, the airspeed and groundspeed were about 100 kts and 120 kts, respectively. The ground speed began to decrease consistent with the pilot’s decision to reject the takeoff. The airplane ultimately reached a maximum of 108 kts airspeed and 121 kts ground speed before it began to decelerate. The coarse GPS data indicated that the airplane departed the runway about 1858:20 at a groundspeed of about 75 kts. The RDM did not record any parameters related to the application of the brakes other than for the parking brake; the parking brake parameter was off during the accident takeoff. -
Analysis
The airport tower controller initially assigned the pilot to take off from runway 28L, which presented a 7-knot headwind. Shortly afterward, the controller informed the pilot of “a storm rolling in . . . from west to east,” and offered runway 10R. The pilot accepted the opposite direction runway for departure and added, “we’re ready to go when we get to the end . . . before the storm comes.” About 4 seconds after the airplane began accelerating during takeoff, the controller advised the pilot of a wind shear alert of plus 20 knots (kts) at a 1-mile final for runway 28L, and the pilot acknowledged the alert. In a postaccident statement, the pilot stated that departing with a 7-kt tailwind was within the operating and performance limitations of the airplane. The pilot reported that after a takeoff ground roll of about 4,000 ft “the left rudder didn’t seem to be functioning properly” and he decided to reject the takeoff. However, when he applied full braking, the airplane tended to turn to the right. He used minimal braking consistent with maintaining directional control of the airplane. The airplane ultimately overran the runway, impacted the airport perimeter fence, and encountered a ditch before it came to a rest. A postimpact fire ensued and consumed a majority of the fuselage. An examination of the runway revealed skid marks beginning about 4,700 ft from the arrival end of runway 10R. The initial set of skid marks were about 300 ft long. Skid marks resumed about 300 ft further down the runway and continued until they departed the left side of the pavement near the departure threshold. The skid marks associated with the left tire were consistent with heavy braking from the left main landing gear. The skid marks associated with the right tire were consistent with light braking from the right main landing gear. A postrecovery airframe examination did not reveal any anomalies consistent with a preimpact failure or malfunction. Data revealed that as the airplane began to accelerate during takeoff the airspeed lagged the ground speed, which was consistent with a tailwind condition at the time. The heading began to oscillate about the same time that the airspeed stagnated. During this time, the ground speed continued to increase consistent with an encounter with a tailwind gust. A few seconds later, the pilot initiated the rejected takeoff. About the time of the accident, the airport was impacted from the west by a gust front that caused low-level wind shear and surface winds increased from about 10 kts from the west-southwest to about 30 kts from the northwest. Weather forecasts and advisories in effect at the time of the accident noted the possibility of severe thunderstorms and strong wind gusts. The airport’s low-level wind shear alert system display, located in the control tower, presented numerous wind shear alerts applicable to the east side of the airport at the time of the accident takeoff. The tailwind gust likely reduced the effectiveness of the flight controls and resulted in the pilot’s perception that they were not functioning properly. In addition, the reduced flight control effectiveness, combined with the lack of nose wheel steering in the airplane model, resulted in a reduction of directional stability as evidenced by the heading oscillations. While the distinct runway skid marks indicated that the brakes were operating, the pilot was unable to stop on the remaining runway available.
Probable cause
The pilot’s decision to depart with a tailwind as a thunderstorm approached, which resulted in a loss of airplane performance due to an encounter with a significant tailwind gust and a subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SF50
Amateur built
false
Engines
1 Turbo fan
Registration number
N1GG
Operator
N1GG LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
0202
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-08-25T16:54:04Z guid: 103750 uri: 103750 title: ERA21LA338 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103758/pdf description:
Unique identifier
103758
NTSB case number
ERA21LA338
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-24T20:26:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-09-10T20:44:19.145Z
Event type
Accident
Location
Crittenden, Kentucky
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 24, 2021, about 1926 eastern daylight time, an experimental amateur-built Just Highlander, N101KL, was involved in an accident near Crittenden, Kentucky. The private pilot and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner of the airplane, the accident occurred at the end of a 45-minute “sightseeing” flight. The airplane departed from the pilot’s farm and flew to Gene Snyder Airport (K62), Falmouth, Kentucky, where the pilot performed two touch-and-go landings and then established the airplane on a northwest heading for the return flight. While the airplane was in cruise flight, the pilot confirmed that fuel was visible in the “site tubes” of each wing tank and estimated that the airplane had “over an hour of fuel reserves.” The pilot stated that the airplane was established on the left base leg for a landing on a turf runway oriented to the northeast on a heading of 030°. When the airplane was at an altitude of 300 ft above ground level (agl), he decided to land on the same field but to the south. (A satellite image of the pilot’s property revealed two turf runways bisected by a paved road. When looking north, the second turf runway formed a dogleg to the left after the road and was oriented to the north on a heading of about 345°.) The pilot added “full power” and initiated a climb, but the engine lost total power. The pilot then initiated a left bank to use the remaining field beneath the airplane, but he would not have been able to finish the turn, avoid a building, and complete the landing; as a result, the pilot landed the airplane “abruptly” to the left of the building. The airplane came to rest upright with the right main landing gear separated and substantial damage to the right wing and empennage. The pilot reported that the left-wing fuel tank was leaking after the accident. Data downloaded from the airplane’s avionics depicted the airplane crossing over the paved road that bisected two turf runways at an airspeed of 35 knots, on a 290° heading, and an altitude of about 800 ft agl. The airplane entered a left descending 260° turn, aligned with the northeast-oriented runway, and flew its full length (940 ft). The airplane was at an altitude of 100 ft agl, an airspeed of 35 knots, and an engine speed of 1,024 rpm when it overflew the departure end and the extended centerline at the approach end of the north-oriented runway. Five seconds later, the airplane was 215 ft to the right of the north-oriented runway centerline at an altitude of 75 ft agl, an airspeed of 43 knots, and an engine speed of 0 rpm. The airplane’s track arced back toward the north-oriented runway and crossed it on a 320° heading. The final two targets depicted the airplane bisecting the runway on the ground traveling at 35 knots, after which the data ended. Fuel fed from the wing tanks to a small header tank (about 0.3 gallons) and then to the electric fuel boost pump; the gascolator; the engine-driven fuel pump; and the “splitter,” which supplied fuel to the two carburetors. The pilot reported that he serviced the airplane with 93-octane automotive gasoline and that the engine manufacturer’s estimated rate of fuel consumption was 4.5 gallons per hour; the pilot usually planned for 5 gallons per hour. The pilot stated that, at the time of the accident, he had flown the airplane for about 4 hours since its most recent refueling (2 days before the accident), during which the airplane was fueled with 26 gallons (the total fuel capacity). The pilot also stated that he did not turn on the electric boost pump during the flight, which was his normal practice. Postaccident examination of the airplane revealed that the left-wing tank was empty and that 1.5 to 2.0 gallons of fuel was drained from the right-wing tank. The gascolator was full of fuel, and fuel was present in the inlet line to the engine-driven fuel pump. No fuel was observed in the outlet line of the pump or in either carburetor bowl. The carburetors were reassembled, the fuel lines were resecured, and the fuel system was primed with the electric boost pump. Afterward, an engine start was attempted with the airplane’s battery. The engine started immediately, accelerated smoothly, and ran continuously without interruption until it was stopped with the engine controls in the cockpit. A field test was conducted during which the Federal Aviation Administration inspector assigned to this case returned to the accident site and, with the pilot/owner’s assistance, suspended the airplane by a sling. The purpose of the field test, which was performed in a static environment, was to determine usable versus unusable fuel in each wing tank at pitch and roll attitudes (using the airplane’s electronic flight instrument system) that reflected those in the downloaded data from the accident flight. The results of the testing were intended to demonstrate the fuel quantities at which the main fuel pickups could unport and fuel flow to the 0.3gallon header tank would be interrupted. Each 13-gallon main fuel tank was equipped with one fuel pickup; neither had a secondary pickup due to the airplane’s folding-wing design. The inspector disconnected the main fuel lines, added water to the fuel tanks, and noted the quantity at which water would flow from the lines. When the airplane’s extended left turn before landing was simulated with a 12.5° nose-down pitch attitude and an 8° left roll, water flowed from the right fuel tank at a quantity of 3.5 gallons. Water did not flow from the left fuel tank until it contained 6.5 gallons. The pilot reported that the fuel pickup in each wing tank was located on the inboard part of the tank and that, given the continuous left turn before landing, the fuel “might have unported.” -
Analysis
The personal flight was approaching a private turf runway for landing. After the airplane completed a continuous 260° left-turning approach toward the runway, the pilot decided that he wanted to land to the south rather than to the north and applied engine power. However, the engine lost total power, and the pilot landed the airplane “abruptly” before it impacted a building. The airplane sustained substantial damage to the right wing and empennage. The pilot reported that the left-wing fuel tank was leaking after the accident. The pilot also reported that, at the time of the accident, the airplane had flown a total of about 4 hours since it was last refueled to capacity (26 gallons total). The pilot stated that his planned fuel consumption rate was 5 gallons per hour. Postaccident examination of the airplane found that the left-wing tank contained no fuel and that the right-wing tank contained about 1.5 to 2.0 gallons. A test run of the engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. A field test was then performed in which the airplane was suspended from a sling, and the pitch and roll attitude captured by avionics data during the continuous left turn just before the accident was applied to the airplane. Water was added to each of the wing fuel tanks to determine the quantity needed to reach the fuel pickup (which unports fuel) on the inboard side of each tank. The test indicated that, when the airplane was in a descending left-turn attitude, fuel began to flow from the right tank at a quantity of about 3.5 gallons; however, about 6.5 gallons had to be added to the left tank before fuel flow was noted. The total amount of fuel onboard the airplane at the time of the accident and its distribution could not be determined based on the available evidence for this accident investigation. However, given the pilot’s estimated fuel consumption rate and the time since refueling, the airplane likely consumed about 20 gallons of fuel, leaving about 6 gallons divided between the two wing tanks. Postaccident testing showed that it is likely that this amount of fuel could have caused fuel unporting from the tank pickups during the extended left turn, resulting in fuel starvation and a total loss of engine power.
Probable cause
The pilot’s inadequate fuel planning, which resulted in fuel starvation and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SCHMITT
Model
Just Acft Highlander
Amateur built
true
Engines
1 Reciprocating
Registration number
N101KL
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JA536-11-18
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-10T20:44:19Z guid: 103758 uri: 103758 title: WPR21LA329 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103761/pdf description:
Unique identifier
103761
NTSB case number
WPR21LA329
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-25T10:45:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-10-20T06:47:40.964Z
Event type
Accident
Location
Chino, California
Airport
CHINO (CNO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On August 25, 2021 about 0945 Pacific daylight time, a Cessna 150D, N4375U, was substantially damaged when it was involved in an accident near Ontario, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.    The pilot stated that, before departure, she added 16 gallons of fuel to the fuel tank, which brought the total fuel aboard to 28 gallons. The pilot maneuvered in the local area for about 2 hours 45 minutes before returning to the airport. During the descent to 2,500 ft mean sea level (msl), the engine began to surge; in response, the pilot added carburetor heat. The engine sounded normal for about 3 to 4 minutes and then began to surge again. As the airplane approached the airport, the pilot noticed that a partial loss of engine power had occurred, and that the engine was running between 1,000 and 1,200 rpm, equivalent to a near-idle setting. The pilot attempted to troubleshoot the partial loss of power by verifying that the mixture was rich, the fuel selector was positioned to “BOTH,” and the magnetos were both selected. The pilot further stated that, despite these attempts, the airplane could not maintain level altitude, so she selected an area for an off-airport landing. About 20 seconds before touchdown, the engine lost total power, and the airplane collided with a fence, causing damage to the airplane wings. The pilot noted that, after the accident, fuel was draining from the airplane, and moisture (haze) was visible.   Postaccident examination at the accident site found that the fuel tanks were intact, and only a small drip from the left fuel vent was observed. The airplane owner stated that he recovered the airplane and that about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons from the right wing were drained. The owner added that both the carburetor bowl and gascolator contained fuel. A representative from Cessna Aircraft stated that the airplane was equipped with longrange fuel tanks that held a total of 38 gallons of fuel. The representative estimated that the airplane had a range of 800 miles (or 7.1 hours) at 5,000 ft msl, with the engine at 2,500 rpm, and at a cruise speed of 113 mph. The airplane was equipped with an on/off fuel selector valve, and the two fuel tanks were interconnected before the valve. A check valve in the left fuel tank vent line was designed to prevent fuel from leaking out, but the valve contained a small (0.04inch) hole so that pressure in a full tank could bleed out. The Cessna representative stated that this hole would allow a small drip of fuel to leak out of the tank when the airplane was in a leftwinglow position. The amount of fuel that leaked out would be based on the amount of fuel that was in the tank (head pressure) and the length of time that the airplane was in that position. Fuel could escape from the system if damage had occurred forward of the fuel valve. The Cessna representative estimated that, on the basis of the accident flight track, the airplane should have had more than 10 gallons of fuel when the engine failure occurred. In a postaccident statement, the pilot indicated that, given the haze outside, she should have applied carburetor heat as soon as she began descending the airplane. The pilot further stated that she should have had a greater reserve of fuel and had planned for a 20% discrepancy in the airplane’s fuel performance numbers. The meteorological aerodrome report for Chino, California, that was issued at 0953 stated that the temperature was 79°F and the dew point was 61°F. The temperatures were applied to the FAA Carburetor Icing Probability Chart, which revealed that both recorded temperatures were within the "serious icing at glide power" portion of the chart. The FAA published Special Airworthiness Information Bulletin (SAIB) CE-09-35 in June 2009, which discussed carburetor ice prevention. The SAIB noted that carburetor icing does not only occur in freezing conditions; it can occur at temperatures well above freezing when visible moisture or high humidity is present. Vaporization of fuel combined with the expansion of air as it flows through the carburetor (the Venturi effect) causes sudden cooling, and a significant amount of ice can build up within a fraction of a second. -
Analysis
The pilot flew in the local area for about 2 hours 45 minutes and then began to return to the departure airport. While the airplane was descending to 2,500 ft mean sea level, the engine surged, prompting the pilot to use carburetor heat. After a brief period of normal engine operation, the engine surging resumed, resulting in a partial power loss as the airplane approached the airport. Despite the pilot’s attempts to troubleshoot the issue, the airplane was unable to maintain altitude. The pilot performed an off-airport landing, during which the airplane collided with a fence. During the recovery of the airplane, about 3.5 to 4 gallons of fuel from the left wing and about 0.5 gallons of fuel from the right wing were drained, and both the carburetor bowl and gascolator contained fuel. The fuel tanks in the wing were intact, but fuel was dripping from the left fuel vent due to the angle at which the airplane came to rest (left wing down). Because fuel was dripping from the vent, the investigation could not determine if the airplane had a sufficient amount of fuel aboard at the time of the engine failure; the amount of fuel found in the tanks did not represent the amount of fuel aboard before impact. The Federal Aviation Administration (FAA) Carburetor Icing Probability Chart revealed that the outside air temperature and dew point temperature were within the "serious icing at glide power" portion of the chart, and the pilot reported haze in the area. An FAA Special Airworthiness Information Bulletin emphasized the risk of carburetor icing, even in above-freezing conditions with visible moisture, due to fuel vaporization and air expansion. Thus, it is likely that carburetor icing during the accident flight resulted in the loss of engine power, which might have been mitigated if the pilot had applied carburetor heat earlier in the descent.
Probable cause
The pilot’s delayed use of carburetor heat, which resulted in a loss of engine power due to carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150D
Amateur built
false
Engines
1 Reciprocating
Registration number
N4375U
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15060375
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-20T06:47:40Z guid: 103761 uri: 103761 title: CEN21LA386 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103760/pdf description:
Unique identifier
103760
NTSB case number
CEN21LA386
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-25T19:22:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-08-30T19:12:58.348Z
Event type
Accident
Location
Fishers, Indiana
Airport
Indianapolis Metro Airport (UMP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The experimental biplane was designed for aerobatic flight, and its engine was modified with oversized cylinders and pistons. The engine had no data plate or serial number. During the airplane’s last condition inspection, the tachometer was reset to 0 hours. At that time, the airframe total time and engine time since overhaul were 641 and 60 hours, respectively. On August 24, 2021, cylinder Nos. 3 and 4 were replaced after being refurbished due to low compression. The mechanic, who was also the pilot/owner, reported no issues during his engine runup after the cylinder replacements. At that time, the airframe total time and engine time since overhaul were 669 and 88 hours, respectively. Air traffic control radar track data showed that the pilot flew the airplane about 1 hour 15 minutes (1.25 hours) during the accident flight. Thus, at the time of the accident, the airframe total time and engine time since overhaul would have been 670 and 89 hours, respectively. - On August 25, 2021, about 1822 eastern daylight time, an Acro Sport II experimental airplane, N169BF, was substantially damaged when it was involved in an accident near Fishers, Indiana. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the purpose of the flight was to “break-in” two engine cylinders that were replaced on the day before the accident. According to the pilot’s statement and fueling documentation, the airplane’s 23-gallon fuel tank was topped off before the flight. The pilot reported that the engine was operated at maximum speed (2,800 rpm) with a full rich mixture setting throughout the flight and that the airplane lost total engine power about 1 hour after takeoff. During the forced landing, the forward right side of the fuselage impacted a street signpost, resulting in substantial damage to a structural tube in the fuselage. - Postaccident examination of the airplane found that its fuel tank was empty, with 2 to 3 fluid ounces of fuel recovered when the fuel system was drained during the examination. Evidence of a fuel leak was found within the engine compartment and on the exterior lower fuselage skins aft of the firewall. This evidence included areas of fuel pooling, droplets of fuel dripping from control cable clamps, a fuel sheen on the firewall, and fuel streaking on the exterior lower fuselage skins aft of the firewall. Engine control continuity was confirmed from the cockpit controls to the throttle arm and mixture control at the fuel servo. The fuel inlet fitting to the fuel control unit was finger tight. In preparation for an engine test the loose fuel inlet fitting was tightened (to determine the fuel consumption at the maximum static engine rpm), and the fuel system was pressurized at least twice, which confirmed that no other leak sources existed. During the test, the engine started and ran normally without any hesitation, stumbling, or interruption in power. No evidence of a fuel system leak was found after the engine run. The fuel consumption rate at maximum engine power on the ground (static power) was about 13.69 gallons per hour at 2,260 rpm. On the basis of the engine test run results, the estimated fuel consumption rate while in flight at maximum engine power (2,800 rpm) was about 16.96 gallons per hour. With a full fuel tank (23 gallons) at departure, the airplane’s fuel endurance would have been about 1 hour 21 minutes (1.35 hours) if the engine was operated at maximum power with a full rich mixture setting. Other than the loose fuel inlet fitting, the engine examination and test run revealed no mechanical malfunctions that would have prevented normal engine operation during the flight. -
Analysis
The pilot was conducting a post-maintenance flight in the experimental airplane to “break-in” two engine cylinders that were replaced on the day before the accident. The engine was operated at maximum speed with a full rich mixture setting throughout the flight. The pilot stated that the airplane lost total engine power about 1 hour after takeoff. During the forced landing, the airplane impacted a street signpost, resulting in substantial damage to a structural fuselage tube. The pilot reported that the fuel tank contained 23 gallons of fuel at the start of the flight. Postaccident examination found that the airplane’s fuel tank was empty and that only 2 to 3 fluid ounces of fuel were recovered from the fuel system. Evidence of a fuel leak was found within the engine compartment and on the exterior lower fuselage skins aft of the firewall. Examination of the fuel system revealed that the fuel inlet fitting to the fuel control unit was finger tight. In preparation for a postaccident engine test, the loose fuel inlet fitting was tightened, and the fuel system was pressurized to confirm that no other leak sources existed. The engine started and ran normally without any hesitation, stumbling, or interruption in power. There was no evidence of a fuel system leak following the engine run. Based on data collected during the engine test, the fuel consumption rate at maximum engine power on the ground (static power) was about 13.69 gallons per hour (gph) at an engine speed of 2,260 rpm. The estimated fuel consumption rate while in flight at maximum engine power (2,800 rpm) was about 16.96 gph. With a full fuel tank (23 gallons) at departure, the airplane’s fuel endurance was about 1 hour 21 minutes if the engine was operated at maximum power with a full rich mixture setting. Other than the loose fuel inlet fitting, the engine examination and test run revealed no mechanical malfunctions that would have prevented normal engine operation during the flight. Air traffic control radar data showed that the airplane was airborne for about 1 hour 15 minutes during the accident flight. Thus, it is likely that the loose fuel inlet fitting leaked fuel during the flight, which resulted in fuel exhaustion and the subsequent total loss of engine power.
Probable cause
The airplane’s total loss of engine power due to fuel exhaustion as a result of leaking fuel from a loose fuel inlet fitting to the fuel control unit.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Acro Sport
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N169BF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1392
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-08-30T19:12:58Z guid: 103760 uri: 103760 title: ERA21LA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103828/pdf description:
Unique identifier
103828
NTSB case number
ERA21LA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-26T14:34:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-10-04T18:15:36.912Z
Event type
Accident
Location
Banner Elk, North Carolina
Airport
ELK RIVER (NC06)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 26, 2021, about 1334 eastern daylight time, N413N, an Embraer EMB-505 (Phenom 300), sustained substantial damage when it was involved in an accident while landing at Elk River Airport (NC06), Banner Elk, North Carolina. The two pilots were not injured. The flight was conducted as a Title 14 Code of Federal Regulations (CFR) Part 91 repositioning flight. The airplane was operated by Nicholas Services, dba Nicholas Air, on an instrument flight rules (IFR) flight plan from Teterboro Airport (TEB), Teterboro, New Jersey, to NC06. NC06 was a private, exclusive-use-only airport surrounded by mountainous terrain. All flights were restricted to daytime visual flight rules (VFR) operations. According to the Elk River Airport website, all pilots who fly into NC06 are advised to “carefully read the Elk River Pilot Manual” and view the “video presentation of arrival and departure procedures for the Elk River Airport.” The pilotincommand (PIC) and the secondincommand (SIC) reported that the accident flight was the first time that they had flown into the airport. They prepared for the flight during the night before; their preparations included reviewing landing performance data for a dry and wet runway, watching the airport video, and reading the manual suggested by the airport website. The PIC, who was the pilot flying, reported that, while en route to NC06, he and the SIC observed a small rain cell near the airport on the weather radar. The SIC contacted airport security via radio to ask about weather conditions on the field and was told that the wind was calm, and that light rain was occurring. The crew decided that, if they could not make the visual approach, they would divert the airplane to another airport or enter a holding pattern until the weather passed. As the airplane approached the airport, the PIC made visual contact with the runway and canceled the IFR flight plan. The PIC then began the visual approach to runway 12 (the preferred runway due to surrounding terrain) using the visual cues recommended in the airport video. He stated that he and the SIC configured the airplane to land and that the airplane was at the landing reference speed (Vref) by the time of the 1-mile final. The PIC also used the precision approach path indicator (PAPI) to fly the airplane down to the runway at the Vref. The PIC stated that he applied full brakes once the airplane touched down on the runway, but the airplane did not slow down and started to veer to the right. After the airplane departed the right side of the paved runway surface, the PIC applied full left rudder to steer the airplane back to the left to avoid a cliff located off the end of the runway. The PIC also stated that the airplane crossed over a small taxiway and into a grassy area, where the airplane impacted a sign with the left wing. The airplane continued to travel forward before the left wingtip impacted a parked sport utility vehicle, which stopped the airplane and resulted in substantial damage to the left wing. The airplane stopped in the grass area near the threshold of runway 30, with its left wingtip still in contact with the vehicle. The nose of the airplane came to rest about 20 ft from the cliff located off the end of the runway. Airport security video captured the airplane during landing roll. The video depicted the left side of the airplane as it traveled down the runway. The airplane’s spoilers could be seen on the left wing. Rain was falling, and water spray was trailing behind the airplane. AIRCRAFT INFORMATION The accident airplane was equipped with a combination cockpit voice and data recorder (CVDR). The unit was recovered and sent to the National Transportation Safety Board (NTSB) Recorders Laboratory in Washington, DC, for readout. The airplane’s hydraulic brake system delivers hydraulic pressure to the brakes as a function of the brake pedals input. The pilot’s (left seat) and copilot's (right seat) brake pedals are mechanically linked. Each brake pedal of the pilot station is connected to a pedal position transducer, which produces two independent electrical outputs to the brake control unit (BCU) that are proportional to the respective pedal displacement. The BCU controls the main brake system, which is a brake-by-wire system with an antiskid function. METEOROLOGICAL INFORMATION NC06 was not equipped with any weather reporting equipment. Watauga County Hospital Heliport (TNB), Boone, North Carolina, located about 12 miles east of NC06, at 1350, reported wind from 190 degrees at 7 knots, wind variable between 150 and 210 degrees, visibility 10 miles, temperature 28 degrees C, dewpoint 18 degrees C, and a barometric pressure setting of 30.30 inHg. Lightning was observed north and southwest of the airport. The multi-radar multi-sensor Q3 radar, which was operated by the National Severe Storms Laboratory at the National Oceanic and Atmospheric Administration, provided an estimate of precipitation accumulation and rate. At 1348, the estimated rainfall rate near NC06 was about 1/2 to 2/3 -inch per hour. AIRPORT INFORMATION NC06 was a non-tower-controller airport with an elevation of about 3,468 ft. The airport had a single runway, 12/30. The runway was 4,605 ft-long by 75 ft-wide and constructed of asphalt. It was not equipped with centerline lights or runway end identifier lights. A two-light PAPI system was located on the right side of runway 12. There were no instrument approaches to NC06. Because of mountainous terrain, the visual approach to runway 12 was not straight-in; pilots were required to fly through a valley and then make a left turn while on short final approach to align with the runway. The Elk River Airport Pilot’s Manual stated the following: • Expect potentially significant changes in wind direction and velocity over the approach end of runway 12. • Higher terrain exists in close proximity to the approach end of runway 12. • A slightly higher approach angle is suggested to compensate for the higher terrain and the possibility of occasional wind shear. In addition, due to the higher terrain at the approach end of the runway, the initial heading for the approach should be approximately 140 degrees until the aircraft is aligned with the runway on short final. • Maintain strict alignment with the centerline! Remember, runway width is only 75 feet, and the existence of hills and trees on either side of the end of runway 12 allows for little deviation from the centerline. • It is important to fly a controlled and stabilized approach as go arounds are not recommended. Runway 12 has a significant upslope and higher terrain exists at the departure end of the runway…. • Wind speed and direction may indicate a landing on runway 30. Be advised that the terrain at the approach end of runway 30 is higher than that at the approach end of runway 12, requiring a steeper approach and that you will be landing on a downward sloping runway. WRECKAGE AND IMPACT INFORMATION The airplane sustained substantial damage to the left-wing attach point link fitting. The leading edges of both wings were also damaged. The BCU was removed from the airplane and sent to the manufacturer to be functionally tested. Test results revealed no anomalies that would have precluded normal operation of the unit at the time of the accident. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology testing was performed by the operator after the accident. The results were negative for both pilots for all substances tested. TESTS AND RESEARCH The NTSB conducted an airplane performance study to analyze the motion of the airplane during its approach and landing and the braking performance achieved during the landing roll on a wet runway. The study used various data sources, including FDR data, automatic dependent surveillance-broadcast (ADS-B) data, and airplane thrust and aerodynamic performance information. The study also referenced the landing performance parameters in the EMB-505 (POH) to determine if the airplane had sufficient runway length to land and if the pilot followed specified landing procedures and techniques outlined in the POH. According to the EMB-505 POH, landing performance data were predicated on the following criteria: · Steady 3° angle approach at Vref in the landing configuration, · Vref maintained at the runway threshold, · idle thrust established at the runway threshold, · attitude maintained until main landing gear touchdown, · maximum brake applied immediately after main landing gear touchdown, and · antiskid system operative. Any deviation from these criteria caould increase the total landing distance. The performance study revealed that the airplane was configured to land (full flaps and landing gear extended) as it flew toward the airport. The airplane’s flightpath angle averaged about 5° and the decreased to -8° as the airplane made a left turn on short final approach to align with the runway. As the airplane was crossing over the runway threshold at 1334:40, it was still rolling back to a wings-level attitude. The airplane’s indicated airspeed was 118 knots (Vref for the assumed landing weight was 110 knots) at a radio altitude of 86 ft. The airplane reached a wings-level attitude at 1334:41 when it was about 54 ft above and 313 ft past the runway threshold. The airplane touched down at 1334:47, about 1,410 ft past the runway threshold, at an indicated airspeed of 111 knots, a true airspeed of 118 knots, and groundspeed of 121 knots. The difference between the true airspeed and groundspeed indicated a 3-knot tailwind at touchdown. The airplane landed about 9 ft to the right of the runway centerline and reached 29 ft to the right of the runway centerline at 1335:05. At that point, the airplane was about 4,292 ft from the runway threshold and 313 ft from the runway end. As the airplane was moving down and to the right on the runway, between 1334:47 and 1335:05, the rudder was deflected between 0° and 3° right and reached 9.2° right at 1335:01 before deflecting to the left, reaching 31.6° at 1335:07. The airplane’s heading responded to this pedal input, decreasing from 121° true at 1335:02 to 71.3° true at 1335:07. The drift angle increased during this time, indicating that the tires became yawed at a considerable angle to the direction of travel and were likely unable to produce much braking force at the time. Both the heading and drift angle exhibited oscillations between about 1334:53 and 1335:02; these oscillations were reflected in the rudder deflections during this time, suggesting that some aircraft-pilot coupling might have contributed to the pilot’s directional control difficulties and the continued drift of the airplane toward the right edge of the runway. The FDR data confirmed that the pilot applied brakes after touching down on the runway, with the left brake pedal applied somewhat more aggressively than the right brake pedal. The left and right brake pressures increased nearly simultaneously, with the right brake pressure leading the left brake pressure by a fraction of a second. The brake pressures reached their peak values 4 seconds after the start of the brake application. The brake pedals were applied symmetrically from about 1334:52 to about 1335:01. Between 1335:03 and 1335:06, the right brake pedal was released, and the left brake pedal was deflected consistent with the use of differential braking to assist the rudder in yawing the airplane to the left. The airplane crossed over the northeast corner of the runway into the grass at 1335:10 at a groundspeed of about 30 knots. After entering the grass, rudder and differential braking to the right were applied, keeping the airplane on the grass and off the paved ramp next to the hangars on the southeast end of the airport. The airplane came to rest at 1335:16, 4,752 ft past the runway 12 threshold (147 ft past the end of the runway) and 147 ft to the left of the runway centerline. The performance study determined that the airplane exceeded some of the landing criteria outlined in the POH most likely because of the unique approach characteristics required to land at NC06, which made it more difficult for the pilot to satisfy the landing criteria and achieve the published landing distances outlined in the POH. In addition, the performance study found that the maximum wheel braking friction coefficient developed by the airplane during the landing ground roll was significantly less than that implied in the unfactored wet-runway landing distances published in the POH. The study determined that, if the maximum braking coefficient implied in the POH wet-runway landing distances had been achieved on the accident landing (and if maximum braking could have been maintained from the point in the landing at which both brakes were applied), the airplane would have stopped on the runway with about 290 ft remaining, even with the higher-than-nominal airspeed over the threshold. Further, if the airplane had crossed the threshold at Vref instead of Vref plus 8 knots and had achieved the same maximum braking coefficient as during the accident landing roll, then the airplane would have stopped on the wet runway with about 265 ft remaining. Additionally, the friction available from the runway has to be shared between the braking and cornering demands of the airplane. It is not possible to achieve the maximum available braking force from the runway while at the same time maneuvering to correct for a deviation from the centerline. Consequently, circumstances that place cornering or maneuvering demands on the tires during the landing roll (such as a crosswind) can increase the required stopping distance. In this case, the airplane was unable to stop on the paved runway because the combination of airspeed above Vref, the lower-than-assumed runway friction achieved during the landing roll, and the cornering forces required for directional control increased the required stopping distance beyond the stopping distance available. ORGANIZATIONAL AND MANAGEMENT INFORMATION Nicholas Air holds operation specifications for its operations conducted under Parts 91 and 135. Nicholas Air’s General Operations Manual (GOM) specifies requirements and procedures for operations that comply with Part 135 requirements. The GOM does not distinguish between flights conducted under Part 135 and those conducted under Part 91, but section 3.4.4 does state that “aircraft repositioning upon completion of a revenue flight may be operated under 14 CFR Part 91.” The GOM does not state whether the procedures or requirements for determining the limiting weight at landing could be changed or relaxed for flights conducted under Part 91. The destination airport runway length requirements for dispatching flights under Part 135 were also incorporated into Nicholas Air’s GOM. A review of these procedures revealed that the accident airplane could only have been dispatched to NC06 with wet conditions under the provisions of the Destination Airport Analysis Program (DAAP). The DAAP allows 80% of the available runway length to be used for landing instead of the 60% allowed by 14 CFR 135.385(b), but 25% of the unfactored dry landing distance must still be added to the required length to account for wet conditions. Section 4.5.3 of the GOM, “Runway Analysis – Landing Performance Planning,” describes the steps used to determine the maximum allowable weight for landing using the runway analysis application developed by the commercial company Aircraft Performance Group (APG). The application was accessible to the flight crew through ARINCDirect or iPreflight. The input data to the application included the airport, aircraft type, powerplant, systems configuration, landing flap setting, wind, and temperature. One of the steps listed in the GOM was to “enter [the resulting landing distance tables] at zero wind for pre-departure planning. For inflight computations, due to changing circumstances, enter at [sic] applicable headwind / tailwind component.” The application then provides the maximum allowable landing weight, which “is the lowest of the Approach Climb Weight Limit, the Field Length Weight Limit, and the structural Landing Weight Limit.” This information was provided for both the 60% and 80% available runway lengths. At the NTSB’s request, APG provided the output of the runway analysis application for the conditions of the accident landing. The results indicated that, for landing with a wet runway, the limiting weights were 13,267 pounds (60% factor) and 17,042 pounds (80% factor). According to the load manifest, the expected landing weight was 15,210 pounds, so the landing could only have been made using the 80% factor. The PIC stated that he does not operate airplanes differently under Part 91 and Part 135 because “performance doesn’t differ between the two types of flights.” The PIC added that he normally uses the 60% runway calculations for flights conducted under both Part 91 and 135, even though he could use the 80% factor for Part 91 flights, which would provide a “good” and “comfortable” buffer. According to the GOM, the 80% factor can be used by exercising the provisions of Nicholas Air’s DAAP, but “prior permission must be received from the Director of Operations before DAPP [sic] performance can be initiated.” No evidence indicated whether the PIC and Nicholas Air’s director of operations consulted with each other before the accident flight. Nicholas Air’s DAAP is regulated by 14 CFR 135.23(r), which stated that the GOM must take “airport facilities and topography” into account when “establishing runway safety margins at destination airports.” Although Nicholas Air’s GOM contains most of the requirements contained in 135.23(r), it does not specifically require that “airport facilities and topography” be considered. According to the FAA, the omission of “airport facilities and topography” from the DAAP requirements listed in Nicholas Air’s GOM is not an oversight or omission because a different section of the GOM reflects the requirements of section 135.385(b)(2), which states that “landing distance calculations assume…landing on the most suitable runway considering the probable wind velocity and direction and the ground handling characteristics of the airplane and considering the other conditions such as landing aids and terrain.” The NTSB became aware of another Nicholas Air pilot who made an unsuccessful approach to land at NC06 11 days before the accident. This pilot submitted a safety management system (SMS) report to the operator, which stated, Arriving into NC06 as per instructional video, flying the plane at VREF and on the VASI [visual approach slope indicator], after negotiating the last terrain avoidance maneuver on short final, we found ourselves still around 100 feet over the runway and halfway down the runway. As landing would be impossible, we performed a missed approach and diverted to our alternate airport…it is my professional opinion that this airport should not be utilized for part 135 operations. In response to the SMS report, an FAA inspector asked Nicholas Air’s vice president of flight operations, the chief pilot, and the director of operations who in the company had reviewed the SMS report. The vice president stated that he reviewed the report but was not sure who else might have reviewed it. The vice president also stated, “the company wasn’t going to change the way it does business based on one report from a pilot.” ADDITIONAL INFORMATION As previously stated, the accident flight was conducted under the provisions of Part 91, and the corresponding regulation governing the runway lengths required at destination airports is section 91.103, “Preflight Action:” According to the regulation, “each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include…for any flight, runway lengths at airports of intended use, and…takeoff and landing distance information.” On March 11, 2019, the FAA, issued Safety Alert for Operators (SAFO) 19001, which recommended that operators use a conservative approach to assessing landing distance requirements, including using the most adverse reliable braking action report or runway condition code and values for air distances and approach speeds that represent actual operations. A safety margin of at least 15% should be added to the computed (unfactored) landing distance “when the landing runway is contaminated or not the same runway analyzed for preflight calculations.” At the airplane’s calculated landing weight of 15,210 pounds, the unfactored dry runway landing distance was 2,757 ft. For the 60% factor, the minimum runway length would be 4,595 ft. Dispatching to a wet runway with the 60% factor and the recommended additional 15% safety margin, 689 ft, would have resulted in a total required runway length of 5,284 ft. For the 80% factor, the calculated landing distance would have been 3,446 ft, and the wet runway length with the additional 15% safety margin would have been 4,135 ft. -
Analysis
The pilots were conducting a repositioning flight in a light business jet to a private airport located in mountainous terrain. Both pilots reviewed a manual and a video to become familiar with the unique approach and landing features at this airport along with the landing performance data for both a dry and a wet runway. Visual meteorological conditions existed at the time; however, a rainstorm had just passed over the airport, the runway was wet, and a security video showed rain as the airplane rolled down the runway. The PIC stated that he flew the approach at the landing reference speed (Vref) and applied full brakes once the airplane touched down on the 4,600 ft-long runway. The airplane did not slow down and started to veer to the right. The PIC applied full left rudder to steer the airplane back to the left to avoid a cliff located off the end of the runway. The PIC also stated that the airplane crossed over a small taxiway and into a grassy area, where the airplane’s left wing impacted a sign. The airplane continued to travel forward before the left wingtip impacted a parked vehicle, which stopped the airplane but also resulted in substantial damage to the left wing. Flight recorder data revealed that the airplane was configured to land (full flaps and landing gear extended) as it flew toward the airport. As the airplane was crossing over the runway threshold, it was still rolling back to a wingslevel attitude. The airplane’s indicated airspeed was 118 knots (the landing reference speed [Vref] for the assumed landing weight was 110 knots). The airplane touched down about 1,410 ft past the runway threshold with a 3-knot tailwind. The airplane landed about 9 ft to the right of the runway centerline and continued to drift right about 29 ft before returning toward the runway centerline. The pilot applied the brakes and used the rudder pedals to steer the airplane back to the left to maintain control, but this effort did not prevent the airplane from departing the runway. An airplane performance study of the FDR and other data for this accident determined that the airplane exceeded some of the landing criteria outlined in the manufacturer’s Pilot’s Operating Handbook (POH), which was most likely due to the unique characteristics of the landing approach, including a steeper-than-normal approach and the requirement for a left turn to align with the runway on short final, which would have made it more difficult to achieve the published landing distances outlined in the POH. In addition, the performance study found that the maximum wheel braking friction coefficient developed by the airplane during the landing ground roll was significantly less than that implied in the unfactored wet-runway landing distances published in the POH. The study further determined that, if the maximum wheel braking friction coefficient implied in the POH wet-runway landing distances had been achieved during the accident landing (and if maximum braking could have been maintained from the point at which both brakes were applied), the airplane would have stopped on the runway with about 290 ft remaining, even with the higher-than-nominal airspeed over the threshold. In addition, if the airplane had crossed the runway threshold at the Vref (instead of at Vref plus 8 knots) and had achieved the same maximum wheel braking friction coefficient as during the accident landing roll (lower than that implied in the POH but still with continuous braking), then the airplane would have stopped on the runway with about 265 ft remaining. However, the friction available from the runway has to be shared between the braking and cornering demands of the airplane. In this case, the airplane was unable to stop on the paved runway because the combination of the airspeed above Vref, the lower-than-assumed maximum wheel braking friction coefficient during the landing roll, and the cornering forces required for directional control increased the required stopping distance beyond the stopping distance available. The flight’s operator held a Part 135 operating certificate, but the accident flight was conducted under the provisions of Part 91. The operator’s General Operations Manual (GOM) did not state whether any of the Part 135 procedures or requirements for determining an airplane’s limiting weight at landing could be changed for a Part 91 repositioning flight. According to the pilot, he did not differentiate between a Part 91 and a Part 135 flight. The operator’s runway length requirements for dispatching flights under Part 135 were incorporated in the GOM. A review of those procedures revealed that the airplane could only have been dispatched (based on landing weight and runway conditions) using the Destination Airport Analysis Program (DAAP). The DAAP allows 80% of the available runway length to be used for landing instead of the 60% allowed by section 135.385(b), but 25% of the unfactored dry landing distance must still be added to the required runway length to account for wet conditions. The airplane’s calculated landing weight was 15,210 lbs. The unfactored dry runway landing distance using the 60% factor was 4,595 ft (2,757 ft. / 0.6). Dispatching to a wet runway with the 60% factor would require an additional 15% safety margin (as recommended by FAA SAFO 19001), or 689 ft, for a total required runway length of 5,284 ft. Therefore, the flight could not be dispatched to NC06 using the 60% factor. However, using the 80% factor the required dry runway length was 3,446 ft (2,757 /.08), and 4,135 ft with the 15% safety margin. Consequently, the airplane could only have been dispatched using the 80% factor. The GOM content for the DAAP is regulated by section 135.23(r), which in-part states that the GOM must account for “airport facilities and topography” when “establishing runway safety margins at destination airports.” However, the operator’s GOM did not specifically require consideration of airport facilities and topography in its DAAP. The absence of this requirement is concerning because the terrain surrounding the accident airport requires a relatively steep glidepath angle and a significant heading change on short final approach to the runway, which makes it difficult to achieve the airplane state at 50 ft above the runway threshold needed for the landing distances published in the manufacturer’s POH. Thus, if the operator’s GOM had considered airport topography (that is, the unique terrain and approach procedures for landing on the runway) as a DAAP requirement for calculating runway safety margins, the accident flight would most likely not have been dispatched. Per the GOM, the 80% factor can be used but only with prior permission from the director of operations. The available evidence did not show whether the pilot and the director of operations spoke before the accident about landing at the airport. However, the director of operations was aware that another company pilot had attempted to land at the airport 11 days before accident but diverted to another airport due to the terrain. The investigation revealed that the airplane could have landed using 80% of the available runway length, as outlined in the DAAP. However, the combination of factors described above increased the required landing distance beyond the runway distance available, and the pilot lost control of the airplane while maneuvering on the runway.
Probable cause
The pilot’s failure to achieve the approach criteria for the available runway landing distances published in the POH, likely as a result of the steeper-than-normal approach and the required left turn on short final to avoid the terrain surrounding the airport. Contributing to the accident were a lower runway friction than that assumed by the airframe manufacturer and tire cornering forces imparted during the landing roll, which reduced the airplane’s reduced braking effectiveness, which when combined with a high approach speed, increased the required stopping distance beyond the runway distance available. Also contributing to the accident was the operator’s lack of consideration of airport topography in its Destination Airport Analysis Program.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EMBRAER
Model
EMB-505
Amateur built
false
Engines
2 Turbo jet
Registration number
N413N
Operator
NICHOLAS SERVICES LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
50500455
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-04T18:15:36Z guid: 103828 uri: 103828 title: ERA21LA344 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103769/pdf description:
Unique identifier
103769
NTSB case number
ERA21LA344
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-28T13:40:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-15T20:06:46.261Z
Event type
Accident
Location
Spartanburg, South Carolina
Airport
SPARTANBURG DOWNTOWN MEML/SIMPSON FLD (SPA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Factual narrative
On August 28, 2021, about 1240 eastern daylight time, a Piper PA-32-260, N3862W, was substantially damaged when it was involved in an accident near Spartanburg Downtown Memorial Airport/Simpson Field (SPA), Spartanburg, South Carolina. The student pilot and flight instructor sustained minor injuries; the passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the student pilot, who was also the owner of the airplane, the airplane was fueled the day before the accident at SPA with 12 gallons of aviation fuel which brought the fuel level in the main fuel tanks to the bottom of the “tabs,” and each wingtip fuel tank contained 17 gallons. On the day of the accident, the student pilot, his spouse, and the flight instructor departed SPA and flew to Foothills Regional Airport (MRN), Morganton, North Carolina, about 60 nautical miles away. They performed two touch-and-go landings at MRN before returning to SPA. During the return flight, they performed several training maneuvers. The student pilot thought they were in the air about 2 to 2.3 hours. When the airplane was about 2 nautical miles from SPA, it experienced a sudden loss of engine power. According to the flight instructor, “It felt like the throttle was pulled back to idle.” The rpm decreased from about 2,300 to 1,500 rpm and the propeller continued to “windmill.” The flight instructor took control of the airplane, which was about 800 ft above ground level and descending. They performed the emergency checklist and attempted to regain engine power but were unsuccessful. During the subsequent forced landing, the airplane impacted trees in a residential neighborhood about 3/4 nautical-mile northeast of SPA and came to rest in a nearly vertical position. Neither pilot recalled the reading of the fuel quantity indicators or engine instrument readings during the loss of power. When they departed, the fuel selector was on the right tank, and they switched to the left tank during the flight, but neither pilot recalled if they switched back to the right tank during the later stages of the flight. According to a witness who was present at the accident site, he heard the flight instructor state that they may have run out of fuel. Responding Spartanburg fire rescue personnel stated that the fuel selector was on the left main tank when they arrived and that they moved it two detents to the left to the OFF position. A residential video device partially recorded the impact of the airplane with the trees. Little ambient sound was present in the video, and no engine sound was emanating from the airplane prior to impact. As the airplane impacted the trees, the sound of the collision was heard, and a light-colored cloudy mist that propagated from the top of the trees downwards was visible; pieces of the wreckage were then visible as they descended to the ground. The actual impact and main wreckage were not seen in the video. Postaccident examination of the wreckage revealed that the engine was partially separated from the impact-damaged engine mount. The propeller and spinner remained attached to the engine crankshaft flange, and both blades were bent aft 10 degrees and 45 degrees, respectively. The spark plugs dislpayed normal wear when compared to the Champion Check-A-Plug chart and did not display any evidence of carbon or lead fouling that would preclude normal operation. Engine thumb compression and suction on all cylinders was confirmed, and crankshaft continuity was confirmed through a full rotation. The interiors of the cylinders were viewed using a lighted borescope and no anomalies were detected. All valves, pushrods, and springs operated normally, and the crankshaft rotation was smooth, with no noticeable abnormal noise or friction noted. Both magnetos were rotated by turning the drive assemblies and produced spark from all ignition towers. The ignition harness cap for the left magneto was partially separated from the magneto and was retained by only one of the four required attaching screws. The carburetor remained attached to the engine and no damage was noted. No damage was noted to the brass floats or other internal components. About a teaspoon of water and a small amount of dirt were observed in the bottom of the float bowl. The carburetor fuel inlet screen was unobstructed. The engine-driven fuel pump remained attached to the engine; no damage was noted, and air flowed freely through the unit. The pump was partially disassembled, and no damage was noted to the rubber diaphragms or internal check valves. The electric fuel pump was connected to a DC power source, and residual fuel flowed through the pump and lines as designed. Impact damage was noted to the right-wing tip fuel selector valve port and right inboard fuel tank ports; all fuel lines remained intact. Residual fuel was noted in the right-wing tip fuel selector port and right inboard fuel tank positions during a low-pressure air continuity check. No fuel was observed within the gascolator bowl. About 3 ft of the left wing remained attached to the fuselage; the outboard portions of the wing were separated and fragmented. The inboard fuel tank was breeched from impact and exhibited leading edge impact damage; the vent and pick-up screen were clear of obstruction, and the fuel cap remained attached. The wingtip fuel tank was separated and fragmented; the pick-up screen was clear of obstruction and the fuel cap remained attached to its receptacle. There were no anomalies with the left-wing fuel caps. Fuel line continuity was established with low-pressure air from the fuel selector through impact and overload separations to both fuel tank pick-up screens. The right wing was impact separated from the fuselage and was partially separated about 8 ft out from the wing root. Leading-edge impact damage was noted to the wing. The right wingtip fuel tank was separated and fragmented; the fuel cap was separated from its receptacle; and no anomalies were noted. The pick-up screen was clear of obstruction; however, the tank’s fuel level sending unit float was separated from the assembly and was not observed. The inboard fuel tank exhibited impact damage, but no tank breech was observed. A residual blue liquid consistent in color odor with aviation gasoline was observed within the fuel tank, and the tank’s pick-up screen and vent were clear of obstructions. The inboard tank’s fuel cap remained attached to its receptacle; however, the fuel cap’s gasket and valve were not installed and were not observed within the recovered wreckage. Fuel line continuity was established with low-pressure air from the fuel selector through impact and overload separations to both fuel tank pick-up screens. Fuel tank position and continuity of the fuel selector valve were established with low-pressure air; however, the valve was difficult to operate between tank positions. Disassembly of the fuel selector valve revealed a substantial amount of material consistent with rust within the fuel selector valve, its gascolator bowl, and filters. The wreckage remained on scene for 24 hours prior to recovery and was exposed to heavy rain and wind until it was transported to a secured facility where it remained in exterior conditions prior to examination. According to the airplane specification and engine performance data, at best power setting, the fuel consumption was between 15.2 gallons per hour (gph) and 18.5 gph at 65% and 75% power, respectively. At the best economy power setting, the fuel consumption was 12.2 gph and 14 gph at 65% and 75% power, respectively. According to the pilot, each wingtip fuel tank was topped off with 17 gallons of fuel, and the main fuel tanks were filled up to the tabs, which would provide about 18 gallons each for a total of 35 gallons per side (70 gallons total) enough for about 5 hours of total flight time at a 14 gph consumption rate. According to the airplane’s hour meter, the flight had lasted 2.3 hours when the power loss occurred. The fuel selector control was located below the center of the instrument panel; it had five positions clockwise from left to right: OFF, Left Tip, Left Main, Right Main, and Right Tip. -
Analysis
Prior to the cross-country instructional flight, the airplane had a total fuel load of about 70 gallons, which was enough for about 5 hours of total flight time. After about 2.3 hours of flight, as they approached the home airport about 800 ft above ground level, there was a complete loss of engine power. The flight instructor and student pilot performed the emergency checklist to no avail. During the ensuing forced landing, the airplane impacted trees and terrain about 3/4 of a mile from the airport. The instructor and student had departed with the fuel selector on the right tank and switched to the left tank during the flight. Neither pilot recalled switching back to the right tank during the later stages of the flight. Fire rescue personnel reported that they moved the fuel selector from the left main tank to the off position after the accident. A surveillance video that captured a portion of the final impact showed a misty vapor that was likely vaporized fuel emanating from the trees as a fuel tank ruptured during impact, indicating there was fuel on board. A postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical anomalies that would have precluded normal operation. Based on this information it is most likely that the fuel selector remained on the left main tank until all the fuel it contained was exhausted, which resulted in a loss of engine power due to fuel starvation.
Probable cause
The flight instructor’s improper fuel management, which resulted in fuel starvation and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA32
Amateur built
false
Engines
1 Reciprocating
Registration number
N3862W
Operator
MMF AIRCRAFT LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
32-805
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-15T20:06:46Z guid: 103769 uri: 103769 title: ERA21LA349 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103810/pdf description:
Unique identifier
103810
NTSB case number
ERA21LA349
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-08-30T09:19:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-23T20:45:42.925Z
Event type
Accident
Location
Grant-Valkaria, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On August 30, 2021, about 0819 eastern daylight time, a Piper PA-28-161, N864ZLM, was substantially damaged during a forced landing at Grant-Valkaria, Florida. The private pilot and the pilot-rated passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the preflight inspection, departure, and climb phases of flight were normal and uneventful. She leveled off at 7,500 feet mean sea level and began to lean the mixture. While leaning, the engine rpm dropped below 1,000. She responded by increasing the mixture to full rich and applying full throttle; however, the engine did not respond. The airplane began to lose altitude rapidly and she tried to restart the engine to no avail. She declared an emergency, and air traffic control provided radar vectors to Valkaria Airport (X59), Valkaria, Florida. Unable to make the airport, she force-landed the airplane in a farm field. The airplane collided with a fence and a ditch before coming to a stop. The pilot and passenger exited the airplane and were met by first responders. Inspectors with the Federal Aviation Administration responded to the accident site and examined the wreckage. Both wings and the fuselage received substantial damage. There was no fire. The right-wing fuel tank contained about 17 to 18 gallons of fuel and the left tank was empty; however, the left tank was compromised by impact forces. The wreckage was recovered to an aircraft salvage facility for further examination. The engine crankshaft was rotated manually using the propeller; it rotated freely and no internal binding was noted. The engine appeared to be freshly painted and recently overhauled. The fuel and oil lines, spark plugs, the intake, and exhaust systems were in a like-new condition. The carburetor was fractured in half by impact forces. The top spark plugs were removed, and the propeller was rotated by hand; engine continuity was established through the engine drive train and the impulse couplings in the magnetos could be heard snapping. Compression was established on all cylinders. Other than the impact-damaged carburetor, the examination of the engine did not reveal evidence of a preexisting mechanical anomaly or failure. -
Analysis
The pilot reported that the preflight, departure, and climb phases of the flight were normal and uneventful. She leveled off at 7,500 feet mean sea level and began to lean the mixture. While leaning, the engine rpm dropped below 1,000. She responded by increasing the mixture to full rich and applying full throttle; however, the engine did not respond. The airplane began to lose altitude rapidly and she tried to restart the engine to no avail. She declared an emergency and was unable to glide to a nearby airport, so she force-landed the airplane in a farm field. The airplane collided with a fence and a ditch before coming to a stop, which resulted in substantial damage to the airframe. A postaccident examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation, and the reason for the loss of engine power could not be determined.
Probable cause
A total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA-28-161
Amateur built
false
Engines
1 Reciprocating
Registration number
N864LM
Operator
Airborne Systems Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-8516063
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-23T20:45:42Z guid: 103810 uri: 103810 title: ERA21LA347 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103793/pdf description:
Unique identifier
103793
NTSB case number
ERA21LA347
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-01T18:00:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-21T22:25:20.597Z
Event type
Accident
Location
Geneva, Alabama
Airport
Geneva Municipal Airport (33J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On September 1, 2021, about 1700 central daylight time, an experimental amateur-built Challenger II, N1225G, was substantially damaged when it was involved in an accident near Geneva, Alabama. The commercial pilot received minor injuries. The flight was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he adjusted the carburetors on the airplane prior to the flight. The pilot departed and stayed in the airport traffic pattern. While approaching to land, the pilot reduced power while turning onto the base leg. As he turned onto the final leg, he attempted to increase power, but the engine “quit.” He made several attempts to restart the engine but was unsuccessful. The airplane lost altitude and collided with the roof of a shed. During the postaccident examination of the engine, it was examined using a borescope, and all four spark plugs were removed. No anomalies were discovered internally within the engine’s cylinders. The carburetors were removed and examined; both were in good operating order. During the examination, a small “cut” was discovered on the fuel line where a clamp held the fuel line to the front carburetor. There was no sign of a leak at the time of examination. The examination also revealed that the rubber boot that held the front carburetor to the manifold was dry rotted. The engine was removed and placed on another airframe for a test run. The engine was started, and a test run was completed successfully with no anomalies noted. -
Analysis
The pilot reported that he adjusted the engine carburation system on the airplane prior to the flight. While approaching to land, the pilot reduced power and the engine lost total power. The pilot made several attempts to restart the engine but was unsuccessful. The airplane lost altitude and was substantially damaged when it impacted the roof of a shed. During a postaccident engine examination, no mechanical anomalies were discovered internally within the engine. The carburetors were removed, and a small cut was discovered on a fuel line along with dry rot on the rubber boot for the front carburetor manifold. The engine then was removed and placed on another airframe for a test run. The test run was completed successfully with no anomalies noted. Based on these findings, the reason for the loss of engine power could not be determined.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
QUAD CITY
Model
CHALLENGER
Amateur built
true
Engines
1 Reciprocating
Registration number
N1225G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CH2-0697 1632
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T22:25:20Z guid: 103793 uri: 103793 title: ERA21FA346 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103791/pdf description:
Unique identifier
103791
NTSB case number
ERA21FA346
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-02T10:51:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-09-17T16:57:55.595Z
Event type
Accident
Location
Farmington, Connecticut
Airport
ROBERTSON FLD (4B8)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 1 serious, 3 minor
Factual narrative
Performance Study An NTSB performance study with representatives of the airplane manufacturer and the FAA used data from the FDR, CVR, video footage, tire skid marks on the runway, witness information, environmental conditions, engine performance, weight and balance calculations, aerodynamics and engine data generated during flight test, and airplane flight manual data. The study found that for the accident flight conditions that day at 15° flap setting, the calculated values in terms of knots calibrated airspeed (KCAS) for target V1, rotational speed (Vr), and angle-of-climb speed (V2) speeds were 106, 111, and 120, respectively. During the four preceding takeoffs, the calculated airplane braking coefficient values (the friction between the tires and the runway) during the takeoff ground roll were between about 0.02 to 0.03. During the accident takeoff ground roll, the calculated airplane braking coefficient values ranged from about 0.09 to 0.11 for groundspeeds below 100 knots and from 0.11 to 0.35 between 100 and 118 knots. Peak longitudinal acceleration was about 0.27 g during the accident flight and about 0.4 g during the previous 2 takeoffs. In both previous takeoffs, the elevator began deflecting at similar speeds to the accident takeoff attempt and the airplane rotated to about 10° over about 4 seconds, lifting off from the runway in both cases as it rotated. The FDR data showed that the recorded aileron and elevator trim readings during the accident flight takeoff were consistent with the previous four takeoff settings. During the accident flight takeoff roll, FDR data showed that the crew began ANU elevator deflection near V1 and reached full ANU elevator deflection at Vr. The airplane accelerated while on the runway to an airspeed above 115 knots, but the airplane pitch attitude did not increase above 1° before the airplane’s departure from the improved pavement surface. The study indicated that the Vr value correlated to about 105 knots ground speed. Using the vertical center of gravity value of 5.4 ft, at the Vr groundspeed, the calculated equivalent AND pitching moment due to adverse retarding force was about 12,420 ft pounds which was 77% greater than the nominal elevator/horizontal tail ANU pitching moment capability which was at least 7,000 ft pounds. Between 105 and 110 knots groundspeed, the equivalent AND pitching moment decreased to about 9,180 ft pounds but was still about 31% greater than the nominal elevator/horizontal tail ANU pitching moment capability. Beginning at 110 knots groundspeed, the equivalent AND pitching moment due to the adverse retarding force significantly increased from about 9,180 ft pounds and reached an equivalent AND pitching moment of 32,940 ft pounds at 118 knots. For speeds at and beyond Vr, a successful takeoff with such an unexpected, adverse retarding force at the wheel/runway interface would have required an ANU pitching moment capability that exceeded the accident airplane’s certified envelope, as measured by the forward center of gravity limit of the weight and balance envelope. Takeoff Checklists A review of the FAA-approved airplane flight manual revealed that its checklists for preliminary cockpit inspection, before starting engines, and shutdown each include setting the parking brake. The static takeoff and rolling takeoff checklists both cite “Brakes…Release” with no specific mention of the wheel brakes or parking brake. Airplane Location Correlated with Smoke To determine the airplane’s location when smoke appeared, NTSB created a ground track reconstruction model overlaid onto aerial imagery, which included video surveillance frames, longitudinal acceleration from FDR data, and the measured runway tire marks. According to the model, the video frame time 0952:33 aligned with FDR time 5048.8. After this video frame time, the FDR showed a decrease in the longitudinal acceleration data – a decrease of 0.10/0.15 g to 0.1 g and lower. According to the time alignment with the model, the white smoke on the video aligned with where the runway marks associated with the right main landing gear darkened, 2,685 ft past the approach end of runway 2. Previous Related Recommendations and Similar Accidents During its investigation of this accident and another Cessna 560XL accident (NTSB case number WPR19FA230), the NTSB determined that without a parking brake indication, some Cessna 560XL pilots may not recognize that the parking brake is not fully released and attempt to take off, which could result in a runway overrun. Because Cessna 560XL airplanes continue to operate in the United States without a parking brake indication and the manufacturer continues to manufacture and deliver airplanes in the United States without such an alert, the NTSB issued the following safety recommendations: Safety Recommendation A-22-8 to the FAA: Issue an airworthiness directive for in-service Cessna 560XL airplanes to require that they meet the parking brake indication requirements of Amendment 25-107 of 14 CFR 25.735. Safety Recommendation A-22-9 to the FAA: Revise the type certification basis for Cessna 560XL airplanes and future derivative models to require that newly manufactured airplanes meet the parking brake indication requirements of Amendment 25-107 of 14 CFR 25.735. (NTSB Aviation Investigation Report NTSB/AIR-22-06, “Require Safeguards to Prevent Cessna 560XL Takeoff with Parking Brake Engaged.”) In September 2015, the Australian Transport Safety Bureau (ATSB) investigated a similar accident near Lismore, New South Wales, Australia, involving a Cessna 550 that did not have cockpit annunciation to alert the pilots that the parking brake was set. The pilot did not release the parking brake before attempting to takeoff, which led to a rejected takeoff and runway overrun. The ATSB made recommendations for all Cessna Citation airplanes (including the Cessna 560XL) to include a parking brake annunciation. In an October 2017 response, the manufacturer stated that the recommended actions were not needed because it was “simple airmanship” to remember to release the parking brake before the takeoff run. (ATSB Transport Safety Report AO-2015-114, “Runway excursion involving Cessna 550, VH-FGK, Lismore Airport, New South Wales, 25 December 2015.”) On October 3, 2018, a Cessna 560XL, 5N-HAR, was involved in a serious incident in Bauchi State, Nigeria. The XLS+ derivative model airplane, which was not equipped with parking brake annunciation, would not rotate during takeoff at Vr and the takeoff was aborted, which resulted in a wheel fire and no injuries. The Nigerian Accident Investigation Bureau (AIB) recommended the airplane manufacturer redesign the parking brake system to incorporate takeoff protection visual and aural warnings, and to make the position of the parking brake control visible to both flight crew members. The manufacturer stated that, as of the publication of this report, it was reviewing the recommendations but had not yet responded to AIB. (AIB Aircraft Accident Report NPF/2018/10/03/F, “Final Report on serious incident involving Cessna Citation 560 XLS+ aircraft with nationality and registration marks 5N-HAR operated by the Nigeria Police Airwing which occurred at Sir Abubakar Tafawa Balewa Airport Bauchi, Nigeria on 3rd October, 2018.”) - According to the airplane’s type certificate data sheet and FAA-approved airplane flight manual, the minimum flight crew for all operations were one pilot and one copilot. Inspections of the airplane and its systems as part of the manufacturer’s scheduled inspection program were last performed last on July 2, 2021. At the beginning of the accident flight, the airplane had accumulated 11.3 hours since the last inspections were completed. According to the aircraft status report, the airplane’s parking brake valve, which is considered an on-condition item, was original to the airplane when it was manufactured in 2009. A pilot who had flown the airplane on August 10, 2021, and again on August 13, 2021, reported there were “zero squawks” on either flight. The parking brake knob was located on the tilt panel forward of the left seat pilot’s seat adjacent to the occupant’s knee and was not visible to the right seat occupant. Per the airplane operating manual, the parking brake is set by depressing the toe brakes in the normal manner, then pulling out the parking brake pull knob on the left lower side of the tilt panel. That action mechanically actuates the parking brake valve, trapping fluid in the brakes. The parking brake is released by pushing in the parking brake pull knob. Figure 1.   Pictures from an exemplar 560 XLS+ showing the parking brake off (left) and set (right). The airplane was equipped with a crew alerting system (CAS) that did not incorporate parking brake valve position as part of its activation logic, nor was there an indication or annunciation in the cockpit when the parking brake was not fully released. A red NO TAKEOFF warning CAS message would display a NO TAKEOFF aural warning for some conditions that would impede a safe takeoff, such as if the throttles were advanced beyond the climb setting or the flaps were not configured for takeoff. Certification The parking brake standard outlined in 14 CFR 25.735, Brakes and Braking Systems, was first issued in 1965 and remained the standard until May 2002. To meet the original requirements of 14 CFR 25.735 in force between 1965 and 2002, the parking brake must prevent the airplane from rolling on a paved, level runway when set by the pilot and with takeoff power on the critical engine. In May 2002, the regulation was changed to Amendment 25-107, which incorporated, in part, indication in the cockpit when the parking brake was not fully released. The FAA’s aircraft certification process in 14 CFR 21.101, Certification Procedures for Products and Parts - Changes to Type Certificates, allowed an aircraft manufacturer to introduce a derivative model (or “changed aeronautical product”) as a design update on a previously certificated aircraft and to add the changed product to an existing type certificate. The FAA approved changes for derivative models if it found that (1) if the change was not significant, (2) for those areas or components not affected by the change, (3) if such compliance would not contribute materially to the level of safety, and (4) if such compliance would be impractical. That process enabled a manufacturer to introduce design updates without resubmitting the entire aircraft design for certification review. When the accident aircraft manufacturer applied to the FAA for certification of the XLS+ on February 17, 2006, 14 CFR 21.101 Amendment 21-77 was effective and stated that an applicant must show that the changed product complies with the airworthiness regulations in effect on the date of the application. However, the applicant may show compliance with an earlier amendment of a regulation for a change the FAA finds not to be significant. Although the location and movement of the parking brake knob in the cockpit for the XLS+ changed from the previous design, there was no change to the parking brake architecture or operation. Because there were no significant changes to the parking brake system, the FAA did not require recertification of the parking brake system on the XLS+. Thus, the XLS+ was certificated on May 30, 2008, to the 1965 parking brake standard. - The elevation at the approach and departure ends of runway 02 were reported to be 188.6 ft and 201.6 ft, respectively. An approximate 20 ft width of grass was noted beyond the departure end of runway 02, followed by an approximate 20 to 25 ft elevation decrease past the airport boundary terrain. Examination of the taxiway leading onto the approach end of runway 2, and entire length of runway 2 included three-dimensional laser scanning of the entire length of the runway, the area immediately past the departure end of the runway, and the area of the impacted pole. No tire remnants were found on or near the runway. There were no discernable tire marks associated with the accident airplane near the approach end of runway 2. The first discernable mark associated with the right main landing gear tire was located about 9 ft right of runway centerline and about 2,361 ft from the approach end of the runway. The first discernable mark from the left main landing gear tire was located about 6 ft left of runway centerline and 2,482 ft from the approach end of the runway. The marks from both main landing gear tires continued past the end of the runway. - The airplane was equipped with a CVR and FDR. The CVR did not show obvious signs of deformation damage but did show some evidence of heat damage. The recorder’s crash survivable memory unit and the internal non-volatile memory chip stack appeared undamaged. The chip stack and associated ribbon cable were in good condition and were read out normally using an L3 FA-2100 surrogate. The data downloaded normally from the CVR and produced files consistent with the logic of a 2-hour CVR. The audio quality for all channels was characterized as “good.” The FDR was covered with dirt and carbon soot and combustion particles. The memory module ribbon cable, and connector showed no signs of heat stress. The temperature dot indicated the memory module was not compromised by heat exposure. The memory module was downloaded and contained approximately 197 hours of data. The event flight was the last flight of the recording, and its duration was approximately 6 minutes. - On September 2, 2021, at 0951 eastern daylight time, a Cessna 560XLS+ airplane, N560AR, was destroyed when it was involved in an accident near Farmington, Connecticut. All four airplane occupants (the pilot, copilot, and two passengers) were fatally injured. One person on the ground sustained serious injuries, and three people sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to FAA air traffic control audio recordings and CVR transcription, about 0913, the copilot contacted the Yankee Terminal Radar Approach Control Facility to obtain an instrument flight rules clearance to Dare County Regional Airport (MQI), Manteo, North Carolina. The controller provided the clearance and advised the flight to hold for release. About 0948, the copilot contacted the controller and advised that the flight was taxiing and would be ready in 1 minute, and the controller instructed the flight crew to hold for release. The flight taxied toward runway 2, and at 0948:20, the CVR recorded the controller advising the flight crew that the flight was released for departure and to enter controlled airspace on a 20° heading. The copilot, who was the PM and seated in the right seat as SIC, repeated the instruction. The CVR recorded the PM discussing the departure frequency and transponder code while the PF, who was seated in the left seat and was PIC, said, “kay flaps. trim three times. pitot heat on.” The copilot then said that the pitot static was coming on. Those items were part of the before takeoff checklist, but there was no challenge response for the taxi, before takeoff, or takeoff checklists, and the flight crew did not perform a crew briefing. Further, there was no mention in the CVR recording of releasing the parking brake before takeoff was initiated. FDR data did not indicate any flight control movements consistent with a check of the flight controls. The CVR recorded the copilot make a radio call on the airport common traffic advisory frequency advising that the flight would be departing runway 2 straight out and that the final and base legs of the airport traffic pattern appeared clear. The sound of engine power advancing was heard at 0950:15. According to data from the airplane’s FDR, both thrust levers were set at about 65°, and both engines were set at and remained at 91% N1 throughout the takeoff roll. While accelerating on the runway the CVR recorded the copilot stating that “power is set…airspeed’s alive… eighty knots cross check… v one”, with the v one call occurring about 1,670 ft down the 3,665-ft-long runway. The flight continued on the runway and at 0950:44, the copilot called, “Rotate.” According to the data from the FDR, the airplane was about 2,000 ft down the runway at about 104 knots calibrated airspeed and the elevator was about +9° when the copilot made the rotate callout. Three seconds later, the CVR recorded the copilot stating, “Oht oht ‘sa matter,” followed 1.7 seconds later by a sound of heavy strain from the pilot and him stating, “it’s [not] rotating.” Then 2.4 seconds later, a sound of physical strain/grunt was recorded from the pilot. The airplane continued along the runway centerline with left rudder input between 2° and 4,° which decreased to about 0.3° when the airplane was about 2,375 ft down the runway. The flight crew applied an increasing amount of right rudder input to a maximum of about 10°, while the right rudder input remained until the flight was about 2,500 ft down the runway, and a slight deviation to the right began. Several on- and off-airport video cameras that captured the takeoff roll and final portion of the flight showed smoke trailing the airplane, and a ground track reconstruction model determined the smoke appeared about 2,685 ft down the runway (the model is further discussed in the Additional Information section of this report). While deviating to the right, the flight crew applied left rudder input to a maximum of about 18°, and the deviation to the right ended about 0950:52 when the airplane was about 3,125 ft down the runway. The rudder values remained near neutral from the point when the right deviation stopped and the airplane track remained straight to the end of the runway, though the airplane path was offset right of the runway centerline. When the airplane reached the end of the airport terrain, FDR data indicated the airspeed had increased to about 120 knots, the elevator deflection increased to a maximum value of about +16°, the WOW remained in an on-ground state, and the pitch of the airplane minimally changed briefly to +1° then decreased to 0°. The FDR data further indicated that past the end of the airport terrain where the ground elevation decreased 20 to 25 ft, the WOW indication changed from on-ground to air mode, the elevator position increased to a maximum recorded value of about +17° deflection (or ANU), and the airplane’s pitch increased to about +22° in less than 2 seconds. While the airplane rapidly pitched up, the elevator position rapidly decreased to about 1.0°. At 0950:54, the CVR recorded the sound of electronic stall warning followed one-tenth of a second later by stick shaker activation. Two witnesses on the ground reported seeing a puff of blue smoke behind the airplane during the takeoff roll. One witness noted the airplane appeared to be “going slower” compared to previous flights, and because of that, he knew there was a problem. That same witness also reported that the airplane never lifted off from the runway. A witness who was located about 280 ft north-northeast of the departure end of the runway reported seeing the airplane come off the runway in a level attitude. As the airplane continued, it pitched into a nose-up attitude but was not climbing. He noted the front portion of the right engine impact a nearby pole followed by a shower of sparks and a metallic grinding sound. FDR data showed that the N1 and N2 values of the No. 2 engine were 91.0% and 99.4%, respectively before the airplane impacted the pole past the departure end of the runway. After impacting the pole, the right engine N1 and N2 values immediately decreased to 80.1% and 95.1%, respectively, then both continued to decrease despite the thrust lever angle for both engines remaining at 65° for the remainder of the recording. The airplane began a roll to the right and became inverted in about 3.5 seconds. The airplane impacted the ground then an occupied building, whose sprinkler system was activated. The building and its contents sustained significant structural and fire damage. - Postmortem examinations of the flight crew were performed by the Office of the Chief Medical Examiner, Farmington, Connecticut. The cause of death for the pilot was blunt injuries of head, torso, and extremities, and the cause of death for the copilot was blunt injuries of head, neck, torso, and extremities. The autopsy report for the copilot also cited moderate coronary artery atherosclerosis. Toxicology testing performed by the FAA Forensic Sciences Laboratory on the pilot’s specimens detected 51 mg/dL glucose, along with unquantified amounts of atenolol (which is used to treat high blood pressure), acetaminophen (sometimes marketed as Tylenol), and salicylic acid (Aspirin), which are not generally considered impairing. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on the copilot’s urine and vitreus detected 14 mg/dL and 48 mg/dL glucose, respectively, along with unquantified amounts of amlodipine, which the copilot had reported using to treat high blood pressure; these are not generally considered impairing. Toxicology testing also detected desmethylsildenafil (Viagra), which is not generally considered impairing, but the FAA states that pilots should wait 8 hours before flying to monitor for side effects such as symptomatic low blood pressure. - Pilot The pilot was a salaried pilot employed by Interstate Aviation, Inc., which was the accident operator. He received transition training in a level D simulator for the Cessna 560XL (Excel), which was the original type design of the accident airplane, at Flight Safety International (FSI) in December 2009. He subsequently obtained recurrent training at FSI in the Excel in 2017, and recurrent training in the XLS+ (a derivative model of the Cessna 560XL) in 2018, 2019, 2020, and 2021. All training was conducted in a level D simulator, and he passed all of the practical tests on the first attempt. On the paperwork for his latest training, Citation XLS+ Recurrent Pilot-In-Command Course, the instructor remarked during one flight that he observed no weaknesses, and his strengths were, “Good aircraft control, CRM [crew resource management], and procedures.” The accident operator’s president, who normally flew as copilot with the accident pilot, reported that during typical takeoffs, the accident pilot would center the airplane on the runway, then when almost to a full stop, he would begin the takeoff. The accident pilot would not normally stop on the runway, apply the brakes, then advance thrust and release the brakes. When they flew together, they used the checklist and performed challenge and response. During takeoff, they would call airspeed alive, 80 knots crosscheck, takeoff-decision speed (V1), rotate. At V1, the flight crew’s hands would move from the thrust levers to the control yoke, then engage the autopilot at 400 ft. Copilot The copilot was a contract pilot for the accident operator. A review of his available training records revealed that he completed initial training at FSI in a Cessna 525 (Citation Jet) in November 2015. He also received training in the Gulfstream G450 in 2018 and recurrent training at FSI in the Gulfstream G550 on two occasions in 2019. The latest training performed in a level D simulator between November 18, 2019, and November 23, 2019, consisted of 6 hours as the PF and 6 hours as the PM. A review of provided logbook entries revealed no entries showing a sign off as SIC specifically for the accident make and model airplane. Entries between September 2020 and July 29, 2021, showed that he logged 11 flights as SIC in the accident airplane totaling 25 hours. The remarks section for the flights in the accident airplane did not indicate whether he had performed engine-out procedures, maneuvering with an engine out while acting as pilot-in-command, and CRM training. The attorney representing the copilot’s estate cited the flights in the accident airplane but reported the copilot’s family was unable to locate any records concerning simulator training and had no recollection of whether he had attended training for the Cessna 560 series. - Examination of the accident site area revealed a broken telephone/electrical pole about 011° and 361 ft past the departure end of the runway, about 27 ft above ground level and about 1.8 ft lower than the departure end of the runway. An approximate 3ftlong section of the outboard end of the airplane’s right inboard flap was located in wetlands east of the impacted pole. Additional airplane wreckage was located close to the impacted pole. Examination of the area north of the impacted pole revealed ground scars on grass about 850 ft from the damaged pole on a magnetic heading of 036° about 245 ft from the impacted building. The aft empennage came to rest inverted on a magnetic heading of 130° outside of the building, while the heatdamaged cockpit and cabin were just inside the impacted building. The wing, which exhibited extensive impact and fire damage, was both inside and immediately outside the building. Wreckage including upper cabin material, were found along the ground impact energy path consistent with the airplane being inverted at impact. Flight control surfaces, and engine components were also noted along the energy path between the ground scar and the resting position of the airplane. Examination of the wreckage revealed the wings, cockpit, and cabin were damaged and/or consumed by a post-crash fire. All primary and secondary flight control surfaces or the remains of them, both wingtips, the top of the vertical stabilizer and rudder, ends of both horizontal stabilizers and elevators were accounted for at the accident site. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. Both speed brakes were retracted. Although the positions of the flaps based on the flap actuators could not be determined, the FDR data reflected they were set to and remained at 15° throughout the recorded data. The two-position horizontal stabilizer was positioned to takeoff/land, and according to FDR data, it remained at that position throughout the recorded data. According to the FDR data during takeoff, the aileron trim was between 10° and 11° tab trailing edge down or left wing down, while the elevator trim was 18.02° ANU, which was beyond the maximum limit and did not change throughout the recorded data. The rudder trim actuator measured 1.9 inches, which equated to neutral. The elevator and aileron trim values recorded by the FDR during the accident flight were consistent with the same values for the entirety of data for each recorded by the FDR. Examination of the parking brake handle revealed it remained partially attached to the tilt panel. The handle was extended about 2.5 inches and its sleeve was bent and fractured. Examination of the parking brake push/pull rod and knob with section of panel mount, deformed and fractured sleeve, and sections of control cable revealed that the fractured or cut surfaces of the sleeve, Bowden cable, and inner actuated cable were consistent, respectively, with overstress fractures or being cut in the field for recovery. The field examination of both engines revealed no anomalies on either engine that would have precluded normal operation. FDR data further showed there were no fault codes for either engine recorded on its respective data collection unit, and both engines were operating normally until just past the impact with the pole. Parking Brake Valve, Landing Gear, and Brake System Components Examination of the parking brake valve revealed it was separated from the structure and thermally damaged. The cable remained attached to the lever, which was bent aft and positioned against the parking brake full-on stop toward the single structural attach bolt. X-ray radiograph and computed tomography scanning of the parking brake valve revealed that the shaft flat was adjacent to the mechanisms (consistent with the valve being in the closed or brake set position), and the levertoshaft interface did not show any indications of cracks, missing material, or other abnormalities. Further, there were indications of high-density particles and possible debris consistent with burned material from outside the valve or from heated material within the valve. Comparison between the accident valve and an exemplar valve revealed that the accident valve was in a closed position when exposed to elevated temperatures, which was confirmed when disassembled. The parking brake valve position and normal wheel or parking brake application were not recorded by the FDR. Other than its closed position during operation, examination of the parking brake valve did not reveal any anomalies that would have precluded normal operation. Examination of the left and right main landing gear revealed postimpact thermal damage and no anomalies that would have precluded normal operation. Examination of the left brake revealed it could not be pressurized. The wear pin right of shuttle valve was bent and could not be measured, and without hydraulic pressure applied to the brake stack, the other wear pin left of shuttle valve was measured at 0.941 inch. The pistons appeared to be fully retracted. Disassembly of the brake stack revealed normal wear of the pressure plate, and the stators and rotors exhibited normal wear. No anomalies were noted with the left brake that would have precluded normal operation. Examination of the right brake revealed it could not be pressurized. Without hydraulic pressure applied to the brake stack, one wear pin (right of shuttle valve) extension was 0.285 inch and the other wear pin (left of shuttle valve) extension was 0.300 inch. Disassembly of the brake stack revealed normal wear of the pressure plate, and the stators and rotors exhibited normal wear. No anomalies were noted with the right brake that would have precluded normal operation. -
Analysis
The flight crew was conducting a personal flight with two passengers onboard. Before departure, the cockpit voice recorder (CVR) captured the pilots verbalizing items from the before takeoff checklist, but there was no challenge response for the taxi, before takeoff, or takeoff checklists. Further, no crew briefing was performed and neither pilot mentioned releasing the parking brake. The left seat pilot, who was the pilot flying (PF) and pilotincommand (PIC), initiated takeoff from the slightly upsloping 3,665-ft-long asphalt runway. According to takeoff performance data that day and takeoff performance models, the airplane had adequate performance capability to take off from that runway. Flight data recorder (FDR) data indicated each thrust lever angle was set and remained at 65° while the engines were set and remained at 91% N1. During the takeoff roll, the CVR recorded the copilot, who was the pilot monitoring (PM) and secondincommand (SIC), making callouts for “airspeed’s alive,” “eighty knots cross check,” “v one,” and “rotate.” A comparison of FDR data from the accident flight with the previous two takeoffs showed that the airplane did not become airborne at the usual location along the runway, and the longitudinal acceleration was about 33% less. At the time of the rotate callout, the airspeed was about 104 knots calibrated airspeed, and the elevator was about +9° airplane nose up (ANU). Three seconds after the rotate callout, the CVR recorded the sound of physical straining, suggesting the pilot was likely attempting to rotate the airplane by pulling the control yoke. The CVR also captured statements from both the copilot and pilot expressing surprise that the airplane was not rotating as they expected. CVR and FDR data indicated that between the time of the rotate callout and the airplane reaching the end of the airport terrain, the airspeed increased to about 120 knots, the weight-on-wheels (WOW) remained in an on-ground state, and the elevator position increased to a maximum value of about +16° ANU. However, the airplane’s pitch attitude minimally changed. After the airplane cleared the end of the airport terrain where the ground elevation decreased 20 to 25 ft, FDR data indicate that the WOW transitioned to air mode with nearfull ANU elevator control input, and the airplane pitched up nearly 22° in less than 2 seconds. FDR data depicted forward elevator control input in response to the rapid pitch-up, and the CVR recorded a stall warning then stick shaker activation. An off airport witness reported seeing the front portion of the right engine impact a nearby pole past the departure end of the runway. The airplane then rolled right to an inverted attitude, impacted the ground, then impacted an off-airport occupied building. There was no evidence of preimpact failure or malfunction of the flight controls or engines before impact with the pole. Postaccident examination and computed tomography of the parking brake valve revealed the parking brake was in the ON (or closed) position at the time of the accident. There was no evidence of preimpact failure or malfunction of the brakes, parking brake knob, cable, or parking brake valve. The closed position of the parking brake valve would have continued to apply pressure to both main landing gear wheel brakes during the takeoff roll, and resulted in the continuous rubber transfer from both main landing gear tires on the runway that was observed from the starting point of each to the departure end of the runway. Additionally, the smoke that witnesses observed and the surveillance video captured trailing the airplane as it traveled down the runway was likely the result of the brakes still being applied. An NTSB performance study found that the retarding force at the wheel/runway interface that would have resulted from application of the wheel brakes during the takeoff roll created an airplane-nose-down (AND) pitching moment that opposed airplane-nose-up (ANU) rotation. When the airplane reached Vr, the pitching moment opposing the ANU rotation likely overpowered the elevator’s ability to rotate the airplane nose up and prevented the airplane from taking off. When the retarding force at the wheel/runway interface was no longer present after the airplane reached the end of the airport terrain, the airplane responded aerodynamically to the near-full aft control yoke/column input and began pitching up rapidly. Although the airplane flight manual takeoff checklist included an item for “brake release,” it did not specifically indicate “parking brake release.” While a specific and unambiguous checklist item that directed flight crews to verify that the parking brake had been released prior to takeoff might generally provide a mechanism for flight crews to consistently perform this pre-takeoff task, it is unlikely that a specific mention to release the parking brake in the takeoff checklist would have mitigated this accident because there were no challenge responses to checklists during the flight. The ON position of the parking brake knob and its associated valve could not be observed by the copilot (due to its obscured location on the lower left side of the left seat pilot), therefore only by completing a challenge response as part of a specified checklist could the copilot have any knowledge of the position of the parking brake. Further, the status of the parking brake was not indicated or annunciated in the cockpit and was not part of the NO TAKEOFF configuration warning system. The accident airplane was manufactured as an XLS+ derivative model of the Cessna 560XL, which was certified to a parking brake standard that was first issued in 1965. Cessna Aircraft Company (now Textron Aviation, Inc.), the airplane manufacturer, applied to the Federal Aviation Administration (FAA) for certification of the XLS+ as a derivative airplane in February 2006, nearly 4 years after a change to the parking brake regulation that required indication in the cockpit when the parking brake was not fully released. Because there were no substantial changes to the parking brake system of the XLS+ from the original type design, the FAA process for certification of a derivative aircraft allowed the parking brake system to be certified to the original 1965 standard without a parking brake indication. It is likely that a cockpit indication when the parking brake was not fully released would have alerted both the pilot and copilot of the parking brake’s status so that they could have immediately aborted the takeoff attempt and prevented the accident. To address this safety issue, which was also identified in NTSB case number WPR19FA230, the NTSB issued recommendations to the FAA on May 4, 2022, to require that in-service (A-22-8) and newly manufactured Cessna 560XL airplanes and future derivative models (A-22-9) meet the in-cockpit parking brake indication requirements of the updated certification standard. Based on a similar accident in 2015 involving a Cessna 550 and a serious incident in 2018 involving a Cessna 560XLS+, the Australian Transport Safety Bureau (ATSB) and Nigerian Accident Investigation Bureau (AIB), respectively, also recommended that the manufacturer include a parking brake indication. In addition, the FAA’s certification process for derivative aircraft or changed aeronautical product did not consider or require compliance with regulation changes to systems like the Cessna 560XL parking brake indication because it determined that there were no significant changes to the parking brake system. Although the FAA accurately followed the certification process for derivative aircraft, identifying and requiring the safety benefit of a parking brake indication during that process could have prevented this accident and at least one other serious incident. Therefore, the certification process for the Cessna 560XL, as a derivative aircraft, likely contributed to this accident by not evaluating the impact that the updated certification standards would have and did not identify the safety enhancing value that requiring a parking brake indication would provide.
Probable cause
The pilot-in-command’s failure to release the parking brake before attempting to initiate the takeoff, which produced an unexpected retarding force and airplane-nose-down pitching moment that prevented the airplane from becoming airborne within the takeoff distance available and not before the end of the airport terrain. Contributing to the accident were the airplane’s lack of a warning that the parking brake was not fully released and the Federal Aviation Administration’s process for certification of a derivative aircraft that did not identify the need for such an indication.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
560
Amateur built
false
Engines
2 Turbo fan
Registration number
N560AR
Operator
BROOK HAVEN PROPERTIES LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
560-6026
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-09-17T16:57:55Z guid: 103791 uri: 103791 title: CEN21LA405 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103815/pdf description:
Unique identifier
103815
NTSB case number
CEN21LA405
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-02T11:45:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-09-14T18:47:09.343Z
Event type
Accident
Location
Morrilton, Arkansas
Airport
MORRILTON MUNI (BDQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On September 2, 2021, about 1045 central daylight time, a Beech A35 airplane, N8419A, was substantially damaged when it was involved in an accident near Morrilton, Arkansas. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The passenger reported that he recently purchased the airplane and that he and the pilot were in the process of flying it to his home airport. The pilot and passenger flew the airplane before the purchase and for familiarization before the accident flight and the airplane operated normally. For the accident flight, they departed the Ada Regional Airport (ADH), Ada, Oklahoma, about 0910 with an intended fuel stop at the Searcy Municipal Airport (SRC), Searcy, Arkansas, a distance of about 244 nautical miles. The pilot reported that the airplane’s cruise altitude was 8,500 ft. msl., and they had the left fuel tank for about 1.25 hours. He then switched to the rear auxiliary fuel tank and fuel pressures were normal. About 7 to 8 minutes later, the engine suddenly lost all power, but the propeller remained windmilling. The pilot switched the fuel selector from the rear auxiliary tank to the right tank and attempted to restart the engine to no avail. He then switched to the left tank and after descending through a cloud layer was again unable to restart the engine. After descending below the clouds, the pilot switched to the right fuel tank again and power was restored for 5 to 10 seconds but then all engine power was again lost. The pilot attempted to glide the airplane to the Morrilton Municipal Airport, Morrilton, Arkansas, but had insufficient altitude. The airplane impacted trees and became suspended in the trees. The airplane sustained substantial damage to both wings and the fuselage. Postaccident examination of the airplane and engine did not reveal any preimpact mechanical failures or malfunctions that would have precluded normal operation. An examination of the fuel system showed fuel in the lines and in the fuel selector. A bench test of the electric fuel pump shoed normal operation. Both fuel tanks had been breached during impact and determination of fuel quantity was not possible. -
Analysis
The pilot and passenger were in the process of flying the recently purchased airplane to the passenger’s home airport. The pilot and passenger flew the airplane twice before the accident flight, and the airplane operated normally. While in cruise flight, about 1.25 hours after departure, the pilot switched from the left fuel tank to the rear auxiliary fuel tank and noted that the fuel pressure was normal. About 7 to 8 minutes later, the engine suddenly lost all power. The pilot then switched to the right fuel tank and attempted to restart the engine to no avail. He then switched back to the left tank and, after descending through a cloud layer, was again unable to restart the engine. After descending through the clouds, the pilot switched back to the right fuel tank and power was restored for 5 to 10 seconds before all engine power was again lost. The pilot attempted to glide to a nearby airport but had insufficient altitude and executed a forced landing. The airplane impacted trees and became suspended in the trees, incurring substantial damage to the fuselage and wings. Postaccident examination of the airplane and engine did not reveal any preimpact mechanical failures or malfunctions that would have precluded normal operation. Both fuel tanks had been breached during impact and determination of fuel quantity was not possible. Based on the available information, the reason for the loss of engine power could not be determined.
Probable cause
The total loss of engine power for reasons that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A35
Amateur built
false
Engines
1 Reciprocating
Registration number
N8419A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-1854
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-14T18:47:09Z guid: 103815 uri: 103815 title: ERA21LA350 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103812/pdf description:
Unique identifier
103812
NTSB case number
ERA21LA350
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-03T13:44:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-09-14T17:04:04.394Z
Event type
Accident
Location
Naples, Florida
Airport
NAPLES MUNI (APF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 3, 2021, about 1244 eastern daylight time, a Raytheon Aircraft Company 390, N351CW, was substantially damaged when it was involved in an accident at Naples Municipal Airport (APF), Naples, Florida. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on-demand flight. According to the pilot, the takeoff and en route portions of the flight were uneventful. During landing, he applied normal braking and the airplane started to slow down. Suddenly the brakes “faded away,” and he was unable to stop the airplane. He further described that he applied full braking pressure and the pedals were operating as they should, but the airplane was not stopping. He added that every few feet the brakes would grab, lock-up for a few feet, and then release. The brakes grabbed several times during the landing roll but were not slowing the airplane down. The airplane overran the end of the runway, and the pilot steered the airplane into the grass and away from a jet blast fence. A Federal Aviation Administration inspector who examined the airplane after the accident observed that the airplane sustained substantial damage to both wings during the runway excursion. The pilot reported the runway surface condition as “damp.” He further stated that it was not raining, there was no standing water on the runway and “If I had to choose between the descriptor of either wet or dry as my only options, I would choose dry.” According to automatic dependent surveillance broadcast (ADS-B) data, the airplane made a normal Vref approach and landed about 8 knots higher than the landing chart for 10,200 lbs about 110 knots. The runway length was 6,600 ft and about 4,500 ft of runway remained for the airplane to stop. The landing chart in the airplane flight manual (AFM) revealed that about 3,000 ft was required for landing on a dry runway, and about 3,750 ft was required for a wet runway. The anti-skid box, brake valve, anti-skid valve, and both wheel speed transducers were removed and sent to the manufacturer for testing. All the components passed the tests, and no anomalies were noted. The airplane was not equipped with a flight data recorder. The cockpit voice recorder was removed and sent the National Transportation Safety Board’s recorders laboratory for download. The airplane was not equipped with thrust reversers. The wind was reported from 150° at 5 knots, at APF, at 1235. -
Analysis
The pilot stated that the flight was uneventful. During landing, he applied normal braking and the airplane started to slow down. Suddenly the brakes “faded away,” and he was unable to stop the airplane. He further described that he applied full braking pressure and the pedals were operating as they should, but the airplane was not stopping. He added that every few feet the brakes would grab, lock-up for a few feet, and then release. The brakes grabbed several times during the landing roll but were not slowing the airplane down. The airplane overran the end of the runway, and the pilot steered the airplane into the grass and away from a jet blast fence. The anti-skid box, brake valve, anti-skid valve, and both wheel speed transducers were removed and sent to the manufacturer for bench testing. All the components passed the bench tests, and no anomalies were noted. The airplane was not equipped with a flight data recorder. According to automatic dependent surveillance broadcast (ADS-B) data, the airplane landed about 8 knots higher than the Vref speed of 110 knots, with about 4,500 ft of runway remaining. According to the airplane flight manual, the airplane required about 3,000 ft for landing. Based on the available evidence, the reason that the pilot was unable to stop the airplane on the runway could not be determined.
Probable cause
The pilot was unable to stop the airplane during the landing for reasons which could not be determined, resulting in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RAYTHEON AIRCRAFT COMPANY
Model
390
Amateur built
false
Engines
2 Turbo fan
Registration number
N351CW
Operator
Executive Aero Charter Management LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
RB-53
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-14T17:04:04Z guid: 103812 uri: 103812 title: CEN21LA402 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103805/pdf description:
Unique identifier
103805
NTSB case number
CEN21LA402
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-05T14:23:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-09-07T20:36:55.152Z
Event type
Accident
Location
Sheridan, Illinois
Airport
Cushing Field Ltd Airport (NA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 15, 2013, the FAA issued the airplane an experimental airworthiness certificate and associated operating limitations. Although requested, the pilot did not provide any airplane maintenance logbook documentation during the investigation. - On September 5, 2021, about 1323 central daylight time, a Murphy Renegade II experimental airplane, N490DJ, was substantially damaged when it was involved in an accident near Sheridan, Illinois. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot stated that he was conducting “fast taxi” operations and did not intend to fly the airplane but that, after the airplane’s tail became airborne, he decided to continue the takeoff. After liftoff, at an altitude of about 500 ft above ground level, the pilot heard a “click” before the engine lost total power. The pilot made a forced landing in a soybean field, during which the airplane nosed over shortly after touchdown. - A search of Federal Aviation Administration (FAA) airman certification records found no record of a pilot certificate for the pilot. The pilot reported that he had previous experience flying ultralight aircraft operated under 14 CFR Part 103. - Postaccident examination confirmed that the airplane nosed over in a soybean field during the forced landing. The left main landing gear wheel separated from the gear leg during the forced landing. The outboard 3 ft of the upper right wing’s leading edge was crushed aft. Examination of the engine compartment revealed a fractured engine mount tube. The remaining fuselage, wings, and empennage were relatively undamaged. Flight control continuity was confirmed from the cockpit controls to each flight control surface. The engine remained attached to the fuselage through the engine mounts. A partial teardown examination of the engine revealed that the magneto-side piston had seized in the cylinder. The piston and cylinder bore exhibited scrape marks consistent with a piston seizure, as shown in figure 1. Piston and ring material was missing with associated batter to the cylinder head, piston dome, and spark plug, as shown in figure 2. The power-takeoff piston and cylinder exhibited no evidence of piston seizure. Other than the magneto-side piston seizure and associated secondary damage, the engine exhibited no evidence of a mechanical malfunction that would prevent normal operation. Figure 1. Magneto-side cylinder and piston. Figure 2. Magneto-side piston dome, cylinder head, and spark plug. -
Analysis
The pilot and passenger were conducting “fast taxi” operations and did not intend to fly the airplane, but, after the airplane’s tail became airborne, the pilot decided to continue the takeoff. When the airplane was about 500 ft above ground level, he heard a “click” before the engine lost total power. The pilot made a forced landing in a soybean field, during which the airplane nosed over shortly after touchdown. The airplane sustained substantial damage to the upper right wing and an engine mount tube. Postaccident examination of the engine revealed that one of the two pistons, the magneto-side piston, had seized in the cylinder. The piston and cylinder bore exhibited scrape marks consistent with a piston seizure, and piston and ring material was missing with associated batter to the cylinder head, piston dome, and spark plug. The other, power-takeoff piston and cylinder exhibited no evidence of a piston seizure. Other than the magneto-side piston seizure and associated secondary damage, the engine exhibited no evidence of a mechanical malfunction that would have prevented normal operation. Thus, the total loss of engine power during initial climb was likely due to the piston seizure.
Probable cause
A total loss of engine power during initial climb due to a piston seizure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Murphy
Model
Renegade II
Amateur built
true
Engines
1 Reciprocating
Registration number
N490DJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0028
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-07T20:36:55Z guid: 103805 uri: 103805 title: ERA21FA354 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103831/pdf description:
Unique identifier
103831
NTSB case number
ERA21FA354
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-09T16:27:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-09-14T21:58:57.419Z
Event type
Accident
Location
Provincetown, Massachusetts
Airport
PROVINCETOWN MUNI (PVC)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 7 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On September 9, 2021, about 1527 eastern daylight time, a Cessna 402C, N88833, was substantially damaged when it was involved in an accident near Provincetown, Massachusetts. The pilot and the six passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 flight. The flight was being operated by Hyannis Air Service, Inc. d.b.a. Cape Air on an instrument flight rules flight plan from Boston-Logan International Airport (BOS), Boston, Massachusetts, to Provincetown Municipal Airport (PVC), Provincetown, Massachusetts. In a postaccident interview, the pilot said he obtained weather information before the flight via a computer in the pilot crew room at BOS just before the passengers were boarded. The weather information included the graphic forecast for aviation; weather advisories including AIRMETs and SIGMETs, weather radar, METARs, and NOTAMs. The pilot reported that the radar was showing green bands of rain only between BOS and PVC. The pilot said that based on the weather conditions, he planned for the ILS RWY 7 approach into PVC. He then filed an IFR flight plan and began the boarding process. According to Federal Aviation Administration (FAA) air traffic control (ATC) communications, the flight departed BOS about 1504. The pilot said it was a very quick flight and the AWOS frequency for PVC was already dialed into the No. 2 radio. He said he checked the AWOS “at least twice” during the flight but did not recall exactly when. He was required by the operator to check the AWOS before he started the approach and before he crossed the final approach fix (FAF) on the approach. He recalled the weather being 200 ft overcast, visibility 3 to 4 miles in moderate rain, and the wind was 5 knots or below from the southwest. The pilot knew he would be landing with a quartering tailwind on runway 7 (a 3,502 ft-long runway) and that the wind conditions favored runway 25, but the ILS to runway 7 allowed for a lower ceiling minima than the RNAV approach to runway 25. So, runway 7 was preferable based on the existing weather conditions. The pilot also calculated that the tailwind component was within the performance limits for the airplane and the company requirements since Cape Air prohibited instrument approaches to short runways (4,000 ft or less) when the tailwind component was 5 knots or more. At 1511, the pilot advised ATC that he had the weather at PVC and could accept the ILS RWY 7 approach. A controller instructed the pilot to proceed direct to WOMECK intersection, an intermediate fix for the approach. At 1513, a controller cleared him for the ILS RWY 7 approach, and the pilot acknowledged. At 1521, a controller advised the pilot to cancel his flight plan once on the ground, and the pilot acknowledged. This was the last communication received by the pilot before the accident. Review of FAA radar surveillance data revealed that the airplane crossed over the FAF at 1524, at an altitude of about 2,000 ft msl, and landed about 3 minutes later, at 1527. According to the pilot, he said he flew the approach using the autopilot and extended the flaps to 15° a few miles outside the final-approach-fix (FAF). He stated that when the airplane crossed the FAF, the airplane’s indicated airspeed was 120 knots, and he extended the landing gear. Once inside the FAF, he turned off the autopilot at 1,000 ft and extended the flaps to 20°-25° to compensate for the tailwind and wet runway. The pilot said the airplane slowed to about 90 knots and they broke out of the clouds at 500 ft, which gave him extra time to set up for the landing. The airport’s runway landing lights were on, and it was raining. The pilot stated that he extended the flaps to 45° when the airplane was about 300 ft above the ground. He said that when the airplane was about 50 to 100 ft above the ground, the airplane encountered “an aggressive sinking tendency” and “very heavy rain.” The pilot believed he had encountered a downdraft and associated wind gust (which he estimated to be about 20 knots), which pushed the airplane down and to the left. The pilot added that the approach became unstable and that he immediately initiated a go-around before the airplane touched down. He brought both throttles full forward and retracted the flaps to 15°. The airplane continued to descend and touched down on the runway for about 2 seconds before it became airborne again. The pilot said that he never applied the brakes because he was fully committed to going around. The pilot did not remember where on the runway the airplane touched down, but said it was beyond his intended landing point due to him initiating the go-around. The pilot said he was unable to establish a positive rate of climb and that he could feel the wings buffeting. The airplane impacted the trees off the end of the runway, then the ground, and caught on fire. Another Cape Air pilot was holding short of runway 25 waiting to depart and witnessed the accident. He said that he first saw the accident airplane after it landed and was about halfway down the runway. As the accident airplane got closer to his position, he could tell that it was traveling “a little faster than it should be” and would not have room to stop on the remaining runway. The accident airplane then took off and entered a slow climb. The accident airplane cleared the localizer antennas at the far end of the runway, then the perimeter fence, before it collided with trees. The accident airplane disappeared into the trees and a ball of flames erupted shortly afterwards. The pilot told ATC that the accident airplane had gone off the runway and that he was returning to the terminal to contact his company about the accident. The accident was recorded on three airport surveillance cameras, which showed a different series of events versus what the pilot recalled. The videos revealed the airplane actually made a normal landing and touched down about 500 ft from the end of the runway’s threshold. It was raining heavily at the time and a splash of water was observed when the main landing gear contacted the ground. The airplane rolled down the runway before it became airborne near the end of the runway. The airplane entered a shallow climb, collided with trees, and caught on fire. The airport’s windsock was observed in the video and was consistent with the airplane landing with a tailwind. The passengers reported that they perceived the airplane was moving too fast to land and stop safely on the runway. One passenger said that after the airplane landed, the pilot tried to stop, and she felt the sensation of decelerating in her seat as the brakes were applied. But the airplane did not slow down. The pilot brought power up on both engines as they neared the end of the runway and attempted to take off. The passengers could see the trees located off the end of the runway and did not believe the airplane would get high enough to clear them. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with a rating for airplane multiengine land. He also held a commercial pilot certificate with ratings for single and multiengine land airplanes, and instrument airplane. In addition, the pilot was a certified flight instructor with ratings for single and multiengine airplanes, and instrument airplane. His last FAA first-class medical certificate was issued on April 2, 2021. The pilot had been employed by Cape Air for about 9 years and reported a total of 17,617 flight hours, of which, 10,000 hours were in the Cessna 402C. He was also type rated in Boeing 727 and Beech 1900 airplanes. AIRCRAFT INFORMATION The Cessna 402C is a light twin, piston engine aircraft and certificated for single-pilot operations. The airplane is powered by two 325 hp turbocharged Continental engines with three-bladed, constant-speed, fully feathering propellers. The airplane was maintained via an FAA-approved inspection program (AAIP). The last inspection was completed on August 26, 2021. At the time of the accident, the airplane had accrued a total of 36,722 hours. The airplane was not equipped, and was not required to be equipped, with a flight data recorder (FDR) or cockpit voice recorder (CVR). There were no other sources of nonvolatile memory devices installed onboard the airplane. METEOROLOGICAL INFORMATION A review of the weather conditions at the time of the accident indicated a low-pressure system and associated cold front was moving across Massachusetts with moderate to heavy rain and thunderstorms across the region. A convective SIGMET was current during the period over the route of flight and destination airport. IFR conditions were reported approximately 40 minutes before departure with LIFR conditions at the time of the accident due to moderate to heavy rain and low ceilings at 200 ft above ground level. Figure 1 – Boston WSR-88D Composite reflectivity image and flight track at 1527 EDT The High Resolution Rapid-Refresh (HRRR) sounding indicated an unstable atmosphere favorable for convection, with a low potential for any non-convective low-level wind shear at the time of the accident. The sounding (and satellite imagery) did not indicate any microburst potential over the accident site at the time of the accident. Furthermore, WSR-88D weather radar imagery did not detect any outflow boundaries or microburst at the time of the accident. PVC was equipped with an AWOS. The AWOS disseminated weather in two formats: hourly and continuous. The hourly reports (which also included any special observations) were in the form of an official meteorological aerodrome report (METAR). At the time of the accident, the hourly issued METAR observations at PVC were: At 1456, wind was 200° at 5 knots, visibility 4 miles, moderate rain, mist, ceiling broken clouds at 200 ft, overcast clouds at 600 ft, temperature 21° C, dewpoint 21° C, and an altimeter setting of 29.79 in Hg. The hourly precipitation at that time was reported as 0.27 inches. At 1537, a special observation was issued and reported wind from 210° at 10 knots, visibility 3 miles, heavy rain, mist, few clouds at 200 ft, ceiling broken at 3,400 ft, overcast clouds at 5,000 ft, temperature 21° C, dewpoint 21° C, and an altimeter setting of 29.79 in Hg. The continuous AWOS information, updated once a minute, which included wind speed and direction, cloud cover, temperature, precipitation, and visibility, could only be accessed by a pilot via VHF radio. An FAA technician was able to retrieve some of the AWOS data immediately after the accident, including wind speed and direction. Cape Air requires pilots to check the arrival airport’s weather/AWOS twice before starting an instrument approach per their Cessna 402 Normal Procedures Handbook, Section 3.11 – Instrument Approach. The procedure was to check weather (AWOS) once before setting up for the approach and then “recheck it again prior to crossing the FAF to assure regulatory compliance.” The pilot said he checked the weather “at least twice” but did not recall when he checked it. Since the pilot was monitoring the AWOS via VHF radio, there was no way to determine which observation he obtained. However, a review of the wind data between 1504 and 1511, the time the airplane departed and when the pilot informed ATC that he had the weather at PVC, revealed the tailwind components ranged between 1 and 4 knots respectively. Between 1513 and 1524, the times the airplane was cleared for the approach and reached the FAF, the tailwind components ranged between 1 and 7 knots respectively. Between 1524 through 1527, when the airplane was crossing over the FAF and landed, the wind speeds increased, and the tailwind component ranged from 6 to 11 knots in heavy rain. AIRPORT INFORMATION PVC is a noncontrolled, publicly owned commercial service airport with an elevation of about 8 ft above sea level. PVC has a single runway, 7/25, which is 3,502 ft long by 100 ft wide and is constructed of asphalt. Runway 7 was equipped with high-intensity runway lights along the edges, a medium intensity approach lighting system with sequenced flashers, and a 4-light precision approach path indicator (PAPI) system. Scheduled passenger operations at PVC include airplanes that do not exceed nine passenger seats. Therefore, the airport was not required to provide aircraft rescue and firefighting services as outlined in 14 CFR Part 139. WRECKAGE AND IMPACT INFORMATION An on-scene examination of the wreckage revealed the airplane collided with a cluster of about 20-foot-tall pine trees that bordered the airport’s perimeter fence, about 660 ft from the end of the runway. The airplane traveled through this cluster of trees, crossed a two-lane road, impacted the ground and more trees on an approximate heading of 068°, before coming to rest upright in a nose low/tail high attitude on an approximate heading of 300°. All major components of the airplane were accounted for at the accident site. A postimpact fire consumed most of the left wing and a portion of the right wing. From the point of initial impact with trees to where the airplane came to rest was about 200 ft. Numerous broken tree limbs were found along the wreckage path. Several of these limbs exhibited flat angular cuts, with black paint transfer marks, consistent with contact with a moving propeller blade. Also found along the wreckage path were portions of left- and right-wing structure and a landing gear door panel. The airplane fuselage and the leading edges of the tail flight control surfaces sustained impact damage. The instrument panel and window on the co-pilot’s side was pushed aft into the cockpit area due to impact with a tree, which was still partially embedded in the impact area. A concentrated area of fire damage was observed to the external fuselage below the co-pilot’s side window. Examination of the airframe revealed flight control continuity to all major flight control surfaces. The flap indicator in the cockpit indicated 0°, and the flap handle was displaced toward the 15° down position. Examination and measurement of the chains that move the flaps up and down revealed that the right flap was in the fully retracted position. The chain for the left flap was impact damaged and could not be measured. The landing gear were down at the time of impact. The left main gear remained attached to its respective wing and sustained extensive fire damage; however, the brake did not appear to be worn. The right main gear separated from the airframe and was found under the right wing and protected from the fire. The brake did not appear to be worn. Examination of the right main landing gear tire revealed two oval-shaped areas of melted rubber. The tread depth was measured, and photos were sent to the National Transportation Safety Board’s (NTSB) Materials Laboratory for analysis. Examination of the tire marks were consistent with multiple skid events. The left and right engines were located with the main wreckage and sustained impact and fire damage. Examination of both engines and the airplane revealed no mechanical deficiencies that would have precluded normal operation at the time of impact. SURVIVAL ASPECTS The pilot and all six passengers sustained extensive burns, and some had soft tissue damage and bone fractures. All seven exited the airplane from the top opening of the main cabin (clamshell-style) door, located in the rear cabin area on the left side of the passenger compartment adjacent to row 4. After the pilot and passengers exited, they each had to jump/fall about 9.5 ft to the ground due to the nose down/high-tail position of the airplane. All six passengers reported that the pilot did not provide “any” safety briefing before takeoff and were confused after the accident on how to exit the burning airplane. The passenger seated in 2B, where the emergency exit window was located, said she punched the window to try and open it. She then read the passenger briefing card and learned how to open the window. Another passenger said he tried to open the main cabin door, but it would not open. He then kicked the door and the top half of the door opened. A third passenger said her seat broke during the impact with trees, and she was unable to unclasp her lap belt, which delayed her exiting the airplane. The pilot stated that he gave a passenger safety briefing. The briefing included making sure the passengers knew they were going to Provincetown; what the weather was going to be, and to expect a smooth flight. He stated he also instructed the passengers on how to use the seatbelts, directed them to where the emergency exits were located, how to find the passenger life vests and to review the passenger briefing card. An NTSB Survival Factors Specialist examined the airplane, along with the seats and restraints. The examination revealed that the airplane was equipped with two doors and an emergency exit window. The pilot’s door (crew door) located in the cockpit on the left side of the airplane, was found partially separated from the airframe and remained attached via the upper forward hinge. The window sustained extensive heat damage and was breeched and curled inward. The pilot said the door broke from impact and fire was coming in through the door. He tried to block the fire by holding the door up, but it was too intense, and his hands got badly burned along with the left side of his arms and face. This forced him to exit through the main cabin door. The crew door could not be tested due to impact and fire damage. The emergency exit (passenger window) located in the forward cabin area on the right side of the passenger compartment (seat 2B) was found open. The passenger, who was seated in 2B, said that she was able to open the window, but when she put her hands on the frame of the window to get out, her fingers were immediately burned. She turned around and exited out the main door. The main door was a two-section, outward opening, airstair door. The lower section folded down when open to provide two steps for ease in boarding and deplaning passengers, while the top portion folded up when open. The top portion of the door was found open at the accident site. The lower portion was found up and latched at the accident site. The door handle was manually tested by investigators, and the lower portion of the door folded out normally. An approximate 5-inch diameter tree limb was observed laying diagonally adjacent to the bottom hinge area of the door. If the lower door had been opened, the tree limb would have prevented the door from being able to fold down to its completely open position. All the passenger seats remained attached to their respective seat rails which were fastened to the floor. The only seat that exhibited any structural damage was seat 2A, which the passenger in that seat said had “twisted” when the airplane impacted the trees. The seatback was rotated forward and had visible damage along the back seat pan/seatback junction. The seat covering was a single sewn piece that went over the seat and was glued to the bottom of the pedestal base, which was anchored to the floor. When the broken seat back was lifted, the cover for the seat bottom was no longer attached and there was tearing of the foam along the seat bottom. The seat’s lap belt wrapped around the back of the seat back, so the passenger would have been held to the broken seat by the lap belt. The passenger said the lap belt’s clasp was “jammed” and she tried to lay down to see if she could get out of the belt. She screamed for help, and the pilot, who was just about to exit, went back and released the lap belt. He then assisted her out of the airplane via the main door before he exited. The lap belt was found unclasped at the accident site but functioned normally when manually tested. All the other seat restraints were still attached to their seats/structure. Each of the restraints were manually tested and all functioned normally. Passenger safety briefing cards were found in some of the seat back pockets and throughout the cabin area. The cards contained instructions in graphical form on both sides and included information on how to use both exit doors and the emergency exit. Examination of the emergency exit (passenger window), main cabin door, seats and restraints revealed no mechanical deficiencies that would have precluded normal function/operation at the time of the accident. TESTS AND RESEARCH An NTSB airplane performance engineer conducted a performance study which examined the performance of the airplane on final approach, through its landing and deceleration on runway 7, and its attempted takeoff/go-around. Since the airplane was not equipped with a CVR or FDR, the control inputs, engine power, speed, and acceleration of the airplane throughout the entire approach, landing, and go-around could not be determined with precision. In addition, the lack of FDR data, and the unknown lift characteristics of the airplane at flaps 45° in ground effect, precluded a computation of the wheel braking friction coefficient achieved on the wet runway during the landing, and a comparison of the friction achieved with the friction levels achieved in other wet-runway landing accidents investigated by the NTSB. However, the airplane’s altitude, position, and speed during the approach to runway 7 could be computed from ADS-B data. Furthermore, the NTSB conducted a video study utilizing the images recorded on the three airport surveillance cameras, which captured the airplane’s landing, landing roll, and go-around. Data from the videos was used to determine the airplane’s position and speed on portions of the runway, as well as the time elapsed between the touchdown and the impact with the trees. This information, together with airplane performance data published in the Cessna 402C Pilot’s Operating Handbook & Airplane Flight Manual (POH/AFM) and additional performance information provided by the airplane manufacturer was used to evaluate the distance required to stop on the runway and the climb capability of the airplane during the go-around. The study also referenced Cape Air’s General Operations Manual (GOM). The performance study revealed that at 1525:40, the airplane was centered on the localizer for the ILS approach as it descended through 1,100 ft msl. The airplane was slightly above the ILS glideslope centerline, at an airspeed of 129 knots calibrated airspeed (KCAS) descending at about 760 ft/min and decelerating at about 1 knot every 10 seconds. At 1526:15, at about 660 ft msl, the deceleration increased to about 6 knots every 10 seconds. At about the same time, the airplane started to deviate further above the ILS glideslope centerline and at 600 ft msl exceeded the ILS glideslope 1-dot “fly down” beam. At 1526:38, the sink rate briefly exceeded 1,000 ft/min as the airplane descended through 400 ft msl. The pilot stated he did not break out of the clouds until 500 ft msl, but the operator stated that the glideslope exceedance at 1526:15 might have been the result of the “ballooning” effect of extending the flaps to 45° after breaking out of the clouds closer to 600 ft msl (the pilot reported extending the flaps to 20°-25° at 1,000 ft msl, and then to 45° when the airplane was 300 ft msl). If the cloud base was at 500 ft msl (as reported by the pilot), then the airplane was below 1,000 ft msl and still in instrument meteorological conditions (IMC) when the glideslope exceedance occurred. Per the GOM, this should have triggered “an immediate go-around” due to the approach not being stabilized. If the cloud base was closer to 600 ft msl, the airplane could have been below the cloud base and in visual meteorological conditions (VMC) when the exceedance occurred, in which case a go-around would not have been required per the GOM. However, the GOM would still have required a go-around when the sink rate exceeded 1,000 ft/min at 400 ft msl. At 1527:00, the airplane was 50 ft above the runway surface. At that time, the airplane’s calibrated airspeed (with an 11-knot tailwind component) was 107 KCAS. Per the POH/AFM, at the airplane’s planned landing weight of 6,215 lbs., the airplane’s calibrated airspeed at 50 ft above the runway should have been 89 knots. Hence, the airspeed was about 18 knots higher than that assumed in the landing distance tables in the POH/AFM. Per the landing performance charts in the airplane’s POH/AFM, the required landing distance at the 5-knot tailwind component limit allowed by Cape Air (and at the nominal airspeed at 50 ft assumed in the POH/AFM) would have been about 2,628 ft. With an 11-knot tailwind, the required landing distance, without any adjustment for wet runway conditions, would have been about 3,015 ft. However, the reduction in braking friction resulting from a wet runway increased the required landing distance significantly. According to the video study, the estimated deceleration rate of the airplane as it was moving past the midpoint of the runway was constant at 0.16 g. The video study estimated that if the airplane continued decelerating along the runway at a rate of 0.16 g, it would have stopped somewhere between 66 ft before the end of the runway and 88 ft past the end of the runway (in an open field). The airplane was on the runway for about 21 seconds before it became airborne and began to climb/accelerate at 5.0 ft/s2. The airplane’s calculated climb performance with this rate of acceleration revealed that it was unlikely that it could have simultaneously climbed out of ground effect and accelerated continuously at this rate. The airplane could have achieved a higher climb angle and likely cleared the trees if it had maintained a constant airspeed after liftoff, instead of accelerating, even though the liftoff airspeed was below the airplane’s best angle of climb speed (Vx). However, it is understandable that a pilot would first want to accelerate to Vx before climbing to clear obstacles. Unfortunately, in this case there was insufficient space to clear the trees by first accelerating to Vx before climbing. Given the outcome of the attempted takeoff, the performance data determined that the better option for the pilot would have been to accept an overrun into the open area beyond the end of runway 7. ADDITIONAL DATA The accident flight was conducted under the provisions of Part 135. However, since the Cessna 402C is a small, normal category airplane with reciprocating engines and fewer than 10 passenger seats, the corresponding regulation regarding the runway lengths required at a destination airport was §91.103, “Preflight Action”. The rule states that, “Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include: (a) … (b) For any flight, runway lengths at airports of intended use, and the following takeoff and landing distance information: (1) For civil aircraft for which an approved Airplane or Rotorcraft Flight Manual containing takeoff and landing distance data is required, the takeoff and landing distance data contained therein; … The regulation only specifies that the pilot in command shall “become familiar” with the available runway lengths and AFM takeoff and landing distances requirements, but no safety factor on the available length is specified. Section 2.14.2 of Cape Air’s GOM (“Preparation and Planning”) states that, “Before each flight, the pilot shall become familiar with all available information concerning that flight. For all flights, this includes, but is not limited to: Runway lengths, and takeoff and landing distances. This content reflects the same language of 14 CFR §91.103. The GOM does not provide any additional guidance or instructions for adjusting the POH/AFM landing distances to account for non-dry runway conditions. To address non-dry runway conditions, Cape Air provides pilots with training regarding “Adverse Weather Practices”, which includes a module on “Operations from Contaminated Runways.” This module notes that: • Normal landing distance calculations for the Cessna 402C are predicated on Level, Hard Surface Runway and do not account for contamination. • The FAA recommends pilots follow the recommendations of Safety Alert for Operators (SAFO) 19001, Landing Performance Assessments at Time of Arrival, for operating on wet or contaminated runways. • The SAFO recommends adding a safety margin of at least 15% be added to the actual airplane landing distance. Although the SAFO intends that the 15% safety margin be added to the required landing distance computed considering the actual arrival conditions (including the friction reduction associated with a wet runway), Cape Air reported that a 15% safety margin applied to the dry-runway landing distances to account for reduced performance on wet runways has been sufficient for their operations. Based on the POH/AFM dry runway landing performance data previously discussed, with the 15% safety margin added to account for a wet runway, the runway required landing distance would have been about 3,022 ft with a 5 kt tailwind, and about 3,467 ft with the 11 kt tailwind. A passenger provided two photos that he took when the airplane was on final approach. Both photos were taken near the back of the airplane looking forward and the runway is clearly visible through the windshield. In the first photo, the runway’s precision approach path indicator (PAPI) system is visible on the right side of the runway. The PAPI shows four white lights, indicating the aircraft was above the glidepath for the runway. The Performance Study indicates that between approximately 600 and 300 ft msl, the airplane was above the ILS 1-dot “fly down” glideslope deviation beam. This beam is approximately 0.33° above the glideslope centerline. The PAPI will present four white lights when the airplane is about 0.5° above the (PAPI) glideslope centerline; consequently, the photograph depicting four white lights (and VMC conditions) must have been taken when the airplane’s altitude was below 600 ft msl and above 300 ft msl. In the second photo, the PAPI shows two white lights, and the other two lights are obscured by the center of the windscreen. It could not be determined if the airplane was either at or above the glidepath for the runway. A review of the metadata in the phone revealed that it was not set up to capture altitude and the time setting was not accurate, so it was not possible to determine at what time or what altitude the photos were taken. Both photos also revealed manifold pressure for both engines indicated around 17 inHg, and the rpm for both propellers indicated around 2,400 rpm. Visible engine instruments appeared to have nominal values. The resolution of the image did not provide enough clarity to resolve the settings on the Garmin GPS navigation device. -
Analysis
The pilot was transporting six passengers on a scheduled revenue flight in instrument meteorological conditions. The pilot familiarized himself with the weather conditions before departure and surmised that he would be executing the instrument landing system (ILS) instrument approach for the landing runway at the destination airport. The operator prohibited approaches to runways less than 4,000 ft long if the tailwind component was 5 knots or more. The landing runway was 498 ft shorter than the operator-specified length. The pilot said he obtained the automated weather observing system (AWOS) data at least twice during the flight since he was required to obtain it before starting the instrument approach and then once again before he crossed the approach’s final-approach-fix (FAF). Though the pilot could not recall when he checked the AWOS, he said the conditions were within the airplane and company performance limits and he continued with the approach. A review of the wind data at the time he accepted the approach revealed the tailwind component was within limitations. As the airplane approached the FAF, wind speed increased, and the tailwind component ranged between 1 and 7 knots. Since the exact time the pilot checked the AWOS is unknown, it is possible that he obtained an observation when the tailwind component was within operator limits; however, between the time that the airplane crossed over the FAF and the time it landed, the tailwind component increased above 5 knots. The pilot said the approach was normal until he encountered a strong downdraft when the airplane was about 50 to 100 ft above the ground. He said that the approach became unstabilized and that he immediately executed a go-around; the airplane touched down briefly before becoming airborne again. The pilot said he was unable to establish a positive rate of climb and the airplane impacted trees off the end of the runway. The accident was captured on three airport surveillance cameras. A study of the video data revealed the airplane made a normal landing and touched down about 500 ft from the beginning of the runway. It was raining heavily at the time. The airplane rolled down the runway for about 21 seconds, and then took off again. The airplane entered a shallow climb, collided with trees, and caught on fire. An airplane performance study was conducted using automatic dependent surveillance – broadcast (ADS-B) data, weather information, and aircraft performance data provided by the manufacturer. The study revealed that the approach became unstabilized when the airplane exceeded a sink rate of 1,000 ft/minute at 400 ft above mean sea level (msl). Per the operator’s General Operations Manual (GOM), the pilot should have immediately executed a missed approach. In addition, the wind speed and tailwind component increased as the airplane was on approach. Consequently, the airplane landed at a calibrated airspeed that was about 18 knots faster than the speed assumed in the pilot operating handbook (POH)/airplane flight manual (AFM) landing distance tables, with a tailwind component of about 11 knots. Landing performance calculations indicated that even with the fast touchdown speed, the airplane had sufficient runway available to stop on a dry runway, including a 15% safety margin. However, the combination of the fast touchdown speed and reduced deceleration due to the wet runway significantly increased the distance that would have been required to stop the airplane. The video study revealed that if the pilot just continued to let the airplane decelerate on the runway, it would have stopped somewhere between 60 ft before the end of the runway to 88 ft beyond the end of the runway. Due to the reduced deceleration, the pilot most likely thought the airplane was going to go off the end of the runway and he opted to go-around. After lifting off, the airplane continued to accelerate at 5.0 ft/s2. Climb performance calculations revealed that it was unlikely that the airplane could have simultaneously maintained this acceleration and climbed out of ground effect. The airplane could have achieved a higher climb angle and likely cleared the trees if it had maintained a constant airspeed after liftoff, instead of accelerating, even though the liftoff airspeed was below the airplane’s best angle of climb speed. However, it is understandable that a pilot would want to accelerate to this speed before climbing to clear obstacles. Given the outcome of the attempted go-around, the performance data determined that the better option for the pilot would have been to accept an overrun into the open area beyond the end of the runway.
Probable cause
The pilot’s delayed decision to perform an aborted landing late in the landing roll with insufficient runway remaining. Contributing to the accident was the pilot’s failure to execute a go-around once the approach became unstabilized, per the operator’s procedures.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
402C
Amateur built
false
Engines
2 Reciprocating
Registration number
N88833
Operator
Cape Air
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
402C0265
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-14T21:58:57Z guid: 103831 uri: 103831 title: CEN21LA414 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103843/pdf description:
Unique identifier
103843
NTSB case number
CEN21LA414
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-10T12:00:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-09-21T17:21:12.597Z
Event type
Accident
Location
LaSalle, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On September 10, 2021, about 1100 central daylight time , a Cessna 172S airplane, N2099J, was substantially damaged when it was involved in an accident near LaSalle, Colorado. The flight instructor and the student pilot sustained minor injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. The flight was intended as pre-solo cross-country progress check. The flight originated from Rocky Mountain Metropolitan Airport (BJC), Broomfield, Colorado. After 40 minutes of flight, the flight instructor told the student pilot to perform a touch-and-go landing at Greeley-Weld County Airport (GXY), Greeley Colorado, and then navigate back to BJC. After the touch-and-go landing at GXY, the flight instructor initiated a simulated highoilpressure and hightemperature scenario as the airplane was in cruise flight at 7,500 ft mean sea level. The student pilot responded by initiating a return to GXY. During the return flight to GXY, the flight instructor reduced the engine power to 2,000 rpm and informed the student pilot that he had a simulated engine fire. The student pilot responded by reducing the engine power to idle and began a descent. Once the flight instructor announced that the simulated engine fire was out, the student pilot established a glide and chose a location for a simulated off-field emergency landing. When the airplane was at an altitude of about 1,000 ft above ground level, the flight instructor determined that the student pilot would safely reach the intended landing location. The flight instructor then instructed the student pilot to apply power, commence a go-around, and fly back to BJC. When the student pilot applied power, the engine did not respond. The flight instructor took control of the airplane and attempted to restart the engine with no success. The flight instructor then declared an emergency and performed a 180° poweroff turn to a different landing location than the student pilot had selected earlier. During the landing, the airplane contacted a raised embankment, nosed over, and came to rest inverted. The airplane sustained substantial damage to both wings and the fuselage. A postaccident examination of the airframe showed no preaccident failures or malfunctions that would have precluded normal operation. Postaccident examination of the engine showed continuity throughout. Both magnetos produced spark. The fuel lines, fuel distribution manifold, airbox, and fuel pumps were intact. Fuel was observed in the manifold and lines. The spark plugs showed normal signatures. Throttle and mixture cables to the cockpit were connected. The propeller remained attached to the engine at the flange. The spinner was crushed and broken in the aft direction. Both propeller blades were straight and showed little rotational damage. At the time of the accident meteorological conditions were conducive for carburetor icing at glide and cruise power. -
Analysis
The flight instructor and student pilot were conducting a simulated off-field emergency landing as part of a pre-solo cross-country progress check. The flight instructor told the student pilot to break off the maneuver and apply engine power, but the airplane’s engine did not respond when power was added. The flight instructor took control of the airplane and attempted to restart the engine with no success. He then declared an emergency and performed a 180° power-off turn to a field. During the touchdown, the airplane contacted a raised embankment, nosed over, and came to rest inverted. The airplane sustained substantial damage to both wings and the fuselage. A postaccident examination of the airframe and engine showed no preaccident failures or malfunctions that would have precluded normal operation. As a result, the cause of the total loss of engine power could not be determined. At the time of the accident, meteorological conditions were conducive to the formation of carburetor icing during glide and cruise power. Based upon the available information, it is likely that carburetor icing formed during the extended simulated emergency decent and resulted in the loss of engine power.
Probable cause
A loss of engine power due to the formation of carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N2099J
Operator
Mcair
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S9586
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T17:21:12Z guid: 103843 uri: 103843 title: CEN21LA420 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103862/pdf description:
Unique identifier
103862
NTSB case number
CEN21LA420
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-11T08:45:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-09-21T17:24:12.253Z
Event type
Accident
Location
Rogers City, Michigan
Airport
Presque Isle County Airport (PZQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
The pilot did not maintain maintenance records for the airplane, nor had the airplane undergone a condition inspection since the FAA issued the experimental airworthiness certificate on December 14, 2007. - On September 11, 2021, about 0745 eastern daylight time, a Quad City Ultralight Challenger II experimental airplane, N778H, was substantially damaged when it was involved in an accident near Rogers City, Michigan. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The noncertificated pilot reported that about 100 ft into the takeoff roll on runway 27 the airplane began to swerve right, but before he could abort the takeoff, he heard a bang and the airplane pitched up and rolled. A witness reported that the airplane abruptly pitched up, rolled right, and impacted the ground in a left-wing-down attitude. The witness stated that the airplane completed about 270° of right roll when the left wing impacted the ground. - A search of FAA airman certification records found no record of a pilot certificate ever being issued to the pilot. The pilot reported that he had previous flying experience in 14 CFR Part 103 ultralights. - Postaccident examination revealed substantial damage to the airplane’s left wing, fuselage, tailboom, and left horizontal stabilizer. Flight control continuity was confirmed from the cockpit controls to each flight control surface. Further examination of the right wing revealed that the forward lift strut separated from the fuselage longeron, as shown in figure 1. The channel bracket remained attached to the lift strut, but the AN4-24A bolt pulled out of the fuselage longeron. The 0.25-inch AN365-248 nylon-insert lock nut, depicted in figure 2, that normally secured the AN4-24A bolt was not located during the investigation. Figure 1. Lower attachment point of the right wing forward lift strut (FAA photos). Figure 2. Wing lift strut assembly, lower attachment. -
Analysis
The noncertificated pilot was departing on a local flight. The pilot reported that about 100 ft into the takeoff roll the airplane began to swerve right, but before he could abort the takeoff, he heard a bang and the airplane pitched up and rolled. A witness reported that the airplane abruptly pitched up, rolled right, and impacted the ground in a left-wing-down attitude. The witness stated that the airplane completed about 270° of right roll when the left wing impacted the ground. The airplane sustained substantial damage to the left wing, fuselage, tailboom, and left horizontal stabilizer. Postaccident examination of the airplane revealed that the right wing’s forward lift strut separated from the fuselage longeron. The channel bracket remained attached to the lift strut, but the attachment bolt pulled out of the fuselage longeron. The nylon-insert lock nut that normally secured the attachment bolt to the fuselage longeron was not located during the investigation. Flight control continuity was confirmed from the cockpit controls to each flight control surface. The pilot did not maintain maintenance records for the airplane, nor had the airplane undergone a condition inspection since the Federal Aviation Administration (FAA) issued the experimental airworthiness certificate in December, 2007.
Probable cause
The separation of the right wing’s forward lift strut from the fuselage due to a missing nylon-insert lock nut. Contributing to the accident was the noncertificated pilot’s decision to operate the airplane even though a condition inspection had not been completed in the 13 years since the airplane received its experimental airworthiness certificate.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Quad City Ultralight
Model
Challenger II
Amateur built
false
Engines
1 Reciprocating
Registration number
N778H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CH2-0905-CW-2671
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T17:24:12Z guid: 103862 uri: 103862 title: WPR21LA358 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104012/pdf description:
Unique identifier
104012
NTSB case number
WPR21LA358
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-11T14:00:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-10-01T05:26:38.238Z
Event type
Accident
Location
Baker, Nevada
Airport
Baker Landing Strip (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 11, 2021, about 1300 Pacific daylight time, a Beech BE35-B33, N8983M, was substantially damaged when it was involved in an accident near Baker, Nevada. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before the flight, a mechanic replaced the exhaust pushrod for the No. 1 cylinder. The engine was ground tested at various power settings with no anomalies noted. The mechanic subsequently deemed the airplane safe to fly to the pilot’s home airport. The pilot reported that the airplane departed from a dirt runway and once a positive rate of climb and airspeed were attained, he raised the landing gear. As the landing gear retracted, he heard a “loud bang,” followed a loss of total engine power. The pilot stated that he was able to extend the landing gear and make a forced landing onto open desert terrain. During the landing roll, the nose landing gear and right main landing gear collapsed, resulting in substantial damage to the fuselage and right wing. Postaccident examination of the engine revealed two holes in the top of the engine crankcase at cylinder Nos. 5 and 6. No oil was indicated on the oil dipstick. The undercarriage of the airframe from the nose to the tail was covered in oil, as was the top portion of the cowling. The assemblies for cylinder Nos. 5 and 6, piston assemblies, connecting rod pieces, and bearing pieces were examined by the NTSB Materials Laboratory in Washington, DC. The examination revealed that portions of the No. 5 connecting rod exhibited a dark tint, consistent with exposure to high heat. The bearing for the No. 5 connecting rod was severely worn, deformed, flattened, and darkened, consistent with high heat exposure. The connecting rod strap was fractured into multiple pieces. One portion, the fracture area near the exterior surface exhibited rachet marks and curving crack arrest lines, consistent with fatigue. Another portion of the fractured strap exhibited relatively smooth fracture features with curving crack arrest lines and ratchet marks, which were consistent with fatigue. For both of those portions of the strap, the fatigue origins were located at the radius for the attachment bolt boss. Examination of the damaged connecting rod journals on the crankshaft revealed scoring, deposited material, and heat tint damage on the journal for the No. 5 connecting rod. Scoring and pitting damage was also observed on the journal for the No. 6 connecting rod. The remaining journals for the connecting rods and the main journals exhibited no damage. -
Analysis
The accident flight occurred after a mechanic replaced the exhaust pushrod for the No. 1 cylinder. After takeoff and during the initial climb, the engine lost total power. The airplane sustained substantial damage during a forced landing in desert terrain. Postaccident examination of the engine revealed that the No. 5 connecting rod strap exhibited fracture signatures consistent with fatigue cracks in multiple areas. The connecting rod also exhibited signs of heat distress. The No. 5 connecting rod bearing was severely worn, deformed, flattened, and darkened, consistent with high heat exposure. The general heat tinting and damage on the bearing, connecting rod, and crankshaft journal indicated that the No. 5 connecting rod bearing likely experienced frictional heating from insufficient clearance between the bearing and the journal. The insufficient clearance could have been produced by excessive wear on the bearing or journal, bearing surface damage such as spalling, or insufficient lubrication.
Probable cause
A total loss of engine power during the initial climb due to the failure of the No. 5 connecting rod bearing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35-B33
Amateur built
false
Engines
1 Reciprocating
Registration number
N8983M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CD-733
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-01T05:26:38Z guid: 104012 uri: 104012 title: ANC21LA086 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103847/pdf description:
Unique identifier
103847
NTSB case number
ANC21LA086
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-12T10:00:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-09-13T22:24:59.757Z
Event type
Accident
Location
Port Alsworth, Alaska
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 12, 2021, about 0900 Alaska daylight time, a Stinson 108-3, N6476M, was substantially damaged when it was involved in an accident near Port Alsworth, Alaska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, during the landing roll while applying the brakes, the right brake “went flat.” The airplane veered to the left, impacted a stump, and nosed over, resulting in substantial damage to the fuselage and left wing. A postaccident examination revealed no mechanical anomalies with the brake system that would have precluded normal operation. -
Analysis
The pilot reported that, during the landing roll while applying the brakes, the right brake “went flat.” The airplane veered to the left, impacted a stump, and nosed over, resulting in substantial damage to the fuselage and left wing. A postaccident examination revealed no mechanical anomalies with the brake system that would have precluded normal operation. Based on the available information, the reason for the loss of control during landing could not be determined.
Probable cause
A loss of directional control for reasons that could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108-3
Amateur built
false
Engines
1 Reciprocating
Registration number
N6476M
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
108-4476
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-13T22:24:59Z guid: 103847 uri: 103847 title: ERA21FA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103839/pdf description:
Unique identifier
103839
NTSB case number
ERA21FA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-12T10:30:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-09-30T22:35:54.996Z
Event type
Accident
Location
Rhine, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On September 12, 2021, about 0930 eastern daylight time, an American Champion Aircraft 8KCAB, N390PE, was substantially damaged when it was involved in an accident near Rhine, Georgia. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness, who was a friend of the pilot, reported that the pilot told him that he felt dizzy, nauseous, and vomited while practicing aerobatics earlier in the day before the accident flight. The pilot landed at a private airstrip and subsequently departed to fly to a nearby field, where the witness was located, to look for birds. While the witness was in the field, the pilot "buzzed" him and flew around for a second pass. During the second pass, the pilot descended the airplane below the tree line and started an aileron roll. However, about halfway through the roll, the pilot abruptly stopped the maneuver, and the airplane flew straight into the trees at full engine power. The airplane came to rest oriented on a magnetic heading of 220°, and all major components of the airplane were located at the accident site. The fuselage, from the firewall to the empennage, exhibited accordion crush and impact damage. The instrument panel and cockpit were destroyed due to the impact. Both wings had separated from the fuselage, while the horizontal stabilizers and vertical stabilizer remained attached to the empennage displaying damage consistent with the impact. Flight control continuity was established from the flight control surfaces to the cockpit controls. The propeller was splintered and broken. Fresh cuts, which were consistent with propeller slash marks, were found on several trees at the accident site. The examination of flight controls and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The Georgia Bureau of Investigation Division of Forensic Sciences performed the pilot’s autopsy at the request of the Dodge County Coroner. According to the autopsy report, the cause of death was multiple blunt impact injuries, and the manner of death was accident. The Federal Aviation Administration Forensic Sciences Laboratory performed toxicological testing of specimens from the pilot, identifying only tadalafil, in cavity blood and liver. Tadalafil, sometimes marketed as Cialis, is a prescription medication commonly used to treat erectile dysfunction. It may also be used to treat symptoms of a large prostate, or to reduce high blood pressure in the lungs. According to reviewed primary care records, the pilot visited his primary care provider 5 days before the accident, on September 7, 2021, for sore throat and fever. No complaints of cough, nausea, vomiting, dizziness, or other symptoms apart from sore throat and fever were noted. -
Analysis
A witness, who was a friend of the pilot, stated the pilot had mentioned feeling dizzy and nauseous while performing aerobatics during a flight earlier on the day of the accident and landed due to vomiting. Later that same day, the pilot departed his private airstrip and headed to a nearby field where the witness was located with the intention of searching for birds. While the witness was in the field, the pilot flew past him and circled for a second pass. During the second pass, the pilot descended below the tree line and initiated an aileron roll. However, the pilot abruptly stopped the maneuver halfway through and the aircraft flew into the trees at full engine power. The airplane sustained impact damage to the fuselage, while the instrument panel and cockpit were destroyed. Postaccident examination of the flight control system and engine did not reveal any anomalies that would have precluded normal operation. To what degree the pilot’s symptoms of dizziness and nausea from earlier in the day had resolved, persisted, or progressed at the time of the accident flight is unknown. If the pilot was still feeling unwell at the time of the flight, this may have impaired his ability to execute the aileron roll.
Probable cause
A collision with trees during a low-altitude aerobatic maneuver for unknown reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN CHAMPION AIRCRAFT
Model
8KCAB
Amateur built
false
Engines
1 Reciprocating
Registration number
N390PE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1156-2015
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T22:35:54Z guid: 103839 uri: 103839 title: WPR21FA340 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103838/pdf description:
Unique identifier
103838
NTSB case number
WPR21FA340
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-12T17:09:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-09-30T04:18:29.849Z
Event type
Accident
Location
Lake Havasu City, Arizona
Airport
LAKE HAVASU CITY (HII)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The pilot’s wife stated that he performed most of the airplane’s maintenance and that he flew the airplane regularly after purchasing it in 2013. A review of the pilot’s logbook revealed that the airplane had a total time of 3,487.3 hours and that the engine had accumulated 1,219.4 hours since the time that it was remanufactured at the manufacturer. The logbook indicated that the camshaft and lifters were replaced with new parts in December 2004, 682 hours before the accident. The logbook also indicated that the No. 1 cylinder had been replaced with an overhauled assembly in March 2020, 75.1 hours before the accident. The last recorded oil change was performed at the airplane’s last annual inspection. To monitor engine component wear rate, the pilot had sent samples of the engine oil for spectrometer analysis multiple times; the most recent of which was September 9, 2021 (3 days before the accident). At that time, the engine had accumulated 1,216.7 hours or 2.7 flight hours. The sample had not been run before the accident occurred; after the accident, the sample showed elevated levels of aluminum, chromium, iron, silicon, and nickel (see figure 3). Figure 3: Oil analysis report showing six samples, including the one taken 3 days before the accident (Source: BlackStone Laboratories). The laboratory oil report for the September 2019 sample stated that there were elevated levels of metal and that, if work had not been done recently on the engine, the amount of aluminum, chromium, and iron would indicate piston, ring, and steel wear. The oil report further stated that the amount of chrome indicated “a ring problem.” - On September 12, 2021, about 1609 mountain standard time, a Cessna 177RG, N2085Q, was substantially damaged when it was involved in an accident near Lake Havasu Airport, Lake Havasu, Arizona. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot was planning to make a cross-country flight to Reno, Nevada, in the days after the accident, and the purpose of the accident flight was to refuel for the flight to Reno. The airplane was based at Eagle Airpark, Bullhead City, Arizona, and the pilot performed maintenance there earlier in the day, including replacing the bushings on the nosewheel because the airplane had been experiencing a vibration during takeoff and landing. The airplane departed about 1530 and landed at Lake Havasu about 1545. The pilot then purchased 24.8 gallons of fuel at the self-serve fuel tank. According to his wife, the pilot had planned to top off the fuel tanks to full. Video and audio recordings and Federal Aviation Administration (FAA) automatic dependent surveillance-broadcast (ADS-B) data showed that the pilot taxied the airplane to runway 14, performed a run-up, and departed about 1608. Witnesses reported that the airplane traveled down the runway at a slow groundspeed and noted that the engine sounded abnormal, as if it were producing partial power. The airplane veered to the right of the centerline and ascended 100 to 150 ft above ground level (see figure 1). ADS-B data showed that the airplane accelerated down the runway at airspeeds up to 65 knots. Figure 1: Security camera video showing initial right veer The video showed the airplane pitch to a nose-high attitude and banked to the left (see figure 2). Witnesses observed the airplane’s wingspan turn nearly perpendicular to the horizon and then stall with the left wing dropping toward terrain. Figure 2: Security camera video of left bank At an undetermined time during the takeoff, the pilot stated, on the airport common frequency, “Lake Havasu traffic Cardinal 2085Q making a uh” The next recorded transmission, which occurred less than 1 second later, was a high-pitch tone similar to a stall warning horn. The airplane impacted desert terrain about 830 ft from the end of runway 14, and a postcrash fire ensued. - The accident site was at an elevation of 790 ft mean sea level, and the terrain was composed of dry, soft dirt with sparse brush. The terrain ahead of the accident site was uninhabited and populated with low brush. The wreckage was found distributed over a 200-ft distance on a median magnetic bearing of about 60°. The main wreckage included the airframe and engine, most of which had been consumed by fire. The first identified points of contact consisted of disrupted dirt on the flat desert terrain at the far east-southeast end of the debris field. The markings started as a dirt indentation with shards of red fragments imbedded within the soil, consistent with the left wingtip impacting the ground first. The crater was continuous toward the main wreckage, and the end of the crater had blue/green fragments imbedded (see figure 4). A larger center indentation (referred to in the figure as the middle crater) was found in between the red fragments and the green/blue fragments; this indentation had a large arc-shaped disruption of dirt that was consistent with a rotating propeller blade. Figure 4: Main wreckage in reference to first identified point of impact. As part of the postaccident examination, most of the engine and its components were disassembled. The Nos. 1 and 4 top compression piston rings had fractured in multiple locations (see figure 5). All the piston skirts showed evidence of corrosion and wear with light scuffs/grooves oriented from the base to the crowns. Additionally, the piston skirts on all cylinders showed evidence of blow-by, with the No. 3 cylinder exhibiting the least amount of damage. Figure 5: Fractured rings from the Nos. 1 and 4 pistons. The National Transportation Safety Board Materials Laboratory examined the No. 1 and No. 4 fractured piston rings. The upper compression piston ring from the No. 1 cylinder had fractured in four locations. All fracture and parting surfaces exhibited iron oxides with high amounts of carbon, lead, and bromine, consistent with exposure to combustion gases from airplane fuel. Extensive wear and smoothing were observed on the fracture and parting surfaces, consistent with the fractures occurring before the accident and continuing to wear during the repetitive actuation of the pistons inside the cylinders. Fracture and wear of the rings could allow blowby of combustion gasses past the piston and oil leakage into the combustion chamber. Separation of the crankcase halves revealed severe spalling on the faces of all the intake lifters and the No. 3 exhaust lifter; evidence of galling was also noted. The remaining lifters showed evidence of wear with a circular pattern and pitting (see figure 6). The camshaft revealed signatures of excessive wear on the cam lobes, including rounding of the lobes, pitting, and material deformation on the lobes. Figure 6: Wear signatures on intake lifter faces (top row) and exhaust lifter faces (bottom row). The lifter on the No. 4 exhaust valve exhibited a tear in the base of the body, consistent with contact with the hydraulic socket; the pushrods did not show evidence of bending. The bearings showed light wear, and the crankshaft had light rotational scoring. -
Analysis
The airplane was departing at a slow groundspeed, and the engine sounded as if it was producing partial power. The airplane did not ascend as expected and veered to the right of the centerline. The airplane then pitched up to a nose-high attitude and made an aggressive left bank, consistent with pilot attempting to make 180° turn to the runway while making a radio transmission that he did not complete. The airplane’s wingspan turned nearly perpendicular to the horizon and then stalled with the left wing dropping toward terrain. The airplane subsequently impacted terrain, and a postcrash fire ensued. The terrain ahead of the accident site was uninhabited and populated with low brush. If the pilot had considered landing there instead of making a 180° turn, the outcome of this accident might have been different. A postaccident examination revealed that two piston rings were fractured and that the pistons showed evidence of excessive wear and heat. The extensive wear on the piston ring surfaces indicated that they had fractured before the accident and were continuing to wear during the accident flight when the pistons actuated inside the cylinders. Fracture and wear of the rings likely resulted in blow-by of combustion gases past the cylinder and oil leakage into the combustion chamber. The lifter surfaces were spalled, the cam lobes were worn, and one of the lifter bodies was cracked, all consistent with excessive wear. The fractured rings, a lack of sealing, and blow-by would all have contributed to partial engine power and led to an airplane stall and a loss of altitude. Three days before the accident, the pilot had sent samples of the engine oil for analysis and did not receive the results before the accident. The oil sample exhibited elevated aluminum, chromium, iron, silicon, and nickel levels. A previous oil sample report had stated that the amounts of aluminum, chromium, and iron would indicate piston, ring, and steel wear. All were indications of the excessive wear of the engine components and broken piston rings, which likely would result in blowby and contribute to the partial loss of power.
Probable cause
A partial loss of engine power during the airplane's initial climb due to wear of internal engine components, which prevented the engine from developing full-rated power and resulted in a loss of altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177RG
Amateur built
false
Engines
1 Reciprocating
Registration number
N2085Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
177RG0485
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T04:18:29Z guid: 103838 uri: 103838 title: ERA21LA361 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103880/pdf description:
Unique identifier
103880
NTSB case number
ERA21LA361
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-13T11:45:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-10-07T16:42:40.365Z
Event type
Accident
Location
AUGUSTINE, Florida
Airport
NORTHEAST FLORIDA RGNL (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On September 13, 2021, about 1045 eastern daylight time , a Beechcraft C24R, N5246M, was substantially damaged when it was involved in an accident at Northeast Florida Regional Airport (SGJ), St Augustine, Florida. The two flight instructors and pilotrated passenger, who was also a flight instructor, sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the three flight instructors, who were all employed by the flight school, the chief flight instructor, who was in the left front seat, was checking out the other two flight instructors in the airplane when the accident occurred. After conducting a preflight inspection and engine run up, the flight instructor in the front right seat performed a short-field takeoff maneuver from runway 13 at SGJ. The runway was 8,001 ft in length. The airplane became airborne in about 2,000 ft; however, about 150 ft above ground level, the airplane failed to climb and “wouldn’t hold altitude or airspeed.” The chief flight instructor in the left seat took control of the airplane and attempted a forced landing on the remaining runway. During the forced landing, the airplane impacted the approach lighting system, flipped over, and came to rest in a marsh about 150 ft off the runway 31 displaced threshold. Postaccident examination of the wreckage by a Federal Aviation Administration inspector revealed that the left wing partially detached from the fuselage, the empennage was twisted, and there was crushing and buckling damage to much of the airframe. The airplane’s last annual inspection on March 12, 2021, 6 months before the accident over which time it accumulated about 5 hours. The engine had 5,386 hours total time and 1,883 hours total time since overhaul. According to the maintenance logbooks the airplane was under a 100 hour/annual maintenance inspection program. As of the last inspection, both the engine, airframe and propeller were signed off as being airworthy and no defects or irregularities were noted in the logbooks. The wreckage was recovered from the marsh and examined. The valve covers were removed for examination of the rocker arms. The propeller was rotated by hand and thumb compression was established on all cylinders. Crankshaft continuity was established through the engine. The magneto couplings could be heard rotating and the vacuum pump shaft was observed rotating. Upon removal, the magnetos were rotated by electric drill with no spark produced on either magneto. Upon disassembly, examination of the magnetos revealed water damage, and corrosion. The No. 4 fuel injector line was observed cracked on the threaded nut. The injector fuel line pulled off the injector and was not secured tightly to the injector. The No. 2 fuel injector line was only secured to the injector by one thread and removed by fingers turning the nut. Examination of the air filter box revealed that the filter element was in the intake hose and partially obstructing the air intake line but the damage to the filer box was consistent with water impact damage. Examination of the oil filter screen revealed large pieces of carbon and metal deposits. The weight and balance and performance data were computed using the airplane’s pilot operating handbook. The weight of the airplane was within the weight and moment envelope and the take-off distance was calculated to be about 1,600 ft. -
Analysis
The chief flight instructor of the flight school was performing a checkout flight for two other flight instructors, one of whom was in the front right seat and conducted the short-field takeoff. During the takeoff roll, the airplane lifted off in about 2,000 ft, leaving about 6,000 ft of runway remaining. Shortly after liftoff, the airplane failed to maintain airspeed or altitude upon reaching an altitude of about 150 ft above ground level. The chief flight instructor took control of the airplane and attempted to land on the remaining runway; however, the airplane struck the approach lighting system, flipped over, and came to rest inverted in a marsh. Examination of the engine revealed that two fuel injector lines were not installed properly: one contained a damaged nut and was pulled off the injector with ease, and the other was secured by only one thread. In addition, the oil filter screen was contaminated with large pieces of carbon and metal. These discrepancies should have been detected and addressed during the previous annual/100-hour inspections that occurred 5 flight hours before the accident flight. Based on this information, it is likely that condition of one or both of the fuel injector components allowed air to be introduced into the fuel stream for their respective cylinders, thus reducing the engine performance and resulting in a partial loss of power during the initial climb.
Probable cause
Improperly installed fuel injection system components, which resulted in a partial loss of engine power shortly after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C24R
Amateur built
false
Engines
1 Reciprocating
Registration number
N5246M
Operator
FLORIDA AVIATION CAREER TRAINING INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
MC-564
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-07T16:42:40Z guid: 103880 uri: 103880 title: ERA21LA356 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103855/pdf description:
Unique identifier
103855
NTSB case number
ERA21LA356
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-13T15:05:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-15T23:53:16.955Z
Event type
Accident
Location
Burt, New York
Airport
OLCOTT-NEWFANE (D80)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 13, 2021, about 1405 eastern daylight time, a Waco GXE, N8564, was substantially damaged when it was involved in an accident near Burt, New York. The airline transport pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the accident flight was the first flight since the airplane was restored a few years prior. The airplane’s most recent annual inspection was completed on the morning of the accident. During takeoff, the airplane departed the turf runway “normally,” and once it was in ground effect, it would not climb any further even though the “engine was producing power just fine.” The pilot elected to land the airplane in a nearby field to avoid trees in the flight path. During the landing, the airplane nosed over and came to rest inverted, which resulted in substantial damage to the wings and fuselage. According to the maintenance logs, in March 2013, the engine was reassembled and reinstalled on the airplane. The next maintenance entry, in June 2019, with 0 hours since major overhaul, indicated that the engine and propeller were inspected in accordance with a 100-hr inspection. A high-speed taxi test was performed and the engine and propeller were found to be in airworthy condition. The final entry of the engine log was dated September 9, 2021. It indicated that the engine had 38 hours SMOH, a 100-hr inspection was performed, and the engine was found to be in an airworthy condition. The airplane was equipped with a vintage Curtis Aeroplane Model OX-5 engine. The engine was designed to be equipped with a variable timing magneto that assisted with engine starting. A postaccident examination of the engine by a Federal Aviation Administration inspector revealed that the accident airplane’s magnetos were set to fire about 22° before top dead center (BTDC). The engine logbook indicated that the magnetos should be timed to 30° BTDC. To obtain a “full advanced” setting, the engine historical reference handbook stated that the magnetos needed to have an external lever connected to a control in the cockpit to mechanically vary the magneto to engine timing while the engine was running. In addition, the handbook stated that the magnetos should be timed to 28° BTDC. The magnetos installed on the accident airplane’s engine did not have external control levers and without the levers, the ignition could not be timed to 28°-30° BTDC. -
Analysis
The accident flight was the vintage biplane’s first since it had been restored 2 years prior. During takeoff, once the airplane was in ground effect, the pilot described that the airplane would not climb any further even though the engine was producing power. The pilot elected to land the airplane in a nearby field and during the landing, the airplane nosed over and came to rest inverted, which resulted in substantial damage to the wings and fuselage. A postaccident examination of the engine revealed that the magnetos were set to fire about 7° away from the proper position in order to obtain full engine power. Furthermore, a historical reference handbook for the vintage engine stated that the magnetos needed to have an external lever connected to a control in the cockpit to mechanically vary the magneto to engine timing while the engine was running. The magnetos installed on the accident airplane did not have these controls installed. Based on this information, it is likely the engine could not produce full power as a result of the incorrect magneto timing.
Probable cause
The improper magneto timing, which resulted in the engine’s inability to produce full power during the takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WACO
Model
GXE
Amateur built
false
Engines
1 Reciprocating
Registration number
N8564
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1927
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-15T23:53:16Z guid: 103855 uri: 103855 title: CEN21LA425 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103901/pdf description:
Unique identifier
103901
NTSB case number
CEN21LA425
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-13T19:30:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-09-21T17:31:28.453Z
Event type
Accident
Location
Steamboat Springs, Colorado
Airport
Private Strip (n/a)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On September 13, 2021, at 1830 mountain daylight time, a Kolb Mark III airplane, N4365E, was substantially damaged when it was involved in an accident near Steamboat Springs, Colorado. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot’s wife, who witnessed the accident, reported that the pilot recently purchased the airplane. She stated that the pilot flew the airplane with the previous owner in Indiana before driving it on a trailer to Steamboat Springs. On the day of the accident, the pilot intended to taxi the airplane around his private airstrip to get used to the feel of the airplane. The airplane subsequently lifted off, cleared several fences, but only made it about 20 ft above the ground when the airplane’s nose suddenly lowered and impacted the ground. The airplane sustained substantial damage to the fuselage. The witness stated the engine was still running and she was unable to turn it off when she reached the accident site. The pilot told the witness that he did not command the airplane down but that it just fell. The pilot later told a family member that he stalled the airplane. The airplane was not made available for investigators to examine the airframe or flight control system. The pilot did not submit the National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident Report (NTSB Form 6120.1). -
Analysis
The pilot flew the airplane with the previous owner in Indiana before purchasing it and driving it on a trailer to Steamboat Springs. A witness reported that the pilot intended to taxi around his private airstrip to get a better feel for the airplane. The airplane subsequently lifted off the ground, cleared several fences, and was about 20 ft above the ground when the airplane’s nose suddenly lowered and impacted the ground. The airplane sustained substantial damage to the fuselage. The pilot told the witness that he did not intentionally lower the nose of the airplane. The pilot later told a family member that he stalled the airplane. The airplane was not made available for investigators to examine.
Probable cause
The pilot’s failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KOLB
Model
Mark III
Amateur built
true
Engines
1 Reciprocating
Registration number
N4365E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M3086
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T17:31:28Z guid: 103901 uri: 103901 title: ERA21LA360 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103866/pdf description:
Unique identifier
103866
NTSB case number
ERA21LA360
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-14T10:40:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-09-15T19:47:01.788Z
Event type
Accident
Location
New Smyrna, Florida
Airport
MASSEY RANCH AIRPARK (X50)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 14, 2021, about 0940 eastern daylight time, an experimental, amateur-built Zenith 750 Cruzer, N161AR, was substantially damaged when it was involved in an accident near New Smyrna Beach, Florida. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot purchased the airplane on the day of the accident and intended to fly it back to Greenville, Tennessee. He conducted a short post-purchase inspection and noted that there were no brakes or throttle control for the pilot-rated passenger in the right seat. Shortly after departing X50, he “heard a very loud boom” and the airplane “jolted nose down and to the left.” The controls were locked, and the pilot could not move the control column. The pilot applied force to the controls, and they subsequently moved, and they felt free. He then decided to return to the airport, and during a left turn onto the final approach leg of the traffic pattern, the controls intermittently locked two more times and the pilot performed a go-around. During the next approach, he heard another boom, and the controls locked again. The airplane was descending too rapidly, and the pilot performed another go-around. The pilot was able to fly the airplane back to the final approach leg of the traffic pattern without the controls locking up; however, when the airplane was about 10 ft above the runway, the controls locked again. The airplane pitched nose down and to the left and the left wing contacted the ground, followed by the nose landing gear, which collapsed. The airplane then departed the left side of the runway, impacted an embankment, and came to rest inverted in a pond. Postaccident examination of the airplane revealed that the elevator bracket was jammed on the nylon stop block, which resulted in the elevator to remain in the nose down position until force was used to move the elevator bracket off the nylon stop block. Several cycles forward and aft of the control column resulted in the elevator bracket becoming lodged on the nylon stop block each time during the examination. The nylon stop exhibited impression marks where the elevator bracket would contact it. Additionally, the rudder and elevator cables were loose, and a bungee cord was noted holding one cable up off the empennage floor. There were marks in the structure of the empennage that exhibited evidence of long-term wear due to control cable contact. The control stick could be moved several inches before cable tension and movement would occur. According to the pilot, the airplane had been retrofitted with flight controls so a handicapped individual could fly it. Prior to his purchase of the airplane, the retrofitted flight controls were removed. Review of the airplane’s maintenance logs revealed that there was no entry documenting that such maintenance had occurred. The maintenance logs also noted that the airplane’s most recent condition inspection had been completed on September 13, 2021. At that time, the airplane had accumulated 45 hours of total time in service and the mechanic certified that the airplane was inspected in accordance with 14 CFR Part 43, Appendix D and was “found to be in a condition for safe operation.” -
Analysis
The pilot had just purchased the experimental amateur-built airplane and performed a preflight inspection that revealed no anomalies. After departure, the elevator control became momentarily jammed in the nose-down position multiple times, and the pilot elected to return to the departure airport. After two go-around maneuvers due to elevator jamming, the elevator jammed again about 10 ft above the ground during the third landing attempt. The left wing impacted the ground and the airplane veered off the runway and came to rest inverted in a pond. Postaccident examination of the airframe revealed that the elevator bracket was becoming lodged against a nylon stop block installed in the empennage. It is likely that, while in flight, once the elevator was moved far enough in the nose-down position, the airflow around the elevator forced the elevator to contact the nylon block and jam it in the nose-down position. Examination also revealed evidence of long-term control cable contact with the empennage structure and a lack of tension on the elevator and flight control cables. A mechanic completed a condition inspection, which included examination of the flight control cables and structure, the day before the accident. Based on all available information, it is likely that this inspection was inadequate because it failed to identify and correct the flight control anomalies that ultimately resulted in the accident.
Probable cause
The mechanic’s inadequate inspection of the flight control system, which resulted in a loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
750 Cruzer
Amateur built
true
Engines
1 Reciprocating
Registration number
N161AR
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
C75-10543
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-15T19:47:01Z guid: 103866 uri: 103866 title: ERA21LA379 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103967/pdf description:
Unique identifier
103967
NTSB case number
ERA21LA379
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-14T13:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-09-30T21:31:59.88Z
Event type
Accident
Location
Charleston, South Carolina
Airport
CHARLESTON EXEC (JZI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 14, 2021, about 1230 eastern daylight time, a Hawker Beechcraft Corp 400A airplane, N100FN, was substantially damaged when it was involved in an accident en route to the Charleston Executive Airport (JZI), Charleston, South Carolina. The two flight crewmembers were not injured. The airplane was operated by Aircraft Management Group as a Title 14 Code of Federal Regulations Part 91 repositioning flight. The flight crew reported that they performed a standard preflight inspection of the airplane as it had just been released from scheduled maintenance from Winner Aviation, a Part 145 repair station at Youngstown Regional Airport (YNG), Youngstown, Ohio. The only discrepancy noted during preflight inspection was a loose screw on the nose cone, which was tightened by a mechanic before departure. The flight was uneventful until the airplane was about 15 minutes from JZI. The flight crew reported that while descending about 1,500 feet per minute through about 21,000 ft, they heard a loud bang and felt a shudder and yaw. They disconnected the autopilot, and a noticeable yaw was felt; however, there were no anomalies noted on any flight or engine instruments. The flight crew continued and landed without further incident. During the post-flight inspection, they discovered that the left engine cowling had entirely separated. Photographs provided by the Federal Aviation Administration (FAA) revealed that the fuselage and horizontal stabilator sustained substantial damage. Figure 1 shown below provides an overview of the left engine and cowling fastener areas at the forward and aft portion of the engine. Figure 1: View of the left engine and cowling attachment areas. (Photos Courtesy of FAA) Postaccident examination of the left engine found that the entire cowling had separated. Several fasteners that would normally be installed on the forward and aft attachment areas around the engine were missing. There were no abnormalities discovered with cowling fastener receptacle areas or nut plates that remained in place. The aft top attachment area, shown in the top right photo in Figure 1, showed evidence of a rearward pulling of the metal attachment area. The right cowling remained attached. About 1 month after the accident, a large dent and rippling were discovered in the middle and top inboard cowling areas. A stripped fastener was observed on the right cowling; however, no fasteners were missing. Investigators contacted local authorities near the presumed area of the cowling separation; however, the cowling sections were never located. According to a representative of Winner Aviation and company work orders, on September 13, 2021, the airplane had been signed off for an A and B inspection, which required the removal and re-installation of the engine cowlings. The mechanics involved in re-installing the cowlings reported that several fasteners on the left cowling had to be loosened and tightened a second time during re-installation due to an alignment issue with the cowling panels. The mechanic who resolved the alignment issue reported that he re-tightened the fasteners and noted that “everything was secure and double checked.” The mechanic also reported that he replaced some of the fasteners as some were missing and the overall condition of others warranted replacement. The following day another mechanic looked at the airplane before the accident flight and did not notice any abnormalities. No mechanics observed any dents on either cowling. According to the Hawker Beechcraft 400/400A Maintenance Manual, the cowling consisted of four removable sections that fully enclosed the engine. The cowling panels were secured by several quarter-turn fasteners located around the circumferences of the forward and aft engine areas. In December 2006, Raytheon Aircraft Company issued a Service Bulletin titled Nacelles – Engine Cowling Fastener Modification. The bulletin required a modification to the engine cowling attachment hardware to provide threaded fasteners at specific locations on the engine cowling panels. The bulletin stated that three reports had been received related to cowling panel separations and that aerodynamic forces acting on unsecured cowlings could cause panel separation or damage to the engine and nacelle components. In October 2007, the FAA issued an Airworthiness Directive making the Raytheon Service Bulletin mandatory. The accident airplane was manufactured after the issuance of the original service bulletin, and the cowlings had been modified per the bulletin. On April 29, 2022, the FAA published Special Airworthiness Information Bulletin (SAIB-AIR-22-10), Engine Cowling System, Quarter-Turn Fastener Maintenance Information. The bulletin highlighted several incidents and accidents that involved cowling separations and provided several best practices that mechanics can use to ensure cowlings are properly and securely installed. This accident was one of several events highlighted in the SAIB. -
Analysis
The flight crew initiated a positioning flight following major maintenance, which included the removal and re-installation of both engine cowlings. The flight was uneventful until about 15 minutes from the destination. While descending, a sudden bang and yaw occurred. There were no annunciations or other warnings observed before or after the event, and the airplane remained controllable. The flight crew continued to the destination and landed without further incident. On the ground, it was discovered that the entirety of the left engine’s four-panel cowling had separated in flight and impacted the rear fuselage and horizontal stabilizer resulting in substantial damage. Further examination of the left engine area revealed that several cowling fasteners were missing from the receptacles. During maintenance immediately preceding the flight, the left cowling fasteners had to be removed a second time due to an alignment issue with the panels. The mechanic who performed the work reported that the misalignment was resolved, and the fasteners were tightened. A second mechanic visually inspected the work and did not notice any abnormalities, nor did the pilots during their preflight inspection. It is likely that several fasteners departed the left cowling during this first flight after maintenance, which resulted in a rapid departure of the cowling panels. Given that none of the cowling was recovered, the initiating factors that would lead to the separation could not be determined. Denting and rippling were discovered on the right cowling; however, the investigation was unable to determine when the damage was incurred as it was not discovered until about 1 month after the accident. The mechanics and flight crew did not recall observing any damage to either cowling before flight.
Probable cause
The in-flight separation of the left engine’s four-panel cowling for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HAWKER BEECHCRAFT CORP
Model
400A
Amateur built
false
Engines
2 Turbo fan
Registration number
N100FN
Operator
Aircraft Management Group
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
RK-566
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T21:31:59Z guid: 103967 uri: 103967 title: ERA21FA362 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103882/pdf description:
Unique identifier
103882
NTSB case number
ERA21FA362
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-15T21:46:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-10-08T21:10:59.094Z
Event type
Accident
Location
Monticello, Georgia
Weather conditions
Instrument Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
On September 15, 2021, at 2046 eastern daylight time, a Robinson R66 helicopter, N888DV, was destroyed when it was involved in an accident at the Oconee National Forest, near Monticello, Georgia. The commercial pilot, the pilot-rated passenger, and one other passenger sustained fatal injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 on-demand charter flight. The pilot, who was the owner of the company, and a pilot-rated passenger, a part time company employee, were transporting a revenue passenger to southern Georgia and north Florida for personal business. The spouse of the passenger confirmed that the passenger chartered the flight to “look at properties” in the area and was supposed to return later that evening. The flight originated at Fulton County Executive Airport/Charlie Brown Field (FTY) Atlanta, Georgia, about 0700 and proceeded south, making a stop in Reidsville, Georgia, before continuing to Finlayson Farm Airport (9FL8) Greenville, Florida, where they landed and stayed for several hours before departing on the return flight under visual flight rules. During the return trip, they landed at Thomasville Regional Airport (TVI), Thomasville, Georgia, where they refueled with 40 gallons of fuel. Automatic dependent surveillance–broadcast (ADS–B) data indicated the flight departed TVI at 1840, then proceeded on a northerly track for about 80 nautical miles near the town of Andersonville, Georgia. At 1937, the passenger’s spouse sent a text message her husband and asked him, “What’s your ETA to home?” He responded with a photograph taken with his mobile device and stated “Approx 9:30, bad storm pop up had to land in field. It’s blowing over now.” The photograph showed a grass field, gray skies and rain on the helicopter’s window (figure 1). After departing the field to the west, the helicopter proceeded north and followed a powerline right-of-way for about 4 nautical miles (nm) before reversing course and following the same right-of-way south for about 3 nm. The helicopter then turned left on a southeast track for about 15 nm before making a left turn to the northeast where they made an approach and landing to Perry-Houston County Airport (PXE) Perry, Georgia about 2015. Five minutes later, the helicopter continued to the north, following a six-lane divided highway (Interstate 75); it passed 5 miles west of downtown Macon, Georgia, then about 10 minutes later passed about 2 miles east of a large powerplant shortly before entering the Piedmont National Wildlife Refuge, a remote area covered with dense forest. The passenger sent a second series of text messages to his spouse during this en route portion of the flight and included a screen shot of the weather radar and their location (figure 1). Figure 1 – Screen captures of mobile telephone messages from the passenger. These included a photo of the weather about 1937 and a weather radar composite image (right). About 2043, the helicopter made a series of left and right track changes (figure 2), then during the last 25 seconds of the flight, when the helicopter was at 1,650 ft above mean sea level , it entered a rapidly descending right turn where the vertical speed decreased steadily from level flight to a nearly 4,000 ft per minute descent; at 2046, the ADS-B signal was lost. The helicopter collided with trees and hilly terrain at an elevation of 570 ft. A witness south of the accident site reported hearing a low-flying helicopter and stated that at the time it was “very rainy.” Figure 2 - Orthographic image of helicopter flight path (white overlay), looking south. An additional background witness, who was also the mechanic and a helicopter pilot, stated that the operator, Atlanta Helicopters Inc, used a Robinson R-44 for charter operations, and at the time of the flight, that helicopter was down for maintenance. The owner had used the “new” R-66 for the accident flight. The owner had acquired the helicopter several months before. The witness further stated that the pilot-rated passenger was a relatively “low time” helicopter pilot with several hundred hours and likely accompanying the pilot to get some extra turbine flight experience. AIRCRAFT INFORMATION The helicopter was equipped with a Garmin GDU 1060L 10-inch display and a GTN 750xi with GPS Navigation and Com; the Garmin GDU 1060L was a 10.6” horizontal format display that could accommodate Primary Flight Display (PFD) information and a multifunction display (MFD) side by side within the same unit. The display was pilot-selectable for PFD or PFD/MFD presentation, and was equipped with Helicopter Synthetic Vision, which would create a graphic display of the terrain in front of the helicopter based on a geographic database. It was driven by the Garmin GTN 750xi GPS/NAV/COMM/MFD, which performed the basic functions of GPS and VOR navigation, as well as a communication radio. The combination of the two components could display maps, weather, traffic, airport information, and synthesized terrain in various configurations. In addition, a HeliSAS autopilot was installed. The HeliSAS autopilot system in the accident helicopter was primarily a Stability Augmentation System (SAS), which would maintain a steady helicopter attitude by applying corrective inputs to the cyclic. The autopilot would not provide any collective or pedal inputs. Additional modes of operation could provide heading hold, altitude hold, and navigation functionality. Control inputs from the autopilot system were felt as a light cyclic centering force. The autopilot sensed helicopter attitude using a combination of sensors in the flight control computer and the onboard attitude source. The computer then sent signals to the servomotors which were connected to the bottom of the cyclic in the control tunnel. The helicopter was not certified for operation under instrument flight rules and was only certified for day/night visual flight rules operation. According to the operator’s operations specifications (D085) section a. “The certificate holder is authorized to conduct operations under 14 CFR Part 135 using the aircraft identified on this operations specification,” registration number N206TJ, which was a Robinson R-44-II. METEROLOGICAL INFORMATION The recorded weather conditions at Covington Municipal Airport (CVC), Atlanta, Georgia, located about 27 miles north of the accident site at an elevation of 820 ft included, wind from 090° at 5 knots, 5 statute miles visibility, moderate rain, scattered clouds at 500 ft, broken 2,300 ft, and overcast at 11,000 ft, temperature 20° C, dewpoint 20° C; and an altimeter setting of 30.02 inches of mercury. The recorded weather conditions at Thomaston-Upson County Airport (OPN), Thomaston, GA, about 28 miles southwest of the accident site at an elevation of 798 ft included wind from 070° at 4 knots, 10 statute miles visibility, moderate drizzle, overcast 500 ft, temperature 21° C, dewpoint 21° C, and an altimeter setting of 30.00 inches of mercury. The recorded weather conditions at Middle Georgia Regional Airport (MCN), Macon, GA, located about 28 miles south of the accident site at an elevation of 354 ft included wind from 060° at 7 knots, 10 statute miles visibility, light rain, few clouds 4,500 ft, broken clouds 8,500 ft, overcast 9,000 ft, temperature 22° C, dewpoint 22° C, and an altimeter setting of 29.97 inches of mercury. The closest National Weather Service (NWS) Weather Surveillance Doppler Radar (WSR-88D) was located at Atlanta Regional Airport-Falcon Field (FFC) Atlanta, Georgia about 42 miles north-northwest of the accident site. The FFC 0.5° base reflectivity image for 2047 with the flight track overlaid is included as figure 3. The base reflectivity inset image depicted echoes of 20 to 37 dBZ along the flight track, and the accident site located about 4 miles from an isolated cell with maximum echo intensity of 53 dBZ. The echo was moving northward at a velocity of around 15 knots. No lightning was depicted with the echo or within 25 miles of the accident site between 2000 and 2100. Figure 3 - Doppler radar base reflectivity image for 2047 with flight track overlaid (magenta). The MCN terminal aerodrome forecast (TAF) current at the time of departure was an amended forecast issued at 1550. The forecast period from 1800 through 0100 on September 16 expected marginal visual flight rules (MVFR) conditions to prevail, with wind from 070° at 5 knots, visibility 6 miles in light rain and mist, ceiling broken at 1,500 ft above ground level (agl). Instrument meteorological conditions were forecast at MCN after 0100 on September 16th. The next scheduled TAF was issued at 1923 and was current at the time of the accident. The MCN TAF continued to expect MVFR conditions to prevail with wind variable at 5 knots, visibility 6 miles or more in moderate rain, ceiling broken at 2,500 ft agl, and overcast at 10,000 ft. During a temporary period between 2000 and 2200, a of visibility 4 miles in mist, scattered clouds at 900 ft agl, and ceiling broken at 2,500 ft agl. The United States Naval Observatory’s documented the astronomical conditions for the accident site coordinates, on the day of the accident. The sunset was at 1941 and the end of civil twilight was at 2005, 41 minutes before the accident. Moonrise was at 1633. At the time of the accident the sun was approximately -15° below the horizon at an azimuth of 282°, and the moon was 29° above the horizon at an azimuth of 168°, with the phase a waxing gibbous with 73% of the moon’s disk illuminated. No flight plan had been filed and there was no record found indicating that the pilot received a preflight weather briefing; however, it could not be determined if the pilot obtained weather information using other sources. WRECKAGE AND IMPACT INFORMATION The helicopter entered the trees on a heading of about 145°. It impacted the trees at a steep downward, right bank angle based on damage to surrounding trees before impacting the terrain, which left a 2-ft deep by 6-ft-wide crater. Several trees contained vertical and horizontal branch removal and the bark was scraped from trees prior to the primary impact point. The debris field extended for approximately 150 ft along a generally southeasterly path through the densely wooded and hilly terrain. All major components of the helicopter were located within the area. Smaller debris was widely scattered along the debris field in a fan-like pattern. During the impact, a 24-inch tip of 1 main rotor blade separated and was found about 75 ft from the main wreckage. The main rotor blades were impact-damaged but remained attached to the hub at their respective positions. The transmission and mast separated from the fuselage. The cockpit and cabin were severely damaged by impact forces and postimpact fire. The main rotor gearbox was separated from the airframe. The mast fairing remained attached to the main rotor mast and was heavily distorted on the leading edge. The aft bulkhead casting was fractured, and the empennage was detached from both the tail cone and the tail rotor gearbox. The main rotor gearbox was broken open and the tail rotor output gear nose bearing housing was broken loose. Amber colored oil was visible in places in the gearbox. Rotation of the input shaft produced movement of the tail rotor output shaft and the main rotor shaft, but movement was limited due to the fractured housing, internal damage, and a bend in the main rotor driveshaft. There were broken tree branches and pine needles inside the main rotor head, and pine needles in one blade’s pitch change housing boot. There was very slight scoring on the main rotor hub just inboard of the pitch change housing. The main rotor gearbox output flex coupling was mostly intact, but the fan shaft was separated at the yoke. The tail rotor driveshaft hanger bearing had been exposed to fire, was detached from the tail cone, and the bearing rotated with a ratchet feel. The tail rotor driveshaft was separated in several places. The friction linkage was detached from the tail cone, and the friction at the pivots felt normal. The aft flex coupling appeared undamaged. The tail rotor gearbox was detached from the aft tail cone casting/bulkhead. The tail rotor gearbox was intact and free to rotate at least one full turn and contained amber oil. The tail rotor output shaft and hub appeared to be undamaged. The tail rotor blades were largely intact and had some minor damage and bending. The flight control system was severely damaged by fire and impact forces and continuity was traced through breaks and the control tubes that could be identified. There was no evidence of pre-impact failures or malfunctions to the control system. The engine monitoring unit (EMU) was located in the wreckage. It had been exposed to post crash fire and the internal board and components were melted or reduced to ash. No data from the EMU could be retrieved. The engine remained within the general wreckage of the engine bay and had been exposed to a postimpact fire. The engine exhaust cowling was crushed tightly around the engine. Hand rotation of the compressor was smooth but did not result in rotation of the N1 drive train. Removal and examination of the compressor revealed signatures of engine operation during impact. The fuel spray nozzles exhibited normal carbon coating. All turbine blades were intact and exhibited no evidence of leading-edge impact or thermal distress. Examination of the combustion chamber and gas generator turbine revealed no damage or anomalies. The accessory gearbox revealed no preimpact damage or anomaly. The engine controls were damaged by impact forces but revealed no other damage or anomaly; the control arms remained attached and moved freely. There was no evidence of engine fire, failure, or malfunction prior to impact. All evidence found was consistent with normal engine operation. Examination of the recovered airframe, flight control system components, transmission, rotor system and engine revealed no preimpact mechanical malfunctions or anomalies that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION The Georgia Bureau of Investigation, Division of Forensic Sciences performed an autopsy of the pilot’s remains. According to the autopsy report, the cause of death was multiple generalized blunt impact injuries, and the manner of death was accident. The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. Ethanol was detected at 0.019 g/dL in muscle tissue but was not detected in kidney tissue. No other drugs were detected in muscle. No blood was available for testing. ADDITIONAL INFORMATION According to FAA Advisory Circular 60-4A, “Pilot's Spatial Disorientation,” Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common on overwater flights, at night, and especially at night in extremely sparsely populated areas or in low-visibility conditions. A sloping cloud formation, an obscured horizon, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon. The disoriented pilot may place the aircraft in a dangerous attitude. -
Analysis
The pilot, who was also the owner of the company, and a pilotrated passenger were transporting a revenue-paying passenger on a chartered helicopter flight. The flight began on the morning of the accident with an approximately 200 nautical-mile flight to their destination before returning several hours later under visual flight rules. During the return trip, they stopped at an airport to refuel. About halfway through the subsequent flight, they encountered moderate to heavy rain showers. The passenger sent a text message to his spouse stating they landed in a field because “bad storms popped up” and they were waiting for it to blow over before resuming their flight. The message included a photograph that showed a grass field, gray skies, and rain on the helicopter’s window. According to recorded flight track data, after departing the field, the pilot made a series of meandering track changes before proceeding to a nearby small airport where they stayed for about 5 minutes. Weather data indicated that after takeoff, the helicopter remained in areas of low ceilings and rain for the remainder of the flight. By this point in the flight, the sun had set and the end of civil twilight had passed. The helicopter subsequently passed 5 miles west of a city, then passed 2 miles east of a large powerplant before entering a large national wildlife refuge, a remote area covered with dense forest. Shortly thereafter, the helicopter made a series of shallow left and right track changes. During the last 25 seconds of the flight, the helicopter entered a rapidly descending right turn and descended to ground impact. The calculated rate of descend reached nearly 4,000 feet per minute during the descent. The fragmentation of the wreckage and damage to surrounding trees revealed that the helicopter was in a 90° right bank as it came through the trees and impacted terrain. Postaccident examination of the airframe, flight control system components, transmission, rotor system, and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The helicopter was certified for operation in visual meteorological conditions (both day and night) and was not certified for operation in instrument meteorological conditions. While the helicopter was equipped with modern avionics that included tools like synthetic vision, as well as an autopilot system, the pilot’s proficiency in the use of the systems could not be determined based on available information. Some or all the ethanol detected by postmortem toxicological testing in the pilot’s tissue may have been from sources other than consumption. It is unlikely that ethanol or impairment was a factor in the accident. The weather conditions at the time of and preceding the accident consisted of low ceilings, low visibility, and rain with marginal visual meteorological conditions expected through most of the area. Once the helicopter passed the city and powerplant that contained ground reference lighting, and entered the national forest, the dark night conditions and sparse lighting along the flightpath would have made it even more difficult for the pilot to recognize and recover from a loss of control due to spatial disorientation. Based on the wreckage distribution, which was consistent with a high-energy impact, coupled with the known low visibility present at the time of the accident, it is likely that the pilot experienced spatial disorientation and lost control of the helicopter.
Probable cause
The pilot’s decision to continue the visual flight rules flight into deteriorating weather conditions during a dark night and over unlit terrain, which resulted in spatial disorientation and a subsequent loss of helicopter control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER CO
Model
R66
Amateur built
false
Engines
1 Turbo shaft
Registration number
N888DV
Operator
Atlanta Helicopters LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1000
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-08T21:10:59Z guid: 103882 uri: 103882 title: CEN21FA424 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103896/pdf description:
Unique identifier
103896
NTSB case number
CEN21FA424
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-17T09:00:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2021-09-21T17:30:32.403Z
Event type
Accident
Location
Delta, Colorado
Airport
Delta County Airport Blake Field (AJZ)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to an acquaintance of the pilot, who also witnessed the accident, he and the pilot flew the airplane to AJZ a few days before the accident flight. The acquaintance stated that the airplane operated normally. - On September 17, 2021, about 0800 central daylight time, a Boeing A75 airplane, N19BB, was substantially damaged when it was involved in an accident near Delta, Colorado. The pilot sustained fatal injuries. The flight was operated under the provisions of Title 14 Federal Code of Regulations Part 91 as a personal flight. The airplane took off from runway 3 at Blake Field Airport (AJZ), Delta, Colorado. Two witnesses observed the airplane climb out and begin aerobatic maneuvers about 5 miles to the northeast of AJZ. Both witnesses reported that the airplane began a loop maneuver, and at the top of the loop while inverted, the airplane entered a flat spin. They observed the airplane recover from that spin. The airplane then gained altitude and they observed the airplane begin another loop maneuver. At the top of that loop, while inverted, the airplane entered another flat spin, but this time the pilot did not recover. The airplane impacted rugged, sloped terrain about 5 miles to the northeast of AJZ. First responders located the airplane wreckage and notified authorities. There were no radio or distress calls heard from the pilot. The witnesses reported that the engine could be heard running during the descent to the point of impact. - The Pathology Group, P.C., Grand Junction, Colorado, performed the pilot’ s autopsy as authorized by the Delta County Coroner’s Office, Delta, Colorado. According to the pilot’s autopsy report, his cause of death was multiple blunt force injuries, and his manner of death was accident. The autopsy did not identify significant natural disease. The Federal Aviation Administration Forensic Sciences laboratory performed toxicology testing of postmortem specimens from the pilot. Diphenhydramine, famotidine, desloratadine, and pseudoephedrine were detected in cavity blood and urine. - The wreckage was found resting inverted on a 45-degree sloped hill. The fuselage was oriented downslope and crushed inward from impact forces. The engine was partially separated from its mounts. The empennage section was bent rearward, the upper wings were bent upward, and lower wings were separated from their respective mounting braces, consistent with a flat impact. One blade of the two-bladed propeller had no damage while the other blade was bent aft 45o with no twisting. Flight control continuity was confirmed from the cockpit to all flight control surfaces. The engine throttle control was found in the idle position. Engine rotation continuity (compression resistance) was confirmed. The smell of fuel was present. The airplane was not equipped with inverted fuel or oil supply systems. -
Analysis
The pilot took off and proceeded to an area northeast of the airport where he began performing aerobatic maneuvers. Witnesses reported that the airplane began a loop maneuver and, at the top of the loop while inverted, the airplane entered a flat spin. They observed the airplane recover from the spin. The airplane then gained altitude and entered another loop. At the top of that loop, while inverted, the airplane entered another flat spin, but this time the pilot did not recover. The airplane descended to impact with rugged terrain. The witnesses reported that the engine could be heard running during the descent to the point of impact. A postaccident examination revealed no preaccident failures or malfunctions with the airplane that would have precluded normal operation. The pilot had used the sedating antihistamine diphenhydramine, which has a potential to cause cognitive and psychomotor slowing and drowsiness. There was insufficient evidence to determine whether the pilot was experiencing impairing diphenhydramine effects at the time of the crash, and no specific evidence that pilot impairment contributed to the crash.
Probable cause
The pilot’s loss of control during an aerobatic maneuver, resulting in the airplane impacting terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
A75
Amateur built
false
Engines
1 Reciprocating
Registration number
N19BB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-293
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-21T17:30:32Z guid: 103896 uri: 103896 title: ERA21LA368 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103897/pdf description:
Unique identifier
103897
NTSB case number
ERA21LA368
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-17T11:30:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-11-01T19:10:12.64Z
Event type
Accident
Location
Ash, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 17, 2021, about 1030 eastern daylight time, a Hughes 369HS helicopter, N420AT, was substantially damaged when it was involved in an accident in Ash, North Carolina. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the pilot, he flew from his home base to the remote job site and landed on a flatbed support truck to load the chemical hopper. The helicopter had about 25 gallons of fuel on board when it arrived at the truck. After landing, the pilot reduced the throttle to flight idle while the ground crew loaded 60 gallons of chemical into the hopper. Before liftoff, the pilot increased the throttle until the engine and rotor rpm needles were in the green range of the tachometer. Immediately after liftoff, the pilot heard the low-rotor rpm warning horn, and the helicopter began to descend. He attempted to increase the collective pitch, but the helicopter did not respond. The helicopter descended, impacted a field, and rolled over onto its right side. Postaccident examination of the helicopter revealed that the helicopter sustained substantial damage to the tailboom, which was fractured just forward of the horizontal stabilizer. The flight controls were continuous from the cockpit controls to the main and tail rotors. All main rotor blades were fragmented and had fractured near their roots. Examination and operational testing of the engine revealed that it would start and run but would not achieve 100% N2 (power turbine) speed with no load applied, and the engine temperature exceeded its limit (about 1,460°F). These conditions precluded further operational testing of the engine. A subsequent borescope examination of the first-stage gas-producer turbine blades revealed several blades with impact damage to the outer one-third of their leading edges. One of the split-line bolts in the compressor case halves was found corroded and could not be removed with standard tooling. The bolt had to be drilled out to separate the compressor case halves and remove of one of the halves. The removed compressor case half exhibited significant damage to the third- and fourth-stage stator vanes. All the third-stage vanes had separated from the case at their base and were missing. All the fourth-stage vanes were in place, but most were significantly damaged; the vanes were found fully rolled over, severely distorted, or twisted. Significant erosion of the black plastic case lining was noted at the base of the first- and second-stage stator vanes. The case half is shown in figure 1. Figure 1. Compressor case damage (Source: Rolls-Royce Engines). Heavy impact damage was noted on the compressor rotor blades from the trailing edge of the third stage to the outer one-third of the sixth stage. The rotor is shown in figure 2. Figure 2. Compressor rotor (Source: Rolls-Royce Engines). When the second compressor case half was removed, several of its split-line bolts were found rusted, which required grinding to remove them. The damage to the remnants of the fractured stator vanes precluded a metallurgical examination of the fracture features by the engine manufacturer. Metallurgical examination found that the compressor case had erosion throughout the case. The polymer coating was eroded, exposing areas of the first- and second-stage compressor vane bands. The first- through third-stage compressor vanes exhibited erosion of the leading edge, braze joint fillet, and mid-chord thickness of the airfoils. Corrosion damage was present on several of the vanes. The leading-edge root of the third-stage compressor blades exhibited corrosion pitting. A commercial service letter (CSL-1135), which was originally issued by the engine manufacturer in 1986, advised operators of the risk of corrosion and/or erosion of engine components when operating the engine in a corrosive/and or erosive environment. The letter instructed operators to perform a water-rinse procedure of the engine each day if the engine were operated in these environments. The letter states in part the following: Engines subjected to salt water contamination or other chemically laden atmosphere (industrial pollutants, sulfur laden atmosphere, pesticides, herbicides, etc.) shall undergo water rinsing after shutdown following the last flight of the day. Perform the rinse operation as soon as practical after flight, but not before the engine has cooled to near ambient temperature. A review of the available maintenance records revealed no entries related to the service letter or daily water rinsing of the engine components. The manufacturer’s recommended maximum interval for inspection of the engine’s compressor section (for engines with coated compressor wheels, which were installed in the accident engine) was 300 hours or 12 months, whichever came first. A note in the engine maintenance manual cautioned that the, “INSPECTION FREQUENCY MUST BE BASED ON THE NATURE OF THE EROSIVE AND/OR CORROSIVE ENVIRONMENT. THE OPERATING ENVIRONMENT CAN DICTATE A MORE FREQUENT INSPECTION INTERVAL [emphasis in original].” The helicopter’s maintenance records indicated that the compressor was installed on July 17, 2017, about 327 flight hours before the accident. The only inspection of the compressor case after installation that was recorded in the records occurred on July 23, 2018; the engine had accumulated 58 flight hours since the time of the compressor installation. In this model helicopter, inspection of the compressor section necessitates removal of the engine from the airframe. -
Analysis
The pilot flew the helicopter from his home base to a remote aerial application site, where he landed the helicopter on a support truck so that the ground crew could load the chemical hopper. After loading was completed, the pilot increased the throttle until the engine and rotor rpm needles were in the green range of the tachometer. Immediately after liftoff from the truck, the pilot heard the low-rotor rpm warning horn, and the helicopter began to descend. The pilot attempted to add more pitch; however, the helicopter did not respond. The helicopter subsequently descended, impacted a field, and rolled over onto its right side, resulting in substantial damage to the tailboom. Postaccident examination of the engine revealed that it would start and run but could not reach full operating speed. Upon disassembly of the compressor section, significant erosion and corrosion damage was found on the compressor case halves and stator vanes, which also exhibited structural damage that ranged from being fully rolled over to being severely distorted or twisted. Other stator vanes were missing. The polymer coating on the inside of the compressor case was eroded in several places. Many of the rotating blades of the compressor were mechanically damaged. Since 1986, the engine manufacturer has published guidance instructing operators to perform a daily water rinse of engine components if the engine was operating in a corrosive environment, to reduce the possibility of component damage from corrosion and erosion. The aerial application of agricultural chemicals creates such a corrosive environment. The damage to the blades and polymer coating were consistent with a buildup of chemicals that the daily wash would likely have mitigated. The significant erosion and corrosion damage on the blades and the polymer coating likely began at some point before the accident and resulted in a partial loss of engine power during the accident flight.
Probable cause
A partial loss of engine power due to corrosion and erosion damage to the engine’s compressor section components.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
369
Amateur built
false
Engines
1 Turbo shaft
Registration number
N420AT
Operator
DAT AIRCRAFT LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
940648S
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-01T19:10:12Z guid: 103897 uri: 103897 title: RRD21LR016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103950/pdf description:
Unique identifier
103950
NTSB case number
RRD21LR016
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-22T15:40:00Z
Publication date
2023-04-24T04:00:00Z
Report type
Final
Last updated
2023-04-13T04:00:00Z
Event type
Accident
Location
Castroville, Texas
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the September 22, 2021, equipment operator fatality was the use of a roadway maintenance machine to move a load of steel grating panels suspended in front of the machine with a clamping work head attachment that was not designed for use with such a load.
Has safety recommendations
false

Vehicle 1

Railroad name
UP
Equipment type
Special maintenance-of-way equipment
Train name
Mini-track excavator
Train number
CAT 308
Train type
FRA regulated freight
Total cars
0
Total locomotive units
0
Trailing tons
0
Findings
creator: NTSB last-modified: 2023-04-13T04:00:00Z guid: 103950 uri: 103950 title: WPR21FA352 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103948/pdf description:
Unique identifier
103948
NTSB case number
WPR21FA352
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-22T17:24:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-09-30T01:12:09.667Z
Event type
Accident
Location
Page, Arizona
Airport
PAGE MUNI (PGA)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
Passenger Interview The passenger reported that she heard the engine “smoothly running” and producing a “humming” sound after the airplane impacted the ground. She could not recall if the propeller was moving. The passenger also reported that the sound ceased about 30 seconds after impact. During a telephone interview, the NTSB played three different audio files (from similar make/model airplanes) for the passenger. Those files comprised (1) audio of an engine at idle power, (2) audio of only the master switch engaged and the vacuum pump in the background, and (3) audio of an engine at run-up power. The audio files were played twice, and both times the passenger identified the audio of the master switch and vacuum pump as the sound that she heard after impact. Performance Computations According to the ADS-B track data, the total distance of the accident flight was about 620 statute miles. During this time, the airplane was in a climb for the first 50 minutes of flight, cruise flight at an altitude of about 12,000 ft msl for about 80 minutes, a descent to about 7,700 ft msl for about 8 minutes, and cruise flight at about same altitude (within 1,000 ft) for about 54 minutes before the airplane descended again and crashed. The airplane’s fuel consumption and performance were computed using the pilot’s operating handbook (POH). Calculations from the “Cruise Performance – Range” chart in the POH showed that the airplane had an estimated endurance of about 800 statute miles with the following conditions: 65% throttle, 48 gallons of fuel onboard, and the airplane’s published maximum gross weight of 2,650 pounds. The calculations also assumed the entire flight was flown at 12,000 ft msl; at 7,700 ft msl, the airplane’s endurance was about 750 statute miles. The handbook did not include any performance aids to compute an airplane’s fuel consumption during climb and descent. The airplane’s weight and balance was calculated using an empty airplane weight from the website of a flying club to which the pilot belonged and a fuel weight derived from a weight record that the pilot created before the accident flight. The weight record included an itemized list of the luggage items onboard, which had a total calculated weight of 363 pounds. The cargo aboard the airplane included a boat motor, camping gear, a raft, bags, and the pilot’s two dogs. The autopsy showed that the pilot’s weight was 168 pounds at the time of his death, and the passenger (the pilot’s wife) stated that her weight was about 152 pounds. One additional number was found on the pilot’s weight record document: 256. For the calculations, the “256” number was assumed to be the fuel onboard at the time of takeoff; when 256 was divided by the fuel weight of 100 low lead aviation grade gasoline, the result was about 42 gallons. The passenger thought that the pilot had not completely filled the tanks. With an empty airplane weight of 1,710 pounds, an assumed fuel weight of 256 pounds, and an oil weight of 15 pounds, and the weight of cargo and occupants, the airplane’s total weight would have been 2,664 pounds at the time of departure. The airplane’s center of gravity (CG) at the time of departure was 89 inches behind the datum plane. According to the CG chart in the POH, the airplane’s weight at the time of departure was outside the weight envelope while the CG was within the published tolerance. The published fuel consumption at 65% throttle was 9.16 gallons per hour. Computations showed that the airplane would have had an endurance of about 4 hours 24 minutes with 42 gallons of fuel onboard. The total flight time was 4 hours 12 minutes. The handbook also contained a “WARNING” message that stated the following: “Performance information derived by extrapolation beyond the limits shown on the charts should not be used for flight planning purposes.” - On September 22, 2021, about 1624 mountain standard time, a Piper PA-28R-200, N3906X, was substantially damaged when it was involved in an accident near Page Municipal Airport (PGA), Page, Arizona. The pilot sustained fatal injuries, and the passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Automatic dependent surveillance-broadcast (ADS-B) track data from the Federal Aviation Administration captured the airplane’s climbout from San Martin, California, about 1211 Pacific daylight time. About 1615, the airplane was 30 nautical miles (nm) west of PGA and at an altitude of about 7,250 ft msl (1,100 ft above ground level [agl]). About 1623, the airplane descended to about 6,600 ft msl (500 ft agl), where it remained until 1623:46, when it began its final descent. The final ADS-B data point, at 1624:15, showed that the airplane was at 200 ft agl and about 0.5 nm northwest of the accident site. The airplane continued to descend and impacted the ground. According to the ADS-B track data, the total distance of the accident flight was about 620 statute miles. The passenger (the pilot’s wife) recounted that most of the flight was uneventful but that, a few minutes before the accident, the pilot became visibly upset and began pushing buttons. - The Medical Examiner’s Office of Coconino County, Flagstaff, Arizona, performed an autopsy on the pilot. His cause of death was multiple blunt force injuries. The autopsy report stated that the pilot sustained serious injuries to both his head and torso. The report noted the presence of a right orbital roof/frontal bone fracture and right-sided subarachnoid hemorrhage. Additionally, the pilot sustained open and closed bilateral rib fractures, a fracture of the sternum, scattered pulmonary contusions, and a fracture of the lumbar vertebral column. The passenger’s serious injuries included a fractured left clavicle, fractured right ribs, nasal fractures, pulmonary contusions, a lumbar compression fracture, and a large open laceration of the right knee. She was hospitalized for 6 days. Toxicology testing performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory identified the diphenhydramine at 70 ng/mL in the pilot’s cavity blood and urine and the cetirizine at 109 ng/mL in the pilot’s cavity blood and 7,607 ng/mL in his urine. Diphenhydramine is a sedating antihistamine (commonly marketed as Benadryl) and is available over the counter in several products used to treat colds, allergies, and insomnia. The medication carries the warning that use of the medication may impair mental and physical ability to perform potentially hazardous tasks, including driving or operating heavy machinery. The therapeutic range is 25 to 100 ng/mL and it has a halflife of 3 to 14 hours. Diphenhydramine undergoes postmortem distribution, and central levels may be two to three times higher than peripheral levels. The FAA provides guidance on wait times for flying after using this medication; the post-dose observation time is listed as 60 hours, and the medication is “not for daily use.” Cetirizine is a second-generation antihistamine used to relieve hay fever and allergy symptoms (commonly marketed as Zyrtec). The therapeutic range is between 190 and 1,450 ng/mL and the elimination half-life is between 6.5 and 10 hours. The FAA guidance on Cetirizine includes a post-dose observation time of 48 hours and an indication that the medication is not for daily use. - The autopsy report, on -scene photographs, and other documentation were used to review the survival aspects of this flight. Postaccident photographs showed that the pilot was pinned between the seatback and the forward control panel in a compressed “knees-to-chest” position. The photographs also showed an unrestrained 80-pound outboard boat motor in the airplane cabin behind the front left (pilot’s) seat; the heaviest portion of the motor contacted the back of the front left seat. The airplane was equipped with three-point restraints at both forward seating positions. The passenger reported being restrained during impact, and the pilot’s shoulder harness had a linear separation that was consistent with cutting by emergency response personnel. Both ceilingmounted inertia reels were found in place, and the lap-belt portions of both restraints were still attached to the floor fittings and were undamaged.  The passenger stated that all the items in the back of the airplane were secured with rope. The onsite investigation found that the items were not secured, and rope was not located. - The airplane was located about 11 nm west of PGA on a mesa at a field elevation of about 6,150 ft msl. The airplane came to rest at a level attitude on a magnetic heading of 227°, as shown in the figure below. Figure. Accident site. The first point of impact was identified by a 12-foot-tall tree with several broken branches. A debris path was marked by parallel ground scars that began about 20 ft forward of the first point of impact and was oriented on a magnetic heading of 155°. The outboard right stabilator was located on the left side of the debris path. During a postaccident examination, continuity of the ailerons, stabilator, and rudder were confirmed from the cockpit to their respective control surfaces. Mechanical continuity of the engine was established throughout the rotating group, valve train, and accessory section when the crankshaft was manually rotated at the propeller. Thumb compression was achieved at all four cylinders, and the valves displayed normal lift. Borescope examination of the cylinder’s combustion chamber interior components revealed normal piston face and valve signatures and no indications of catastrophic engine failure. The three-bladed constant-speed propeller remained attached at the crankshaft flange. All three blades remained attached to the hub. One blade was bent aft at the blade root, another was bent aft at the blade tip, and the other blade was straight. None of the propeller blades displayed any visible chordwise scratches, nicks, or gouges. The right and left wing fuel tanks had no fuel and displayed no evidence of fuel staining. There was also no evidence of fuel staining on the ground around the wings or any fuel smell. The fuel system exhibited no visible breaches, and all fuel system components functioned normally. -
Analysis
The pilot and the passenger (the pilot’s wife) were making their first cross-country flight in their private airplane. After loading the airplane with several items, including a boat motor, camping gear, a raft, and two dogs, the pilot completed the airplane’s weight and balance calculations, and the airplane departed. The climb and cruise portions of the flight were uneventful. About 3 hours 15 minutes into the flight, the pilot began to descend the airplane to an altitude of about 7,700 ft mean sea level (msl) and, about 12 minutes before the accident, descended the airplane to about 6,600 ft msl. The passenger stated that the pilot became upset a few minutes before the accident, and the airplane began to descend about 1 minute before the accident until it impacted the ground. The propeller blade signatures at the accident site were consistent with low rotational energy. Postaccident examination of the wreckage revealed no evidence of a preimpact mechanical malfunction or anomaly with the engine or airframe. The examination found no fuel in either fuel tank, neither of which was breached, and there was no evidence of a fuel odor or staining on the airframe. Fuel performance computations suggested that the airplane likely lost power due to fuel exhaustion about 1 minute before the accident. These computations also suggested that the airplane departed with 42 gallons instead of the 48 gallons indicated in the pilot’s operating handbook, likely to accommodate the weight of the cargo. Although the pilot had completed weight and balance calculations for the accident flight, no evidence indicated that he considered the airplane’s performance. If the pilot had properly computed the airplane’s fuel consumption for the planned flight, he should have recognized that the airplane had insufficient fuel to reach its destination. Instead, fuel exhaustion occurred, which led to a total loss of engine power. The airplane was also slightly over gross weight at the time of departure, which likely didn’t affect his forced landing as the airplane landed upright and the center of gravity was within published limitations. Both occupants were wearing their three-point restraints, and they sustained serious traumatic injuries during the impact. Evidence showed that the heaviest portion of the boat motor had contacted the pilot’s seat at the time of impact, which caused the seat to move forward during impact and compress the pilot between the seatback and forward control panel. This loss of occupiable space likely contributed to the severity of his injuries. Toxicology testing of the pilot’s blood detected the presence of two sedating antihistamines. At the time of the pilot’s death, one of the medications was likely at therapeutic levels, and the other was at subtherapeutic levels but was likely at therapeutic levels when the airplane departed. The medications can impair cognitive and psychomotor performance; however, the investigation could not determine, based on the available evidence, if the effects from the pilot’s use of the medications contributed to the accident.
Probable cause
The pilot’s improper fuel planning for a cross-country flight, which resulted in fuel exhaustion and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N3906X
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7535348
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T01:12:09Z guid: 103948 uri: 103948 title: ANC21LA096 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103972/pdf description:
Unique identifier
103972
NTSB case number
ANC21LA096
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-22T20:26:00Z
Publication date
2023-03-29T04:00:00Z
Report type
Final
Last updated
2021-09-27T21:38:19.781Z
Event type
Accident
Location
Chickaloon, Alaska
Airport
King Ranch (AK59)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On September 22, 2021, about 1926 Alaska daylight time, a Piper PA-14 airplane, N4276H, was substantially damaged when it was involved in an accident near Chickaloon, Alaska. The commercial pilot seated in the left seat sustained minor injuries, and the commercial pilot in the right seat was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the left-seat pilot, the accident flight was the first flight after the airplane’s annual inspection. The left-seat pilot was flying at the time of the accident; the right-seat pilot was the pilot-in-command. Before departure, the pilots completed a “thorough” preflight inspection, and an engine run-up revealed no anomalies. The takeoff was uneventful until immediately after lifting off, when the engine lost power, regained power momentarily, and then lost power again. Insufficient runway remained on which to land, and the airplane impacted an area of tree- and brush-covered terrain off and nosed over, resulting in substantial damage to the fuselage, wings, wing struts, and rudder. Examination of the engine and fuel system did not reveal any anomalies that would have resulted in a loss of engine power. Weather conditions were conducive to the development of carburetor icing at glide and cruise power. -
Analysis
The accident flight was the first flight after the airplane’s annual inspection. The pilots completed a “thorough” preflight inspection, and an engine run-up revealed no anomalies. Just after the airplane became airborne during takeoff, the engine lost power, regained power momentarily, and then lost power again. Insufficient runway remained on which to land, and the airplane impacted an area of tree- and brush-covered terrain off the end of the runway and nosed over. Examination of the engine and fuel system did not reveal any anomalies that would have resulted in a loss of engine power. The reason for the loss of power could not be determined based on the available information.
Probable cause
A total loss of engine power during takeoff for reasons that could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-14
Amateur built
false
Engines
1 Reciprocating
Registration number
N4276H
Operator
Kingdom Air Corps
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1480
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-27T21:38:19Z guid: 103972 uri: 103972 title: WPR21LA354 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103976/pdf description:
Unique identifier
103976
NTSB case number
WPR21LA354
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-23T16:00:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-10-05T06:43:20.109Z
Event type
Accident
Location
Bovill, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 23, 2021, about 1500 Pacific daylight time, a Hiller UH-12E helicopter, N5334V, was substantially damaged when it was involved in an accident near Bovill, Idaho. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he had been applying dry fertilizer over trees as part of a timber company contract and had flown about 5.7 hours that day. The pilot also reported that he refueled the helicopter every hour. About 20 minutes after the last refueling, the pilot was on approach to the fertilizer service truck to refill the bucket. About 40 ft above ground level and about 20 ft from the truck, the pilot felt a “sudden jolt,” and the helicopter “dropped” to the sloping terrain below. The pilot stated that he had no time to react and that the helicopter did not yaw after the jolt. He recalled that the torque gauge indicated between 85% and 90% at the time. The helicopter impacted the ground and came to rest on its side. The pilot further stated that “everything” on the helicopter automatically shut down before he exited. A witness, who was staffing the truck, stated that he did not hear anything abnormal regarding the engine. The witness also stated that the wind was light and variable at the time of the accident. Review of the maintenance logbooks revealed that an annual inspection was accomplished on the day before the accident and that the engine was determined to be in an airworthy condition. At the time of the inspection, the airframe had a total time of 21,096 hours, and the engine had a total time of 15,415 hours of total time. Postaccident examination of the helicopter found that the cabin area and windshield structure were bent and distorted. The tailboom separated near the midsection, and the main rotor blades were buckled in multiple areas. The examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The engine was shipped to the manufacturer for further examination, which found that fuel was present throughout the engine fuel system, including the spray nozzle. A test run showed that the engine was capable of producing sufficient power. -
Analysis
The helicopter was performing an aerial application flight. While approaching the fertilizer service truck to refill the bucket, the pilot felt a “sudden jolt,” and the helicopter lost altitude. The pilot was unable to regain control, and the helicopter did not yaw after the jolt. The helicopter subsequently impacted the terrain below. The helicopter sustained substantial damage to its main rotor blades and fuselage. Before the pilot could exit the helicopter, “everything” on the helicopter, including the engine, automatically shut down. Postaccident examination of the wreckage, including the engine, revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Also, the examination yielded no evidence to explain why the engine automatically shut down after the accident. As a result, the reason for the pilot’s loss of helicopter control could not be determined based on the available evidence for this accident investigation.
Probable cause
A loss of helicopter control for undetermined reasons based on the available evidence for this accident.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HILLER
Model
UH-12E
Amateur built
false
Engines
1 Turbo shaft
Registration number
N5334V
Operator
Western Helicopter Services
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
2008
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-05T06:43:20Z guid: 103976 uri: 103976 title: RRD21MR017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103960/pdf description:
Unique identifier
103960
NTSB case number
RRD21MR017
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-25T16:55:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2023-07-05T04:00:00Z
Event type
Accident
Location
Joplin, Montana
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the derailment of Amtrak Train 7 on BNSF Railway track was the combination of worn rail, vertical track deflection at a four-bolt rail joint, subgrade instability, and track misalignment. Contributing to the severity of the injuries were the occupant protections that did not restrain passengers in the overturn event and the failure of the window retention systems.
Has safety recommendations
true

Vehicle 1

Railroad name
Amtrak
Equipment type
Passenger train-pulling
Train name
Empire Builder
Train number
AMTK 7(24)
Train type
FRA regulated passenger
Total cars
10
Total locomotive units
2
Findings
creator: NTSB last-modified: 2023-07-05T04:00:00Z guid: 103960 uri: 103960 title: WPR21FA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103962/pdf description:
Unique identifier
103962
NTSB case number
WPR21FA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-26T20:22:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-10-05T21:13:06.954Z
Event type
Accident
Location
Billings, Montana
Airport
BILLINGS FLYING SERVICE (63MT)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 1 serious, 0 minor
Factual narrative
The airplane was equipped with a single control yoke. The left side was equipped with rudder pedals and brakes, and the right side was equipped with rudder pedals only. - The runway at the private airport was oriented on an east-west heading. The runway was about 4,696 ft in length, of which, the western 3,100 ft of the runway surface was asphalt. The remaining runway surface was comprised of dirt and gravel. The runway was not equipped with runway lights or approach angle indicating equipment. Most of the length of the runway was surrounded by open fields. - On September 26, 2021, about 1922 mountain daylight time, a Beech S35 airplane, N354M, was destroyed when it was involved in an accident near Billings, Montana. The pilot was seriously injured, and the two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was conducting a cross-country flight from Colorado to a private airstrip in Montana. As the airplane neared the intended destination, the pilot voiced his concern to one passenger (who was pilot rated) about the dusk conditions with no runway lights at the airstrip, and the passenger reassured the pilot about the landing. As the airplane entered the airport traffic pattern, the pilot was feeling “okay” and conducted the checklist. The pilot stated that, as the airplane was landing, one passenger knew something was wrong and told the pilot to “add power.” Subsequently, the airplane turned left and impacted trees, and a postimpact fire ensued. The pilot reported that he did not know what happened when the airplane touched down or why the airplane turned toward the trees. Regarding the airplane’s left turn after landing, the pilot “chalk[ed] it up to floating the landing somehow” and stated that everything was normal until the airplane turned left. He added that “something made the left wing hit the ground first, instead of the wheels.” Witnesses located near the accident site reported observing the airplane on final approach for the runway from the northeast. One witness stated that the airplane appeared to be “slightly high and slightly fast” while on final and that the airplane had “floated down the runway” before a “hard” touchdown. Another witness stated that the left wing appeared to have stalled and that the airplane landed hard on the left main landing gear first. A witness further stated that the airplane began to “wobble” and then depart the left side of the runway, which was followed by the sound of an increase in engine power. This witness stated that the airplane accelerated through a field in a nose-high attitude while doing what he described as a “duck waddle.” The witness indicated that engine power remained on as the left wingtip was dragged across the ground about halfway through an attempted go-around. - The airplane came to rest within a tree line that was about 450 ft north of the runway and about 1,938 ft northeast of the approach end the runway. All major structural components of the airplane were located within about 40 ft of the main wreckage. Examination of the runway revealed that the first identified point of contact was a tire mark, consistent with the left main landing gear, about 882 ft from the approach end of the runway. An additional mark, consistent with the right main landing gear, was located about 924 ft from the approach end of the runway. A solid black track, consistent with main tire material transfer, originated from both marks and progressed toward the left side of the runway. The tracks exited the runway surface about 1,078 ft from the approach end of the runway, as shown in figure 1. Figure 1.: Runway marks. A ground scar, consistent with the left wing, was about 60 ft in length and was located about 1,500 ft from the approach end of the runway and 91 ft left of the runway edge. Additional ground scars, consistent with the main landing gear, were observed about 68 ft beyond the left wing ground scar and in an arc toward the north and main wreckage, as shown in figure 2. Figure 3. Aerial view of the accident site, with ground scars and runway marks annotated. (Source: Witness to the accident). The fuselage was significantly damaged by the postimpact fire from the firewall to just behind the baggage area. Flight control continuity was established from the ailerons to the control column. Elevator control continuity was established from the forward spar to the control surfaces. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. -
Analysis
The pilot reported that he was conducting a cross-country flight with an intended destination that did not have runway lighting. As the airplane neared the intended destination, the pilot voiced his concern to one passenger (who was pilot rated) about the dusk conditions with no runway lights and the passenger reassured him about the landing. The pilot stated that, as the airplane was landing, the pilot-rated passenger knew something was wrong and told the pilot to “add power.” The airplane subsequently made a left turn and impacted trees in a nose-high attitude; a postimpact fire ensued. Witnesses located near the accident site reported observing the airplane on final approach. One witness stated that the airplane appeared to be “slightly high and slightly fast” while on final approach to the runway and that the airplane had “floated down the runway” before a hard touchdown. Another witness stated that the left wing appeared to have stalled, and that the airplane landed hard on the left main landing gear first. One of the witnesses further stated that the airplane began to “wobble” and depart the left side of the runway, which followed by an increase in engine power and a go-around attempt. The witness added that engine power continued as the left wingtip was dragged across the ground about halfway through the go-around attempt. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on the runway and ground marks, and witnesses’ observations of the landing, the pilot continued an unstabilized landing approach, and delayed execution of a go-around, which resulted in a hard landing and subsequent loss of airplane control.
Probable cause
The pilot’s improper flare, which led to a hard landing, subsequent loss of control, and collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
S35
Amateur built
false
Engines
1 Reciprocating
Registration number
N354M
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-7516
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-05T21:13:06Z guid: 103962 uri: 103962 title: ERA21LA383 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103981/pdf description:
Unique identifier
103981
NTSB case number
ERA21LA383
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-27T23:38:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-10-23T00:03:01.31Z
Event type
Accident
Location
Miramar, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On September 27, 2021, about 2238 eastern daylight time, a Cessna 172G, N4118L, was substantially damaged when it was involved in an accident near Miramar, Florida. The flight instructor and student pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The student pilot stated that, as part of the preflight inspection, she noted that the airplane had been operated for 1.2 hours since the fuel tanks were filled. She visually inspected both fuel tanks and could see fuel inside but did not have a fuel dipstick available. She informed the flight instructor that the fuel level was a “little less” than full. She further reported that the flight instructor also performed a preflight inspection of the airplane but did not check the fuel tanks. The flight instructor stated that she checked the right fuel tank, which she verified by feel as full, but she did not check the left fuel tank, nor did she use the fuel dipstick. She added that the student pilot checked the left fuel tank and informed her that it was full. After proceeding to a nearby airport with the mixture control full rich, the student pilot performed 11 stop-and-go landings, then proceeded to return to the departure airport with the mixture control full rich. She indicated that, had she known the left fuel tank was not full, she would have fueled before returning to the departure airport. About 3 miles from the airport, the engine lost total power. At that time, she noted that both fuel gauges were stuck between 1/2 and empty. She repositioned the fuel selector from the BOTH position, where it had remained since engine start, to the LEFT and then the RIGHT tank positions but that did not restore engine power. She informed her student of the impending forced landing to a street and after touchdown on the road, she turned to avoid traffic and impacted another tree. She was not wearing the shoulder harness, which she said contributed to her injury. The airplane came to rest upright with substantial damage to the fuselage and right horizontal stabilizer. Neither fuel tank was breached. The right fuel tank was empty, while about 2.5 gallons of fuel were drained from the left fuel tank. The fuel selector was found between the BOTH and RIGHT fuel tank positions. The airplane’s published total unusable fuel amount was 3.0 gallons; 1.5 gallons in each fuel tank. The engine was removed from the airframe for recovery and only “drops” of fuel were noted in the fuel line between the fuel strainer and carburetor. No fuel was noted in the airframe fuel strainer.   Extensive impact damage precluded operational testing of the fuel quantity indicating system; the fuel transmitters were not tested. No fuel was noted in the carburetor bowl. Based on the hour meter, the airplane had been operated for about 4.5 hours since the fuel tanks had been filled. -
Analysis
The airplane’s fuel tanks were filled to capacity and the airplane was flown 1.2 hours before the flight instructor and student pilot departed on the accident flight. The student and instructor flew to a nearby airport, where they performed 11 stop-and-go landings, then departed to return to the departure airport. About 3 miles from the airport, the engine lost total power. The instructor switched the fuel selector from BOTH to the LEFT, then RIGHT tank positions, but engine power was not restored. The airplane impacted trees and a stop sign during the forced landing, resulting in substantial damage. The flight instructor reported that she was not wearing a shoulder harness, which contributed to the extent of her injury. Based on the hour meter, the airplane was operated about 4.5 hours since the fuel tanks had been filled. Following the accident, about 2.5 gallons of fuel were drained from the left fuel tank, which was 1 gallon more than the unusable amount, and no fuel was noted in the right fuel tank. The fuel strainer and carburetor bowl were absent of fuel. Based on the available information, the loss of engine power was the result of fuel starvation. The instructor stated that she did not use the fuel dipstick to confirm fuel quantity before departing on the flight. Had she done so, it is likely that she would have noted the airplane’s fuel state and fueled the airplane before returning to the departure airport, thus preventing the accident.
Probable cause
The flight instructor’s inadequate preflight and inflight fuel planning, which resulted in a total loss of engine power due to fuel starvation. Contributing to the flight instructor’s injury was her failure to wear the shoulder harness.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N4118L
Operator
Jacobs Flight Services LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17254187
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-23T00:03:01Z guid: 103981 uri: 103981 title: CEN21FA459 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103984/pdf description:
Unique identifier
103984
NTSB case number
CEN21FA459
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-28T10:00:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-10-04T23:59:02.266Z
Event type
Accident
Location
Hiles, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
Aircraft Performance Study An aircraft performance study was conducted for this investigation. The study was largely based on ADS-B data. Figure 3 shows the ADS-B altitude and estimated airspeed for the 11-minute flight in an overhead view. The airplane’s airspeed was estimated to be at the stall speed at the altitude, airspeed, and time marked in red in the figure. Figure 3. ADS-B altitudes and airspeeds for the accident flight. At 0900:38.7, the airplane pitched down in excess of 30° and descended at a rate that reached 20,000 ft per minute. About the time that the airplane pitched down, the estimated normal load factor decreased from about 1.6 Gs to less than 1 G. The study stated that a decrease in normal load factor is consistent a stall when the wing reaches its critical angle of attack, at which time the air flow becomes separated at the wing and the wing can no longer generate the necessary lift. The study also stated that a spin could result if an airplane were in uncoordinated flight at the time of a stall. Airplane Stall/Spin Recovery Procedures Certification The accident airplane was certificated under Civil Air Regulations Part 3 (CAR 3) for normal-category operations. According to the FAA, per CAR 3.20(a)(1), the airplane was intended for non-aerobatic, nonscheduled passenger, and nonscheduled cargo operations. For this operational category, manufacturers are not required to include spin recovery procedures in the POH, but there is a requirement for airplanes to be placarded against spins. For the accident airplane model, the required placard was located on the left side of instrument panel. The FAA stated that some normal-category airplanes have a placard describing the control inputs required for recovery from spinning maneuvers, but these placards are only required for utility- and acrobatic-category airplanes, and there are no regulatory requirements to include these procedures in the POH. As previously stated, the POH for the accident airplane model (a 690B) does not contain the recovery procedures, but the POHs for the 690C and 690D models POHs contain the recovery procedure. The FAA stated that it was unclear why the POH for the 690C and 690D models had spin recovery procedures given that the POH for the accident model and the 690A did not. In addition, the FAA stated that guidance from General Aviation Manufacturers Association (GAMA) Specification No. 1, “Specification for Pilot’s Operating Handbook,” section 3.9(h), Spins, suggested that “it is largely up to the applicant’s [that is, manufacturer’s] discretion as to the inclusion of spin recovery procedures for multiengine airplanes in the POH.” According to GAMA Specification No. 1, section 3.9 (h), if the manufacturer opts to include spin recovery procedures in the POH, “it should be noted that multi-engine airplanes have not been spin tested by the manufacturer, if such is the case.” - According to the airplane maintenance records, the airframe’s most recent inspection was a 150-hour periodic inspection, which was performed on September 24, 2021, at a total airframe time of 7,854.7 hours. In addition, the 150-, 200-, and 300-hour inspections were performed on both engines. In July 2021, the accident pilot performed an in-flight shutdown of the right engine and performed a single-engine landing. According to the engine maintenance work order, “Pilot reported that torque would hang up at 300 HP [horsepower] while power lever at flight idle causing the pilot to shut down the engine to land [the] aircraft.” Maintenance performed a ground run and could not duplicate the problem. According to the work order, the engine fuel control unit and fuel inlet sensor were removed and replaced with overhauled components. No additional maintenance was performed on the right engine between July and September 24, 2021. The airplane was equipped with a Collins AP-106 Flight Control Systems autopilot. According to its description, the system is a fully integrated autopilot/flight director/compass system that provides the following modes: heading, navigation, altitude hold, and indicated airspeed hold. The airplane’s stall warning system consisted of a warning horn and a stall warning switch. The switch, installed on the right-wing leading edge, was factory adjusted to close when the airplane was between 4 and 9 knots above the aircraft stall speed. According to the Commander 690B Pilot’s Operating Handbook (POH), section II, Limitations, the airplane’s stall speed with landing gear and flaps retracted at gross weight was 82 knots calibrated airspeed (KCAS), and its minimum controllable airspeed was 86 KCAS. The POH did not include a procedure for recovery from an inadvertent spin. The POH stated, “acrobatic maneuvers, including spins, are unauthorized.” - On September 28, 2021, about 0900 central daylight time, a Rockwell International 690B airplane, N690LS, was destroyed when it was involved in an accident near Hiles, Wisconsin. The pilot and two passengers sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 aerial imagery survey flight. According to the operator, the purpose of the flight was to obtain aerial imagery of forest vegetation for the Wisconsin Department of Natural Resources. Automatic dependent surveillance-broadcast (ADS-B) and ATC information provided by the Federal Aviation Administration (FAA) indicated the airplane departed Rhinelander-Oneida County Airport (RHI), Rhinelander, Wisconsin, about 0850. About 8 minutes later, the airplane began to level off at an altitude of about 16,100 ft and accelerated to a maximum recorded groundspeed of 209 knots. Between 0858 and 0900, the airplane’s groundspeed decreased to about 93 knots, and the airplane descended about 500 ft while on a steady northeasterly heading. The airplane subsequently made a right turn with a rapid descent (see figure 1), and the ADS-B data ended at 0900:56. According to ATC audio, transmissions indicating “mayday, mayday, mayday” and ”we’re in a spin” were broadcast while the accident airplane was in flight. Figure 1. Airplane flightpath and accident site location. A witness, who was located about 1 mile from the accident site, reported that he heard a “loud, strange sounding airplane.” He looked up and noticed an airplane “nose down at high rate of speed spinning about its longitudinal axis at about 30 to 60 rpm.” The witness lost sight of the airplane after it descended behind trees, and then he heard an impact. - The pilot’s logbook was not located during the investigation. According to training records that the operator provided, on February 5, 2021, the pilot successfully completed Turbo Commander 690B ground and simulator training (10.0 hours) provided by SIMCOM Aviation Training. In addition, on March 19, 2021, the pilot completed 40.9 flight hours in the operator’s Aircraft Familiarization and Pilot Qualification Mentoring Program. - The airplane wreckage was located in remote wetlands and wooded terrain (see figure 2). The wreckage was distributed in an area with a diameter of about 150 ft. Figure 2. Accident site and main wreckage. Most of the main wreckage was highly fragmented and submerged beneath the water surface; other debris was located in the adjacent trees. The forward fuselage, fragmented sections of the wings, and a portion of the rear fuselage were submerged in the wetlands. A smell of Jet A aviation fuel and sheen on the wetlands were noted at the accident site. The cockpit and fuselage were crushed aft and fragmented by impact forces. Flight control cable continuity could not be established due to the fragmentation of the airplane. All flight control cable connections exhibited tensile overload fractures. The primary and secondary control surfaces were found fragmented within the debris field. Examination and disassembly of the left and right engines revealed damage that was consistent with engine rotation and operation at the time of the impact. Examination of the propeller blades indicated that both the left and right blades showed evidence of aft bending and twisting to a low-pitch position. Blade butt impact marks indicated aft impact loads consistent with a low blade angle, low power, and a steep impact angle. -
Analysis
The company pilot and two employees had departed on an aerial imagery survey flight of forest vegetation. The airplane began to level off at an altitude of about 16,100 ft mean sea level (msl) and accelerated to a maximum recorded groundspeed of 209 knots. Less than 2 minutes later, the groundspeed decreased to about 93 knots, and the airplane descended about 500 ft while on a steady heading. The airplane subsequently entered a rapid descent and a right turn, and “mayday, mayday, mayday” and “we’re in a spin” transmissions were broadcast to air traffic control (ATC). A witness, who was located near the accident site, noticed the airplane nose down at high rate of speed and then saw the airplane spinning rapidly about its longitudinal axis. The airplane wreckage was located in remote wetlands and wooded terrain. Postaccident examination revealed that the airplane impacted the ground in a noselow vertical attitude and at high speed. All major components of the airplane were located at the accident site. Examination of the airframe, engines, and propellers revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. According to the aircraft performance study for this accident, when the airplane pitched down, the normal load factor decreased rapidly from about 1.6 to less than 1 G. A rapid decrease in normal load factor is consistent with a stall when the wing exceeds its critical angle of attack. At that point, the air flow becomes separated at the wing, and the wing can no longer generate the necessary lift. If the airplane is in uncoordinated flight at the stall, a spin can result. Thus, the pilot likely did not maintain adequate airspeed, causing the airplane to exceed its critical angle of attack and enter a stall and spin. An important but unknown factor before and during the initial stall was the behavior of the pilot regarding his flight control inputs, including his possible attempt to recover. The airplane’s Pilot Operating Handbook states that spins are not authorized and does not include a procedure for inadvertent spin recovery.
Probable cause
The pilot’s failure to maintain adequate airspeed, which caused the airplane to exceed its critical angle of attack and enter an inadvertent stall and spin.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL INTERNATIONAL
Model
690B
Amateur built
false
Engines
2 Turbo prop
Registration number
N690LS
Operator
SURDEX CORP
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
11475
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-04T23:59:02Z guid: 103984 uri: 103984 title: ERA21LA384 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103989/pdf description:
Unique identifier
103989
NTSB case number
ERA21LA384
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-28T15:53:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-11-02T01:01:29.375Z
Event type
Accident
Location
Hobe Sound, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On September 28, 2021, at 1453 eastern daylight time, a Cessna 150M, N4100V, was substantially damaged when it was involved in an accident in Hobe Sound, Florida. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he performed a preflight inspection with no anomalies noted and then flew 9 nautical miles from his home base at Valkaria Airport (X59), Valkaria, Florida, to Sebastian Airport (X26), Sebastian, Florida, for fuel. After the pilot filled the fuel tanks, the airplane departed X26 for a flight to Witham Field Airport (SUA), Stuart, Florida. During the initial climb, the pilot noticed that the “angle of attack of the aircraft was higher than usual and the climb performance was less than expected.” He surmised that the airplane’s performance was likely due to the heat and full fuel load. The pilot further stated that the “clouds were relatively low so I didn't mind staying low.” He did not recall the route of flight but did recall monitoring the gauges because the performance of the airplane had him “concerned.” When the airplane was about 48 miles away from X26, the pilot determined that the airplane was “losing performance” and that it would not be able to reach an airport. As a result, the pilot initiated a forced landing in an open field. During the landing flare, the airplane stalled and impacted the ground. The airplane came to rest upright in the field with substantial damage to the wings and fuselage. Postaccident examination of the accident site revealed that the right wing was partially separated from the fuselage at its root and was crushed and bent upward and aft outboard of the wing strut. The left wing was damaged near its root, and both pillars forward of the cabin doors were crushed. The aft fuselage was fractured and partially separated just aft of the rear window. Fuel sampled from the right wing tank was blue in color and appeared cloudy. No fuel was present in the left wing. The fuel selector was in the “ON” position. The elevator trim tab actuator length was measured as 1 inch, which corresponded to a tab position of 10° trailing edge down (airplane nose up). A follow-up examination of the wreckage revealed that the engine was mostly undamaged. One propeller blade was bent 90° midspan, and the other propeller was bent and twisted about 10 inches from the tip. No leading-edge gouges or chordwise scratch marks were noted on either blade. The top spark plugs were removed. The electrodes were light gray in color and appeared “worn-normal” compared with the Champion check-a-plug chart. Thumb compression and suction were confirmed on all cylinders when the propeller was rotated by hand. Both magnetos produced sparks on all leads when the input drive shafts were rotated. Fuel sampled from the fuel strainer was blue in color and tested negative for the presence of water. The carburetor had fractured and separated from the intake manifold. The throttle, mixture, and carburetor heat control cables remained attached to their respective control arms. The fuel inlet screen was unobstructed. The bowl was dry and contained a trace amount of debris. The metal float assembly and needle valve/seat were intact. The 1458 weather conditions reported at SUA, located 8 nautical miles north of the accident site at an elevation of 18 ft, included a temperature of 29°C, dew point of 16°C, and a scattered cloud layer at 3,500 ft. The temperatures were within the “serious icing at glide power” portion of the Federal Aviation Administration’s carburetor icing probability chart. A review of the performance section of the airplane’s information manual revealed that, at maximum gross weight and a temperature of 30°C, the airplane’s expected climb performance was 625 ft per minute at sea level and an airspeed of 68 knots and 435 ft per minute at a pressure altitude of 4,000 ft and an airspeed of 65 knots. The engine had accrued a total time of 4,683 hours and 1,167 hours since overhaul. A review of the maintenance records revealed that the most recent inspection of the engine before the accident was a 100-hr inspection performed on June 8, 2021. At that time, the cylinder compression test results for three of the cylinders showed a decrease in compression (reductions of 17, 10, and 8 pounds per square inch [psi]) since the previous inspection; the remaining cylinder had a 6-psi increase in compression. One cylinder’s compression had decreased during previous two consecutive inspections. Cylinder Nos. 1 and 4 had the lowest test value (55 psi). According to a service bulletin from the engine manufacturer, acceptable compression test values vary and are to be determined at the time of the test. No conditions related to low compression (such as excessive oil consumption, abnormal appearance or condition of oil, or indications of high crankcase pressure) were noted in the previous 3 years of the accident airplane’s maintenance records. -
Analysis
The pilot departed his home base and flew to a nearby airport for fuel, where he filled the tanks. Afterward, the pilot departed for a cross-country visual flight rules flight. During the takeoff climb, he noticed that “the angle of attack of the airplane was higher than usual and the climb performance was less than expected.” The pilot surmised that the airplane’s reduced performance was a result of the air temperature (about 30°C) and the full fuel load. He continued the flight and recalled monitoring the gauges because the performance of the airplane had him “concerned.” When the airplane was about 48 miles from the departure airport, he determined that the airplane was “losing performance” and that the airplane would not be able to reach an airport. He elected to perform a forced landing to a field. During the landing flare, the airplane stalled and impacted the ground. The pilot was seriously injured, and the airplane sustained substantial damage to the fuselage and wings. A postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operation. A review of weather records and airplane performance data indicated the airplane’s expected maximum rate of climb would have been 435 ft per minute or greater at altitudes below 4,000 ft. According to the Federal Aviation Administration’s carburetor icing probability chart, at the surface temperature and dew point during the accident flight, “serious icing at glide power” could be expected. One key symptom of carburetor ice is a reduction in engine rpm, which would result in reduced engine power and climb performance. However, another key symptom of carburetor ice is a roughness in engine operation, which the pilot did not report. He first noticed the decreased performance during the climb, when the engine was likely set for takeoff (full) power. The pilot then determined, while the airplane was flying presumably at a cruise power setting, that the airplane’s performance had decreased such that the airplane would be unable to continue to an airport. Given these presumed power settings along with no reported engine roughness, carburetor icing was likely not a factor in the accident. A review of the airplane’s maintenance records revealed that, at the time of the most recent engine inspection (performed almost 4 months before the accident), the compression test values for some cylinders were lower than during the previous inspection. Significantly reduced cylinder compression results in reduced engine power and decreased airplane performance. However, results between compression tests can occur. Results depend on a number of variables, including ambient and engine temperatures at the time of the tests; therefore, acceptable values are determined at the time of each inspection. No other conditions related to typical concerns with low compression (such as excessive oil consumption, abnormal appearance or condition of oil, or indications of high crankcase pressure) were noted in the airplane’s maintenance log entries during the previous 3 years. The investigation could not determine whether one or more cylinders experienced progressive wear or another condition that might have resulted in deteriorating compression over time.
Probable cause
A reported loss of engine performance for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N4100V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15076701
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-02T01:01:29Z guid: 103989 uri: 103989 title: CEN21LA472 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104057/pdf description:
Unique identifier
104057
NTSB case number
CEN21LA472
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-28T17:08:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-10-07T00:58:16.256Z
Event type
Accident
Location
East Sparta, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s Continental TSIO-520-R engine, serial No. 1032649, was manufactured on July 18, 2016, and was installed new on the airplane on August 18, 2016. At that time, the airframe total time (AFTT) was 5,262.0 hours. At the time of the airplane’s last annual inspection, the airframe total time and the engine time since new were 6,272 and 1,010 hours, respectively. At the time of the accident, the engine time since new was 1,134 hours. An oil analysis was performed on an oil sample collected during the last oil change, which was completed on August 16, 2021. The results of the oil analysis indicated an increased level of chromium, iron, and nickel. The chromium and iron levels were somewhat similar to the levels that had been reported on a previous oil analysis, dated October 1, 2020, but were above the long-term averages for each. The nickel level, at 51 parts per million, was about 34% higher than the 38 parts per million reported on the October 1, 2020, oil analysis. The material composition of the exhaust valve stem and valve guide included a significant amount of nickel. The comments section of the oil analysis report noted the increased metal wear, which the laboratory thought was not an immediate concern as long the levels did not trend upward. The engine accumulated 20 hours since the last oil change. A review of the available maintenance documentation revealed no evidence of an unresolved engine issue. - On September 28, 2021, about 1608 eastern daylight time, a Cessna T210N airplane, N1925U, was substantially damaged when it was involved in an accident near East Sparta, Ohio. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) track data, about 1534, the airplane departed from runway 2 at Wadsworth Municipal Airport (3G3), Wadsworth, Ohio. A plot of the airplane’s ground track during the flight is depicted in figure 1. The airplane flew about 2.8 miles north of the airport before entering a climbing turn to a south course. The airplane leveled at 3,500 ft mean sea level (msl) as it continued to the south. At 1555:12, the airplane entered a left turn to the southeast at 3,500 ft msl. Figure 1. Airplane ground track for accident flight. The pilot reported that, during cruise flight, the engine began running rough with a sudden decrease of exhaust gas temperature (EGT) for cylinder Nos. 2 and 4. He contacted Cleveland approach, declared an emergency with the controller, and turned left toward Akron-Canton Regional Airport (CAK), Akron, Ohio, as depicted in figure 2. Figure 2. Airplane ground track showing left turn. According to engine monitor data, at 1604:54, the engine began to run erratically with a sudden decrease in manifold pressure and EGT for cylinders Nos. 2 and 4, as depicted in figures 3 and 4. The engine continued to run with partial power for about 100 seconds before it lost total power. Figure 3. Turbine inlet temperature, cylinder head temperature, and EGT during the accident flight. Figure 4. Engine speed, manifold pressure, and fuel flow during the accident flight. According to ADS-B data, after the loss of engine power, the airplane entered a descent from 3,500 ft msl and decelerated from 130 to 79 knots calibrated airspeed, as depicted in figure 5. Figure 5. Airplane altitude, speed, and vertical speed during the accident flight. At 1608:05, the last ADS-B return was recorded, which showed that the airplane was about 240 ft west of the accident site and about 163 ft above ground level. The pilot chose to make a forced landing into a hilly pasture. The airplane’s ground track and descent profile was consistent with the forced landing occurring on an east-southeast heading. The pilot reported that the nose gear separated during landing roll and that the airplane came to rest nose down. - Postaccident examination revealed that the airplane’s engine mount and lower fuselage structure were substantially damaged during the forced landing. A partial teardown of the engine determined that the No. 2 cylinder exhaust valve was fractured. The No. 2 cylinder assembly and ancillary components, shown in figure 6, were examined at the National Transportation Safety Board Materials Laboratory, Washington, DC. The exhaust valve head was situated on edge and embedded in the cylinder head adjacent to the intake valve seat, as shown in figure 7. The intake valve head was fractured in multiple locations and was pushed through the valve seat. The exhaust valve seat was missing, and much of the cylinder head material around the exhaust outlet exhibited erosion and impact damage. Figure 6. Cylinder No. 2 component layout. Figure 7. Cylinder No. 2 intake and exhaust valve heads. The exhaust valve fractured near the stem-to-fillet transition. The fracture surface exhibited a flat morphology with ratchet marks at one location along the edge, as shown in figure 8. The features were consistent with the crack initiating at that location. The fracture origin was obscured by damage, which prevented a detailed examination. Away from the origin, the fracture surface exhibited curved crack arrest marks and features that were consistent with a fatigue fracture. The valve stem surface did not exhibit any pitting, erosion, or other notable features. Figure 8. Cylinder No. 2 exhaust valve stem fracture surface. The clearance from the exhaust valve stem to the valve guide clearance, which was measured in the upper and middle thirds of the valve guide, were 0.0067 and 0.0111 inch, respectively. The manufacturer’s service limit for the exhaust valve stem clearance is 0.0085 inch. The clearance from the exhaust rocker arm shaft to the rocker arm bearing was similarly measured and found to be 0.0032 and 0.0041 inch at the inboard and outboard ends, respectively. The manufacturer’s service limit for the exhaust valve rocker arm shaft clearance was 0.0040 inch. -
Analysis
The pilot reported that during cruise flight the engine began to run rough with a sudden decrease in engine manifold pressure and exhaust gas temperature for cylinder Nos. 2 and 4. The engine continued to run erratically for another 100 seconds before it lost total power. The pilot made a forced landing on hilly terrain, during which the nose gear collapsed. The airplane’s engine mount and lower fuselage structure were substantially damaged. Postaccident examination determined that the No. 2 cylinder exhaust valve fractured near the stem-to-fillet transition. The fracture surface exhibited features consistent with a fatigue failure. Additionally, the clearance from the exhaust valve stem to the valve guide exceeded the manufacturer’s service limit. The No. 2 cylinder exhaust valve failed in fatigue likely due to the wear of the valve guide and rocker arm bearing systems. The wear of the guide allowed the exhaust valve to move so that it could no longer consistently contact the valve seat. The asymmetric load induced a bending moment on the exhaust valve stem that eventually resulted in the initiation of a fatigue crack along the stem edge. The wear of the rocker arm shaft and rocker arm bearing likely contributed to the exhaust valve failure by tilting the rocker arm and changing the angle at which it engaged the tip of the exhaust valve stem.
Probable cause
A total loss of engine power due to a fatigue failure of the No. 2 cylinder exhaust valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N1925U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21064750
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-07T00:58:16Z guid: 104057 uri: 104057 title: ERA21LA387 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103995/pdf description:
Unique identifier
103995
NTSB case number
ERA21LA387
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-28T20:00:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-04-29T04:28:15.172Z
Event type
Accident
Location
Miami, Florida
Airport
MIAMI EXEC (TMB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On September 28, 2021, at 1900 eastern daylight time, a Robinson R44 II helicopter, N212HT, was substantially damaged when it was involved in an accident near Miami, Florida. The private pilot sustained minor injuries and the three passengers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot provided a detailed statement and was interviewed by telephone. He said a colleague wanted to take two of his friends for a helicopter ride and the pilot agreed. The pilot rented the helicopter from an individual at Palm Beach County Park Airport (LNA), West Palm Beach, Florida, flew to Miami Executive Airport (TMB), Miami, Florida, picked up the three passengers, flew around the Miami area, and returned to TMB, where he landed the helicopter to deplane the passengers. According to the pilot, he lowered the collective and began the shutoff procedure. He said he first reduced the throttle to idle and applied collective friction. The pilot further said his recollection of events from this point was “blurry,” as the helicopter began “spinning” and the helicopter subsequently impacted the ground on its left side. In a written statement, a passenger stated that, once on the ground, the pilot “was reducing the engine and preparing for shutdown [when] suddenly we started spinning.” He said the pilot attempted to regain control, but the spinning was “very powerful” before the helicopter became airborne and then crashed. A flight instructor and his student witnessed the event from the ground. The instructor said that he saw the helicopter rotating around the mast “out of control” before it descended to ground contact. The student stated that he observed the passenger onboard the accident helicopter remove his shoulder harnesses and headset when the helicopter “made a strong turn to the left,” rotated “uncontrollably” around the main rotor mast, and “took off without control” before “plummeting” to the ground. Surveillance video captured the accident sequence from a front quartering view toward the right side of the cockpit. The “coning” of the rotor system reduced to a flat rotor disc after touchdown, and the passenger in the helicopter’s left front seat could be seen removing his shoulder harnesses and headset. The passenger moved the headset to his front when the helicopter began a rapid yaw to its left and rotated around the main rotor mast. After one full revolution, the helicopter lifted rapidly from the ground and climbed immediately out of the camera’s view as it continued to rotate rapidly around the main rotor mast. Seconds later, the helicopter descended back into view in an uncontrolled descent. The main rotor disc severed the tailboom in two places ahead of the tail section, which included the tailrotor and tailrotor gearbox, before ground contact. The pilot held a private pilot certificate with a rating for rotorcraft-helicopter, which was issued based on his pilot certificate issued by the State of Israel. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued March 10, 2021. The pilot declared 220 total hours of flight experience on that date. Review of the pilot’s logbook by an FAA aviation safety inspector revealed an estimated 178 total hours of flight experience logged, with an estimated 100 total hours of experience in the accident helicopter make and model, and 78 in the Robinson R22. Those hours were accrued over a 10-year span, with two flights recorded in 2021. One flight was recorded May 1, 2021, in a Robinson R44 helicopter, and the other was recorded in Israel on July 3, 2021, in a Robinson R22 helicopter. The July flight was annotated as a “checkride.” The pilot had obtained logbook endorsements for FAA Special Federal Aviation Regulation (SFAR) 73 Awareness training for the Robinson R22/R44 model helicopters on August 20, 2012, and December 6, 2013; however, his logbook did not contain any of the required endorsements to act as pilot-in-command as a solo student pilot nor had the pilot obtained the proper endorsements to act as pilot-in-command in either the Robinson R22 or the Robinson R44 after receiving his private pilot certificate as required by (SFAR) 73 2 (B)1 and (B)2, which was an annual requirement at his experience level. Additionally, at the time of the accident, the pilot did not meet recency of flight experience requirements to carry passengers in the R44. The inspector’s review also revealed that the pilot conducted six flights between April 2020 and January 2021 without a valid medical certificate. The 1051 recorded weather observation at TMB included wind from 090° at 7 knots. The temperature was 26°C and the dewpoint was 19°C. The helicopter was examined at the accident site by FAA aviation safety inspectors, and all major components were accounted for at the scene. The helicopter rested on its left side, with the cockpit and cabin area largely intact. The left windscreen was fractured and separated. Control continuity was confirmed from the flight controls to the main rotor head, and to the tailrotor through the severed sections of the tailboom. A video study was completed by a National Transportation Safety Board performance engineer. A comparison of the manufacturer’s published maximum main rotor rpm operating limit of 408 rpm and the video frame rate revealed that, throughout the approach and landing and the uncontrolled takeoff and impact, the observed rotor speed was constant and close to the nominal speed of 408 rpm. During the telephone interview, the pilot was reminded of what he wrote in his written statement, and he said he didn’t remember anything in addition to what he had written. He had no recollection of his front seat passenger removing his seatbelts or headset, and only remembered what he was told after the accident. The pilot was asked if his left hand was guarding the collective control, or if he was perhaps using his left hand to shut off radios or some other task, and he said he could not remember where his left hand was placed when the helicopter started to rotate around the mast. The pilot was asked if his watch or clothing could have interfered with the collective control, and he said “no”. When asked about the performance and handling of the helicopter, the pilot said, “Everything went well. Just like the many other times that I’ve flown it.” -
Analysis
The pilot landed the helicopter following a local sightseeing flight with three friends. Review of surveillance video revealed that, after touchdown, the passenger in the helicopter’s left front seat began removing his shoulder harnesses and headset. The passenger moved the headset to his front when the helicopter began a rapid yaw to its left and rotated around the main rotor mast. After one full revolution, the helicopter lifted rapidly from the ground and climbed immediately out of the camera’s view as it continued to rotate rapidly around the main rotor mast. Seconds later, the helicopter descended back into view in an uncontrolled descent. The main rotor disc severed the tailboom in two places ahead of the tail section, which included the tailrotor and tailrotor gearbox, before ground contact. The pilot stated that he had reduced the throttle to idle after touchdown; however, review of the video indicated that the helicopter’s main rotor speed remained constant at its maximum rpm throughout the approach, landing, ground operation, and the accident sequence. The accident helicopter make and model was the subject of a Federal Aviation Administration Special Federal Aviation Regulation (SFAR), which specified academic, flight training, qualification, and currency requirements for pilots acting as pilot-in-command. Review of the pilot’s logbook revealed that he had not received the proper endorsements for operating the helicopter as pilot-in-command as a student pilot, nor had he complied with the annual requirements of the SFAR after receiving his private pilot certificate. Additionally, at the time of the accident, he did not meet the currency requirements specified by the SFAR for carrying passengers in the accident helicopter make/model. Examination of the helicopter revealed no evidence of preimpact mechanical anomalies that would have precluded normal operation. Based on the available information, the pilot’s loss of control and the helicopter’s uncontrolled takeoff was likely due to his misapplication of collective control after landing or his failure to guard the collective against the passenger’s interference. The pilot displayed a history of intentional noncompliance with regulations, including the SFAR and medical certificate requirements. The pilot's loss of helicopter control after landing is consistent with his lack of recent flight experience and his failure to comply with the training and currency requirements of the SFAR.
Probable cause
The pilot’s loss of helicopter control after landing. Also causal was the pilot’s intentional operation of the helicopter without the required training, experience, and endorsements.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N212HT
Operator
Iftach Shimonovich
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
12217
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-29T04:28:15Z guid: 103995 uri: 103995 title: ERA21LA386 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103994/pdf description:
Unique identifier
103994
NTSB case number
ERA21LA386
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-29T11:30:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-09-30T17:19:11.192Z
Event type
Accident
Location
Millen, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On September 29, 2021, about 1030 eastern daylight time, a Hiller UH-12E helicopter, N430NR, was substantially damaged when it was involved in an accident near Millen, Georgia. The pilot sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was enroute to his next jobsite at 500 ft above ground level and 70 knots airspeed when he heard a “pop” sound. The engine accelerated to a high rpm, and the helicopter began to spin counterclockwise at a high rate. The pilot reported that the cyclic stick would not move and that pedal and collective control inputs had no effect. The pilot continued his attempts to counteract the helicopter’s rotation as it descended to ground impact. The helicopter came to rest on its left side in a field. Examination by a Federal Aviation Administration inspector revealed that the impact sheared the right skid and that the outer sections of the two main rotor blades separated. The separated sections of the two main rotor blades were found about 225 ft west-northwest and 180 feet north-northwest of the main wreckage site, respectively. The ‘yellow’ control rotor had separated and was found about 270 ft southwest of the main wreckage site. The main rotor head, containing the main rotor hub, gimbal ring assembly, collective ballast assembly, the upper portion of the main rotor mast, the ‘blue’ and ‘yellow’ main rotor blade inboard ends, and the ‘blue’ control rotor, had separated and was found about 135 ft south of the main wreckage site. Postaccident examination of the wreckage revealed that airframe damage was consistent with ground impact and that main rotor blade deformation and damage were consistent with powered impact with terrain. Examination of the main rotor system and the flight control system revealed no evidence of preimpact anomalies that would have prevented normal flight. Damage to the tail rotor blades was consistent with the tail rotor not being under power at impact, and the tail rotor gearbox input pinion bevel gear was found fractured from its gear shaft. The National Transportation Safety Board Office of Research and Engineering, Materials Laboratory Division, performed metallurgical examinations of the main rotor hub, the ‘yellow’ control rotor and trunnion, and pieces of the tail rotor gearbox input pinion. Examination revealed that the fractures and separations of the ‘yellow’ control rotor and trunnion studs occurred due to overload and that the tail rotor gearbox input pinion bevel gear shaft had fractured from fatigue. Examination revealed that the fatigue cracking initiated at gouge marks on the outer surface of the cylindrical shaft and propagated through nearly the entirety of the shaft cross-section. Review of maintenance records revealed that the tail rotor gearbox was disassembled, visually inspected, and reassembled on August 28, 2018, about 330.3 hours before the accident. Attempts to contact the mechanic who performed this maintenance action were unsuccessful. -
Analysis
During cruise flight, the pilot heard a “pop” sound followed by the engine accelerating to a high rpm. According to the pilot, the helicopter began spinning counterclockwise at a high rate; the cyclic stick would not move; and collective and pedal control inputs had no effect. The pilot continued his attempts to counteract the helicopter’s rotation as it descended to ground impact. Postaccident examination of the wreckage revealed that airframe damage was consistent with ground impact and that main rotor blade deformation and damage were consistent with powered impact with terrain. Damage to the tail rotor blades was consistent with the tail rotor not being under power at impact, and the tail rotor gearbox input pinion bevel gear was found fractured from its gear shaft. Metallurgical examination of the input pinion gear shaft revealed that it had fractured from fatigue. The fatigue cracking initiated at gouge marks on the outer surface of the cylindrical shaft and propagated through nearly the entirety of the shaft cross-section. The length of the fatigue cracks and the fine spacing of the striations were indicative of high cycle fatigue crack propagation. Review of maintenance records revealed that the tail rotor gearbox was disassembled, visually inspected, and reassembled about 330.3 hours before the accident. Based on the high cycle fatigue crack propagation and the presence of fatigue cracking on the majority of the fracture cross-section, it is likely the gouge marks on the input pinion gear shaft were created during reassembly of the tail rotor gearbox during this maintenance action. A loss of drive to the tail rotor would result in a clockwise, nose-right yaw of the helicopter due to the torque effect on the fuselage of the counterclockwise rotation of the main rotor. The sudden loss of tail rotor drive due to the fracture of the input pinion bevel gear would unload the powertrain of the power being used by the tail rotor, leading to a temporary increase of rotor rpm as well as engine rpm, consistent with the pilot’s report. Although the pilot reported that the helicopter began to spin counterclockwise, it is likely he misidentified the direction of yaw.
Probable cause
The improper reassembly of the tail rotor gearbox following maintenance, which resulted in fatigue failure of the input pinion gear shaft, and the subsequent loss of tail rotor drive.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HILLER
Model
UH-12E
Amateur built
false
Engines
1 Reciprocating
Registration number
N430NR
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
2074
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-09-30T17:19:11Z guid: 103994 uri: 103994 title: ERA21LA388 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103998/pdf description:
Unique identifier
103998
NTSB case number
ERA21LA388
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-29T15:06:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-10-20T20:11:31.815Z
Event type
Accident
Location
Port Orange, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 29, 2021, about 1406 eastern daylight time, a Cessna 172S, N116SV, was substantially damaged when it was involved in an accident near Port Orange, Florida. The flight instructor and the student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The flight instructor stated that, earlier that day, the student pilot flew from Massey Ranch Airpark (X50), New Smyrna Beach, Florida, to Gainesville Regional Airport (GNV), Gainesville, Florida, and made an uneventful full-stop landing. Afterward, the airplane departed GNV to return to X50 with the student pilot at the controls. The airplane had an adequate supply of fuel, and the engine fuel-to-air ratio was leaned once the airplane climbed to 3,500 ft mean sea level (msl). The controller at Daytona Beach Approach Control cleared the flight to descend to 2,500 and then 1,600 ft msl. While the airplane descended with the power reduced to 1,900 rpm, the flight instructor informed the student pilot that the airplane was 100 ft below the assigned altitude, and the student pilot replied, “we have no power.” The flight instructor took over the flight controls and applied full throttle, but the engine rpm did not change. He confirmed that the mixture control was in the full rich position and that the fuel selector was in the “both” position. The flight instructor simultaneously pitched the airplane to achieve the best glide speed (68 knots) and told the student pilot to complete the checklist for an engine failure during flight. As the student pilot performed the checklist, the flight instructor advised the controller that the engine had lost power, and the controller provided information about nearby airports. Due to the airplane’s altitude and distance from those airports at the time, the flight instructor realized an off-airport landing was necessary. The flight instructor located a field and performed a forced landing. After the airplane rolled on the ground for a few feet, the nose landing gear contacted “something,” and the airplane nosed over, resulting in substantial damage to the left wing, the vertical stabilizer, and the bottom and left side of the fuselage near the horizontal stabilizer. The airplane was equipped with a Garmin G1000 multifunction display. No pertinent data from the accident flight could be recovered because the unit firmware version installed on the unit did not store data. Postaccident examination of the engine revealed that rotation of the crankshaft did not result in rotation of the camshaft. After removal of the accessory case, the left crankshaft idler gear assembly, which was driven by the crankshaft gear and drove the camshaft, was found out of position. Extensive damage was noted in the area of the left crankcase (which supported and secured the crankshaft idler gear shaft). The left crankcase (which received the securing bolt on the lower portion of the crankshaft idler gear shaft) exhibited extensive damage. A castellated nut (which secured the upper portion of the crankshaft idler gear shaft to a stud in the left crankcase) was separated, and a bolt (which secured the lower portion of the crankshaft idler gear shaft to the left crankcase) was fractured. The right crankshaft idler gear shaft remained secured to the crankcase by two bolts that were safety wired. A photograph of the oil filter element showed non-ferrous particles. The owner/operator of the airplane reported that maintenance personnel had not cut open the oil filter (to inspect the filter element) during each engine inspection performed while he owned the airplane. The engine had been overhauled by a repair station in December 2010 and was installed in the airplane several days later. The engine was removed from the airplane in July 2011 for a disassembly inspection due to a stuck valve and bent pushrods. The engine was reinstalled in the airplane on July 20, 2011, where it remained through the time of the accident. The engine accrued about 3,488 hours since June 25, 2021, which was the date of the engine’s last inspection and oil change. No evidence for this investigation allowed a determination regarding the engine time accrued between the last inspection and the accident. -
Analysis
After an uneventful 1-hour flight, the flight instructor and student pilot were returning to the airplane’s home base. The flight instructor pointed out to the student that the airplane had descended below the assigned altitude, and the student replied, “we have no power.” The flight instructor took over the flight controls and attempted to restore power. Because that effort was unsuccessful, the flight instructor pitched the airplane to achieve the best glide speed. After realizing that the airplane would not reach the nearest airport, he performed a forced landing in a field, and the airplane nosed over during the landing roll. Postaccident examination of the engine revealed that the camshaft was not being driven by the left crankshaft idler gear assembly because it was out of position. The nut that secured the idler gear to a stud at the left crankcase was separated, and a bolt that also secured the idler gear to the left crankcase was fractured. Extensive damage was noted to the left crankcase in the area that supported the idler gear and the area into which the securing bolt was threaded, indicating movement of the crankshaft idler gear shaft for an extended period of time. The available evidence for this investigation did not allow a determination regarding the reason for the separation of the nut from the stud and the fracture of the bolt that secured the idler gear to the crankcase. The engine was last overhauled about 11 years and 3,488 hours before the accident. The owner/operator of the airplane at the time of the accident stated that, during the time that he owned the airplane, maintenance personnel had not cut open the oil filter to inspect the filter element during each oil change. Photographic evidence showed the presence of non-ferrous particles in the oil filter element. It is likely that these particles were from the damaged left crankcase. If maintenance personnel had cut open the oil filter and inspected the filter element during each oil change (the most recent of which was during the last inspection of the engine 3 months before the accident), it is possible that they would have detected the presence of non-ferrous particles in the filter element and taken action to identify the source.
Probable cause
The separation of the nut from the stud and the fracture of the bolt that secured the crankshaft idler gear to the engine crankcase, which resulted in a total loss of engine power due to the inability of the left crankshaft idler gear assembly to drive of the camshaft.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N116SV
Operator
Aviation Pacific Flight Training School
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S9815
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-20T20:11:31Z guid: 103998 uri: 103998 title: ERA21LA391 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104049/pdf description:
Unique identifier
104049
NTSB case number
ERA21LA391
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-09-30T14:30:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-02T01:07:47.931Z
Event type
Accident
Location
Nicholson, Pennsylvania
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 30, 2021, about 1330 eastern daylight time, a Boeing E75, N1654M, was substantially damaged when it was involved in an accident near Nicholson, Pennsylvania. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, while the airplane was at an altitude of 3,500 ft, the engine suddenly lost total power. He adjusted the throttle, mixture control, fuel valve controls, and carburetor heat, but the engine would not restart. Shortly afterward, the pilot noticed a strong smell of fuel. He then flew the airplane toward a nearby private airstrip. While setting up an approach to the runway, the pilot determined that the airplane would not reach the airstrip and performed a forced landing into trees that bordered the airport property, which resulted in substantial damage to the fuselage and wings. Postaccident examination of the airplane found that the engine separated from the fuselage during the accident sequence and that fuel had been draining from the fuel line for “some time” after the accident occurred. A subsequent examination of the engine revealed that the carburetor’s rotating mixture actuating rod was difficult to rotate, and binding occurred as the actuating rod was rotated by hand. (The cockpit mixture control lever, through a linkage of push-pull tubes and control arms, rotates the mixture actuating rod.) The carburetor was then disassembled, and the actuating rod and the metering needle connected to the inner end of the rod were found bent, as shown in the figure below. (The metering needle attaches to an offset pin at the inner end of the actuating rod. As the rod rotates, the metering needle moves up or down [out of or into its seat] to control the amount of fuel that flows through the carburetor, setting the mixture.) Figure. - Mixture actuating rod and metering needle. The carburetor was otherwise undamaged. No impact marks, deformation, or other damage was found to the housing or bushings that surround the actuating rod and the seat for the metering needle. Other than the mixture actuating rod and the metering needle, no preimpact anomalies were found with the engine or the airframe fuel system components that would have precluded normal operation. The front spark plugs were removed from the cylinders. Two had gray-colored electrodes, four had black-colored electrodes, and three of the electrodes were oil soaked. A review of the maintenance records revealed no entries related to the carburetor or its controls during the preceding 4 years. During that time, the engine accumulated 81 hours total time. -
Analysis
The pilot reported that, while the airplane was at an altitude of 3,500 ft, the engine lost total power. He attempted to regain engine power by adjusting the throttle, mixture control, fuel valve controls, and carburetor heat; however, the engine would not restart. As the pilot set up an approach to a nearby airstrip, he determined that the airplane would not reach the runway and performed a forced landing into trees, resulting in substantial damage to the fuselage and wings. Postaccident examination of the engine revealed that the carburetor’s rotating mixture actuating rod was difficult to rotate, and binding occurred as the actuating rod was rotated by hand. Upon disassembly of the carburetor, the mixture control actuating rod and the metering needle, which is connected to the inner end of the rod, were found bent. No other damage to the carburetor was found. Because these components are largely or entirely internal to the carburetor, the bending of actuating rod and the metering needle was likely not a result of impact damage. The investigation was unable to determine how or when the carburetor components became bent. Although the bends in the actuating rod and metering needle would not have prevented the mixture control from operating, the bends would have changed how the mixture setting in the carburetor responded to the mixture control lever in the cockpit. If the cockpit control was moved toward the cutoff position, the metering needle might not have performed as expected and might have moved into the cutoff position before or after the cockpit control reached its expected cutoff position. Likewise, with the cockpit control in the normal fullrich position, the metering needle might have been in a position that was either more or less than full rich. Therefore, the bent components likely resulted in a mixture setting that was not expected for any given cockpit mixture control setting. The investigation could not determine whether the mixture would have been too lean (less fuel) or too rich (more fuel), either of which could have resulted in the engine not producing power. Four of the cylinders’ spark plugs had black-colored deposits on their electrodes, consistent with a rich mixture condition. Two spark plugs had gray-colored deposits, consistent with a normal mixture condition. The remaining three spark plugs were oil soaked, masking their electrode color, but these spark plugs would generally be more consistent with a rich mixture condition rather than a lean condition.
Probable cause
A total loss of engine power as a result of damaged internal carburetor mixture control components.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
E75
Amateur built
false
Engines
1 Reciprocating
Registration number
N1654M
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-8300
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-02T01:07:47Z guid: 104049 uri: 104049 title: DCA22FM001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104053/pdf description:
Unique identifier
104053
NTSB case number
DCA22FM001
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2021-10-01T04:00:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2024-01-02T05:00:00Z
Event type
Accident
Location
Huntington Beach, California
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The probable cause of the damage to and subsequent crude oil release from the San Pedro Bay Pipeline was the proximity of established anchorage positions tothe pipeline, which resulted in two containerships’ anchors striking the pipeline when the ships dragged anchor in high winds and seas. Contributing to the crude oil release was the undetected damage to the pipeline, which allowed fatigue cracks to initiate and grow to a critical size and the pipeline to leak nearly 9 months later.Contributing to the amount of crude oil released was Beta Offshore’s insufficient training of its pipeline controllers, which resulted in the failure of the controllers to appropriately respond to leak alarms by shutting down and isolating the pipeline. Contributing to the pipeline controllers’ inappropriate response to the leak alarms was the water buildup in the pipeline, an incorrect leak location indicated by Beta Offshore’s leak detection system, and frequent previous communication-loss alarms.
Has safety recommendations
true

Vehicle 1

Vessel name
San Pedro Bay Pipeline
Vessel type
Other
Findings

Vehicle 2

Callsign
3FZU8
Vessel name
MSC Danit
Vessel type
Cargo
IMO number
9404649
Maritime Mobile Service Identity
357051000
Port of registry
Panama City, Panama
Classification society
DNV-GL
Flag state
PM
Findings

Vehicle 3

Callsign
9HA4041
Vessel name
Beijing
Vessel type
Cargo
IMO number
9308508
Maritime Mobile Service Identity
256937000
Port of registry
Valetta
Classification society
DNV-GL
Flag state
MT
Findings
creator: Coast Guard last-modified: 2024-01-02T05:00:00Z guid: 104053 uri: 104053 title: WPR22FA001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104018/pdf description:
Unique identifier
104018
NTSB case number
WPR22FA001
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-01T08:40:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Last updated
2021-10-08T01:52:18.667Z
Event type
Accident
Location
Chandler, Arizona
Airport
CHANDLER MUNI (CHD)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The Chandler Municipal Airport (CHD) FAA contract tower (FCT) had a Letter of Agreement (LOA), dated August 2020, with the helicopter operator that specified responsibilities, defined terms, and established the procedures for operations of helicopters within the CHD class D airspace. The provision of the letter applied only to helicopters conducting operations by persons authorized by the helicopter operator and only when CHD control tower was in operation. The LOA established a helicopter traffic pattern to taxiway C. (see Figure 2.) The helicopter traffic pattern altitude was 1,900 ft msl and the fixed wing traffic pattern altitude was 2,300 ft msl. Figure 2. View of helicopter and airplane traffic pattern - On October 1, 2021, about 0740 mountain standard time, a Piper PA-28-181 airplane, N2868H, and a Robinson Helicopter Company R22 helicopter, N412TL, were involved in a midair collision near Chandler, Arizona. The airplane sustained minor damage and the flight instructor and student pilot onboard were not injured. The flight instructor and student pilot onboard the helicopter were fatally injured, and the helicopter was destroyed. Both aircraft were operated as Title 14 Code of Federal Regulations Part 91 instructional flights. The flight instructor and student on board the airplane requested and received clearance from the tower controller to perform takeoffs and landings from runway 4L, remaining in the airport traffic pattern. After completing three touch-and-go landings, the tower controller instructed the airplane to switch to runway 4R and issued a frequency change. The instructor and student continued to perform touch-and-go takeoffs and landings from runway 4R, and the instructor recalled the controller requesting that the airplane extend their crosswind leg for helicopter traffic during one of their patterns. During the accident approach, the airplane was cleared for landing behind a twin-engine airplane. The instructor stated that he scanned the area for traffic, and abeam the runway numbers on the downwind leg of the traffic pattern, reduced engine power to idle to simulate a loss of engine power. On final approach for landing, the instructor took control of the airplane to demonstrate a slip and they heard and felt a loud bang. The instructor declared an emergency, thinking that the airplane had hit birds. During the landing flare, the flight instructor noticed the left wing continued to descend and used aileron inputs to keep the wing up. After the airplane touched down, it veered left and exited the runway before it came to a stop between runway 04R and 04L. Once the airplane came to a stop, he and the student pilot exited the airplane. Witnesses reported that an airplane on final approach descended on top of a helicopter and impacted the helicopter’s main rotor blades. The helicopter descended, impacted terrain, and a post-impact fire ensued. Review of air traffic control communications revealed that, about 0732, the accident airplane was advised to extend the upwind leg for helicopters operating in the parallel taxiway pattern; one of the pilots acknowledged. About 737:06, the accident helicopter was cleared to land on the taxiway. At 0737:52, the controller cleared the airplane to land behind the twin-engine airplane, and also stated that a helicopter was present at low level, ahead of the airplane to the right, proceeding southbound. The accident airplane acknowledged. At 0740:41, the instructor onboard the airplane declared an emergency following the collision. Recorded Automatic Dependent Surveillance-Broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) showed that both aircraft appeared to be on a base to final turn, with the airplane on the approach to runway 04R and the helicopter on the approach to taxiway C (parallel to and to the right of runway 04R). The data showed that the flight paths of the aircraft intersected about 0740:15 at an altitude of about 1,400 ft mean sea level (msl), as seen in Figure 1. Figure 1. View of helicopter and airplane ADS-B flight track data - The Maricopa County Office of the Medical Examiner in Phoenix, Arizona, performed an autopsy of the helicopter flight instructor and student pilot. The flight instructor and student pilot’s cause of death was multiple blunt impact injuries. The helicopter flight instructor toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. The helicopter student pilot’s toxicology testing performed by the FAA Forensic Sciences Laboratory detected amphetamine at 7 ng/ml in the student pilot’s urine. Amphetamine is a Schedule II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, the prescription drug is metabolized to amphetamine; commonly marketed names include Adderall, Dexedrine, and Vyvanse. After a single 30 mg oral dose, early blood levels averaged 0.111 ug/ml and average blood levels in adults using the long-acting prescription orally for a week were about 0.065 ug/ml. - At the time of the accident, the airplane flight instructor had accumulated about 425 total hours of flight experience, of which 32 hours were as a flight instructor. - Examination of the airplane accident site revealed that the airplane came to rest upright on the dirt field between runways 04R and 04L, on a heading of about 345° magnetic. The helicopter impacted terrain about .5 mile southwest of the approach end of runway 04R. Postaccident examination of the airplane did not reveal evidence of any mechanical anomalies that would have precluded normal operation. Flight control continuity was established from the cockpit to all primary flight controls. The airplane’s nose landing gear and tire, as well as the left main landing gear, had separated from the airplane and were located near the helicopter wreckage. Both tires were cut consistent with contact from the helicopter’s main rotor blades. A piece of the helicopter’s canopy was found lodged in the hat channel on the underside of the airplane. The helicopter came to rest on its left side on a heading of about 053° magnetic, at an elevation of 1,236 ft msl. No visible ground scars were observed surrounding the wreckage. All major structural components of the helicopter were located within about 15 ft of the main wreckage. Postaccident examination of the helicopter was limited due to impact damage and post-crash fire. -
Analysis
A low-wing airplane and a helicopter, both of which were operating as instructional flights with flight instructors onboard, were performing takeoffs and landings at the tower-controlled airport in day visual meteorological conditions. The helicopter was performing right traffic patterns to the taxiway that paralleled the runway, while the airplane was performing right traffic patterns, outside of and above the helicopter pattern, to the runway. The helicopter had been cleared for “the option” to the taxiway, while the airplane was cleared to land shortly thereafter. After receiving landing clearance, the instructor onboard the airplane elected to conduct a simulated engine failure to a full-stop landing, reducing the engine power to idle abeam the approach end of the runway, but did not advise the tower controller of his intentions. While on final approach, the instructor took control of the airplane and entered a forward slip. The instructor and student then heard and felt a loud “bang” and the instructor declared an emergency, thinking that the airplane had impacted birds. Flight track information, witness statements, and damage to the airplane indicated that the airplane descended into the helicopter while both aircraft were on final approach for landing. Review of tower control communications indicated that the accident airplane had been advised and was aware of helicopters operating to the parallel taxiway. The tower controller cleared the airplane to land behind a twin-engine airplane, and advised of a helicopter low and to the airplane's right (the accident helicopter). The circumstances of the accident are consistent with the failure of the pilots onboard the airplane to see and avoid the helicopter during landing approach, resulting in a collision with the helicopter. It is possible that the airplane’s low-wing configuration and steep descent while in the forward slip may have contributed to the pilots’ failure to see the helicopter below them.
Probable cause
The failure of the pilots onboard the airplane to see and avoid the helicopter while maneuvering in the traffic pattern, which resulted in a midair collision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R22
Amateur built
false
Engines
1 Reciprocating
Registration number
N412TL
Operator
Quantum Helicopters
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
4689
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N2868H
Operator
FLIGHT OPERATIONS ACADEMY LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7990508
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2021-10-08T01:52:18Z guid: 104018 uri: 104018 title: CEN22LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104040/pdf description:
Unique identifier
104040
NTSB case number
CEN22LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-02T13:25:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2021-10-12T21:32:13.777Z
Event type
Accident
Location
Lamesa, Texas
Airport
LAMESA MUNI (LUV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 2, 2021, about 1225 central daylight time, a Beech 23 airplane, N6996Q, was substantially damaged when it was involved in an accident near the Lamesa Municipal Airport (LUV), Lamesa, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane had just undergone an annual inspection that included replacement of the carburetor. She said that she returned to the maintenance facility several times because work that was requested had not been performed or noted discrepancies had not been repaired. On the day of the accident, the pilot planned to perform three takeoffs and landings before departing the area to fly the airplane to her home airport. She performed a preflight inspection, noting the only discrepancy being a non-working rotating beacon. She verified that both fuel tanks were full. Engine start, taxi and run-up were normal except that she noted the idle rpm and full throttle rpm were both slightly lower than before the carburetor replacement. The pilot took off from runway 34 and remained in the traffic pattern, which concluded in a touchdown before mid-field. She noted that she did not use carburetor heat during this landing approach as the temperature was above 75° F and the humidity was low. After touchdown she raised the flaps and applied engine power, performing a touch and go. When the airplane reached the departure end of the runway on the ensuing takeoff, the engine power suddenly reduced to idle. Due to the low altitude the pilot did not attempt to turn the airplane and landed in a field. The airplane sustained substantial damage to its right wing, engine mount, and forward fuselage,. Postaccident examination revealed that the fuel selector valve was not in a detent and was positioned between the left and off positions. The long end of the fuel selector handle was designed to reside between two spring loaded gates to prevent inadvertent selection of the off position during normal operation. The design required that one of the gates be depressed to allow the handle to be rotated to the off position. The handle was found outside of the gated area. The right-wing fuel tank was full of fuel and the left-wing fuel tank was empty. A cotter pin was not installed on the nut and bolt that secured the throttle cable to the carburetor throttle arm; however, the nut and bolt were still in their proper position and finger tight, and did not prevent normal operation of the throttle. No other mechanical discrepancies were found during the postaccident examination. In the pilot’s statement, she noted that the fuel selector handle was attached 180 degrees off. She noted that she, previous owners, and instructors were not aware of this and had always used the long end of the handle as an indicator of fuel selector position. According to the Federal Aviation Administration inspector that responded to the accident, the fuel selector handle was properly installed, but the pilot believed that the long end of the fuel selector handle was the indicator that was to be used to determine the fuel selector position. The fuel selector handle had a white triangular arrow on the opposite end from the long end of the handle that was to be used to indicate the selected position. The remainder of the handle was red in color. On the accident airplane, the paint on the fuel selector handle was faded and worn and the white triangular portion was also worn making it difficult to discern the triangular pointer. At the time of the accident, the recorded temperature and dewpoint at the accident airport were 22° C (72° F), and 13° C (55° F), respectively. These were in the range of susceptibility for serious icing at glide power settings. -
Analysis
The airplane was on the first flight following an annual inspection in which the carburetor had been changed along with other maintenance. The pilot reported that, during the preflight inspection, both fuel tanks were full and everything was normal except for a non-working rotating beacon. She reported that the engine started normally, and the engine checks were normal except that the engine rpms were slightly lower than before the carburetor replacement. The pilot performed one takeoff and landing without difficulty. On the ensuing takeoff, when the airplane reached the departure threshold, the engine power reduced to idle. The pilot made a forced landing in a field and the airplane sustained substantial damage to the right wing. The pilot reported that she did not use carburetor heat during the takeoff or landing because the temperature was above 75° F and the humidity was low; however, the temperature and dewpoint recorded at the accident airport were favorable for serious carburetor icing at glide power settings. Postaccident examination revealed that the fuel selector valve was not in a detent and was positioned between the left and off positions. The pilot stated she did not move the fuel selector valve during or after the flight. Investigators were unable to determine when the fuel selector valve was moved to this position. The postaccident examination also revealed that a cotter pin was not installed on the nut and bolt that secured the throttle cable to the carburetor throttle arm; however, the nut and bolt were still in their proper position and finger tight and did not prevent normal operation of the throttle. The right fuel tank was found full of fuel and the left tank was empty after the accident. The fuel tanks were not compromised and no leaks were noted. The reason the left fuel tank was empty when the pilot had verified it was full before the flight could not be determined. No other mechanical discrepancies were found that would have prevented normal operation. Based on the available information, the loss of engine power could have been the result of improper fuel selector positioning, which reduced fuel flow and starved the engine for fuel, fuel starvation due to inadequate fuel supply from the left fuel tank, or the pilot’s failure to use carburetor heat during the flight when conditions were conducive for serious carburetor icing. The reason for the loss of engine power could not be determined due to the multiple possibilities discovered during postaccident examination.
Probable cause
The loss of engine power for a reason that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B23
Amateur built
false
Engines
1 Reciprocating
Registration number
N6996Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-1103
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-12T21:32:13Z guid: 104040 uri: 104040 title: WPR22LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104033/pdf description:
Unique identifier
104033
NTSB case number
WPR22LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-02T17:46:00Z
Publication date
2023-10-12T04:00:00Z
Report type
Final
Last updated
2021-10-19T03:17:11.342Z
Event type
Accident
Location
Oregon City, Oregon
Airport
FAIRWAYS (OG20)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 2, 2021, about 1646 Pacific daylight time, an amateur-built Zenith CH750 airplane, N99HX, was substantially damaged when it was involved in an accident near the Fairways Airport, Oregon City, Oregon. The pilot was not injured, and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed about an hour before the accident. Following an uneventful local flight, he entered the airport traffic pattern on left downwind for runway 32. After the pilot turned onto final approach, the passenger told him she smelled something burning, and shortly after the pilot did as well. The pilot stated that, a few moments later, the sound of the engine changed for about 5 seconds, followed by a total loss of engine power. The pilot realized he was unable to make it to the airport and initiated an off-airport landing between two tall trees. During the landing sequence, the airplane impacted trees and terrain before it nosed over and came to rest inverted, which resulted in substantial damage to both wings. Following the accident, the pilot reported that the right fuel tank appeared to be empty, and that some fuel was leaking “slightly” from the left wing fuel tank. The pilot reported that, after refueling the airplane's left wing with 4 gallons of automotive fuel before the flight, the left wing contained about 10 gallons of fuel and the right wing contained about 3 gallons of fuel. When asked about verifying the fuel levels, the pilot stated that he measured the right fuel tank using the electronic flight information system and did not “dip the tank.” He said that the left fuel tank was “right between 3 and 4 gallons” before he added fuel, and that the after he fueled the left wing, it was at “7 gallons dipped via a dip stick.” The pilot reiterated that it was “7” gallons when he finished refueling and that the fuel burn rate was about 4.3 gallons per hour. The pilot reported on the Pilot/Operator Aircraft Accident Report Form that the airplane had 10 to 11 gallons of fuel at the time of takeoff. Postaccident examination of the recovered airplane revealed the fuel valves between the header tank and the wings were in the “off” position, and the fuel valve from the header tank to the electronic fuel pump was in the “on” position. The header fuel tank was void of any fuel. About a teaspoon of fuel was removed from the mechanical fuel pump. The electric fuel pump was turned on, and the pump emitted a loud audible noise, consistent with operating with no liquid (cavitating). No fuel was observed within either carburetor float bowl. The engine was test run “for several seconds” uneventfully. No evidence of any preexisting mechanical malfunctions were observed with the recovered engine or airframe. The airplane was equipped with 2 wing fuel tanks (left and right), which have a total capacity of 24 gallons of fuel, of which 22 gallons is usable. In addition to the fuel tanks, the airplane was equipped with a 1.6 gallon header tank. -
Analysis
According to the pilot, following an uneventful local flight, as he turned onto final approach to land, the passenger told him that she smelled something burning, and shortly after the pilot did as well. The pilot stated that, a few moments later, the sound of the engine changed for about 5 seconds, followed by a total loss of engine power. The pilot realized he was unable to make it to the airport so he initiated an off-airport landing. During the landing sequence, the airplane impacted trees and terrain before it nosed over and came to rest inverted. The pilot reported that before the flight, he refueled the left wing fuel tank with 4 gallons of automotive fuel, to a level of fuel between 7 and 10 gallons, and had noted the right wing contained 2 to 4 gallons of fuel. Additionally, he reported that he did not visually verify the fuel quantity in the right fuel tank, however, he did “dip” the left fuel tank. The pilot reported that the right fuel tank was empty after the accident and the left fuel tank was leaking “slightly.” Postaccident examination of the recovered airplane revealed the fuel valves between the header tank and the wings were in the “off” position, and the fuel valve from the header tank to the electronic fuel pump was in the “on” position. The header fuel tank was empty. About a teaspoon of fuel was removed from the mechanical fuel pump. No fuel was observed within either carburetor float bowl. A fuel source was attached to the engine inlet fuel pump, and the engine was successfully run. Each main fuel tank can hold a maximum of 24 gallons of fuel of which 22 gallons are usable. No evidence of any preexisting mechanical malfunctions were observed with the recovered engine or airframe.
Probable cause
The total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
CH750
Amateur built
true
Engines
1 Reciprocating
Registration number
N99HX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
8423
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-19T03:17:11Z guid: 104033 uri: 104033 title: ERA22FA001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104031/pdf description:
Unique identifier
104031
NTSB case number
ERA22FA001
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-03T20:49:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-10-18T18:08:42.763Z
Event type
Accident
Location
Andrews, North Carolina
Airport
WESTERN CAROLINA RGNL (RHP)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On October 3, 2021, about 1949 eastern daylight time, a Beech S35, N876T, was destroyed when it was involved in an accident near Andrews, North Carolina. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot was performing the first leg of a cross-country flight to Pennsylvania that originated at Liberty Municipal Airport (T78), Liberty, Texas, about 1134 central daylight time with an intended destination of Macon County Airport (1A5), Franklin, North Carolina. Due to weather conditions, the pilot diverted to Western Carolina Regional Airport (RHP) in Andrews. A witness on the ramp, who was also a pilot, reported that the accident pilot entered the left downwind of the airport traffic pattern for runway 8 from the east and flew north of the runway; however, the published traffic pattern for runway 8 was right traffic (due to rising terrain north of the runway). The witness further reported that the pilot’s first approach was too fast, and he performed a go-around. The pilot continued to fly a left traffic pattern and landed on his second attempt.   While on the ground at RHP, the pilot purchased 60 gallons of 100 low lead aviation fuel, received a weather briefing through Leidos Flight Service, and filed an instrument flight rules flight plan to Lancaster Airport (LNS), Lancaster, Pennsylvania.   The airplane was equipped with a handheld GPS receiver that was found inside the wreckage. The recovered data revealed that the airplane departed runway 8 at 1945 and made a slight left turn toward the northeast and mountainous terrain (figure 1). The airplane continued to climb at a rate of about 700 fpm, and at a groundspeed of about 95-100 knots for about 3 minutes and 20 seconds. The altitude peaked at 4,011 ft GPS altitude at 1948:57, and the last GPS position was recorded at 1949:00. At that time, the airplane suddenly turned to the right 11°, descended about 31 ft, and slowed by 25 knots of groundspeed. The last GPS position was located about 518 ft southwest of the accident site at an elevation of about 3,880 ft. The elevation at RHP was 1,698 ft. Figure 1 - Airplane's GPS-derived departure track (magenta overlay) from runway 8 toward the rising terrain northeast of the airport. - According to autopsy report from the Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, the cause of death of the pilot was multiple blunt force injuries and the manner of death was accident. Testing for ethanol and drugs was negative. - The RHP weather at 1945 included scattered clouds at 1,400 ft, broken clouds at 3,200 ft, and 7 miles visibility in rain. Sunset at Andrews was about 1916 and the end of civil twilight was about 1941.  According to the National Weather Service Surface Analysis Chart, a stationary front stretched from Michigan southwestward through the Ohio Valley and into Mississippi at the time of the accident. A low pressure system was located in southern Michigan, along the front. The accident site was located to the east of the stationary front in an area of southerly and calm surface winds. The accident site was located east of a low- and mid-level trough. Troughs can act as lifting mechanisms to help produce clouds and precipitation if sufficient moisture is present. The station models around the accident site depicted air temperatures in the mid-60s degrees F with temperature-dewpoint spreads of 1°F or less. Cloudy skies and light rain were reported at airports to the east of the accident site. The Leidos Flight Service specialist provided weather information to the pilot, including convective SIGMETs, AIRMETs, and TAFs valid at 1839. When asked by the specialist if the pilot would be filing instrument flight rules (IFR) or visual flight rules (VFR), the pilot responded, “IFR, if we have to. I don’t think, I don’t think VFR is going to be possible.” The specialist also informed the pilot, “…mountain tops obscured in the higher terrain pretty much for your entire route of flight.” The specialist, when briefing the SIGMETs and approaching convective weather from the south of the departure airport, stated, “Looks like the sooner you can get out of there the better.” - According to a witness, the pilot recently transitioned from a Piper PA-28 equipped with fixed landing gear to the accident airplane, which he purchased in June 2021. The pilot’s logbook was not located. The flight instructor who administered the pilot’s most recent flight review reported that the pilot had logged about 2,100 hours of flight time. A review of ADS-B data revealed that, after its purchase, the pilot flew the airplane about 51 hours. - The highly fragmented wreckage was found on steep, mountainous, wooded terrain. An examination of the accident site and wreckage revealed that all major structural components of the airplane were accounted for. The airplane collided with a tall pine tree and continued 600 ft before colliding with another tree. The main wreckage impacted the terrain in a steep, nose low attitude and came to rest, inverted. Both wings and the ruddervator separated during the impact sequence. The wing flaps were found in the retracted positions. The landing gear drive system was observed in the “gear extended” position, and the cockpit gear switch was found in the “gear down” position. Numerous tree branches were observed along the wreckage patch that exhibited smooth, 45° cuts and black paint transfer, consistent with propeller blade contact. The wreckage was recovered to a salvage facility where additional examination was performed. Flight control continuity was confirmed from the cockpit controls to each flight control surface bellcrank. Examination of the engine did not reveal any evidence of a preexisting anomaly or malfunction. The propeller blades exhibited s-bending and blade twisting; two blade tips were separated. The landing gear switch was tested and performed in a normal manner. The landing gear position light bulbs were examined: the “up” bulb filament was broken from its leads. The “down” bulb filament remained attached it its leads and appeared stretched. -
Analysis
The pilot was conducting a personal, cross-country flight. As he approached a planned stop en route to his destination, he diverted to a nearby airport due to deteriorating weather conditions. A witness at the diversion airport reported that the pilot’s first approach was too fast, and he landed on his second attempt. Also, he flew visual traffic patterns contrary to what was published for the runway and toward rising terrain. Before departing again to resume the flight to the final destination, the pilot obtained a weather briefing by telephone. Based on the preflight weather briefing, the pilot was likely aware of the weather conditions along his route of flight, which included mountain obscuration. The pilot also seemed to be concerned with deteriorating weather conditions approaching the departure airport, which may have rushed him during his departure preparations. The weather at the time of his departure from the diversion airport included visual meteorological conditions; however, the mountainous terrain near the diversion airport was likely obscured with low clouds, rain, and drizzle. He subsequently departed about 4 minutes after the end of civil twilight. He took off and made a slight left turn toward rapidly rising terrain. While climbing, the airplane collided with trees, near the top of a mountain, about 5 miles from the airport. Postaccident examination of the wreckage found the landing gear extended and the cockpit landing gear switch in the “gear down” position, indicating that the pilot may have forgotten to raise the landing gear after takeoff. Leaving the landing gear extended after takeoff would have reduced the airplane’s climb rate. The pilot had recently purchased the accident airplane and his previous airplane was equipped with fixed landing gear. Examination of the remaining wreckage revealed no evidence of a preexisting mechanical failure or anomaly with the airplane.
Probable cause
The pilot’s decision to fly toward rapidly rising, obscured mountainous terrain after departing under visual flight rules at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
S35
Amateur built
false
Engines
1 Reciprocating
Registration number
N876T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-7753
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-18T18:08:42Z guid: 104031 uri: 104031 title: ERA22FA004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104047/pdf description:
Unique identifier
104047
NTSB case number
ERA22FA004
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-05T06:44:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2021-10-12T20:58:22.781Z
Event type
Accident
Location
Thomson, Georgia
Airport
THOMSON-MCDUFFIE COUNTY (HQU)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The NTSB has outstanding recommendations for Part 135 operators to implement SMS and FDM programs. In 2019-2020, the NTSB published a fact sheet as part of the Most Wanted List of Transportation Safety Improvements titled, Improve the Safety of Part 135 Aircraft Flight Operations. The fact sheet stated in part: What can be done? We know that SMS, FDM, and CFIT [controlled flight into terrain] programs can improve safety and prevent crashes. We currently have 21 open safety recommendations addressing the safety gap in Part 135 operations. Operators must be proactive about safety; they should not wait for regulations or an accident to move them to action. Some operators have already incorporated SMS, FDM, and CFIT programs and are seeing tremendous safety returns. To increase use of SMS, FDM, and CFIT programs in Part 135 aircraft, the following actions should be taken: Operators/Industry · Implement an SMS and FDM, appropriately scaled to the size of your operation, to detect and correct unsafe deviations from company procedures before an accident occurs. · An SMS is an effective way to establish and reinforce a positive safety culture and identify deviations from standard operating procedures so that they can be corrected. · Collect data through an FDM over the entirety of the operation; this is the only means an operator has to consistently and proactively monitor its line operations. FDM should be a nonpunitive system. · Use analysis tools provided by associations and the FAA’s InfoShare to identify safety trends. · Incorporate a CFIT-avoidance training program that addresses current TAWS technologies relevant to your operational environment. Regulators Require all Part 135 operators to install flight data recording devices capable of supporting an FDM program and to establish SMS programs. Work with Part 135 operators to improve voluntarily implemented training programs aimed at reducing the risk of CFIT accidents involving continuing flight under visual flight rules into instrument meteorological conditions, paying special attention to human factors issues. As of the publication of this report, the FAA had no requirement for the operator to implement an SMS or FDM program. On January 11, 2023, the FAA issued a Notice of Proposed Rule Making (NPRM) that may expand SMS requirements to certain on-demand commercial operators. The NPRM summary stated in part: The FAA proposes to update and expand the requirements for safety management systems (SMS) and require certain certificate holders and commercial air tour operators to develop and implement an SMS. This proposed rule would extend the requirement for an SMS to all certificate holders operating under the rules for commuter and on-demand operations, commercial air tour operators, production certificate (PC) holders that are holders or licensees of a type certificate (TC) for the same product, and holders of a TC who license out that TC for production. The FAA also proposes this rule in part to address a Congressional mandate as well as recommendations from the National Transportation Safety Board (NTSB) and two Aviation Rulemaking Committees (ARCs). Additionally, the proposed rule would more closely align the United States with Annex 19 to the Convention on International Civil Aviation. This proposed rule is intended to improve aviation safety by requiring organizations to implement a proactive approach to managing safety. - Approach Speed The airplane’s landing reference speed, Vref, for flaps 40° (which was indicated in the CVR transcript), 20,000 lbs, and no airbrakes was 113 kts. This speed was consistent with what was found set with the speed bugs on both the pilot and co-pilot airspeed indicators (115, 110 knots, respectively). Air Brakes According to the DA20 maintenance manual and operating manual, the air brakes are electro-hydraulic devices on both wings situated on the upper surface that permits aerodynamic braking of the airplane in flight. The maximum deflection is 70° and they are held in place by hydraulic pressure. The airbrakes are deployed through the use of a handle located on the center console of the cockpit closer to the left seat pilot. The air brakes operate in a deployed or stowed configuration. The time to extend the air brakes is 2 to 3 seconds and retraction is 3 to 4 seconds. There were two annunciator lights associated with the deployment of the airbrakes. The DA20 AFM stated in part that the airbrakes were to be checked IN during the approach. The manual further states that, “In approach with flaps extended, the airbrakes must be retracted. If the approach is made with the anti-ice on, the airbrakes may be extended down to 500 ft above the ground.” Furthermore, the approach speed must be increased by 10 kts as long as the air brakes are out. Based upon a review of the CVR transcript, an engine sound spectrum study, and review of meteorological information, there was no evidence that the anti-ice system was on during the approach. Aerodynamic Stall Speed and Systems Information Based upon an expected landing weight of 20,280 lbs and the airplane’s equipped instrumentation, the aerodynamic stall speed was likely about 91 KIAS (Flaps 40°) and 95 KIAS (Flaps 25°). The AFM airspeed limitations stated: CAUTION: DO NOT INTENTIONALLY FLY THE AIRPLANE SLOWER THAN INITIAL STALL WARNING ONSET According to Dassault Aviation representatives, there was no data that existed as to what flight characteristics the airplane would demonstrate in an idle power, full landing flaps, landing gear down, and air brakes deployed configuration. The airplane was equipped with a multi-faceted stall warning system. According to the operations manual, the stall warning system was designed to inform the pilot of a forthcoming stall by sounding an aural warning. When the airplane is approaching stalling conditions a modulated medium pitch will sound 2/3 seconds on, 1/3 seconds off. Operator Information The operator, Pak West Airlines, dba Sierra West Airlines (SWA), held a Title 14 CFR Part 135 air operator certificate with the FAA. According to SWA records, the accident flight crew flew together routinely and commonly performed overnight flights. The flight crew schedules, and duty day were consistent with Part 135 regulations. The SWA DA20 standard operating procedures stated that during visual approaches the PNF (pilot not flying) was to announce 1,000 ft, 500 ft, 100 ft, and 50 ft agl altitude callouts. The CVR transcript revealed that none of these altitude callouts were made by the captain, who was the pilot not flying. The SWA General Operations Manual (GOM) defined “stabilizing approach concept” as the procedure by which the crew maintains a stable speed, configuration, descent rate, vertical flight path, and engines spooled. The GOM further outlined that both pilots were responsible for ensuring the approach was stabilized before continuing below minimum altitudes that varied dependent upon the type of approach being flown. The minimum altitude for visual approaches was 500 ft agl. The GOM further provided a warning that that the flight crew was responsible for taking “immediate action” of a go-around or missed approach if “stabilized conditions” are not met. The GOM stated that it was critical to flight safety that either pilot had the ability to call for a go-around if they believe an unsafe condition exists. The go-around action was required to be associated with immediate action of executing a missed approach, without question, because of the immediacy of the situation. - The HQU airport had one runway (10-28) that was 5,514 ft in total length and 100 ft wide. The usable length when landing on runway 10 from the glideslope was 4,433 ft. The only ILS or localizer approach to HQU was to runway 10. The approach required automatic direction finding (ADF) equipment for the procedure entry. The approach published a minimum altitude of 2,000 ft msl at the final approach fix CEDAR. The published procedure entry required that the airplane fly outbound on a 277° heading and complete a procedure turn back to the final approach course of 097°. The minimum descent altitude was 960 ft msl (492 ft agl), with the glideslope out of service and the local altimeter setting. The approach plate stated that a precision approach path indicator (PAPI) was available on the left side of the runway. Figure 3: Instrument approach procedure chart for the ILS or LOC NDB Runway 10 Approach NOTAM Information Several NOTAMs were published for HQU at the time of the accident. A NOTAM was issued for the ILS runway 10 glidepath, noting it was unserviceable (out of service) from September 27, 2021, 1104 UTC, to October 11, 2021, 2000 UTC estimated. This NOTAM was in effect at the time of the accident. According to FAA Technical Operations, the glideslope was turned off and not radiating at the time of the accident and was scheduled for maintenance later in the month. A NOTAM was issued for the PAPI denoting it was unserviceable (out of service) from October 5, 2021, 1418 UTC to October 12, 2021, 2000 UTC estimated. This NOTAM was published; however, it was not in effect at the time of the accident. An operational ground test of the PAPI for runway 10 was performed after the accident and no anomalies were discovered. A NOTAM was issued for the ILS runway 10 localizer, noting it was unserviceable (out of service) from October 5, 2021, 1200 UTC to October 5, 2021, 1800 UTC estimated. This NOTAM was published; however, it was not in effect at the time of the accident. There were several additional obstruction-related NOTAMs also published for HQU. - Air traffic control (ATC) services were provided by Atlanta Air Route Traffic Control Center (ZTL ARTCC). The controller cleared the airplane to “cross CEDAR at or above 3,000 cleared ILS localizer one zero into Thomson McDuffie” and informed the flight crew to report back when established on the procedure. Subsequently, the captain cancelled the IFR flight plan near CEDAR. FAA Order JO 7110.65Z, Air Traffic Control, prescribed information required when issuing an approach clearance to an aircraft conducting an instrument approach. Chapter 4, section 8, paragraph 4-8-1 stated in part: 4-8-1. APPROACH CLEARANCE a. Clear aircraft for “standard” or “special” instrument approach procedures only. 1. To require an aircraft to execute a particular instrument approach procedure, specify in the approach clearance the name of the approach as published on the approach chart. Where more than one procedure is published on a single chart and a specific procedure is to be flown, amend the approach clearance to specify execution of the specific approach to be flown. If only one instrument approach of a particular type is published, the approach needs not be identified by the runway reference. 2. An aircraft conducting an ILS or LDA approach must be advised at the time an approach clearance is issued when the glideslope is reported out of service, unless the title of the published approach procedure allows (for example, ILS or LOC Rwy 05). 3. Standard instrument approach procedures (SIAP) must begin at an initial approach fix (IAF) or an intermediate fix (IF) if there is not an IAF. 4. Clearances authorizing instrument approaches are issued on the basis that, if visual contact with the ground is made before the approach is completed, the entire approach procedure will be followed unless the pilot receives approval for a contact approach, is cleared for a visual approach, or cancels their IFR flight plan. - On October 5, 2021, at 0544 eastern daylight time, a Dassault Falcon 20C airplane, N283SA, was destroyed when it impacted terrain near the Thomson-McDuffie County Airport (HQU), Thomson, Georgia. The captain and first officer were fatally injured. The airplane was operated as Pak West Airlines Flight 887 dba Sierra West Airlines, as an on-demand cargo flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. The flight crew initiated the first flight of the night which was about 1 hour in duration at 2132 mountain daylight time from their home base of El Paso International Airport (ELP), El Paso, Texas, to Lubbock Preston Smith International Airport (LBB), Lubbock, Texas. After about a 2 hour and 20-minute delay waiting for the freight on the ground, the accident flight was initiated from LBB to HQU. Review of air traffic control communications provided by the Federal Aviation Administration (FAA) revealed that the flight was in contact with Atlanta Air Route Traffic Control Center (ATL Center) for about the final 40 minutes of flight. At 0503 eastern daylight time, Pak West Flight 887 (PKW887) requested information about the NOTAM for the ILS localizer runway 10 instrument approach procedure at HQU. ATL Center informed the flight crew of two NOTAMs; the first pertained to the ILS runway 10 glidepath being unserviceable. When the controller advised the pilot of the glidepath NOTAM, the controller stated that he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The second NOTAM applied to the localizer being unserviceable. The controller informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. About 0525, ATL Center asked PKW887 which approach they would like, to which they responded with the “ILS runway one zero approach.” The controller responded, “roger, standby for that.” (Note: the glidepath/glideslope was out of service at the time of the accident). At 0526, ATL Center cleared PKW887 to CEDAR intersection, which was the initial approach fix for the ILS or localizer/non-directional beacon (NDB) runway 10 approach. About 0537, ATL Center informed PKW887 that they were 15 miles southwest from CEDAR and to “cross CEDAR at or above 3,000 cleared ILS localizer one zero into Thomson McDuffie.” PKW887 read back the clearance and the controller stated it was a “good readback” and to report when established on the “procedure.” About 1 minute later, the controller advised PKW887 of a telephone number to call to cancel their instrument flight rules (IFR) clearance once on the ground; however, about 0543, PKW887 was near CEDAR and requested to cancel their IFR clearance. The controller advised PKW887 to squawk “vfr” and no further communications were received. Surveillance video located at HQU airport showed that about 0539 the airport and runway lights were activated from off to on. About 0542 the airplane’s landing lights came into view in the pitch-black horizon and were subsequently steadily visible for about 2 minutes. The video showed the airplane approaching runway 10 in a relatively constant descent and heading. About 25 seconds before the airplane’s landing lights disappeared, a momentary right turn, followed by a left turn and increased descent rate was observed. No explosion was observed when the landing lights disappeared about 0544. About 0518, the CVR revealed that during the enroute descent while the airplane was flying through an area of storms, the captain repeatedly made comments related to the first officer’s performance as the pilot flying. He sternly stated to the first officer to “fly the airplane” multiple times and the captain subsequently stated, “I’ve got the airplane.” About 1 minute later, the captain issued raised-voice instructions to the first officer on appropriate headings to fly. About 0521, the captain read back a heading clearance from ATC, and the captain stated, “you fly the damn airplane.” A few minutes later, the captain made comments consistent with reading portions of the ILS or Localizer Runway 10 approach chart; however, the comments were interrupted when the captain again made more heading instructions to the first officer. About 0527, as the airplane was approaching an assigned altitude during the descent, the captain exclaimed “altitude” and then shouted, “I’ll get that, you fly the damn airplane. I don’t want you to kill me.” About 0532, the flight crew was attempting to load and navigate to the CEDAR intersection and the captain said that he would fly the airplane while the first officer loaded the waypoint. About 1 minute later, the captain stated to the first officer “you got the airplane.” For the next 3 minutes the captain made repeated comments on what headings, speed, and altitudes the first officer needed to fly, and instructed him to adjust the trim wheel. At 0539:28, as the flight was nearing the final approach fix and attempting to activate the pilot-controlled lighting, the captain stated in a frustrated tone, “would you fly the airplane- man-uhh man- I’ve been doing everything else.” A few seconds later, the captain stated, “here it is right over.” The captain subsequently stated, “fly the ILS approach.” The captain also noted that air brakes were stowed, flaps were set to 40°, and the before landing checklist was complete. At 0541:15, the captain stated, “follow the glideslope without that” and about 30 seconds later stated that the localizer was alive. At 0542:20, the captain stated, “I want you to- I want you to fly the airplane.” A few seconds later, the captain stated that landing flaps were selected, and he reported to ATC that they had joined the localizer, had a “visual” on the runway, and canceled the IFR clearance. At 0543:22, the captain made repeated comments that they were high and fast and that they needed to lose 20 kts. A few seconds later, the captain stated, “let’s use your air brakes again.” At 0543:51, the captain stated, “you’re way high,” and the first officer responded, “no I’m not.” The captain responded with “look” and “you’re fifteen knots fast we got a short runway.” About 0544, the captain again stated, “use your air brake” and about 4 seconds later, the captain stated, “now you’re low.” About 6 seconds later, the captain stated in an elevated voice, “you got trees.” Power was heard to increase rapidly, the audible electronic pulsating stall warning activated, and at 0544:07, the sound of impact was heard. An automatic dependent surveillance – broadcast (ADS-B) performance study conducted by the National Transportation Safety Board’s (NTSB) Vehicle Performance Division found that the airplane crossed CEDAR (the final approach fix) at 2,600 ft mean sea level (msl) and 500 ft to the left of the extended runway centerline. After CEDAR, the flight track continued toward the runway and continued to be about 600 ft above the 3° visual glide path and further deviated to the left of the runway heading until about 3 nautical miles from the threshold, when the descent rate increased. The airplane’s airspeed at that time was about 150 kts. ADS-B coverage ended at 05:43:54, about 3,000 ft short of the first recorded tree strike. The final recorded altitude was 900 ft msl (400 ft above ground level [agl]) and the calculated airspeed was 137 kts. Figures 1 and 2 provide an overview of the flight track data, expected approach path, and summary CVR comments related to the approach. Figure 1: Altitude compared to 3° visual glide slope, flight path compared to runway heading, and calculated ground and airspeeds for final 6 NM of the approach. Figure 2: Altitude, calibrated airspeed, and groundspeed with selected end of flight CVR events. “CRT” is “Comment related to –”. Red dotted line shows estimated altitude trend. ADS-B data ended at 05:43:54. The recorded CVR audio from the cockpit area microphone channel was evaluated in an attempt to determine the engines’ N1 operating speeds during the final approach phase of the accident flight. The sound spectrum study found that for about the last minute of the flight the engine N1 speeds were near flight idle, and further decreased to flight idle for the final 30 seconds before the initial impact with trees. After the initial impact was heard, both N1 speeds were observed to rise rapidly before the recording ended. - The Georgia Bureau of Investigation, Division of Forensic Sciences, performed the captain’s autopsy. According to the autopsy report, the captain’s cause of death was generalized blunt force trauma, and his manner of death was accident. His heart was enlarged, weighing 600 grams (the upper limit of normal is roughly 510 grams for a male of the captain’s body weight). There was moderate-to-severe atherosclerotic disease of his coronary arteries. Visual examination of his heart was otherwise unremarkable for natural disease. There was focally severe atherosclerosis of his aorta. Examination of his brain was limited due to the severity of injury. The autopsy did not identify any other significant natural disease. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the captain. No tested-for substances were detected. The Georgia Bureau of Investigation, Division of Forensic Sciences, performed the first officer’s autopsy. According to the autopsy report, his cause of death was generalized blunt force trauma, and his manner of death was accident. He had severe atherosclerotic disease of his coronary arteries. Visual examination of his heart was otherwise unremarkable for natural disease. He had focally severe atherosclerosis of his aorta. The autopsy did not identify any other significant natural disease. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the first officer. Losartan, rosuvastatin, and acetaminophen were detected in cardiac blood and urine. The glucose levels in vitreous and urine were measured to be 13 mg/dL and 5 mg/dL, respectively. - An NTSB weather study found that low clouds, drizzle and rain, and low visibility likely persisted along the approach path. Dark nighttime conditions existed at the time of the accident with both the sun and the moon below the horizon. Review of a surveillance video at the airport revealed that the airplane’s landing light came into view about 2 minutes before disappearing into the trees. The view of the landing light was steady and continuous, and there was no indication that the airplane entered clouds in the viewable 2 minutes. There were inflight advisories current for the area for thunderstorms west and north of the destination, and for IFR conditions over the region. - According to the SWA GOM, the Director of Operations was responsible for operational control and had the authority to direct all operational functions. It stated the following personnel were also authorized to exercise operational control: The President, Vice President, Chief Pilot, Director of Maintenance for maintenance matters, flight control manager, and flight followers. The Director of Operations reported that SWA, at the time of the accident, did not have an aviation safety action program (ASAP) or a FDM program. He reported that their formal SMS was at the development stage. - Captain According to the operator’s training and employment records, in September 2019 the captain satisfactorily completed indoctrination training and ground training and was subsequently assigned to the DA20 as a pilot in command. The captain completed multiple airman competency/proficiency checks from 2019 through 2021. Each check was ultimately completed satisfactorily; however, multiple line checks required retraining and testing due to unsatisfactory performance of required task items. Some example areas that were required to be retrained and tested were circling approaches and steep turns. According to the captain’s resumé and records from his former employer Ameristar Jetcharter Inc. (Ameristar), he was employed by the operator as a pilot from June 2017 through August 2019. On December 22, 2017, an airman competency/proficiency check (14 CFR 135.293 and 135.297 checks) in a DA20 simulator was marked as disapproved. The remarks from the check airman stated in part that during instrument procedures the captain was “cleared for right turn by ATC, mis-set hdg bug resulting in left turn. Distraction resulted in loss of airspeed to full stall condition.” A few days later, the pilot satisfactorily completed the check. He served as SIC through mid-January 2018 and was subsequently upgraded to PIC. First Officer According to operator training and employment records, on August 20, 2009, the first officer was hired and assigned to the DA20 as an SIC after satisfactorily completing indoctrination training and ground and flight training. The pilot left the operator for 5 years, returned in 2019, and was reassigned again as an SIC DA20 flight crewmember. On December 30, 2020, an airman competency/proficiency check (14 CFR 135.293) was completed satisfactorily with remarks that stated, “SIC Only.” The operator reported that the first officer was designated as a SIC only due to pilot performance and a lack of aeronautical decision making and airmanship necessary to become a PIC/captain. - The initial impact point coincided with broken pine tree branches among a forest where the trees were about 150 ft tall. The debris path was oriented on a heading of about 100° and spanned about 880 ft from the initial impact to the main wreckage area. The airplane was heavily fragmented; however, there was no evidence of fire. The largest fragments of wreckage were concentrated in three primary areas overviewed in Figure 4. The figure shows the initial impact point and a pop-out drone image that describes the three areas. Figure 4: Overview of the wreckage path and concentrated areas of wreckage (Drone image courtesy of Georgia Bureau of Investigations) All major components of the airplane were located in the debris path. Flight control continuity could not be determined from the control surface to the cockpit due to the heavy fragmentation; however, within the fragmented flight control areas continuity was observed. Examination of the cockpit found the flap selector in the full flaps 40° position and the landing gear handle was selected down. The left airspeed speed bug was set to 115 kts and the right side was set to 110 kts. The left and right primary attitude indicators, which contained vertical glideslope indicators, were damaged during the impact and multiple fail flags were visible within the units. The flap surface position, based upon review of their respective jackscrews, was near the 25° position as found. The landing gear were extended. The left air brake surface was found partially extended. It’s actuator was found in a position that corresponded to a near full deployment position. The right air brake surface was found nearly fully extended, which was consistent with the position of its actuator. The horizontal stabilizer and its jackscrew were found to be within a normal envelope. Both engines exhibited impact damage and varying degrees of foreign object debris ingestion that had the appearance of wood chips and green vegetation in the center core of the engine. Several fan blades exhibited leading edge gouging, knicks, and torsional twisting. -
Analysis
The captain and first officer were assigned a two-leg overnight on-demand cargo flight. The flight crew were accustomed to flying night cargo flights, had regularly flown together, and were experienced pilots. The first leg of the trip was uneventful and was flown by the captain; however, their trip was delayed 2 hours and 20 minutes at the intermediate stop due to a delay in the freight arriving. The flight subsequently departed with the first officer as the pilot flying. While enroute, about forty minutes from the destination, the flight crew asked the air traffic controller about the NOTAMs for the instrument landing system (ILS) instrument approach procedure at the destination. The controller informed the flight crew of two NOTAMs: the first pertained to the ILS glidepath being unserviceable and the second applied to the localizer being unserviceable. When the controller read the first NOTAM, he stated he did not know what “GP” meant, which was the abbreviation for the glideslope/glidepath on the approach. The controller also informed the flight crew that the localizer NOTAM was not in effect until later in the morning after their expected arrival, which was consistent with the published NOTAM. The flight crew subsequently requested the ILS approach and when the flight was about 15 miles from the final approach fix, the controller cleared the flight for the ILS or localizer approach, to which the captain read back that they were cleared for the ILS approach. As the flight neared the final approach fix, the captain reported that they had the airport in sight; he cancelled the instrument flight rules flight plan, and the flight continued flying towards the runway. The airplane crossed the final approach fix off course, high, and fast. The cockpit voice recorder (CVR) transcript revealed that the captain repeatedly instructed the first officer to correct for the approach path deviations. Furthermore, the majority of the approach was conducted with a flight-idle power setting and no standard altitude callouts were made during the final approach. Instead of performing a go-around and acknowledging the unstable approach conditions, the captain instructed the first officer to use the air brakes on final approach to reduce the altitude and airspeed. Shortly after this comment was made, the captain announced that they were low on the approach and a few seconds later the captain announced that trees were observed in their flight path. The CVR captured sounds consistent with power increasing; however, the audible stall warning tone was also heard. Subsequently, the airplane continued its descent and impacted terrain about .70 nautical mile from the runway. Airport surveillance video captured the final 2 minutes of flight. Although low clouds and visibility were reported in the area of the airport, it is unlikely that the airplane entered instrument meteorological conditions in the flight’s final 2 minutes given that the airplane’s landing light was continuously in view until the airplane’s impact with trees and terrain. Furthermore, the video revealed that about the time the air brake comment was made by the captain, the airplane’s descent rate was observed to increase. Examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures with the airplane or its engines. The air brakes and their actuators were found in an extended position, the landing gear were down, and the flaps were stated by the captain to be set to full. The airplane flight manual (AFM) prohibited the use of air brakes during the approach unless anti-ice was used; however, there was no indication that anti-ice was used. It is likely that after the captain instructed the first officer to use the air brakes, the flight entered a descent that could not be recovered from, despite the rapid increase in power in the final moments of the flight. The flight profile of idle power, air brakes deployed, landing gear down, and full flaps was not a configuration that the airplane manufacturer possessed data for given that it was not an AFM approved approach configuration. The captain advised the first officer to fly the ILS approach and to follow the glideslope, despite the glideslope being out of service per the NOTAM. It was not possible to determine whether the high and low comments from the flight crew were in reference to precision approach path indicator lights, cockpit instrumentation, or a visual glidepath assessment based upon the crew’s perception of the lighted but dark night runway environment. The glideslope portion of the ILS was not broadcasting a signal due to the equipment being removed for maintenance. The investigation was unable to determine what the glideslope indications displayed in the cockpit were due to impact-related damage to the instrumentation. The approach was being conducted during dark night conditions, which likely further exacerbated the flight crew’s inability to establish a proper glide path and see the approaching trees and terrain. The controller did not state that the glideslope was out of service when he cleared the airplane for the ILS localizer approach procedure, nor was there a requirement to do so when an ILS or localizer approach was to be flown. Furthermore, when the airplane was near the final approach fix, the captain reported that they had the airport in sight, and he cancelled the instrument flight rules flight plan. The decision by the flight crew to continue straight in to land, rather than flying the procedure turn, contributed to the airplane being high for the majority of the final approach. The CVR revealed that throughout the enroute descent and approach, the captain repeatedly instructed the first officer on how to fly the airplane, reprimanding and yelling at him about basic airmanship tasks such as heading and altitude control. The captain also took control of the airplane multiple times before the final approach. The captain had ample indications that the first officer was not performing adequately to continue the flight as the pilot flying. The captain could have demonstrated leadership and positive crew resource management by relieving the first officer of flying duties well before the final approach commenced, given the challenging nature of the dark night approach that was ahead. The operator reported the first officer had not received an upgrade to captain, even after multiple years of experience on the accident airplane, due to his lack of aeronautical decision making and airmanship necessary to become a captain. This assessment was consistent with his performance during the accident flight. Furthermore, the captain’s training record showed multiple deficiencies during training. Had the operator had a flight data monitoring program (FDM) and safety management system (SMS), they could have had additional methods of identifying and monitoring the poor performing flight crew and made proactive decisions, rather than waiting for an accident to occur to discover the flight crew’s procedural non-compliance. The National Transportation Safety Board has standing recommendations to Part 135 operators to implement SMS and FDM, and for the Federal Aviation Administration to require SMS and FDM in Part 135 operations. Both pilots had cardiovascular disease that placed them at increased risk of a sudden impairing or incapacitating medical event such as heart attack or abnormal heartbeat; however, based upon the totality of the investigation’s findings, it is unlikely that the captain’s or first officer’s cardiovascular disease contributed to the accident. Furthermore, the toxicology reports for the flight crew revealed no conditions or findings that would have contributed to the accident.
Probable cause
The flight crew’s continuation of an unstable dark night visual approach and the captain’s instruction to use air brakes during the approach contrary to airplane operating limitations, which resulted in a descent below the glide path, and a collision with terrain. Contributing to the accident was the captain’s poor crew resource management and failure to take over pilot flying responsibilities after the first officer repeatedly demonstrated deficiencies in flying the airplane, and the operator’s lack of safety management system and flight data monitoring program to proactively identify procedural non-compliance and unstable approaches.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DASSAULT
Model
Falcon 20
Amateur built
false
Engines
2 Turbo fan
Registration number
N283SA
Operator
Pak West Airlines Inc.
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
83
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-12T20:58:22Z guid: 104047 uri: 104047 title: CEN22LA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104067/pdf description:
Unique identifier
104067
NTSB case number
CEN22LA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-06T15:30:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-10-07T18:18:06.078Z
Event type
Accident
Location
Gonzales, Louisiana
Airport
LOUISIANA RGNL (REG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 6, 2021, about 1430 central daylight time, a Bell 206B3 helicopter, N373SP, sustained substantial damage when it was involved in an accident near Gonzales, Louisiana. The student pilot sustained minor injuries. The helicopter was operated as a public aircraft flight. The student pilot of the Louisiana State Police Air Support Unit helicopter reported that he was making a short cross-country flight from Baton Rouge, Louisiana to Louisiana Regional Airport (REG), Gonzales, Louisiana. About 10 miles out from REG, he obtained meteorological data and determined that runway 35 was the appropriate runway for the current wind conditions. He entered the traffic pattern, and during the downwind leg, he completed the before landing checks and observed no abnormalities with the helicopter. The student pilot then reduced power and began to slow the helicopter to about 60 knots. After completing the turn to final approach, he maintained 400 ft above ground level (agl) and then started to descend. The student pilot applied a small amount of power to sustain the desired approach angle. Upon reaching 40 knots and 175 ft agl, the helicopter started to yaw to the right. The student pilot applied left pedal, and the helicopter continued to yaw to the right. The student pilot observed the trim indicator and confirmed that the helicopter was in trim; however, he still had to apply left pedal. Shortly thereafter, the helicopter “aggressively” yawed to the right. The student pilot applied forward cyclic input, and the helicopter rolled to the left while it continued to rotate “very aggressively” to the right. The student pilot attempted to regain control using cyclic input; however, he was unable as the helicopter was “rotating so fast.” The student pilot decreased the throttle to idle; the helicopter began to settle; and he applied collective input to cushion the landing. The helicopter experienced a hard landing and came to rest partially upright on a flat grass field about 200 ft short of the approach end of the runway. The student pilot performed an emergency shutdown and was able to egress from the helicopter. After the accident, the student pilot reported to a responding law enforcement officer that the helicopter experienced a loss of tail rotor effectiveness (LTE) during the approach. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tail boom, and the tail rotor system. A postaccident examination of the airframe and the engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. Due to the extensive airframe damage sustained during the impact sequence, pre-accident tail rotor rigging settings could not be determined. The helicopter was equipped with standard tail rotor blades that were manufactured by Bell. An examination of the helicopter’s maintenance records revealed no evidence of uncorrected mechanical discrepancies with the airframe and the engine. At the time of the accident, the student pilot reported he had accumulated 42 flight hours total in helicopters (all in the accident make and model helicopter). At the time of the accident, the student pilot reported the helicopter weighed 2,661 pounds, which was 593 pounds below the helicopter’s certified maximum gross weight. The estimated density altitude for the accident site was 1,948 ft. A review of meteorological data at REG showed that at 35 minutes before the accident, the wind was from 260° at 3 knots. At 15 minutes before the accident, the wind was from 030° at 4 knots. At 5 minutes after the accident, the wind was from 330° at 5 knots. The Federal Aviation Administration (FAA) has published Advisory Circular (AC) 90-95 titled Unanticipated Right Yaw in Helicopters. This document discusses LTE and states, in part: LTE is a critical, low-speed aerodynamic flight characteristic which can result in an uncommanded rapid yaw rate which does not subside of its own accord and, if not corrected, can result in the loss of aircraft control. LTE is not related to a maintenance malfunction and may occur in varying degrees in all single main rotor helicopters at airspeeds less than 30 knots. LTE is not necessarily the result of a control margin deficiency. The anti-torque control margin established during FAA testing is accurate and has been determined to adequately provide for the approved sideward/rearward flight velocities plus counteraction of gusts of reasonable magnitudes. The AC states that flight and wind tunnel tests have identified four relative wind azimuth regions and helicopter characteristics that could, singularly or in combination, result in LTE. The four regions are: Weathercock stability (120° to 240°): The helicopter will attempt to weathercock its nose into the relative wind. The helicopter will then make an uncommanded turn to the right or left, depending on the wind direction. Tail rotor vortex ring state (210° to 330°): The vortex ring state will cause tail rotor thrust variations, which result in yaw rates. Main rotor disc vortex interference (285° to 315°): Main rotor vortex passes the tail rotor, reducing the tail rotor angle of attack. This causes a reduction in thrust and a right yaw acceleration will commence. Loss of translational lift (all azimuths): Results in increased power demand and additional anti-torque requirements. If this occurs during a right turn, the turn will be accelerated as power is increased unless corrective action is taken. The FAA Helicopter Flying Handbook FAA-H-8083-21B discusses LTE and states in part: Some helicopter types are more likely to encounter LTE due to the normal certification thrust produced by having a tail rotor that, although meeting certification standards, is not always able to produce the additional thrust demanded by the pilot. While information on LTE is not published in the Transport Canada-approved rotorcraft flight manual for the Bell 206B3, Bell has published Operations Safety Notice 206-83-10 and Information Letter 206-84-41 that discuss the topic of LTE. -
Analysis
The student pilot entered the traffic pattern for landing at the end of a short cross-country flight in the helicopter. During the downwind leg, he completed the before landing checks and observed no abnormalities with the helicopter. According to the student pilot, he was on final approach at 40 knots and 175 ft above ground level when the helicopter started to yaw to the right. The student pilot applied left pedal, but the helicopter continued to yaw to the right. The student pilot observed the trim indicator and confirmed that the helicopter was in trim. Shortly thereafter, the helicopter “aggressively” yawed to the right. The student pilot applied forward cyclic input, and the helicopter rolled to the left while it continued to rotate rapidly to the right. The student pilot attempted to regain control using cyclic input; however, he was unable due to the high rotation rate. The student pilot decreased the throttle to idle; the helicopter began to settle; and he applied collective input to cushion the landing. The helicopter landed hard about 200 ft short of the approach end of the runway. The helicopter sustained substantial damage to the main rotor system, the fuselage, the tail boom, and the tail rotor system. A postaccident examination of the airframe and the engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation of the helicopter. A review of meteorological data at the accident airport showed the wind speed was about 5 knots or less with the direction shifting from a right crosswind to a left crosswind on the landing runway around the time of the accident. It is likely that while on final approach with a low airspeed, the helicopter lost translational lift, which resulted in increased power demand and additional anti-torque requirements. The helicopter began a right yaw and the student pilot allowed a yaw rate to build, at which point he was unable to successfully arrest the yaw rate, and a loss of tail rotor effectiveness and helicopter control occurred.
Probable cause
The student pilot’s failure to compensate for an unanticipated right yaw, which resulted in a loss of tail rotor effectiveness and helicopter control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206
Amateur built
false
Engines
1 Turbo shaft
Registration number
N373SP
Operator
LOUISIANA DEPARTMENT OF PUBLIC SAFETY
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Commercial sightseeing flight
false
Serial number
2885
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-07T18:18:06Z guid: 104067 uri: 104067 title: CEN22LA010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104068/pdf description:
Unique identifier
104068
NTSB case number
CEN22LA010
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-07T07:54:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-10-08T17:18:42.712Z
Event type
Accident
Location
Loveland, Colorado
Airport
NORTHERN COLORADO RGNL (FNL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 7, 2021, about 0654 mountain daylight time, a Piper PA-24, N5585P, was substantially damaged when it was involved in an accident near Northern Colorado Regional Airport (FNL), Fort Collins, Colorado. The pilot sustained minor injuries and the passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. During takeoff from FNL on Runway 15, pilot reported the airplane was not able to climb normally and that an overspeed occurred of about 2,900 engine rpm. The pilot retarded the throttle, observed a loss of airspeed, and heard a loud bang from near the engine. The pilot executed a forced landing on a road and the airplane impacted a pole, which substantially damaged the left wing. Automatic dependent surveillance-broadcast (ADS-B) data indicated the airplane started to taxi about 0645 and the takeoff roll occurred about 0652. The airplane accelerated to 62 knots groundspeed about 1,800 ft past the runway threshold and the airplane lifted off at 71 knots groundspeed about 3,200 ft past the threshold, which was 5,300 ft from the departure end of the 8,500 ft runway. During the initial climb, about 3,500 ft from the departure end of the runway, the airplane decelerated to 60 knots groundspeed. The airplane flew at 50-60 knots groundspeed and low altitude for the remainder of the flight. About 2,800 ft beyond the departure end of Runway 15, the airplane touched down on a paved road at 59 knots groundspeed. Initial propeller strike marks on the road were 1.17 ft apart, which calculated to an engine speed of about 2,554 rpm at touchdown. Postaccident examination of the airplane revealed no evidence of mechanical anomalies or malfunction. The propeller governor was bench tested and met manufacturer specifications. The pilot reported the airplane’s takeoff weight was about 300 lbs below the maximum gross weight. Manufacturer performance data indicated a takeoff ground roll with no wind of about 1,900 ft at maximum gross weight. During the engine runup before takeoff, the pilot reported pulling the carburetor heat lever out “for a few seconds” and that the engine ran “a little rough” during that period. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at cruise power.” The pilot recalled setting the mixture lever “about a finger” width toward the lean position for the takeoff. Following the accident, the pilot stated that he should have aborted the takeoff due to the airplane’s slower than normal acceleration. -
Analysis
The pilot stated the airplane accelerated slowly during the takeoff roll and did not climb normally during the initial takeoff. The pilot reported the engine oversped and he heard a loud noise that came from the engine during the takeoff climb. A review of flight data showed the takeoff roll was about 1,300 ft longer than normal and immediately after takeoff, the airplane decelerated about 10 knots. The pilot executed a forced landing on a road and the airplane struck a pole, which substantially damaged the left wing. Postaccident examination revealed no evidence of a mechanical failure or malfunction that would have precluded normal operation. No reason for the reported overspeed or noise heard by the pilot was discovered during the postaccident examination. The pilot reported the engine “ran a little rough” when the carburetor heat lever was pulled out for a few seconds during the engine run-up. The weather conditions at the time of the accident were conducive to serious carburetor icing at cruise power. The pilot recalled setting the mixture lever “about a finger width” toward the lean position during the takeoff. The airplane’s extended takeoff roll and deceleration after liftoff were consistent with degraded engine power, which was most likely due to carburetor icing and/or a lean mixture setting. Following the accident, the pilot stated that he should have aborted the takeoff due to the airplane’s slow acceleration.
Probable cause
The pilot’s failure to recognize the degraded engine power and abort the takeoff in a timely manner.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24
Amateur built
false
Engines
1 Reciprocating
Registration number
N5585P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-649
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-08T17:18:42Z guid: 104068 uri: 104068 title: ERA22FA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104077/pdf description:
Unique identifier
104077
NTSB case number
ERA22FA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-08T14:11:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-10-13T18:31:13.492Z
Event type
Accident
Location
Atlanta, Georgia
Airport
DEKALB-PEACHTREE (PDK)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On October 8, 2021, about 1311 eastern daylight time, a Cessna P210N, N128EE, was destroyed when it was involved in an accident near Atlanta, Georgia. The pilot and three passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of airport security surveillance video revealed that the airplane lifted off about 1,000 ft down runway 21 in a nose-high attitude. The airplane then rolled left and became inverted before it impacted the ground next to the runway. AIRCRAFT INFORMATION Examination of the airframe logbooks revealed that Airworthiness Directive (AD) 2011-10-09 was accomplished on July 19, 2021. The AD required inspection of the seat tracks, including but not limited to, the visual inspection of the holes in each track for excessive wear, the seat tracks for dirt or debris, and the seat locking pin for limited vertical play. The pilot and copilot seats were mounted onto a set of seat tracks, which allowed the seats to slide fore and aft. An adjustment bar was used to raise and lower two locking pins into one of multiple positions along each of the seat tracks, which secured the seat in the desired position. The locking pins’ downward travel and positive locking action was aided via a spring mechanism that tensioned the adjustment bar. Weight and balance calculations were performed using weight and balance documents recovered at the accident site, the actual weights of the occupants, and the baggage recovered at the scene. Calculations revealed that the airplane weighed about 4,571 lbs at takeoff, with a center of gravity at 51.19 inches aft of datum. The manufacturer's center of gravity range at maximum gross weight was 38.4 to 49 inches aft of datum. The manufacturer's maximum allowable gross weight was 4,000 lbs. WRECKAGE AND IMPACT INFORMATION The debris area was compact, and the ground scars were consistent with the airplane impacting nose-first, in a right-wing-down attitude. The fuselage came to rest upright oriented on a heading of 245° magnetic. The engine remained attached to the firewall through the tubular engine mount and was heavily fire damaged. The engine’s compressor ingested soil during the impact sequence, resulting in leading edge damage to the first stage turbine and bending several blades in the opposite direction of rotation. A compressor case half was removed to facilitate examination of the remaining compressor stages. All blades and vanes were intact, and no anomalies were noted. The leading edges of all compressor blades exhibited soil accumulation. The propeller was separated from the engine at the propeller gearbox. One propeller blade remained attached to the propeller and the four other blades fractured off at the respective hubs. The cabin and instrument panel were consumed by the postimpact fire. Both wings were separated from the fuselage and sustained significant postimpact fire damage. The tail section was thermally damaged. Flight control cable continuity was partially established due to multiple separations consistent with overload failure and postimpact fire damage. The elevator trim tab actuator was thermally damaged and both actuator rods were separated. The inboard actuator rod measured 1.5 inches extended, which correlated to 5° tab down. The outboard actuator rod measured 1.7 inches extended, which correlated to 5° tab up. Both trim tab actuator rods were free to rotate. Further examination revealed that the front left seat inboard forward seat attachment foot was 5.25 inches aft of the forward seat stop. The inboard seat track was fractured at the fifth hole aft from the forward hole. The seventh hole aft from the front displayed impact-related deformation to the aft side of the hole. Both inboard seat attachment feet were attached to the track. The seat locking pin was resting on top of the seat track; the bottom portion of the pin was deformed forward. The front left seat outboard seat track was intact, and both the forward and aft seat attach feet remained attached to the seat track. The outboard seat locking pin was bent 90° forward and not touching the seat track. The ninth hole aft from the front displayed impact-related deformation to the aft side of the hole. Gouges were observed in the seat track. ADDITIONAL INFORMATION The “Before Starting Engine” checklist contained in the airplane’s pilot operating handbook advised pilots to verify that the seats, seat belts, and shoulder harnesses were adjusted and locked. The Cessna Pilot Safety and Warnings Supplements document warned that a pilot should perform a visual check to verify that their seat was securely on the seat tracks and assure that the seat was locked in position. Failure to ensure that the seat was locked in position could result in the seat sliding aft during a critical phase of flight, such as initial climb. The airframe manufacturer also issued a Service Bulletin (SEB07-R06 Revision 6, issued June 11, 2015), which required the installation of a secondary seat stop for the pilot seat, and recommended one for the co-pilot seat. A secondary seat stop was not installed on either of the front pilot seats. The supplement also warned of previous events involving seats slipping rearward or forward during acceleration or deceleration related to discrepancies in the seat mechanisms. The investigations following these events revealed discrepancies such as gouged lockpin holes, bent lockpins, excessive clearance between seat rollers and tracks, and missing seat stops. Also, dust, dirt, and debris accumulations on the seat tracks and in the intermediate adjustment holes had been found to contribute to the problem. MEDICAL AND PATHOLOGICAL INFORMATION According to autopsy report from the Dekalb County Medical Examiner, Decatur, Georgia, the pilot’s cause of death was inhalation of superheated products of combustion and the manner of death was an accident. The FAA Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot. Ethanol was detected at 0.058 g/dL in cardiac blood, 0.012 g/dL in vitreous, and 0.021 g/dL in urine. N-butanol was detected in cardiac blood, and n-propanol was detected in cardiac blood and urine. Alprazolam was detected at 5 ng/mL in cardiac blood and was also present in urine. Sertraline and its metabolite, desmethylsertraline, were detected in cardiac blood at 1297 ng/mL and 3771 ng/mL, respectively; both were also present in urine. Loratadine and its metabolite, desloratadine, as well as valsartan, atorvastatin, and diclofenac, were detected in cardiac blood and urine. Ethanol is the intoxicating alcohol in beer, wine, and liquor. It can depress the function of the central nervous system (CNS), which can result in impaired judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol. This includes a prohibition on acting as a crewmember of a civil aircraft while having a blood ethanol level of 0.04 g/dL or greater. Ethanol can also be produced by microbes in a person’s body after death. N-propanol and n-butanol are other alcohols that can be produced by microbes in a person’s body after death. They are also present in small amounts in some foods and drinks, but would not be impairing at the detected level, which was below the threshold for quantification. Alprazolam, sometimes marketed as Xanax, is a prescription benzodiazepine medication commonly used to treat anxiety and panic disorder. Alprazolam generally carries a warning that it may depress CNS function, that consuming alcohol may worsen that effect, and that alprazolam users should be cautioned against engaging in hazardous occupations requiring mental alertness such as operating machinery or driving a motor vehicle. Alprazolam is a United States Drug Enforcement Administration Schedule IV controlled substance, with potential for abuse, dependence, and withdrawal. The FAA considers alprazolam a “do not issue/do not fly” medication. The level of alprazolam in a living person’s blood associated with the drug’s desired medicinal effects is typically between about 6 ng/mL and 20 ng/mL. Sertraline, sometimes marketed as Zoloft, is a prescription medication commonly used to treat depression and certain other psychiatric conditions. Depression can cause cognitive and psychomotor impairment, which appropriate sertraline treatment may help reduce. In subjects without depression, multiple studies have found sertraline to cause no significant psychomotor impairment at typical treatment doses. The potential for impairing side effects including sedation may increase at higher doses. Sertraline sometimes carries a warning that it may cause sleepiness or affect the ability to make decisions, think clearly, or react quickly, and that users should not drive, operate heavy machinery, or do other dangerous activities until they know how the drug affects them. An applicant for FAA medical certification who is taking sertraline may be certified by Special Issuance only, contingent upon the findings of a detailed evaluation of that applicant’s underlying disorder and response to treatment. Sertraline levels measured after death do not reliably reflect levels before death, because of the drug’s substantial potential for postmortem redistribution. Valsartan is a prescription medication that may be used to treat high blood pressure and/or heart failure. Atorvastatin is a prescription medication commonly used to control cholesterol and reduce cardiovascular risk. Diclofenac is an anti-inflammatory medication that is typically used to treat pain. In the United States, a topical version of diclofenac is available over the counter for arthritis pain; other formulations including oral formulations require a prescription. Valsartan, atorvastatin, and diclofenac generally are not considered impairing. The pilot’s most recent aviation medical examination was performed on September 29, 2021. At that time, the pilot’s height was recorded at 69 inches. -
Analysis
The pilot and three passengers were taking off when the airplane became airborne about 1,000 ft down the runway, pitched nose up, and rolled left to an inverted attitude before impacting terrain next to the runway in a nose-down attitude. Postaccident examination of the flight controls revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of weight and balance information indicated that the airplane was more than 500 lbs over its maximum gross weight and that the center of gravity was aft of limits. Examination of the wreckage revealed witness marks along the pilot’s seat tracks that corresponded with the seat being in the aft position at the time of impact. Given the pilot's stature, it is unlikely that this position would have allowed him to fully actuate the flight controls, and it is therefore unlikely that he intentionally initiated the takeoff with his seat in this position. Examination of the wreckage and maintenance logs revealed that the airplane was not equipped with manufacturer-recommended secondary seat stop mechanisms for either of the two front seats. Review of operational and maintenance documents published by the airframe manufacturer showed the critical importance of ensuring that the pilot seats were secured before initiating a flight, since accelerations such as those encountered during takeoff could dislodge an unsecured seat. It is likely that the pilot did not properly secure his seat before takeoff, which resulted in the seat sliding aft, and his subsequent inadvertent application of aft inputs to the control yoke during the rotation and initial climb, which resulted in the airplane’s steep climb and a loss of control. The airplane’s aft center of gravity likely contributed to the loss of control. Although toxicology testing of the pilot identified the presence of several medications, whether any medical factors contributed to the accident could not be determined from the available evidence. Some or all of the ethanol detected in the pilot’s toxicology may have been from sources other than consumption.
Probable cause
The pilot’s failure to ensure that his seat was properly secured before initiating the takeoff, which resulted in a loss of control during the initial climb. Contributing to the accident was the lack of an installed secondary seat stop, and the airplane’s aft center of gravity condition.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
P210
Amateur built
false
Engines
1 Turbo prop
Registration number
N128EE
Operator
ALGAB HOLDINGS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
P21000133
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-13T18:31:13Z guid: 104077 uri: 104077 title: WPR22LA005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104084/pdf description:
Unique identifier
104084
NTSB case number
WPR22LA005
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-08T20:04:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2021-10-26T06:25:20.584Z
Event type
Accident
Location
Los Banos, California
Airport
LOS BANOS MUNI (LSN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 8, 2021, about 1904 Pacific daylight time, a Beech B36TC airplane, N7220B, was substantially damaged when it was involved in an accident near Los Banos, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he flew the airplane to Paso Robles Municipal Airport (PRB), Paso Robles, California, where he refueled and was on his return flight to Gnoss Field Airport (DVO), Novato, California, when the accident occurred. The airplane was at about 10,000 ft mean sea level when the engine lost oil pressure and the manifold pressure dropped. He immediately diverted to Los Banos Municipal Airport (LSN), Los Banos, California. While in the descent into LSN, the engine was initially producing partial power, but then exhibited severe vibrations and subsequently lost all power. During this time, the cockpit filled with smoke, and fire and sparks were observed coming from the engine cowling. Due to the fire, the pilot elected to make a forced landing on a road near the approach end of the runway. The airplane struck an object during the landing roll, which caused the airplane to spin around before coming to rest. A review of engine data from a Garmin G500TXi device revealed that the airplane leveled off and the engine was set to about 2,500 rpm. About 9 minutes later, the engine’s oil pressure started to decrease, while the engine rpm was unchanged. In the next 12 minutes, the oil pressure continued to decrease and culminated with the engine rpm decreasing from about 2,371 to zero rpm in about 5 seconds while the airplane was in a descent. Postaccident examination of the engine revealed external damage with an exit hole on the crankcase near the top of the No. 2 cylinder. The hole was about 2 inches wide by 3 inches long. A second hole in the crankcase was noted on the left back side that had a diameter of about 1 inch. Additionally, several large cracks in the crankcase were observed on both crankcase halves. All engine accessories on the back side of the engine remained attached except for the left magneto. The rocker covers were removed and there was evidence of heat distress on all cylinders. Rotational continuity could not be established due to the crankshaft damage. Disassembly of the engine revealed that the No. 4 connecting rod bolt nut was missing. Thermal distress was observed in the area where the No. 4 connecting rod connected to the crankshaft, consistent with oil starvation. The thermal distress in this area was the most prominent in the engine. Considerable metal debris was noted in the oil sump and oil filter. The engine was installed in July of 2012, and logged about 671 hours of time before the accident. In June of 2020, the engine was disassembled for a propeller strike inspection. The inspection was about 27.3 hours before the accident. As part of the inspection, the connecting rods were overhauled by a third-party vendor, and then the vendor reinstalled the connecting rods on the crankshaft using new bearings, rod bolts, and nuts. The most recent annual inspection was accomplished in September of 2021, about 2.3 hours before the accident. -
Analysis
The pilot reported that he was on the return leg of a cross country flight, about 10,000 ft mean sea level, when the engine lost oil pressure and the manifold pressure dropped. He immediately diverted to the nearest airport. While in the descent to his divert location, the engine was initially producing partial power, but then exhibited serious vibrations and subsequently lost all power. During this time, the cockpit filled with smoke, and fire and sparks were observed exiting from the engine cowling. Due to the fire, the pilot elected to make a forced landing on a road near the approach end of runway. The airplane struck an object during the landing roll which resulted in substantial damage to the wings. A postaccident examination of the engine revealed that the No. 4 connecting rod bolt nut was missing. Prominent thermal distress was observed in the area where the No. 4 connecting rod connected to the crankshaft and was consistent with oil starvation. In June of 2020, the engine was disassembled for a propeller strike inspection. The inspection was about 27.3 hours before the accident. As part of the inspection, the connecting rods were overhauled and then reinstalled on the crankshaft using new bearings, rod bolts, and nuts. Given the recency of the work, it is likely that insufficient torque was applied during installation of the No. 4 connecting rod bolt nut, which subsequently became loose and separated.
Probable cause
The total loss of engine power due to the improper installation of the No. 4 connecting rod bolt nut during a recent overhaul.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B36TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N7220B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
EA-425
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-26T06:25:20Z guid: 104084 uri: 104084 title: ERA22LA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104085/pdf description:
Unique identifier
104085
NTSB case number
ERA22LA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-10T13:10:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-10-13T04:12:09.495Z
Event type
Accident
Location
Greenville, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 10, 2021, at 1210 eastern daylight time, a Flight Design GMBH CTLS, N121YT, was substantially damaged when it was involved in an accident near Greenville, South Carolina. The private pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, an annual condition inspection was conducted at Twin Lakes Airport (S17), Graniteville, South Carolina. He conducted a preflight inspection of the airplane with no anomalies noted and departed for Henderson, North Carolina. About 18 mile south of his destination, the engine oil pressure dropped to zero. The pilot turned towards Greenville Downtown Airport (GMU), Greenville, South Carolina, and declared an emergency. The pilot reported that the engine continued to run for about 4 or 5 minutes before it “seized.” The pilot then reported to GMU that he would not be able to make the airport and turned towards an open clearing before deploying the ballistic parachute about 500 ft above ground level (agl). Shortly after deploying the parachute, the airplane descended into pine trees and was suspended about 50 ft above the ground about 9 miles north of GMU. The pilot climbed out of the side window and was rescued by local first responders. A postaccident examination of the airplane by a Federal Aviation Administration inspector revealed substantial damage to the fuselage and left wing. The airplane was recovered to a secure facility and examined. The engine was found to be in good overall condition with oil staining down the right side of the airplane from the engine cowling to the horizontal stabilizer. The hose from the oil tank to the oil thermostat and the hose from the oil thermostat to the oil cooler were found disconnected from the oil thermostat (figure 1). The hoses and barbs were undamaged and intact, and the hose clamps remained installed on the hoses. A representative for the engine manufacturer reported that, with the hoses to and from the oil thermostat disconnected, it would be reasonable to expect that the engine would seize after about 3 to 4 minutes at maximum power due to the loss of lubrication that would occur. The valvetrain components in the cylinder heads were dry and lacked lubrication, and the No. 1 valve cover had metallic debris inside. There were no other anomalies noted within the cylinder heads or their components. All cylinders were removed and the cylinder bores were dry without any oil lubrication. The crankshaft could not be rotated by hand. After removing the cylinders, it was found that the No. 3 connecting rod bearing failed and was discolored consistent with exposure to excessive heating. The No. 3 piston and connecting rod were removed and the crankshaft rotated by hand. Approximately 2.5 quarts of oil were drained from the oil tank. The oil cooler system was not breached or damaged. Figure 1 - View of the oil thermostat and disconnected oil hoses. Data recovered from a Dynon EMS-D120 engine data monitor showed that, about 62 minutes after recording began on the accident flight and about 53 minutes after takeoff, the oil pressure dropped from 51 pounds per square inch (psi) to 0 psi in 55 seconds and remained about 0 psi for the remainder of the recording. The data also showed that the engine rpm decreased from about 5300 rpm, when the oil pressure drop was first noted, to 0 rpm over the course of about 5 minutes. The data were consistent with the pilot’s description of the flight and the loss of engine power. Review of the airplane’s maintenance records showed a condition inspection was completed two days before the accident, on October 8, 2021. The accident flight was the first flight after this inspection was completed. The mechanic who inspected the airplane reported that he did not remove any hoses from the oil thermostat, that he checked them for security before returning the airplane to service, and that they did not come off when he “tugged” on them. On October 14, 2020, the rubber hoses servicing the engine’s oil and fuel systems were replaced in accordance with the engine manufacturer’s 5-year requirement. The airframe had accumulated 152 hours since that work was completed. -
Analysis
The pilot was nearing his destination airport on the first flight after a condition inspection was completed when the engine oil pressure dropped to zero. He declared an emergency and attempted to divert to a closer airport; however, after about 4-5 minutes the engine lost power. Once he realized he would not be able to glide to an airport, the pilot deployed the ballistic parachute system at about 500 ft above ground level. The airplane descended into trees, resulting in substantial damage to the fuselage and left wing. A postaccident examination of the engine found the hoses from the oil tank to the thermostat and from the thermostat to the oil cooler had disconnected. The examination also found that the No. 3 connecting rod bearing displayed failure signatures consistent with a lack of lubrication. The valvetrain components in the cylinder head and the cylinder bores were dry due to a lack of lubrication. Based on this information, it is likely that the disconnection of the oil lines from the thermostat prevented oil from reaching critical components within the engine and subsequently resulted in the failure of the No. 3 connecting rod bearing. A review of maintenance records showed that the airplane’s annual condition inspection was completed two days before the accident flight. The review also found that the oil system hoses had been replaced a year prior as required by the engine manufacturer, and that the airframe had accumulated 152 flight hours since the hoses were replaced. The mechanic who performed the annual condition inspection reported that he did not remove any hoses from the thermostat. The mechanic reported checking the hoses for security, and that they did not come off when tugged on. The investigation was unable to determine why the oil hoses became disconnected from the oil thermostat in flight.
Probable cause
A total loss of engine power resulting from the in-flight disconnection of oil hoses from the oil thermostat.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FLIGHT DESIGN
Model
CTLS
Amateur built
false
Engines
1 Reciprocating
Registration number
N121YT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
08-04-10
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-13T04:12:09Z guid: 104085 uri: 104085 title: ERA22FA010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104078/pdf description:
Unique identifier
104078
NTSB case number
ERA22FA010
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-10T14:57:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2021-10-20T23:37:17.54Z
Event type
Accident
Location
Cornwall, New York
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude. The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. Additionally, according to the Physiology of Spatial Orientation – (StatPearls - NCBI Bookshelf, nih.gov) Spatial Disorientation is defined as: When the pilot fails to sense correctly the position, motion, or attitude of his aircraft or of himself within the fixed coordinate system provided by the surface of the Earth and the gravitational vertical. - The helicopter was equipped with inflatable landing gear floats and a flight control stability augmentation system. - On October 10, 2021, at 1357 eastern daylight time, a Robinson R44 II, N637HP, was destroyed when it was involved in an accident in Cornwall, New York. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to fueling records, the pilot purchased 24.6 gallons of fuel before his departure from Floyd Bennet Memorial Airport (GFL), Glenn Falls, New York. The flight departed about 1247 with a destination of MacArthur Airport (ISP), Ronkonkoma, New York, where the helicopter was based. According to ADS-B tracking data and National Weather Service (NWS) records, as the helicopter flew south along the Hudson River at an altitude of 1,800 to 1,900 ft above mean sea level (msl), the overcast cloud ceiling height was decreasing. As it passed by Poughkeepsie, NY (POU) at 1349, the ceiling reported there was about 2,364 ft msl. At 1353, about 7 miles further south, the helicopter passed by the Stewart International Airport (SWF) where the ceiling was reported to be about 1,991 ft msl. At 1356, the helicopter began to climb (see figure 1). Figure 1 – Helicopter’s ADS-B-derived flight track (red/green dots) and cloud heights at nearby airports (yellow text) According to NWS weather surveillance radar data, near the time the climb began, the helicopter encountered an area of light intensity echoes that were moving to the north-northwest (see figure 2). Figure 2 – Helicopter’s flight track (magenta) and weather radar base reflectivity at 1357 At 1356:03 while at an altitude of 1,875 ft msl, and a ground speed of 101 knots, the helicopter began to climb straight ahead. About 9 seconds later, it reached an altitude of 2,025 ft, which was above the cloud ceiling height reported at SWF (1,991 ft). About 5 seconds later it began the first of two right turns (see figure 3). The first turn lasted about 9 seconds, with an average turn rate of 7 to 11° per second. Figure 3 – Helicopter’s flight track during climbing turn and subsequent descent (red and green dots) From the start of the climb until about the end of the first right turn, the rate of climb continually increased, and the airspeed continually decreased. At the end of the first turn, the rate of climb plateaued at about 2,400 feet per minute, and the airspeed had decreased to about 45 knots. Just as the rate of climb plateaued, the airspeed trend reversed and began to increase. The helicopter continued to climb for about 10 seconds, as the airspeed increased to about 95 knots. During this time the second right turn began, lasted for about 9 seconds, at an average turn rate of 9-12° per second. At 1356:34, just before the end of the second turn, the helicopter began to descend rapidly from its peak altitude of 2,650 ft. About 6 seconds later, the descent rate reached 7,200 feet per minute. As it descended through 1,900 ft (just below the cloud ceiling height reported at SWF), the descent rate reached 16,200 feet per minute. The tracking data ended about 2 seconds later, about 0.6 nautical miles north of the accident site. The entire flight was about 70 minutes long and the accident site was located about 120 nautical miles south of GFL. A witness on a hiking trail about 0.1 mile southeast of the accident site reported hearing the helicopter’s engine “falter and die.” One to two seconds later, he heard a swishing sound, which he attributed to the helicopter “spinning” or being “out of control;” however, he could not see the helicopter due to the tree canopy. Shortly thereafter, he heard a series of loud noises that he described as “backfires, at machine gun speed” for about 2 seconds, which he surmised was “the engine catching and the rotors slapping,” and then the sounds stopped. He reported that the visibility was “clear,” and the clouds were higher than the mountain peaks; there was no fog over the river, and he could see the river clearly from his location on the hiking trail. A second witness located about 1/2-mile northwest of the accident site reported hearing a “loud noise” that he believed was the helicopter’s engine. When he turned toward the noise, he observed the helicopter in a nose-down attitude of nearly 90°, travelling at a “high speed…straight down.” The witness lost sight of the helicopter as it descended below a tree line; shortly thereafter, he “heard it crash.” The noise he associated with the helicopter’s engine was continuous until the sound of impact. - The Office of the Medical Examiner, Orange County, New York, performed an autopsy on the pilot. The autopsy report indicated the cause of death was blunt impact injuries. Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. Tamsulosin was detected in liver and muscle. Tamsulosin (Flomax) is an alpha blocker used to treat prostate hypertrophy and is acceptable for FAA medical certification. - Weather conditions reported at the nearest reporting station (SWF) at the time of the accident included wind from 070° at 5 knots, visibility 5 miles in mist, ceiling overcast at 1,500 ft agl, (1,991 ft msl, based on the station’s elevation), temperature 16° C, dew point temperature 14° C, altimeter setting 30.20 inches of mercury. Data from other reporting stations along the route of flight near the accident and toward the destination airport indicated that overcast ceiling heights were decreasing from north to south. Infrared satellite imagery depicted a thick layer of clouds that obscured the accident site, with cloud tops near 27,000 ft. Weather surveillance radar imagery depicted a small area of light echoes near the end of the ADS-B data, and a large area of light to moderate echoes between the accident site and the intended destination (ISP). The radar’s lowest scanning beam was centered about 5,800 ft msl over the accident site. The Terminal Aerodrome Forecast (TAF) issued at 0723 expected marginal visual flight rules conditions to prevail at SWF, with visibility of 6 statute miles or greater and overcast cloud ceilings at 1,200 ft above ground level (agl). The next closest TAF, also issued at 0723, expected instrument flight rules (IFR) conditions to prevail at Westchester County Airport (HPN), White Plains, New York (located 25 nautical miles southeast of the accident site), with visibility 5 statute miles in light rain showers, and cloud ceiling overcast at 800 ft agl. A national weather service AIRMET Sierra, current at the time of the accident, advised of IFR conditions expected due to ceilings below 1,000 ft agl and/or and visibility below 3 miles in precipitation and mist. The AIRMET extended over the accident site and the planned destination. There were no other SIGMETs, convective SIGMETs, or CWA’s current for the area during the period surrounding the flight. A search of the FAA contract Automated Flight Service Station provider Leidos indicated that they, and no other 3rd party vendors utilizing the Lockheed Flight Service (LFS) System, had any contact with the pilot of the accident helicopter on the day of the accident. A separate search of ForeFlight records indicated that the pilot had an account with the vendor and had used the application at 1113, and that he had created a route string for a flight from ISP to GFL via the Hudson River and back to ISP at an altitude of 1,000 ft. Before the flight, the following airports were viewed in the application (which includes the latest METAR, TAFs, and NOTAMs): Brookhaven Airport (HGV), Shirly, New York, and Minute Man Air Field (6B6), Stow, Massachusetts. The pilot did not view any weather imagery inside the application. No formal route briefing was requested and there was no confirmation the pilot reviewed or searched for the current inflight weather advisories for the area. The pilot had multiple tablet devices in the cockpit, all of which were too damaged to examine after the accident. - The pilot held a private pilot certificate with rotorcraft-helicopter rating. He did not have an instrument rating. A review of his logbook revealed that he had not recorded any actual or simulated instrument flight experience, and no instrument training was noted in the remarks section of any log entries. In November 2020, one flight was remarked with “IFR Conditions, asked for special VFR.” In May of 2021, one flight was remarked with “low clouds, rain, autopilot through clouds.” - Examination of the accident scene revealed a debris path that was about 110 ft-long and oriented on a heading of about 168° magnetic. It began with damaged treetops and broken limbs, where the tail rotor assembly and fragments of the tail rotor guard were located. The tail rotor blades were largely intact with leading edge gouge damage. The main impact crater, which contained fragmented landing gear components, was about 60 ft from the damaged tree, with the main wreckage located about 60 ft beyond the impact crater. The fuselage was fragmented and compressed from the nose toward the rear seats. Flight control continuity could not be confirmed due to impact damage and some system portions were not located. However, all flight control attachment fittings remained attached at their ends. Most of the flight control push-pull tubes were fractured, some in multiple locations, consistent with overload. The overriding clutch operated normally and smoothly when rotated by hand. The upper drive sheave had impact marks on the front and rear faces adjacent to the clutch centering strut and fuselage frame tubes, respectively. A 3-inch imprint consistent with the starter ring gear was present in the grooves of the upper sheave. The main and auxiliary fuel tanks were impact damaged; their bladders were breached, and a trace amount of fuel remained in the bladders. Some vegetation surrounding the impact crater and the main wreckage showed evidence of fuel blight. A portion of each main rotor blade (about 4 to 6 ft) remained attached to the hub. Most of the spar of one blade also remained attached. Fragments of damaged main rotor blades were found along the debris path; the outboard 3 ft of one blade was found 273 ft northwest of the main wreckage. Some fragments were found with wood debris in the leading edge, others with chordwise streaks of brown residue on the surface consistent with tree material. Score marks oriented in the direction of rotation were found on a fuselage frame tube adjacent to the tail rotor drive shaft intermediate coupling. The filament of the low rotor speed warning lamp on the cockpit instrument panel was found intact and demonstrated hot filament stretching. The engine crankshaft rotated smoothly when turned by hand at the cooling fan. Crankshaft and valvetrain continuity were confirmed as the crankshaft was rotated. Two of the cooling fan blades had impact marks/dents that were inline with airframe components located directly above the blades. Thumb suction and compression were attained on all six cylinders. A borescope examination of all cylinders revealed no internal damage or anomalies. Both magnetos were found separated from the engine. The left magneto was fractured in half and with the lower half not recovered. The right magneto’s upper case and capacitor were impact damaged but otherwise intact. It would not produce spark on any leads when tested as found. After replacing the damaged capacitor, it operated normally. The fuel servo was separated from the engine and partially fragmented. The mixture control arm was bent inward toward the servo and was found in the idle-cutoff position. The push-pull mixture cable was not attached to the control arm and the attachment hardware was not present. The cable sheath was found stretched (in tension) in several locations. -
Analysis
The non-instrument-rated helicopter pilot was returning to his home airport as the height of the overcast ceiling gradually decreased along the route of flight, consistent with the forecast conditions. While flying along the river valley at an altitude of 1,800 to 1,900 ft above mean sea level (100 to 200 ft below the clouds), the helicopter flew beneath an area of light-intensity precipitation echoes as detected by weather surveillance radar. It is likely that, at this time, the pilot encountered reduced visibility in very light rain and potential clouds. About the same time, the helicopter began to climb, and its groundspeed decreased. Shortly after climbing above the altitude of the reported cloud ceiling, the helicopter entered a relatively constant-rate turn. About 9 seconds later, the track straightened for about 3 seconds, the climb rate plateaued at about 2,400 feet per minute, and the groundspeed began to increase. The helicopter continued to climb for another 10 seconds as the groundspeed increased to about 95 knots. During this time, it again turned toward the right for about 9 seconds. Just before the end of the turn, the helicopter began to descend rapidly. As it descended through the altitude of the cloud ceiling, the rate of descent reached 16,200 feet per minute. The tracking data ended about 2 seconds later in the vicinity of the accident site. Postaccident examination of the airframe revealed no preimpact anomalies that would have precluded normal operation. Damage and fragmentation to the main and tail rotor blades, along with score marks on a frame tube near the tail rotor drive intermediate coupling, were consistent with rotor system rotation during the impact sequence. Impact marks found on the upper drive sheave and dents found on two of the engine’s cooling fan blades were consistent with the engine’s crankshaft not rotating at the time of impact. The drive sheave mark was an imprint with an outline of teeth from starter ring gear, which was mounted on the engine crankshaft. The imprint, (rather than scoring or cut grooves) was consistent with the engine’s crankshaft was not rotating when it contacted the sheave. Similarly, the dents on the cooling fan blades, each found directly below airframe components that likely caused the dents, suggest the cooling fan was not rotating when its blades made contact during impact. Also, the fuel servo mixture arm was found bent and in the idle-cutoff (no fuel to engine) position. The mixture cable sheathing was found stretched in several locations, consistent with tension. Tension on the cable, and other impact forces, likely pulled the mixture arm toward the idle-cutoff position. Despite these findings, no evidence of any preimpact mechanical malfunctions or failures of the engine were discovered that would have precluded normal engine operation. The flight track information, which showed a simultaneous climb and increase in groundspeed before the accident, was consistent with the engine providing power; therefore, it is likely that the crankshaft stopped during the impact sequence before the helicopter came to rest. The pilot’s continued visual flight rules flight into an area of instrument meteorological conditions due to clouds and precipitation likely resulted in his loss of outside visual references, an environment conducive to the development of spatial disorientation, and the helicopter’s flight track was consistent with the known effects of spatial disorientation. According to the pilot’s logbook, he had not received any instrument training, nor was the helicopter certified for flight in instrument conditions. These factors increased the likelihood of the pilot becoming spatially disoriented after encountering reduced visibility conditions.
Probable cause
The non-instrument-rated pilot’s continued flight into deteriorating weather conditions, which resulted in a loss of control due to spatial disorientation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N637HP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11942
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-20T23:37:17Z guid: 104078 uri: 104078 title: CEN22FA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104079/pdf description:
Unique identifier
104079
NTSB case number
CEN22FA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-11T09:57:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-10-13T22:55:58.053Z
Event type
Accident
Location
Mesa, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The two mechanics who performed most of the maintenance during the airplane’s most recent annual inspection both stated that they were not sure how the right engine fittings would have become loose after the annual inspection. The mechanic who worked on the right propeller governor stated that he was not sure why the propeller governor was not torqued after it was reinstalled. He was also not sure how the turbocharger oil lines and other fittings became loose because he did not remember performing maintenance on those fittings. The other mechanic, who held an inspection authorization, stated that he was not sure how the loose fittings would not have been caught during the annual inspection signoff. Typically, mechanics review the airplane twice to ensure that all items were reinstalled correctly. This mechanic did not know why the turbocharger lines or fuel rail would have been taken apart or loosened for the annual inspection because no discrepancies were related to these items. - At the time of the airplane’s most recent annual inspection, the airplane had accumulated 3,429 hours of total time. Maintenance documentation from the most recent annual inspection listed a discrepancy of oil around the right engine propeller governor. The corrective action, according to the maintenance documentation, was to remove the “left” engine propeller governor and install a new gasket. The mechanic who completed the maintenance work stated that the reference to the left engine in the paperwork was a mistake and that he installed a new gasket on the right engine propeller governor. - On October 11, 2021, about 0857 mountain daylight time, a Beech 58TC airplane, N6748V, was destroyed when it was involved in an accident near Mesa, Colorado. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Fixed-base operator employees at Blake Field Airport (AJZ), Delta, Colorado, stated that, before the airplane departed, the pilot fueled the airplane with 100 gallons of 100 low-lead aviation gasoline. The airplane taxied away from the fuel pump about 0839 and proceeded to runway 3. The airplane departed about 0843 and proceeded northeast toward its destination, Southwest Wyoming Regional Airport (RKS), Rock Springs, Wyoming. The employees also stated that this flight was the first one after the airplane’s latest annual inspection, which had been completed on October 1, 2021. Automatic dependent surveillance-broadcast data revealed that the airplane proceeded northeast for about 4 nautical miles and then turned left to a north-northwest direction and climbed over Grand Mesa. Recorded air traffic control communications revealed that, about 0852, the pilot reported climbing through 11,000 ft mean sea level (msl) for 14,000 ft msl. After crossing over Grand Mesa, the airplane reached an altitude of about 14,000 ft msl. At 0855:51, the airplane turned right, descended about 1,000 ft, and then climbed to 15,000 ft msl. At 0856:26, the airplane descended rapidly toward terrain. At 0857:00, the controller asked the pilot, “did you get an updraft, mountain wave out there? I’m showing you 800 ft high.” The pilot did not respond to this transmission. Figure 1 shows the flight track and the accident location. Figure 1. Flight track and accident location. - A review of meteorological information revealed the potential for lighttomoderate turbulence and mountain wave activity near the accident site. The National Weather Service had no active AIRMET, SIGMET, convective SIGMET, or center weather advisory for the route of flight. - The pilot’s four most recent training flights conducted with a flight instructor were completed in a single-engine Cessna 172 airplane. The pilot’s recent training experience with emergency procedures in the accident airplane make and model could not be determined. - The airplane impacted a rocky mountainside about 25 nautical miles north of AJZ and remained upright on a heading of about 040°. The wreckage debris path was about 30 ft long and consisted mostly of paint chips, shards of windscreen, various small debris, and a large outboard section of the right wing that had separated on impact. The empennage was distorted to the left and remained partially attached to the rear fuselage. The bottom of the airplane exhibited impact damage and scoring from the rocky terrain. The left engine was mostly separated from the left-wing nacelle, and the right engine remained attached to the right-wing nacelle. The six propeller blades were relatively undamaged and did not exhibit leading-edge damage or scoring. The pilot’s lap belt was found unlatched at the accident site, and no evidence showed stretching in the belt webbing. The pilot’s three-point shoulder harness was found unlatched and behind the pilot’s seat. The throttle levers were found near the idle position. The mixture and propeller levers were in intermediate positions that were near full forward. Both ignition switches were found in the OFF position. The right engine was still mostly attached to the nacelle via the engine mounts. The engine compartment, propeller blades, and right-side nose compartment were covered in a layer of engine oil. The oil sump was crushed upward and punctured by the oil dipstick tube. The oil sump was removed; no signs of debris or catastrophic engine failure were evident. The propeller remained attached to the crankshaft. The turbocharger, fuel control, turbocharger controller, and associated plumbing were separated from their respective mounts but remained connected to each other. Multiple oil and fuel lines were fractured and separated at the fittings. The turbocharger wastegate valve was fractured from the valve control housing at the base. The wastegate control was removed from the turbocharger housing mount and examined. The turbocharger compressor housing was fractured and separated from the turbocharger due to impact. The turbine rotor was in contact with the housing and was seized. No evidence indicated any rotational damage on the rotor assembly. The oil line from the turbocharger wastegate control valve outlet to the inlet side of the turbo pressure controller was loose at the wastegate outlet end. During the examination, the B-nut was rotated about three-quarters to one full rotation clockwise before the fitting tightened against the mating surface of the flared union fitting. The fuel rail tube assembly was in place and attached, but the connections were not tight. The fuel injectors were removed from the cylinder heads and were found to be free of obstructions. During removal of the fuel injectors, only two to three threads were engaged. The propeller governor had fractured near the mounting base. The top mounting studs were bent slightly upward. The lower forward mounting nut was not secure and turned counterclockwise with light finger pressure. The top forward and lower rear mounting nuts were not tight and turned easily with a wrench. The top rear mounting nut was tight. The black gasket was torn and damaged at the top near the edge of the unit exterior. The lower area of the gasket did not have any damage or indentions. -
Analysis
The pilot departed on a personal flight that was the first flight after completion of the airplane’s most recent annual inspection. Recorded air traffic control communications revealed that pilot had climbed through 11,000 ft for 14,000 ft. The flight track showed that, after the airplane reached 14,000 ft, it descended about 1,000 ft, climbed to 15,000 ft, and then descended rapidly toward terrain. The airplane impacted a rocky mountainside about 25 nautical miles north of the departure airport. The wreckage debris path was about 30 ft long and consisted mostly of paint chips, shards of windscreen, various small debris, and a large outboard section of the right wing that had separated on impact. The empennage was distorted to the left and remained partially attached to the rear fuselage. The bottom of the airplane exhibited impact damage and scoring from the rocky terrain. The left engine was mostly separated from the leftwing nacelle, and the right engine remained attached to the right-wing nacelle. All six propeller blades were relatively undamaged and did not exhibit leading-edge damage or scoring, which was consistent with minimal, if any, rotation during impact. The right engine compartment, propeller blades, and right-side nose compartment were covered in a layer of engine oil. The engine throttle levers were found near the idle position, and the mixture and propeller control levers were found near the forward position. The pilot’s seatbelt and shoulder harness were not latched during the accident and the pilot was ejected from the airplane. On the right engine, the oil line from the turbocharger wastegate control valve outlet to the inlet side of the turbo pressure controller was loose at the wastegate outlet end. Also on the right engine, the propeller governor had fractured near the mounting base and remained attached to the mounting pad, but three of the four mounting nuts were loose. According to a discrepancy in the maintenance records from the most recent annual inspection, oil was found around the right engine propeller governor. Although the corrective action noted in the maintenance records was to remove the left engine propeller governor and install a new gasket, the mechanics indicated that the reference to the left engine was likely an inadvertent error and that they actually replaced the gasket on the right engine. However, the right engine propeller governor was not properly reinstalled. It is also likely that the turbocharger oil line was not properly tightened. These loose connections likely resulted in a loss of oil during the flight, which led to a loss of engine power. The pilot likely experienced difficulty handling the airplane during the emergency and lost control of the airplane.
Probable cause
The maintenance personnel’s failure to properly tighten the turbocharger oil line and the right engine propeller governor, which resulted in a loss of engine power. Contributing to the accident was the loss of airplane control following the loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
58TC
Amateur built
false
Engines
2 Reciprocating
Registration number
N6748V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TK-120
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-13T22:55:58Z guid: 104079 uri: 104079 title: WPR22FA004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104080/pdf description:
Unique identifier
104080
NTSB case number
WPR22FA004
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-11T13:14:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2021-10-22T06:48:12.833Z
Event type
Accident
Location
Santee, California
Airport
Montgomery-Gibbs Executive Airport (KMYF)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 2 serious, 0 minor
Factual narrative
Spatial Disorientation The Federal Aviation Administration’s (FAA) Airplane Flying Handbook (FAA-H-8083-3B) described some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - Maintenance records for the airplane showed that on November 6, 2020, the following avionics were installed: Garmin GI275, Garmin GFC600 autopilot, Garmin GTN 650, Garmin GTN 750 Xi, and a Garmin G500 TXi; at the time of installation the airplane had a HOBBS time of 2,629 hours. The most recent maintenance performed on the airplane was an oil change, conducted on August 5, 2021, at a HOBBS time of 2,734.5 hours. - Montgomery-Gibbs Executive Airport operates under Class-D airspace and was equipped with 3 runways (runway 28R/10L, 28L/10R, and 05/23). Runway 28R featured an ILS and Localizer instrument approach. Runway 28R also had a GPS instrument approach. Figure 2: ILS / Localizer approach plate for Runway 28R at Montgomery - Gibbs Executive Airport. - On October 11, 2021, about 1214 Pacific daylight time, a Cessna 340A, N7022G, was destroyed when it was involved in an accident near Santee, California. The pilot and one person on the ground were fatally injured, and 2 people on the ground sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of audio recordings from Southern California Terminal Radar Approach Control facilities and recorded ADS-B data revealed that at 1203:58, the controller broadcasted a weather update for Montgomery-Gibbs Executive Airport (MYF), which included a report that visibility was 10 miles, ceiling 1,700 ft broken, overcast at 2,800 ft, and runway 23 was in use. At 1209:20, the controller issued instructions to the pilot to turn right to a 250° heading to join the final approach, which the pilot acknowledged, and ADS-B data showed the airplane at an altitude of 3,900 ft mean sea level (msl). About 28 seconds later, the pilot queried the controller if he was cleared for the ILS Runway 28R approach, with no response from the controller. At 1210:04, the controller told the pilot that he was 4 miles from the PENNY intersection and instructed him to descend to 2,800 ft until established on the localizer and cleared him for the ILS 28R approach before circling to land on runway 23, which the pilot partially read back. The controller reiterated the instruction to descend to 2,800 ft until the flight was established on the localizer, which the pilot acknowledged. At this time, the ADS-B data showed the airplane on a westerly heading at an altitude of 3,900 ft msl. At 1211:19, the controller advised the pilot of traffic at their 2 o’clock position, 3 miles, southbound, at 5,000 ft and descending to 4,000 ft; the traffic reported was a C130 that was restricted above them, and the controller provided a caution about wake turbulence, which the pilot acknowledged while at an altitude of 2,550 ft. Immediately following the pilot’s acknowledgement, the controller queried the pilot that it looked like he was drifting right of course and asked him if he was correcting, to which the pilot responded “I’m correcting, 22G.” At 1211:45, the pilot said “SoCal, is 22G, VFR runway 23” at which time ADS-B data showed the airplane at 2,175 ft msl. The controller told the pilot he was not tracking on the localizer and canceled the approach clearance, followed by issuing instructions to climb and maintain 3,000 ft, followed by the issuance of a low altitude alert; the controller stated that the minimum vectoring altitude in the area was 2,800 ft. The pilot acknowledged the controller’s instructions shortly after. At this time, ADS-B data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. At 1212:12, the controller instructed the pilot to climb and maintain 3,800 and the pilot responded “3,800, 22G.” ADS- B data showed that at this time the airplane was at 3,550 ft msl. About 9 seconds later, the controller issued the pilot instructions to turn right to 090° for vectors to final, to which the pilot responded “090 22G.” At 1212:54, the controller instructed the pilot to turn right to 090° and climb immediately and maintain 4,000 ft. The pilot replied shortly after and acknowledged the controller’s instructions. At this time, ADS-B data showed the airplane at an altitude of 2,500 ft msl, on a north-northeast heading. About 3 seconds after the pilot’s response, the controller told the pilot that it looked like he was descending and that he needed to make sure he was climbing, followed by an acknowledgment from the pilot. At 1213:35, the controller queried the pilot about his altitude; the pilot responded, “2,500 ft., 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb at 1213:39, from 2,550 ft msl. The airplane continued a climb ascent while turning from a northeasterly-easterly heading and reached a maximum altitude of 3,500 ft msl, where it remained for about 4 seconds before it began a descending right turn. The airplane remained in the right descending turn until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. Figure 1: ADS-B data with ATC communication points noted. Multiple witnesses located near the accident site reported hearing or seeing the accident airplane in a right-wing-low descent. One witness, who held a private pilot certificate, reported that he heard the engines for about 3 seconds, and that they sounded like they were at a high-power setting, or “over-revving.” The witness also noted that at the time of the accident there was an overcast cloud layer about 1,900 ft msl. One witness, who was flying a helicopter, reported that while they were inbound for Gillespie Airport (SEE), El Cajon, California, they were informed by the tower controller about an airplane eastbound, 1,100 ft above their altitude. The witness stated they obtained visual contact with the airplane, and saw it make an initial descent of a “few hundred feet” followed by a rapid nose-down descent in a right-wing-low attitude. - An autopsy of the pilot was performed by the San Diego County Medical Examiner, San Diego, California, which listed the cause of death as “multiple blunt force injuries.” Autopsy evaluation for natural disease was extremely limited by the severity of injury. Toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. - The closest weather reporting facility to the accident site was from Gillespie Field Airport (SEE), El Cajon, California, located 1.8 miles south of the accident site. The airport listed an elevation of 386 ft. In part, at 1155, SEE recorded a broken cloud ceiling at 2,700 ft agl. At 1153, recorded weather conditions at the Montgomery-Gibbs Executive Airport (MYF), San Diego, California, located 9 miles west-southwest of the accident site at an elevation of 427 ft msl, included, in part, ceilings broken at 1,700 ft agl, overcast at 2,800 ft. - One of the pilot’s logbooks, which contained previous flight experience from May 4, 2018, to October 6, 2021, was provided during the investigation. The logbook showed that between November 13, 2018, and October 6, 2021, the pilot had logged 152.2 hours in the accident airplane, of which, 8.2 hours were in instrument meteorological conditions and included 48 instrument approaches. No reference to a circle to land maneuver following an instrument approach was located within the provided logbook. The pilot’s most recent flight review and instrument proficiency check was completed on August 27, 2021. The logbook entry indicated that the flight was 0.7 hours in length, and included 0.7 hours of dual instruction received, 2 instrument approaches, and 3 landings. No reference of specific training regarding the recent Garmin avionics that were recently installed in the accident airplane was observed within the provided logbook. However, a magazine article, dated November 2019, noted that the pilot had owned other airplanes that were equipped with a different brand of advanced avionics than those installed in the accident make/model airplane. - Examination of the accident site revealed that the airplane impacted a residential street on a heading of about 113° magnetic. The debris path, which consisted of various airplane, vehicle, and residential structure debris, was about 475 ft long and 400 ft wide, oriented on a heading of about 132°. Numerous residential structures exhibited impact related damage and or fire damage. Figure 3: Annotations of wreckage locations. Aerial photo provided by San Diego County Sheriff. The first identified point of contact (FIPC) was a gouge in the asphalt road about 10 inches long and 5 inches wide. Scrape marks extended from about 18 ft from the FIPC to a second gouge in the asphalt, which was about 2 ft wide and 3 ft long, along with a damaged vehicle. Adjacent to the second scrape mark and vehicle was an additional gouge in the asphalt, about 2 ft long and 4 inches wide. Additional scrape marks extended 28 ft to a large impact crater within the asphalt, which was about 4 ft wide, 3 ft long, and about 6 inches deep, and contained a portion of propeller blade. Additional scratch marks extended another 12 ft to portions of red lens consistent with the left wing navigation lens. Figure 4: Initial impact area. Examination of the main wreckage revealed that the fuselage and wings were located within the main wreckage and exhibited extensive fire damage and fragmentation throughout. Both engines were separated from their respective mounts. The empennage exhibited extensive crushing throughout. The left horizontal stabilizer was impact damaged and the left elevator was separated and located adjacent to the main wreckage within the debris path. The right horizontal stabilizer was impact damaged and was torn open from the leading edge aft about 30 to 40 inches from the outboard tip. The right elevator was separated. About 50 inches of the outboard right elevator was located within the debris area; however, the inboard portion of the right elevator and trim tab were not located. The vertical stabilizer and rudder remained attached to the empennage structure and exhibited impact damage. Control continuity was established from the elevator bellcrank to the cockpit control bellcrank. One control cable exhibited signatures consistent with overload separation. Rudder control continuity was established from the rudder bellcrank to the rudder pedals. One control cable exhibited signatures consistent with overload separation. Aileron control continuity on both wings was established from the aileron bellcrank inboard with overload separations in the cables. Continuity from the aileron cable separations inboard to the control column was not able to be obtained at the accident site due to impact damage. Multiple flap hinges and flap surfaces were observed throughout the debris path. All 3 main landing gear were observed separated from the airframe. Gear position could not be determined. Elevator and rudder trim actuators were located and measured, with both found in the neutral position. Examination of the recovered wreckage revealed that all major structural components were recovered. Remains of all primary flight controls were also located within the recovered debris. Primary flight control cables were located within the recovered wreckage. Segments of cable chains were located. All separations within the cables were consistent with tension overload. Both of the recovered engines exhibited extensive impact damage. Visual and mechanical continuity was established throughout both engines. The propeller assemblies were located within the recovered debris. One propeller assembly had the remains of one blade still connected to the hub and exhibited bending opposite of the direction of rotation, with blade separation about mid span. The remaining 2 blades were separated at the hub. The second propeller assembly had 2 blades that remained attached to the propeller hub. One propeller blade was bent opposite of the direction of rotation and curled almost 360°. The propeller blade tip was separated. The remaining propeller blade that was attached to the propeller hub was impact damaged and separated about mid blade. Propeller blade fragments were located throughout the recovered wreckage and exhibited various degrees of chordwise scratching, blade twisting, and curling along with leading edge and trailing edge gouges. Postaccident examination of the engines revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot was on a cross-country flight, receiving vectors for an instrument approach while in instrument meteorological conditions (IMC). The approach controller instructed the pilot to descend to 2,800 ft mean sea level (msl) until established on the localizer, and subsequently cleared the flight for the instrument landing system (ILS) approach to runway 28R, then circle to land on runway 23. About 1 minute later, the controller told the pilot that it looked like the airplane was drifting right of course and asked him if he was correcting back on course. The pilot responded “correcting, 22G.” About 9 seconds later, the pilot transmitted “SoCal, is 22G, VFR runway 23” to which the controller told the pilot that the airplane was not tracking on the localizer and subsequently canceled the approach clearance and instructed the pilot to climb and maintain 3,000 ft. As the pilot acknowledged the altitude assignment, the controller issued a low altitude alert, and provided the minimum vectoring altitude in the area. The pilot acknowledged the controller’s instructions shortly after. At this time, recorded advanced dependent surveillance-broadcast (ADS-B) data showed the airplane on a northwesterly heading at an altitude of 2,400 ft msl. Over the course of the following 2 minutes, the controller issued multiple instructions for the pilot to climb to 4,000 ft, which the pilot acknowledged; however, ADS-B data showed that the airplane remained between 2,500 ft and 3,500 ft. The controller queried the pilot about his altitude and the pilot responded, “2,500 ft, 22G.” The controller subsequently issued a low altitude alert and advised the pilot to expedite the climb to 5,000 ft. No further communication was received from the pilot despite multiple queries from the controller. ADS-B data showed that the airplane had begun to climb and reached a maximum altitude of 3,500 ft before it began a descending right turn. The airplane remained in the right descending turn at a descent rate of about 5,000 ft per minute until the last recorded target at 900 ft msl, located about 1,333 ft northwest of the accident site. Recorded weather conditions at the pilot’s intended destination airport about 21 minutes before the accident showed that the cloud ceilings were broken at 2,127 ft msl, overcast at 3,227 ft msl. The closest weather reporting station to the accident site, which was about 1.8 miles south, showed a broken cloud layer at 3,086 ft msl. The airplane had undergone a conversion to modern avionics about 11 months before the accident. No reference to any additional training to the installed avionics was found within the provided pilot records. While the pilot had previous experience with other brands modern avionics, the investigation was unable to determine if the pilot had previous experience or training for the specific model of modern avionics installed in the airplane. The controller had cleared the flight to fly the ILS approach to runway 28R, circle to land on runway 23, and ADS-B track data showed that the airplane was about to be established on the localizer when it started to veer off course to the right, ultimately into an area with minimum vectoring altitudes that required the controller to issue instructions to the pilot to climb. During the divergence from the instrument approach, the airplane was at an altitude above the reported base of the broken cloud layer and below the base of the overcast layer at the destination airport, which most likely placed the airplane in and out of IMC conditions. Ultimately, the airplane climbed back into IMC conditions. It could not be determined if the pilot had inadvertently misconfigured the avionics for the instrument approach. Continuing the instrument approach would have afforded the pilot the opportunity to fly a stabilized approach in protected airspace and safely descend below the cloud layer prior to conducting the circle to land on runway 23. Given the airplane was maneuvering in IMC, it placed the pilot in conditions conducive to the development of spatial disorientation. The accident circumstances, including the tightening descending turn, and the subsequent high-energy impact, are consistent with the known effects of spatial disorientation. Additionally, examination of the airframe and engines revealed no evidence of any preexisting anomalies that would have precluded normal operation. Therefore, it is likely that the pilot was experiencing the effects of spatial disorientation when the accident occurred.
Probable cause
Loss of control due to spatial disorientation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
340A
Amateur built
false
Engines
2 Reciprocating
Registration number
N7022G
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
340A0695
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-22T06:48:12Z guid: 104080 uri: 104080 title: RRD22LR001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104093/pdf description:
Unique identifier
104093
NTSB case number
RRD22LR001
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-12T19:00:00Z
Publication date
2024-01-08T05:00:00Z
Report type
Final
Last updated
2023-12-12T05:00:00Z
Event type
Accident
Location
Arlington, Virginia
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the derailment of Washington Metropolitan Area Transit Authority train 407 south of Rosslyn Station was an out-of-specification wheelset that caused a wheel to depart the rail at a turnout; the wheelset was out of specification because the wheelset’s design allowed the wheels to migrate outward and eventually exceed the maximum permitted back-to-back measurement.
Has safety recommendations
true

Vehicle 1

Railroad name
WMATA - Blue line
Equipment type
Commuter train-pulling
Train name
407
Train number
407
Train type
FTA regulated transit
Total cars
8
Findings
creator: NTSB last-modified: 2023-12-12T05:00:00Z guid: 104093 uri: 104093 title: ERA22FA014 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104097/pdf description:
Unique identifier
104097
NTSB case number
ERA22FA014
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-13T09:16:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Last updated
2021-10-18T23:47:58.958Z
Event type
Accident
Location
Blairsville, Georgia
Airport
BLAIRSVILLE (DZJ)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On October 13, 2021, at 0816 eastern daylight time, a Piper PA-24-260, N9126P, was destroyed when it was involved in an accident at Blairsville, Georgia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The instrument-rated pilot, who owned the airplane, filed an IFR flight plan from Blairsville Airport (DZJ) to Sebring Regional Airport (SEF), Sebring, Florida. At 0806, the pilot contacted air traffic control (ATC) and requested an IFR clearance from DZJ to SEF. A clearance void time of 0820 was issued, with instructions to contact Atlanta Center if not airborne by 0820, and to advise no later than 0825 of intentions. The pilot did not report airborne, and a search for the airplane was initiated. The DZJ airport manager subsequently called ATC to report that an airplane had crashed near DZJ. According to automatic dependent surveillance – broadcast (ADS-B) data, the pilot took off on runway 8 about 0815 and immediately commenced a left turn to the northwest to a heading of about 300°, at which point the airplane began a right turn before the ADS-B data ended. The airplane impacted trees and terrain on a heading of 090° about 1.5 nautical miles north of the departure end of runway 8. ADS-B data revealed that the airplane reached an altitude of about 540 ft above the ground before the data ended. The airport manager at DZJ reported that the pilot flew the airplane in the local traffic pattern the day before the accident; this was his normal procedure when he was preparing for a trip. He purchased about 29 gallons of fuel before the flight. The pilot had planned on a departure time of 0600; however, he could not see down the runway due to visible moisture, so he waited for the weather to improve. The pilot was in “very good spirits” before the flight. A witness was outside his residence at the time of the accident and heard the airplane fly over. He recalled that it was so foggy, “you could hardly see the trees around you.” The airplane came over his house very low and close, but he could not see the airplane. He reported that the engine was running loud; it was not missing or sputtering. He heard the engine running all the way to impact. He heard two “pops” and believed they were the sounds of the airplane striking the trees, then a loud noise when the airplane hit the ground. A second witness was at his residence working outside when he heard the airplane go by. He could not see the airplane due to the fog. The engine “went off and came back on,” then he heard the crash. He stated that it was so foggy you could hardly see the lake. He then called 911. - According to the autopsy report from the Division of Forensic Sciences, Georgia Bureau of Investigation, the cause of death of the pilot was multiple generalized blunt force injuries and the manner of death was accident. Toxicology testing performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory detected ethanol in the pilot’s liver tissue at 0.013 grams per hectogram (gm/hg); ethanol was not detected in his muscle tissue. The high blood pressure medication amlodipine was detected in his liver and muscle tissue; this medication is generally considered non-impairing. - According to the National Weather Service Surface Analysis Chart, a warm front stretched from Kansas eastward through Tennessee and Kentucky. A high-pressure system was located just south of the accident site in northwestern Georgia. The accident site was located south of the warm front in an area of light and variable surface winds. Station models around the accident site depicted temperature-dew point spreads of 2°F or less, mostly cloudy skies, mist, and sky obscured noted at several of the station models. The Atlanta Air Route Traffic Control Center (ARTCC) Center Weather Service Unit (CWSU) was responsible for the region around the accident site. Center Weather Advisory (CWA) 102, issued at 0727 and valid through the time of the accident, warned of patchy low IFR (LIFR) ceilings and visibilities in fog and mist with conditions expected to improve by 1000. AIRMET advisory Sierra was valid at the time of the accident and forecast IFR conditions through 1100. The Graphical Forecasts for Aviation (GFA) products issued before the accident flight indicated LIFR surface visibilities in fog, and a calm surface wind. The GFA cloud forecast applicable to the accident region indicated cirrus clouds above the accident site and lower cloud cover in northwestern Georgia and southeastern Tennessee. The pilot requested and received weather information through ForeFlight at 0757. This information included the valid AIRMETs, PIREPs, GFA, and METARs. Takeoff minimums and obstacle departure procedures for DZJ (an uncontrolled airport) required pilots to climb in visual conditions to cross the airport at or above 4,500 ft msl before proceeding on course. Weather minimums for the climb in visual conditions were 2,700 ft ceiling and 3 miles visibility. The DZJ weather at 0815 included a ceiling of 200 ft overcast with ¼ mile visibility in fog. - The airplane struck tree tops before colliding with terrain on the banks of Nottely Lake. The wreckage debris field was about 265 ft long and about 30 ft wide. The measured descent angle from the tree breaks to the initial impact crater was 22°. An examination of the accident site and wreckage revealed that all major structural components of the airplane were accounted for. There was no fire. The fuselage and cabin areas were found inverted. The fuselage wreckage was fragmented and destroyed by impact forces. The front seats were separated from their seat tracks and from the main wreckage. Impact damage to the nose landing gear was to the extent that the preaccident position could not be determined. Primary flight control cable continuity was established from the cockpit to the control surfaces. The left wing was broken near the wing root and folded over onto the right wing. The left main landing gear was found in the retracted position; impact damage to the wing prevented the landing gear from extending from the wheel well. The left flap remained attached to the wing; the preaccident position of the left flap could not be determined due to impact damage. The fuel cells were separated from the wing and shredded; no residual fuel was noted. The right wing exhibited impact damage consistent with multiple tree strikes. The right main landing gear was found in the extended position. The right flap was torn and separated chordwise; its preaccident position could not be determined due to impact damage. The fuel cells were torn and shredded; no residual fuel was noted. The engine was examined at the wreckage storage facility. The Nos. 2 and 4 cylinder heads had impact damage. Impact damage was also noted on the induction tubing, exhaust tubing, exhaust mufflers, and oil sump. The carburetor was fractured and separated. The engine was suspended from a lift to facilitate further examination. The engine was rotated manually; compression and suction were attained on all six cylinders. A lighted borescope was used to examine the interior of the cylinders; no anomalies were noted. Both magnetos produced spark at all towers when rotated by hand. The oil suction screen and paper oil filter element were free of metallic debris. The vacuum pump remained attached to the engine. Internal examination of the pump revealed no anomalies. The propeller remained attached to the engine crankshaft flange. One propeller blade was bent aft about 30° about mid-span. That blade exhibited leading edge gouges, chord-wise scoring, and longitudinal twisting toward the blade face. The other blade was turned about 90° in the hub and curved aft about 30°. That blade exhibited leading and trailing edge gouges, chord-wise scoring, and longitudinal twisting toward the blade face. The airplane was equipped with a JPI EDM 700 engine monitor. The unit was forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for examination and download of the data. The unit was damaged; however, the engineer was able to recover some data. The last recorded segment of flight was about 15 minutes in duration and did not appear to be data from the accident flight, nor was it an entire flight beginning with engine start. Examination of the engine and propeller did not reveal evidence of a mechanical malfunction or anomaly that would have precluded normal operation. -
Analysis
The private pilot arrived at the airport for an instrument flight rules (IFR), cross-country flight to find a low ceiling and thick fog conditions prevailing. He waited for the weather to improve; however, he elected to depart when the ceiling was 200 ft and the visibility was ¼ mile in fog. The published departure procedure required a climb in visual conditions to cross the airport at or above 4,500 ft before continuing on course. Flight track data indicated that, immediately after takeoff, the pilot commenced a left turn to the northwest followed by a reverse turn to the right before the data ended. The airplane impacted trees and the bank of a lake, descending at a 22° angle to the ground. The airplane was destroyed, and the pilot was fatally injured. Witnesses reported that the area around the accident site was enshrouded in thick fog at the time of the accident. The pilot most likely entered instrument meteorological conditions (IMC) immediately after takeoff, experienced spatial disorientation, and lost control of the airplane. An examination of the wreckage revealed no evidence of a preexisting mechanical failure or anomaly.
Probable cause
The pilot’s decision to commence the flight in low IFR weather conditions, and making immediate turns after takeoff in IMC, resulting in spatial disorientation and a loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N9126P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-4605
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-18T23:47:58Z guid: 104097 uri: 104097 title: WPR22LA014 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104121/pdf description:
Unique identifier
104121
NTSB case number
WPR22LA014
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-13T11:20:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-11-04T21:55:12.647Z
Event type
Accident
Location
Payette, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 13, 2021, about 1020 Pacific daylight time, an Avid Mark IV experimental airplane, N583DM, was substantially damaged when it was involved in an accident near Payette, Idaho. The non-certificated pilot was not injured. The experimental amateur-built airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The non-certificated pilot reported that while in level flight, about 1,000 ft above ground level, the engine began to intermittently lose power. He activated the fuel pump and shortly thereafter the engine shut down. The pilot then turned the airplane 180-degrees to the north to land in a cultivated field. During the landing roll, the airplane nosed over resulting in substantial damage to the vertical stabilizer. A postaccident examination of the wreckage revealed bent tubular structure near the landing gear attachment, forward cabin areas and vertical stabilizer. The airplane’s fuel system header tank did not have an outlet screen and the fuel selector valve contained a large quantity of debris from the fiberglass fuel tanks. According to the Federal Aviation Administration inspector who examined the wreckage, the contamination most likely resulted from the construction and previous repairs of the fuel and header fuel tanks. Maintenance logbooks were not found during the investigation. The pilot logbook revealed a total of 4 hours of flight time. The pilot reported to the Federal Aviation Administration inspector that he had mostly flown ultralight airplanes in the past and those flights were not entered in his logbook. -
Analysis
The non-certificated pilot was conducting a local flight in an experimental airplane and during cruise flight about 1,000 ft above ground level, the engine began to intermittently lose power. He activated the fuel pump and shortly thereafter the engine shut down. The pilot maneuvered the airplane to land in a cultivated field. The airplane was substantially damaged when it nosed over during the landing roll. Examination of the wreckage revealed that the airplane’s header tank did not have an outlet screen installed and the fuel selector valve contained a large quantity of debris. It is likely the debris, from the fuel tank construction and/or repairs, entered the fuel selector valve from the header tank, resulting in fuel starvation to the engine and the subsequent loss of engine power.
Probable cause
A total loss of engine power during cruise flight due to fuel starvation. Contributing to the accident was the lack of an outlet screen on the fuel system header tank.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVID
Model
MARK IV
Amateur built
false
Engines
1 Reciprocating
Registration number
N583DM
Operator
Nelson Christopher H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1582D
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-04T21:55:12Z guid: 104121 uri: 104121 title: ERA22FA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104103/pdf description:
Unique identifier
104103
NTSB case number
ERA22FA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-14T16:51:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-10-18T20:44:35.385Z
Event type
Accident
Location
Titusville, Florida
Airport
Space Coast Regional Airport (TIX)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Review of the airplane kit assembly manual revealed instructions to have at least 0.5 inches of thread engagement with the rod end in the 1.5-inch threaded plug. A note indicated, “all the way in is best.” Due to a lack of maintenance documentation recovered, the investigation could not determine when the rod end had been most recently adjusted (for more information, see Materials Laboratory Factual Report in the public docket for this accident). - The maintenance logbooks were not recovered. The pilot purchased the airplane in 2016, about 10 years after it was assembled. - On October 14, 2021, about 1551 eastern daylight time, an experimental amateur-built Velocity SE RG airplane, N755V, was destroyed when it was involved in an accident near Space Coast Regional Airport (TIX), Titusville, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot owned the airplane, which was based at TIX. The airplane flew uneventfully from TIX to Sebastian Municipal Airport (X26), Sebastian, Florida, earlier during the day of the accident. While at X26, the pilot visited the airplane kit manufacturer’s facility to replace a landing-gear-up switch fuse because the landing gear was not retracting. Afterward, the pilot removed the pilot seat and the rear seat from the airplane and left the rear seat at the facility so that maintenance technicians could match color and specifications ahead of an interior aesthetics renovation planned for the next month. The pilot then reinstalled the pilot seat and departed X26 uneventfully about 1528 for the return flight to TIX. According to witness statements, automatic dependent surveillance-broadcast data, and airport surveillance video, while the airplane was on short final approach to runway 9 at TIX, the airplane pitched up, climbed about 300 ft, then descended nose down. The airplane impacted a grass area about 400 ft right of the runway centerline and about 2,000 ft from the runway threshold. A postcrash fire ensued that consumed most of the wreckage. - An autopsy was performed on the pilot by the Office of the Medical Examiner for Brevard County, Rockledge, Florida. His cause of death was multiple blunt force injuries. Toxicology testing performed on the pilot by the Federal Aviation Administration Forensic Sciences Laboratory identified doxylamine in the pilot’s cavity blood (80 ng/ml) and in his liver. Doxylamine is a sedating antihistamine available over the counter in various products intended to treat allergy and cold symptoms and induce sleep. It carries specific warnings about sleepiness. The usual blood level in which effects would be expected in live people is between 50 and 200 ng/ml. - The pilot’s logbook was not recovered. The president of the airplane kit manufacturer, who knew the pilot, estimated that the pilot had about 200 hours of total flight experience in the accident airplane make and model. - The airplane came to rest upright and oriented along a magnetic heading of about 230°, and no debris path was observed. The cockpit and cabin were mostly consumed by fire. The flight control stick was not recovered. The pilot seat was identified, and the four bolts and their respective hard points remained attached. The pilot seat pin was also identified, but the seat frame was bent and separated, consistent with impact forces. A Grand Rapids primary flight display and multifunction display were recovered and retained for data download. Both displays required an installed USB flash drive to record data, but no USB flash drives were installed in the units or recovered in the wreckage. The left and right ailerons separated from their respective wings and were recovered near the wings. Aileron control continuity was confirmed from the separated ailerons to cables, a bellcrank, torque tubes, and the cockpit. The canard spar was intact but fire damaged and the left and right elevators were not recovered and presumed destroyed in the fire. The elevator push-pull tube section that connected to the control stick was recovered with no threaded rod end engaged, and the rod end was not recovered. Continuity of the elevator was confirmed from the torque tubes to the cockpit except for the push-pull tube section, which was retained for metallurgical examination. The elevator trim actuator was destroyed, and the preimpact elevator trim setting could not be determined. The left rudder was identified, and the right rudder was not recovered and presumed destroyed. The left rudder bellcrank remained intact, and its cable exhibited a broomstraw separation. The engine separated from the airframe and came to rest upright. The three propeller blades remained attached to the hub, and all three blades separated about 12 inches from their respective roots. The top spark plugs were removed; their electrodes were intact and light gray in color. Borescope examination of the cylinders revealed no anomalies. The rear accessory section sustained thermal damage. After the rear accessory section was removed, the crankshaft could be rotated by hand. Camshaft, crankshaft, and valvetrain continuity were confirmed, and thumb compression was attained on all cylinders. Due to thermal damage, the ignition and fuel systems could not be tested. Metallurgical examination of the elevator push-pull tube section revealed that it had been exposed to fire, causing a portion of the tube to collapse and melt. No contact marks from the jam nut were observed, and the first three threads in the threaded plug were missing. Examination with a stereo microscope revealed that the first three threads were fractured in shear overstress and that the remaining threads remained intact. -
Analysis
The pilot was conducting a personal flight in an experimental amateur-built airplane that he had owned for about 5 years before the accident. During short final approach, the airplane pitched up, climbed about 300 ft, descended nose down, and impacted a grass area next to the runway. A postcrash fire consumed most of the wreckage. The elevator push-pull tube section that connected to the control stick was recovered with no threaded rod end engaged, and the rod end was not recovered. Metallurgical examination of the elevator push-pull tube section revealed no contact marks from the jam nut. Also, the first three threads in the threaded plug were missing. The threads had fractured in shear overstress, and likely resulted in the push pull tube separating during flight and the pilot’s subsequent loss of airplane control. Review of the airplane kit assembly manual revealed instructions to have at least 0.5 inches of thread engagement with the rod end in the 1.5-inch threaded plug (with a note indicating that “all the way in is best”). Due to the lack of maintenance documentation, the investigation could not determine when or why the most recent adjustment to the rod end was made. Toxicology testing identified doxylamine in the pilot’s specimens. The main effect from doxylamine that can degrade performance is sleepiness. Because sleepiness would not have likely led to the airplane’s sudden pitch up during landing, the pilot’s use of doxylamine likely did not contribute to the accident.
Probable cause
The separation of the airplane’s elevator control push-pull tube, which resulted in a loss of control during the approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Velocity
Model
SE RG
Amateur built
true
Engines
1 Reciprocating
Registration number
N755V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
DMO408
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-18T20:44:35Z guid: 104103 uri: 104103 title: WPR22LA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104128/pdf description:
Unique identifier
104128
NTSB case number
WPR22LA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-14T17:00:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2021-11-06T01:28:58.361Z
Event type
Accident
Location
Wilton, California
Airport
ALTA MESA AIRPARK (3CN7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 2 minor
Factual narrative
On October 14, 2021, about 1600 Pacific daylight time, a WSK Mielec AN-2TD, N857PF, was substantially damaged when it was involved in an accident near Wilton, California. The pilot and one passenger sustained serious injuries and the other two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he configured the airplane for takeoff and had flaps down and the elevator trim was neutral. The departure started normally but, after becoming airborne, the airplane controls were not responding to his inputs as expected. The airplane continued to pitch up in a nose-high attitude and he was unable to push the control yoke forward, which he described as feeling like he was “stretching” cables with forward pressure. The pilot set the electric trim to full nose-down but it had no effect. With the airplane’s pitch uncontrollable, he saw an open area and elected to make a rapid maneuver toward the area. He added full left rudder and aileron and the airplane banked left. The airplane descended into trees; after coming to a stop, a fire erupted. The back door would not open due the deformation of the airframe so he broke a front window. The pilot and passengers all climbed out the window and the airplane continued to burn. There were two witnesses located at the airport that took videos of the airplane departing. One video showed the airplane just prior to the takeoff roll. The tailwheel is positioned backward and, as the airplane starts the roll, the tailwheel swivels and the airplane moves to the right of the runway (see Figure 1 below). Figure 1: The Airplane Starting the Takeoff Roll The airplane then veered to the left of the runway and became airborne shortly thereafter. In the approximate 10 seconds that followed, the airplane pitched up at an increasingly higher and higher angle-of-attack. The airplane then made a sharp left turn and goes behind the trees as it descends (see Figure 2 below). Figure 2: The Airplane Airborne The ground track, ground speed, altitude, angle of attack and roll angle of an airplane that crashed shortly after takeoff were estimated based on a video recorded with a handheld phone. The ground speed of the airplane went as low as 19 knots shortly after it started a left turn and a rapid descent toward ground impact. At that time, the airplane reached its maximum above ground level (AGL) altitude of 170 feet and the angle of attack of its wings was estimated to be 22.5º. Engine speed, estimated via spectrum analysis of sound recorded by two cameras, was 2150 rpm several seconds after liftoff and 2200 rpm when the airplane was already descending toward ground impact. The specified engine speed at takeoff for the WSK Mielec AN-2TD is 2200 rpm. A postaccident examination of the flight control system revealed no evidence of preimpact mechanical malfunctions or failures. The elevator system was extensively damaged and was partially consumed by fire. The No. 5 lower pulley gang was found loose in the wreckage with its cover still attached; the No. 5 upper pulley gang had the elevator cables passing through it. The No. 9 pulley gang has an s-hook attached, which appeared to be a tie down for item in the airplane. There were several markings and abrasions on the cable lengths consistent with rubbing or abrasions. The elevator bellcrank remained intact, with all four elevator cables connected to their respective arms. Control continuity was maintained from the bellcrank to the elevator control surfaces. The airplane’s weight and center of gravity (CG) could not be confirmed. The burned remains of items found in the airplane could not be identified and their location at impact could not be confirmed. The pilot estimated that the airplane was loaded about 1,000 pounds below the maximum gross weight. He had it loaded with two coolers, three motorcycles and camping gear. He had strapped all the items in place and did not believe they shifted during rotation. -
Analysis
The pilot stated that the departure started normally but that, after becoming airborne, the airplane controls were not responding to his inputs as expected. The airplane continued to pitch up in a nose-high attitude and he was unable to push the control yoke forward, which he described as feeling like he was “stretching” cables with forward pressure. With the airplane’s pitch uncontrollable, he elected to make a rapid maneuver toward an unpopulated area. The airplane descended into trees; after coming to a stop, a fire erupted. A postaccident examination of the flight control system revealed no definitive evidence of preimpact mechanical malfunctions or failures. Because the elevator system was extensively damaged and was partially consumed by fire, the investigation was not able to determine the cause of the pitch control anomaly. The airplane’s weight and center of gravity (CG) could not be confirmed. The burned remains of items found in the airplane could not be identified and the location of those items at impact could not be confirmed.
Probable cause
The pilot’s inability to control the airplane’s pitch during departure for reasons that could not be determined because of the extensive fragmentation and thermal damage the airplane sustained in the accident sequence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WSK-MIELEC
Model
AN-2TD
Amateur built
false
Engines
1 Reciprocating
Registration number
N857PF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1G10857
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-06T01:28:58Z guid: 104128 uri: 104128 title: ERA22LA016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104104/pdf description:
Unique identifier
104104
NTSB case number
ERA22LA016
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-14T18:22:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-10-21T22:11:37.01Z
Event type
Accident
Location
North Canaan, Connecticut
Airport
NORTH CANAAN AVIATION FACILITIES INC (CT24)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On October 14, 2021, about 1722 eastern daylight time, an experimental amateur built Kitfox IV airplane, N9259M, was substantially damaged when it was involved in an accident near North Canaan Airport (CT24), North Canaan, Connecticut. The private pilot sustained serious injuries. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the purpose of flight was to see the fall foliage and it was the first flight of the day. After topping off the fuel tanks, he started the engine, warmed it up to “takeoff temps[sic],” checked the magnetos, and departed to the north. During the climbout, the airplane had cleared trees at the departure end of the runway; however, the “engine sputtered.” He subsequently checked the “[magneto] switches, fuel switches, fuel pressure” and all were “good.” He then turned 180° to the airport, however, the airplane was “too high too fast” to land toward the south so he “tried [the] throttle again,” the power came up, and he continued south. Subsequently, the trees at the southbound departure area were cleared; however, shortly thereafter, the “engine sputtered again” as the throttle was increased toward full power. The pilot reported that at this time the airplane was “too close to trees”, the airplane descended, and then he “pulled up and bellied into the trees, to an almost stop,” however, the airplane then fell nose first about 70 ft into mud and swampy terrain. The pilot further reported that he utilized full carburetor choke via the spring-loaded lever to start the engine, then utilized half choke as the engine warmed up. He could not remember shutting the choke off before takeoff and also did not recall checking the choke position in-flight while troubleshooting the partial loss of engine power. He described that the engine would sputter at full power but would run without issue at idle power. Photographs revealed that the airplane came to rest in wooded terrain partially submerged in a creek and mud, with the fuselage nearly vertical and the engine submerged below the terrain and water. The fuselage and both wings sustained substantial damage. There was a smell of fuel at the accident site. Examination of the airplane did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Continuity of the flight controls and fuel system was confirmed. Photographs taken shortly after the accident found that the carburetor choke lever was in the stowed position. The airplane was not equipped with carburetor heat. According to a representative of Kitfox Aircraft, the type of choke installed of the accident airplane would remain on/ open until the pilot turned the choke off. According to a carburetor icing probability chart, the weather conditions at the time of the accident flight were conducive to serious icing at glide power. -
Analysis
The pilot reported that shortly after takeoff during climbout, the engine began to sputter. He checked the magnetos, fuel switches, ignition, and fuel pressure. He did not notice any abnormalities; however, full engine power did not return. He subsequently performed a 180° turn back to the runway, but the airplane was too high and fast to land. The airplane overflew the runway toward a wooded area, and as the pilot attempted to increase power, the engine again sputtered. The pilot maintained a safe airspeed and flew into the tops of the trees. The airplane momentarily was suspended in the trees but then fell vertically and impacted muddy and swampy terrain in a nose-low attitude. Examination of the airplane did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot reported that he utilized full carburetor choke to start the engine and partial carburetor choke to warm-up the engine. He could not recall stowing the lever prior to takeoff (as was required for this type of choke) nor did he recall checking the lever during the troubleshooting in-flight. The pilot reported the partial loss of power would worsen only when he attempted to add full power and that the engine would run normally at idle power. Weather conditions in the area at the time of the accident flight were conducive to serious carburetor icing at glide power; however, the description of the partial loss of engine power and the phase of flight at which it occurred were not indicative of carburetor icing. Given the circumstances described by the pilot, it is likely that the carburetor choke remained partially applied during the takeoff and climbout, which flooded the engine at high power settings. Although the spring-loaded choke lever was photographed in the stowed position shortly after the accident, it is possible that the choke switch was moved to that position during the impact sequence or during the pilot’s evacuation after the accident. The pilot reported that he turned back toward the departure runway while he was troubleshooting the engine issue, but the airplane was too high and fast to land and overflew the runway. Had the pilot managed the altitude, airspeed, and course toward the runway better, the collision with trees likely could have been avoided and a safe landing likely could have been made at the airport.
Probable cause
The pilot's mismanagement of the airplane's altitude, airspeed, and course during a forced landing following a partial loss of engine power, which resulted in collision with trees and terrain. Contributing was the pilot’s inadvertent omission of stowing the carburetor choke before takeoff and in-flight after experiencing a partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Kitfox
Model
IV
Amateur built
true
Engines
1 Reciprocating
Registration number
N9259M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1871
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-21T22:11:37Z guid: 104104 uri: 104104 title: WPR22LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104138/pdf description:
Unique identifier
104138
NTSB case number
WPR22LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-14T19:15:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-11-01T21:37:47.419Z
Event type
Accident
Location
Fall Creek, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 14, 2021, about 1815 Pacific daylight time, a Lancair ES, experimental airplane, N511ZZ, was substantially damaged when it was involved in an accident near Fall Creek, Oregon. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during cruise flight he descended to 4,500 ft mean sea level in preparation to land at Mahlon Sweet Field Airport (EUG), Eugene, Oregon. Soon after disconnecting the autopilot and turning to the North, he felt the engine “decelerate suddenly, and it began misfiring badly.” He realized that he was too far from the airport to land on the runway. The pilot looked at his surroundings for a place to make a forced landing but saw only forest surrounding his route of flight. He decided to focus on restarting the engine; however, his attempts were unsuccessful. The pilot reported that smoke had begun to enter the cockpit and the airplane continued to lose altitude. About 1,000 ft above ground level, he checked his airspeed and pulled the ballistic recovery system handle. The parachute deployed and during the descent through the heavily wooded terrain below, the airplane collided with trees, resulting in substantial damage to the left wing and the separation of the empennage. The airplane came to rest a few feet from the ground, still supported by the parachute, which remained stuck in the trees. The pilot exited the airplane and was able to walk to a nearby road. Postaccident examination of the wreckage revealed that the engine exterior was undamaged, and the oil dip stick indicated about 7 quarts of oil. The lower spark plugs were removed from the engine. The cylinders combustion chambers were examined with the use of a lighted borescope and each cylinder combustion chamber revealed a normal amount of combustion deposits and the valve heads had normal operational signatures. The six piston heads had impact marks from each valve. The crankshaft was rotated by hand from the propeller assembly, and cylinder thumb compression was obtained to only four cylinders. The cylinder rocker covers were removed from each cylinder and the cylinder overhead components were undamaged and covered in an oil residue. The crankshaft was again rotated, and no movement was noted from each of the cylinder overhead components. The engine was removed from the airframe and disassembled. The oil sump contained metal fragments. The crankcase halves were separated, and the crankcase mating surfaces were undamaged. Small metal fragments were found throughout the interior of the engine. The valve lifters installed in both crankcase halves were undamaged. The camshaft drive gear (part number 631845) had missing gear teeth and had material deformation. About two-thirds of the camshaft drive gear teeth were damaged. The camshaft lobes had normal lifter contact wear signatures and several lobes had mechanical damage on their edges. The crankshaft was removed, and the main bearings were undamaged and showed normal operating wear signatures. The camshaft drive gear, five separated gear teeth and gear teeth remnants were sent to the National Transportation Safety Board Materials Laboratory for forensic examination. The examination revealed that 36 of the camshaft gear teeth had fractured and separated from the gear. Three of the separated gear teeth fracture surfaces exhibited a sloping, angled orientation, whose edges were located along the fillet radius below the flank and were consistent with post-fracture smearing. Another gear tooth’s fracture surface was consistent with having fractured from a fatigue crack that propagated about halfway through the tooth cross section before the remainder fractured in overstress. Located along the fillet radius of the tooth, the initiation site exhibited several concentric convex features, consistent with emanating or propagating from the surface site. Another fatigue crack initiation site was near a flat edge surface with radial lines consistent with crack propagation. The last gear tooth showed similar signatures of fatigue crack propagation but only had one initiation site located at the fillet radius, between the bottom land and the flank. The initiation site was collocated with a gouge or machine mark. The composition of the gear was examined using energy dispersive x-ray spectroscopy (EDS) and x-ray fluorescence (XRF). The chemical composition was consistent with a nitrided alloy steel. The gears exhibited a surface layer with a lighter contrast. Examination of this surface layer with EDS found it to contain nitrogen, consistent with a nitride surface treatment. The hardness of the tooth cross section was inspected with a microindentation hardness tester per ASTM E384.2. The hardness of the base alloy exhibited a hardness of 41 HRC (401 HV500). The hardness data and microstructure were consistent with a quench and tempered condition for this alloy composition. Aircraft documentation revealed that the engine was overhauled on July 30, 2015. A serviceable camshaft gear (part number 631845) was installed during the overhaul on the accident engine. Service bulletin (SB) 97-6B was in effect at the time of the accident airplane’s engine overhaul. The engine had about 351 hours of operation at the time of the accident. On August 9, 2005, the engine manufacturer issued SB05-8, which was later superseded by SB05-8A in August 2009, to introduce into service an improved camshaft gear applicable to the accident engine. The improved camshaft gear was nominally 0.060-inches wider than the previous camshaft configurations. The manufacturer recommended the replacement of the camshaft gear during the next engine overhaul or whenever the replacement of the camshaft gear was required. In November 2009, the manufacturer issued revised SB97-6B to identify parts to be replaced during maintenance, preventative maintenance, and overhaul which included the camshaft gear (part number 631845) as a mandatory replacement item at overhaul. In August 2018, the manufacturer revised SB-05-8A and issued Critical Service Bulletin CSB05-8D to eliminate the possibility of camshaft gear tooth fracture, resulting in power loss or in-flight shutdown, and to inspect and remove from service multiple camshaft gears, including part number 631845. -
Analysis
The pilot was conducting a personal cross-country flight when he descended from cruise flight in preparation for landing. Shortly thereafter, the engine lost power and started misfiring. The pilot attempted to restart the engine but was unsuccessful despite his actions. While over heavily wooded terrain, the pilot deployed the parachute system. During the descent through the heavily wooded terrain, the airplane collided with trees resulting in substantial damage. The airplane came to rest a few feet from the ground, still supported by the parachute, which remained stuck in the trees. Postaccident examination of the engine revealed the camshaft gear failed due to fatigue-induced fracturing of multiple teeth. Fatigue cracks initiated at the fillet radii between the flanks and bottom lands of multiple gear teeth. The fillet radii exhibited more roughness and surface discontinuities, likely acting as stress concentration areas for crack initiation. Once the fatigue cracks had propagated through over half the material cross-section, the teeth fractured in overstress. The exact cause of the crack initiation could not be concluded. There were no material defects, such as voids or inclusion, at the initiation sites. However, as previously stated, the fillet radii exhibited more pronounced surface features, which would lead to a higher chance of crack initiation. Once cracking started, propagation would be in high cycle with moderate loading modes, as evidenced by the depth of the fatigue cracks. The gear was a nitrided alloy steel in the quenched and tempered condition. This should be a suitable material and manufacturing process for gear applications, not lending itself to any material incompatibility or excessive wear or corrosion concerns.
Probable cause
Total loss of engine power due to fatigue failure of the camshaft gear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LANCAIR
Model
ES
Amateur built
false
Engines
1 Reciprocating
Registration number
N511ZZ
Operator
YOUNGWERTH AIRPLANES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
ESP-208-10
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-01T21:37:47Z guid: 104138 uri: 104138 title: WPR22FA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104107/pdf description:
Unique identifier
104107
NTSB case number
WPR22FA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-15T10:59:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2021-10-25T04:48:45.525Z
Event type
Accident
Location
Reserve, New Mexico
Airport
N/A (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 2 serious, 0 minor
Factual narrative
On October 15, 2021, about 0959 mountain daylight time, a Cessna 175, N7584M, was substantially damaged when it was involved in an accident near Reserve, New Mexico. The pilot was fatally injured, and the two passengers were seriously injured. The aircraft was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A summary of combined statements obtained from the two passengers, was provided by their attorney. In that summary, the passengers stated that they recall that the weather was cold and clear on the day of the accident flight, and that the purpose of the flight was to scout areas to hunt. When they reached a planned hunting area, they pointed out to the pilot where they wanted to look, and the pilot turned toward that area. They recall a turn to the northeast that was “a sharp turn and then the airplane started to go down quickly.” They thought it sounded like the engine had lost power and the pilot “was having a hard time.” The airplane leveled off and the pilot did not make a distress call, but the mountains kept getting closer. They recall that it was difficult to see out of the windshield, the airplane was “tilted up”, and they impacted trees. Data downloaded from a handheld GPS showed that the airplane departed Grant County Airport, near Silver City, New Mexico about 0907. The airplane flew north-northwest for 21 minutes, then west-northwest for another 17 minutes. In the final 9 minutes of the flight, the data showed that the airplane turned to a northerly heading, before it turned to the southeast. During the last 2 minutes of the flight, the airplane remained on a southeasterly heading and ascended from 6,732 ft mean sea level (msl) to 7,530 ft msl. The last recorded GPS data point was located about 95 ft south of the accident site, at an altitude of 7,523 ft msl. - Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found Losartan, Rosuvastatin, and Diphenhydramine in the pilot’s blood and urine. Losartan is a prescription medication used to treat high blood pressure, and Rosuvastatin is a prescription cholesterol medication. Neither of these medications are known to adversely affect performance. Diphenhydramine is an over-the-counter antihistamine and can impair performance, depending on the circumstances of use. Carboxyhemoglobin, Ethanol, Glucose, and drugs of abuse were not detected. - A review of astronomical data from the National Oceanic and Atmospheric Administration revealed that, at the time and location of the accident, the sun was located at an azimuth of 126.2° true (117.2° magnetic), and an elevation of 29.29° above the horizon. The calculated density altitude at the accident site around the time of the accident was 8,564 ft and the calculated pressure altitude was 7,151 ft. - Examination of the accident site revealed the airplane impacted mountainous terrain at an elevation of 7,521 ft msl. The first identifiable point of contact was the top of a pine tree located about 100 ft downhill from the wreckage. Branches from damaged trees were found on the ground and displayed signatures consistent with propeller strikes. The airplane came to rest on its left side. The left wing was folded upward and remained attached by the control cables. Both wings exhibited impact damage along their leading edges. The horizontal and vertical stabilizers remained attached to the empennage, and the elevator and rudder remained attached at their respective attachment points. Flight control continuity was established for all flight control surfaces. Examination of the recovered engine revealed that when the crankshaft was rotated by hand using the propeller, rotational continuity was established throughout the engine and valvetrain, and thumb compression was obtained on all cylinders. The engine was started and ran at various power settings with no anomalies noted. The propeller remained attached to the crankshaft flange and the propeller blades remained attached to the hub. The propeller blades displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface, and trailing edge “S” bending. No evidence of preexisting mechanical malfunction was observed with the airframe or engine that would have precluded normal operation. -
Analysis
The pilot was conducting a personal flight with two passengers over mountainous terrain, with the intention of scouting areas to hunt. The passengers reported that they were directing the pilot where they wanted to look, and while maneuvering, the airplane entered a “sharp” turn and started to descend. They stated it “felt/sounded” like the engine lost power and that the pilot was not able to get full power back. The pilot was able to level the airplane, but it continued to descend into the trees. The passengers also stated it was difficult to see out of the windshield during the flight because the airplane was “tilted up” the entire flight. Downloaded GPS flight track data showed that in the final 2 minutes of the flight, the airplane turned to the southeast toward rising terrain, and entered a positive rate of climb, which continued until the last recorded GPS data point, which was located about 95 ft south of the accident site. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of sun and moon data for the time and location of the accident revealed that the sun was just above the relative horizon and in the southeast quadrant of the sky. It is likely that when the pilot initiated a climb while on a southeasterly heading, the sun reduced the pilot’s forward visibility and her awareness of rising terrain in the immediate flight path, which led to a collision with the terrain. Although toxicology testing indicated the pilot used Diphenhydramine at some point before the accident flight, the detected blood levels could not be used to infer the level of impairment. Based on the circumstances of the accident, the effect of Diphenhydramine use was determined not to be a likely factor in the accident.
Probable cause
The pilot’s failure to maintain clearance from terrain while maneuvering at a low altitude. Contributing to the accident was the pilot’s reduced forward visibility due to the sun.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
175
Amateur built
false
Engines
1 Reciprocating
Registration number
N7584M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
55884
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-25T04:48:45Z guid: 104107 uri: 104107 title: ERA22LA017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104108/pdf description:
Unique identifier
104108
NTSB case number
ERA22LA017
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-15T16:00:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-10-18T16:11:35.139Z
Event type
Accident
Location
Fire Island, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On October 15, 2021, about 1500 eastern daylight time, a Cessna 182Q, N759AC, was substantially damaged when it was involved in an accident near Fire Island, New York. The pilot and two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the pilot, he was conducting an “introductory” flight for the two passengers around Long Island, New York. He reported departing with 64 gallons of fuel onboard. He stated that he was flying in cruise flight about 1,200 ft mean sea level when the engine started to lose power. He checked the fuel selector to confirm it was in BOTH position and verified the mixture control was full forward, but the engine experienced a total loss of power. He applied carburetor heat, unsuccessfully tried to restart the engine two times, and then performed a forced landing on a beach near Fire Island National Seashore. The pilot further stated he made a normal landing on the beach, however, during the landing roll, the airplane contacted a hump in the sand. The nose landing gear collapsed, which resulted in the propeller and right wing contacting the ground. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the right wing. The propeller was rotated by hand through 360° of motion, and crankshaft and valvetrain continuity were established to the rear accessory case. The magneto timing was checked and found to be within limits. The spark plugs were removed and exhibited normal wear and proper gap. The compression leak down test was satisfactory on all cylinders. The airplane’s maintenance logbooks could not be located. At 1456, the weather reported at Long Island Mac Arthur Airport (ISP), about 9 nautical miles north of the accident site, included a temperature of 25°C and a dew point 16°C. The calculated relative humidity at this temperature and dewpoint was 57 percent. The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, showed a probability of serious icing at glide power. -
Analysis
According to the pilot, he was in cruise flight about 1,200 ft mean sea level when the engine started to lose power. He checked the fuel selector mixture control positions were correct, but the engine experienced a total loss of power. He applied carburetor heat and attempted to restart the engine. When he was unable to restore engine power, he performed a forced landing to a beach. During the landing roll, the airplane contacted a hump in the sand, the nose landing gear collapsed, and the right wing impacted the ground, which resulted in substantial damage to the airframe. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on the temperature and dew point about the time of the accident, the conditions were favorable for serious carburetor icing at a glide power settings. Given that the pilot reported that the airplane was is in cruise flight when the loss of engine power occurred, it is unlikely that the loss of engine power was due to carburetor icing.
Probable cause
A total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N759AC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
18265830
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-18T16:11:35Z guid: 104108 uri: 104108 title: ERA22LA018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104110/pdf description:
Unique identifier
104110
NTSB case number
ERA22LA018
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-16T09:30:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-19T05:56:02.93Z
Event type
Accident
Location
Benton, Pennsylvania
Airport
BENTON (PA40)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On October 16, 2021, at 0830 eastern daylight time, an experimental, amateur-built Z-HI-MAX 1400 airplane, N668CL, was substantially damaged when it was involved in an accident near Benton, Pennsylvania. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Family members reported that the accident flight was the pilot’s first flight in the airplane. He planned to perform a takeoff, teardrop turn and return to the reciprocal runway. The pilot performed a preflight inspection, started the airplane, and taxied to the runway where he performed an engine run-up and remained for “a while,” according to the pilot’s brother who witnessed the takeoff and subsequent accident sequence. The takeoff and initial climb appeared normal. When the airplane reached about 100 ft agl, it began a slow bank to the right, followed by a bank to the left, which “just kept getting steeper.” The airplane then descended to the ground. One witness reported hearing the engine rpm increase at the time of the impact. Another witness reported that although he heard two “momentary misses” from the engine during takeoff, “the engine was running normally and developing power throughout.” The pilot had limited recollection of accident. He stated that at some time during the flight, the engine “develop(ed) a roughness that occurred twice before it lost power.” He stated that a carburetor heat check is normally performed during engine run-up; however, he did not have any recollection of that portion of the accident flight. The pilot’s brother reported that during previous flights, the airplane was “quick” to roll into turns, and “slow” to roll out of them. He further stated that during stalls, the airplane did not “break” but rather would “mush into a buffet.” Photographs of the accident site provided by a Federal Aviation Administration inspector showed the wreckage was confined to a small area, about the diameter of the airplane’s wingspan, with no ground scars leading to the main wreckage. A subsequent examination of the engine revealed no anomalies that would have precluded normal operation. The 0854 weather conditions reported at Williamsport Regional Airport (IPT), Williamsport, Pennsylvania, located about 24 miles west of the accident site at an elevation of 528 ft msl, included a temperature of 21°C (70° F) and a dew point of 17°C (63° F). Review of a carburetor icing probability chart revealed the potential for serious icing at glide and cruise power. -
Analysis
The pilot, who was flying the airplane for the first time, intended to takeoff and perform a teardrop turn, then land on the reciprocal runway. After starting the engine, he taxied to the end of the runway where he paused for some time before takeoff. During the initial climb, about 100 ft above ground level (agl), the airplane made a slow right turn, followed by a left turn that “just kept getting steeper” before the airplane descended and impacted the ground. The pilot did not recall most of the details of the flight; however, he did recall that at some point, the engine ran roughly and then lost power. Several witnesses reported that the engine sounded normal; however, one reported that the engine had briefly “missed” twice during takeoff. One witness reported hearing the engine RPM increase at the time of impact, suggesting that the engine was running at that time. Although a postaccident examination of the engine did not reveal any anomalies that would have precluded normal operation, a review of weather records and a carburetor icing probability chart indicated the potential for serious icing at glide power. While carburetor icing is generally considered to be less likely a factor during takeoff power, the pilot’s pause (presumably at a low power setting) at the end of the runway before departure may have allowed ice to accumulate. Therefore, carburetor icing could not be ruled out as a possible contributing factor. However, based on the pilot’s recollection and the witness’ statements, the investigation was unable to determine if or when a loss of engine power occurred. Based on the witness’ description of the flight, the pilot lost control of the airplane while turning back toward the airport at a relatively low altitude. The wreckage path was confined to an area of about one wingspan, suggesting a near vertical flightpath angle. Given that the turn occurred about 100 ft agl, it is possible that the airplane was also at a relatively slow airspeed when the turn, loss of control, and subsequent aerodynamic stall occurred. Family members described the airplane’s handling characteristics as quick to roll into turns, and slow to roll out of them. A low airspeed may have exacerbated the pilot’s ability to level the wings after initiating the turn.
Probable cause
The pilot’s loss of control and encounter with an aerodynamic stall during a planned low-altitude turn toward the airport after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Z-HI-MAX
Model
1400
Amateur built
true
Engines
1 Reciprocating
Registration number
N668CL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
668
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-19T05:56:02Z guid: 104110 uri: 104110 title: WPR22FA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104111/pdf description:
Unique identifier
104111
NTSB case number
WPR22FA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-17T15:02:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2021-10-18T09:24:24.9Z
Event type
Accident
Location
Three Points, Arizona
Airport
RYAN FLD (RYN)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On October 17, 2021, about 1402 mountain standard time, a Rockwell International 112B airplane, N112LS, was destroyed when it was involved in an accident near Three Points, Arizona. The pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Recorded automatic dependent surveillance-broadcast (ADS-B) data showed that the airplane departed from runway 24L at Ryan Field (RYN), Tucson, Arizona, about 1339, climbed to 4,500 ft mean sea level (msl) [about 2,700 ft above ground level (agl)], and traveled southwest for about 5 minutes before entering into multiple 180° turns over a southbound road. The data shows the airplane continued to the southwest before making a wide right turn and then a left turn. The data showed four 360°- turn maneuvers before heading southwest, and then southeast, as airspeed slowed to about 60 kts. The data showed that about 3,800 ft agl, the airplane’s airspeed slowed to about 50 kts and entered a steep descending left turn. The airplane continued in a descending left turn until ADS-B contact was lost about 1402, at an altitude of about 250 ft agl near the accident site. Concerned friends of the pilot who were tracking the accident flight contacted the local authorities later that afternoon. The airplane was found that evening by local law enforcement on level, wooded desert terrain. According to a friend of the pilot, he was preparing for an upcoming flight review scheduled for the following Tuesday. During the investigation, identification of the flight instructor performing the review could not be found. Examination of the accident site revealed that the airplane impacted terrain in a flat, wings-level attitude, with no debris path. The airplane remained mostly intact and had postimpact fire damage. The engine cowling separated and was found 20 ft from the engine. Broken plexiglass surrounded the main wreckage. All the airplane’s flight controls were found at the accident site and flight control cable continuity was established to the cabin area. The flap and landing gear configuration were not determined during the investigation. Postaccident examination of the engine and airframe revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to Pilot’s Operating Handbook, the airplane’s stall speed with landing gear and flaps retracted is 61 knots. A National Transportation Safety Board aircraft performance study revealed that the airplane slowed to a calibrated airspeed very near its stall speed. The airplane was flying only 4-7 kts above its reported stall speed during the final two minutes of flight. The aircraft’s airspeed then dropped below the reported stall speed, and it rapidly lost altitude while in a tight left turn. The pilot’s logbook was not found during the investigation. -
Analysis
The pilot was conducting a personal training flight for an upcoming flight review. Flight track data revealed that shortly after departure the airplane conducted multiple 180° turns above a road then entered two clearing-turns before conducting multiple steep turns. The airplane then headed southwest and then southeast as airspeed slowed to about 60 kts. The data showed that, about 3,800 ft agl, the airplane’s airspeed slowed to about 50 kts and entered a steep descending left turn. The airplane’s airspeed most likely dropped below stall speed during the slow flight maneuver and the pilot was unable to recover before impact. Postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The flap and landing gear configuration were not determined during the investigation due to the impact and thermal damage.
Probable cause
The pilot’s failure to maintain proper airspeed while maneuvering, which resulted in the exceedance of the airplane’s critical angle of attack and the airplane entering an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL
Model
112
Amateur built
false
Engines
1 Reciprocating
Registration number
N112LS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
511
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-18T09:24:24Z guid: 104111 uri: 104111 title: ERA22LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104118/pdf description:
Unique identifier
104118
NTSB case number
ERA22LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-18T17:16:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2021-10-20T02:59:06.207Z
Event type
Accident
Location
Mount Pleasant, South Carolina
Airport
MT PLEASANT RGNL-FAISON FLD (LRO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 18, 2021, about 1616 eastern daylight time, a Beech 200, N996LM, was substantially damaged when it was involved in an accident in Mount Pleasant, South Carolina. The two pilots and six passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 on-demand air taxi flight. The flight, which was operated by Austin Aviation, was taxiing for departure at Mount Pleasant Regional Airport – Faison Field (LRO), Mount Pleasant, South Carolina, destined for Columbia Metro Airport (CAE), Columbia South Carolina, when the accident occurred. According to the pilot, there was a fuel truck that was parked to his right on the ramp apron, less than 20 ft from the center line taxiway marking. He assessed that he had enough room to depart the parking area. No safety markings or cones were around the fuel truck, and no marshaling assistance or warnings were provided by the fixed base operator. After he had started moving, he noticed a small single-engine airplane to his immediate left, pulling into the parking spot adjacent to his airplane. As the pilot was making a left turn, the single-engine airplane kept inching forward. He instinctively hesitated as he was making a sharp left-hand turn and “shallowed out” his direction to avoid contact with the running engine about 6 feet off his left wingtip, as it was apparent to him that the airplane was not going to stop and allow him to have more movement area. The pilot also added that this short hesitation, and probably 6 feet of movement, resulted in the right-wing tip of his airplane contacting the fuel truck, which was parked on the other side of the ramp to his right. His first thought was that he had run over something on the taxiway itself. As he leaned forward and looked towards the right wing, he could see a small amount of damage to the end of the wingtip and realized that the wingtip had contacted the fuel truck. He immediately stopped his taxi. He then taxied the airplane back around the corner into the original parking spot that he had taxied out of, shut down the engines and deplaned the passengers. He then evaluated that all passengers were safe, and that no injuries had occurred. The pilot reported the airplane wingtip had contacted a ladder handle on the fuel truck, and that the outboard 2-ft section of the wingtip had sheared off at the rivet line. The pilot also advised that the third outboard aileron anchor point was also attached to the wingtip assembly, and that as a result of the wing tip shearing off, the last attach point of the aileron was sheared, the aileron was damaged, and although the aileron was still attached to the airplane, it was loose from the third anchor point, but was still attached to the airplane by the other two hinge points. According to the pilot’s Pilot /Operator Aircraft Accident/Incident Report (NTSB Form 6120), he was the only crewmember, and he had a total of 4 passengers onboard. Review of the load manifest for the flight showed that there were 7 passengers and 1 additional crew member. Review of security camera video also indicated that 8 occupants boarded the airplane. Information provided by a Line Service Technician, indicated that one of the occupants (not the pilot-in-command) was wearing a pilot’s uniform, and had just started working for the operator. According to the occupants of the single-engine airplane, they were taxiing and stopped about 30 yards short of the Beech (the accident airplane). Several passengers were observed entering the Beech. The Beech was parked in the vicinity of the parking space that they intended to park in. As the Beech passenger door closed, they continued their taxi and parked directly on the intended yellow parking “T,” with the main wheel directly on the line of the “T.” As they finalized the shutdown procedure, they observed the Beech taxiing very quickly away from its parking space. They also described that the left wing of the Beech came within about 3 feet of the stationary propeller of their airplane. Both occupants of the single-engine airplane remarked that the airplane was taxiing “very fast.” They continued to observe the Beech as it taxied. After it passed their airplane, they observed that the right wing of the Beech was significantly damaged. A 2-ft section of the wing was also observed on the ground next to a fuel truck. They immediately powered up their airplane to attempt radio communications with the Beech to warn them not to take off because a portion of the right wing was on the ground and the remaining wing was significantly damaged. As they were continuing to power up the airplane, they observed the Beech continue to taxi and return to its original parking space. The passengers soon disembarked. Review of security camera videos indicated that the accident pilot had parked the Beech between two designated parking spaces, with its left wing over one designated parking space, its right wing over another designated parking space, and its tail in the parking space behind it. The single-engine airplane remained clear of the Beech during the boarding process, then parked before the left engine was started on the Beech. The single-engine airplane was parked for about 1 minute 19 seconds before the Beech began to taxi. Further review of security camera video also indicated that the single-engine airplane’s engine had been shut down for about 12 seconds when the Beech made the left turn and its left wing passed in front of it. Review of a postaccident photograph provided by the pilot of the Beech also indicated that the single-engine airplane was parked normally in the parking spot. Calculations done by a Federal Aviation Administration (FAA) inspector indicated that the airplane traveled about 111.7 feet during the taxi out before striking the fuel truck with the right wing. The maximum calculated speed observed during the taxi was 18.6 feet per second, or about 12.7 mph. Examination of photographs provided by the FAA indicated that the fuel truck was parked on the edge of the ramp on a concrete access pad for a hangar. Further examination also revealed that there was a van and another vehicle also parked about 183 feet farther down the ramp, near its edge. On December 11, 2020, the South Carolina Aeronautics Commission inspected the apron and identified 4 inspection issues. Three had to do with obscured/dirty/faded markings on the taxi lanes, and one had to do with the fuel truck being within 50 ft of a building or structure. No mention was made of any other inspection issues with the apron. According to a Line Service Technician, when airplanes typically arrived at LRO, before they entered the ramp area, the FBO would radio the arriving airplane to ask the pilot of their intentions. If the arriving airplane was a jet or a jet prop (such as the Beech) and was arriving to pick up or drop off passengers and it was a short visit, they would instruct the pilot to park on the middle taxiway line (which was between the two rows for small general aviation airplanes that were oriented in a north-south direction). However, if the airplane (jet, or jet prop) was staying longer, for an hour or overnight to several days, they would direct the pilot to the north end of the ramp (where the row oriented in an east-west direction for larger airplanes was) and would chock the airplane accordingly. This was standard for each arriving airplane of that size. They would discourage the pilots of all larger airplanes from parking in front of the FBO terminal due to safety concerns for owners and passengers walking to parked airplanes on the ramp, and vehicle traffic entering and exiting the ramp area through the security gate near the FBO terminal. The Line Service Technician went on to say that the pilot involved in the accident had been to LRO many times, picking up and dropping off passengers for over a year. They had spoken to him over the radio and in person about the ramp congestion and the reasons they insisted he park his airplane on the middle taxiway line. In the 2 to 3 months before the accident, he had pulled through the tiedown spots they reserved for smaller airplanes, taking up two tiedown spots to get around parking in the middle. The ramp congestion, with airplane, vehicle, and foot traffic, was not unusual for LRO and the accident pilot had experienced it many times. Following the accident, to increase safety, the Charleston County Airport Authority took several actions including adding information to the Electronic Chart Supplements and the Airport Facility Directory entries for the airport noted restrictions to parking and taxiing for airplanes with wingspans greater than 38 feet, as well as enhancements to the taxiway and apron pavement and markings. -
Analysis
The twin-engine, turbo-propeller-powered business airplane was taxiing for takeoff when the right wing struck a fuel truck that was parked on a concrete pad between the ramp and a hangar. The outboard section of the wing sustained substantial damage. The pilot reported that he was aware of the fuel truck that was parked less than 20 ft from the ramp taxiway line and assessed that he had enough room to get around it. No safety markings or cones were around the fuel truck, and no marshaling assistance or warnings were provided by the fixed base operator. He stated that after he started to taxi, he noticed a single-engine airplane to his immediate left, pulling into the spot adjacent to his airplane and that the single-engine airplane kept inching forward. The pilot stated he “shallowed out” his left turn to avoid contact with the airplane located about 6 ft from his left wingtip, as it was apparent to him that the pilot was not going to stop. He stated that this short hesitation, and probably 6 ft of movement, resulted in the right-wing tip of his airplane to contact the fuel truck. According to the occupants of the single-engine airplane, they were taxiing and stopped about 30 yards short of the accident airplane. As the accident airplane’s passenger door closed, they continued their taxi and parked directly on the intended yellow parking “T,” with the main wheel directly on the line of the “T.” As they finalized the shutdown procedure, they observed the accident airplane taxiing very quickly away from its parking space. As the airplane taxied away, its left wing came within 3 ft of the stationary propeller of their airplane. Review of security camera videos confirmed the single-engine airplane was parked for about 1 minute and 19 seconds before the accident airplane began to taxi. Review of a postaccident photograph also showed that the single-engine airplane was parked normally in the parking spot. Calculations of the accident airplane’s movement based on the security camera video indicated that the accident airplane traveled about 112 ft during the taxi out before striking the fuel truck with the right wing. The airplane’s taxi speed was calculated to have reached maximum of about 12.7 mph during its movement. According to personnel at the Fixed Base Operator (FBO), the pilot was not parked in an area that was designated for extended parking for airplanes of its size. FBO personnel stated they had spoken to the pilot in the past about the ramp congestion and the reasons why they insisted he park his airplane in the middle on the taxiway line. In the 2 to 3 months before the accident, he had pulled through the tiedown spots they reserved for smaller airplanes, taking up two tiedown spots with the accident airplane. The ramp congestion, with accident airplane, vehicle, and foot traffic was not unusual for the airport and the pilot had also experienced this firsthand during his many visits to the airport. Given this information, the pilot failed to maintain clearance with the fuel truck as he taxied the airplane on the congested ramp. It likely that had he parked the airplane in a less congested location, or taxied the airplane at a lower speed, the accident could have been avoided.
Probable cause
The pilot’s failure to maintain clearance with the parked fuel truck while taxiing for takeoff. Contributing to the outcome was the pilot’s decision to park the airplane in the congested ramp area and his excessive taxi speed.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
200
Amateur built
false
Engines
2 Turbo prop
Registration number
N996LM
Operator
Austin Aviation
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Other work use
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
BB-157
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-20T02:59:06Z guid: 104118 uri: 104118 title: DCA22MA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104129/pdf description:
Unique identifier
104129
NTSB case number
DCA22MA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-19T11:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2021-10-20T18:10:50.522Z
Event type
Accident
Location
Brookshire, Texas
Airport
Houston Executive Airport (TME)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 1 minor
Factual narrative
At the time of the accident, The Boeing Company held the type certificate for the DC-9-87 (MD-87) airplane (generally referred to as a DC-9/MD-80 series airplanes). The owner of 987 Investments purchased the accident airplane in 2015 and maintained it based on Boeing maintenance planning document ME80-020-TNK, dated August 1, 2019. According to the maintenance manager, maintenance checks and inspections to maintain airworthiness were accomplished since the airplane was last flown in April 2021. According to the mechanic, on the day of the accident, he completed a 72-hour service check and daily walk-around tasks, which included checking the security and condition of the airplane’s exterior, including the vertical and horizontal stabilizer surfaces. Cabin Configuration The accident airplane was originally delivered with a commercial cabin configuration, but maintenance records showed that it was modified in 2008 under an STC that specified 19 passenger seating positions (with 1 additional state room seat subject to a limitation that prohibited occupancy during taxi, takeoff, and landing). The accident airplane’s cockpit had seats for the captain and the first officer and included one retractable observer’s seat (which was unoccupied during the accident flight). According to interviews with the airplane’s owner and multiple passengers, the cabin had 22 passenger seats, each of which was equipped with a lift-latch lap belt. The owner said he was unaware that the cabin configuration differed from that specified in the STC. Elevator System The DC-9-87 (MD-87) airplane has a T-tail design, such that the elevators and horizontal stabilizer are attached near the top of the vertical stabilizer about 30 ft above ground level (agl). The left and right elevators are attached by hinges to the rear spar of the horizontal stabilizer, and each is equipped with control, geared, and antifloat tabs attached to the trailing edge (see figure 1). Figure 1. Exemplar airplane (viewed from the ground looking up) showing respective locations of right horizontal stabilizer, elevator, control tab, geared tab, and antifloat tab. (Source: Boeing) Generally, elevator control is accomplished via the elevator control tabs, which are mechanically connected to and directly controlled by the cockpit control columns. During takeoff (at Vr or higher), when a pilot provides aft control column input to command rotation, the control tabs mechanically deflect in response to the control column inputs, and the resultant aerodynamic forces on the deflected control tabs move the elevators to produce the change in airplane pitch. Elevator geared tabs, which mechanically deflect in response to elevator movements, are attached to the horizontal stabilizer through a system of drive linkages. The geared tab drive linkage consists of a pushrod that is attached to the horizontal stabilizer spar by means of an actuating crank and links (see figure 2). Figure 2. Installed location of geared tab linkage components (left) and closer view of the links and actuating crank (right). (Source: Boeing; some labels and revisions added by NTSB) The antifloat tabs (which prevent down-float of the elevator) are mechanically connected to the horizontal stabilizer, and their positions are driven by the stabilizer position. When the airplane is parked, each elevator is free to move independently within the confines of the mechanical stops if acted upon by an external force, such as wind. The elevator system (by design) has no gust lock. Automatic Spoiler System The accident airplane was equipped with an automatic spoiler system designed to automatically deploy to reduce lift and increase drag for more effective braking whenever reverse thrust is commanded. The system, which is electrically controlled and hydraulically actuated, becomes armed when a flight crewmember sets the speed brake handle before takeoff. In the event of a rejected takeoff, when a crewmember raises the thrust levers to the reverse thrust position, electrical signals are sent to the automatic spoiler actuator, which pushes the speed brake handle to its full extension, simultaneously actuating the spoilers on each wing. Owner/Operator Information The owner and operator of the airplane, 987 Investments LLC, was a privately held company that contracted with the maintenance manager, mechanics, and current and qualified pilots to operate the airplane, which the company acquired about 6 or 7 years before the accident. According to the owner, he paid a fee to Everts Air Cargo to provide the maintenance manager with information on the items due for the airplane, such as periodic inspections and airworthiness directives. The maintenance manager said that he had been overseeing the maintenance on the accident airplane for about 5 years. He said that the airplane was maintained under the Boeing maintenance program and that Everts would send him maintenance information weekly that detailed any work that needed to be done and when it was due. For the accident flight, the maintenance manager contacted Everts to inquire about a crew for the upcoming planned flight. For such requests, Everts’ director of operations would check to see which pilots were off duty on the requested days and ask them if they wanted to conduct the flight; if the pilots agreed, the director of operations would provide their contact information to the representative of 987 Investments so they could arrange the logistics. According to records maintained by the FAA’s Houston Flight Standards District Office, in September 2017, an Everts representative submitted an e-mail request to the office to operate the accident airplane under Part 91 with Everts’ pilots who were pilot-in-command-qualified. - TME was a privately owned airport located about 28 miles west of Houston. TME was serviced by a nonfederal control tower that operated from 0600 to 2200 daily and was staffed by one controller (which was the normal staffing level) who was qualified in all positions (local control, ground control, and supervisor). The runway safety area (RSA) at the end of runway 36 extended north 600 ft from the end of the runway to the airport fence and was 500 ft wide. Based on its operations (and as a privately owned airport), TME was not subject to the requirements that applied to airports certificated under 14 CFR Part 139, which included (among other provisions) requirements to provide and maintain RSAs as described in 14 CFR 139.309 and the guidance in FAA advisory circular (AC) 150/5300-13B, Airport Design, and others. (Generally, based on these guidelines, a standard RSA for a similar runway at a Part 139 certificated airport would be 1,000 ft long.) - The airplane was equipped with a Honeywell 6022 CVR designed to record a minimum of 30 minutes of analog audio on a continuous loop tape in a four-channel format: one channel for each pilot, one channel for a cockpit observer, and one channel for the cockpit area microphone. The CVR showed thermal damage but the data downloaded normally and consisted of 31 minutes 14 seconds of fair quality audio from the captain’s channel and poor-quality audio from the cockpit area microphone. The airplane was equipped with a Honeywell Universal FDR designed to record about 25 hours of flight information (which included the accident flight and previous flights) in a binary format, using analog signals, onto eight tracks of magnetic tape. The FDR showed external thermal damage, and the magnetic tape showed minor damage of an undetermined nature. Recorded data parameters included airspeed, engine performance, left and right elevator positions, airplane pitch angle, control column position, left and right brake pressures, left and right thrust reverser lock/unlock, left and right thrust reverser position, spoiler position, and acceleration information. Due to the nature of the tape-based recorder system and readout equipment, data dropouts (gaps in data) were noted, especially at the end of the accident flight recording. Further, a review of the data for the accident flight and previous flights determined that the left and right thrust reverser position parameter was not valid for any of the flights on the recording. - On October 19, 2021, at 1000 central daylight time, a McDonnell Douglas DC-9-87 (MD87) airplane, N987AK, owned and operated by 987 Investments LLC, overran the departure end of runway 36 at Houston Executive Airport (TME), Brookshire, Texas, after the flight crew executed a rejected takeoff. (All times in this report are central daylight time unless otherwise indicated.) Of the 19 passengers and 4 crewmembers on board the airplane, 2 passengers received serious injuries, and 1 passenger received a minor injury. A postcrash fire ensured, and the airplane was destroyed. The personal flight was operated under Part 91 and was destined for Laurence G. Hanscom Field Airport (BED), Bedford, Massachusetts. The captain and the first officer accepted the accident flight as contract work while they were off duty from their primary employer, Everts Air Cargo, a Part 121 air cargo operator headquartered in Fairbanks, Alaska. The airplane was based at TME and kept parked on the ramp, and it had not been flown since April 26, 2021. The captain had flown the airplane on its last trip (and numerous other trips); the first officer had not flown it before. According to the captain, they used an Everts quick reference handbook and checklist for the airplane. On the day of the accident, the captain and the first officer arrived at the airport about 0800. The first officer performed the preflight exterior inspection of the airplane, which included a visual check of the elevators, and he noted no anomalies. An airframe and powerplant mechanic who worked for 987 Investments (and was a crewmember on board the accident flight) said he performed an exterior walk-around of the airplane, and he noted no anomalies. The CVR began recording about 0928:50 and captured that the captain, who was the pilot flying, and the first officer, who was the pilot monitoring, discussed various checks and procedures while the passengers boarded. The CVR captured that the captain told the first officer that they would be using normal Everts procedures. The captain briefed the rejected takeoff procedures, during which he stated that they would reject the takeoff after V1 “only if the airplane won’t fly.” (V1, also known as the decision speed, is defined, in part, as the maximum speed by which a rejected takeoff must be initiated to ensure that the airplane can be stopped on the remaining runway.) The captain and the first officer subsequently started the engines, and, at 0952:33, the TME air traffic controller provided their clearance to taxi to runway 36. According to the first officer, as the captain taxied the airplane, the first officer conducted a flight control check, which included pushing the control column all the way forward then pulling it all the way back and turning the yoke left and right. (The FDR recorded data consistent with a control check being performed during taxi.) The first officer noted no anomalies during the control check. The TME air traffic controller cleared the flight for takeoff about 0959. Shortly after, the CVR captured the captain’s callout that the takeoff thrust was set and the first officer’s acknowledgement then confirmation that the engine and instrument indications were normal. According to FDR data for the accident flight, the takeoff began with the flaps, slats, and horizontal stabilizer set correctly. At 0959:36.3, the first officer called out “80 kts,” followed by “V1” at 0959:47.2 and “rotate” at 0959:48.0. Based on the FDR data, the captain’s attempt to rotate the airplane began about 1 second after the “rotate” callout, but the airplane’s pitch never increased. (See the “Aircraft Performance Study” section.) The captain stated in a postaccident interview that, when he pulled back to move the control column aft, “absolutely nothing happened.” The captain said it felt to him like the control “was in concrete.” When asked to clarify whether he moved the yoke and the airplane didn’t lift off, or whether the yoke was stuck, the captain replied “no” to both scenarios and stated that the yoke was “frozen.” The CVR captured that the first officer subsequently made the “V2” callout (an airspeed reference relevant to single-engine climb performance) and that the captain then said “…come on” in a strained voice at 0959:51.7. Both pilots recalled in postaccident interviews that they both then attempted to pull back on the yoke. At 0959:53.3, the first officer called out “…abort.” According to the captain, the first officer was faster than he was at reaching for the thrust levers, and, when he saw that the first officer pulled the thrust levers to idle, he (the captain) activated the thrust reversers. The first officer said that he heavily applied the brakes and could feel the airplane decelerating, but it overran the departure end of the runway. The airplane crossed the runway safety area and continued through the airport perimeter fence and across a road, striking electrical distribution lines and trees before coming to rest about 1,400 ft beyond the end of the runway in a privately owned pasture. The CVR had ceased recording audio shortly after the airplane departed the runway surface, and no crew conversations after the “abort” callout were captured. According to the captain, once the airplane came to a stop, he saw flames out the left cockpit window and commanded for everyone to evacuate. All passengers and crew evacuated the airplane, and airport and emergency response personnel soon arrived. (See the “Survival Aspects” section.) - Weather at Accident Site National Weather Service (NWS) surface analysis station models near the accident site at the time of the accident depicted east-to-southeasterly winds of 10 kts or less and clear skies. A review of the national composite radar mosaic revealed no significant echoes within 1 hour of the accident. About 0958, the TME air traffic controller informed the flight crew that the wind was from 090° at 6 kts. Previous High-Wind Events A review of high wind events affecting TME between April 26, 2021 (when the airplane had last flown) and the day of the accident identified 23 days with wind gusts of more than 25 kts for more than one consecutive hour. The two strongest wind events included reported gusts up to 46 kts and 45 kts, respectively, as follows: o On May 18, 2021, a line of thunderstorms developed across central and southern Texas and merged into a bow echo configuration with embedded supercell thunderstorms. The line was responsible for producing an extensive area of strong wind, large hail, and several tornadoes. An NWS surface analysis chart for that day depicted a squall line with a distinct wind shift moving across the TME area. An NWS composite radar mosaic for the same day showed a line of echoes of extreme intensity was immediately west of the airport when strong wind conditions were reported. TME weather observations that day included a report at 2115 of wind from 200° at 34 kts gusting to 46 kts; at 2135, wind from 340° at 13 kts gusting to 30 kts; and at 2155, wind from 040° at 19 kts gusting to 28 kts. o On September 13 and 14, 2021, the TME area was affected by Hurricane/Tropical Storm Nicholas, which had come ashore as a hurricane west of Sargent Beach, Texas, before weakening and moving into the Houston area. TME weather observations indicated wind gusts of more than 25 kts on September 13 and 14, with a peak gust of 45 kts and gusts of 35 to 45 kts reported over a 5-hour period. Similar high-wind observations of 39 to 50 kts were reported over the Houston area, with Houston Hobby Airport (about 39 miles east of TME) reporting the highest gust of 50 kts. According to the airport manager at TME, the high wind associated with Tropical Storm Nicholas blew in an 8-ft sliding door at a fixed based operator next to where the accident airplane was parked, requiring replacement of the door. An NWS National Hurricane Center wind speed probability chart issued on September 14 indicated a greater than 50 percent probability of wind greater than 50 kts for the TME area with a greater than 90 percent probability for the area immediately south of TME. - The captain and the first officer accepted the Part 91 accident flight as contract work for 987 Investments. Their primary employer was Everts Air Cargo, which trained them and provided the quick reference handbook, checklist, and procedures they chose to use for the accident flight. Exterior Inspection Procedures According to the exterior inspector procedure in Everts’ MD-80 operating manual, the checklist item for the elevators and tabs indicates that the crew is to check for “CONDITION GOOD.” Everts also provided its pilots with a pictorial, “Exterior Preflight General Instructions,” that included 150 slides detailing the exterior preflight inspection of the airplane. One slide stated the following: Airplanes that are exposed to high and sustained winds, or wind gusts, greater than 65 knots, are susceptible to elevator damage or jamming. There are procedures from the Aircraft Maintenance Manual for airplanes suspected to have been subjected to such conditions, requiring visual and physical inspections (moving the surfaces from the cockpit controls) to assure proper flight control operation. The pictorial contained five slides detailing what pilots should look for when inspecting the elevators. The slides discussed observing the condition of the leading edges of the horizontal and vertical stabilizer, the ram air inlet, static wicks, rudder deflection, and elevator and rudder attach points. Everts’ MD-80 operating manual did not include a copy of the Boeing MD-80 FCOM Temporary Revision 80-2-153, dated May 15, 2020, that provided an exterior inspection procedure that included the following warning and caution regarding jammed elevators (emphasis in original): WARNING: Prior to every flight, elevator surfaces must be confirmed as not jammed in the Trailing Edge Down (TED) position. If both elevators are faired with or above the stabilizer surface, confirmation is complete. CAUTION: Airplanes that are exposed to high-sustained winds, or wind gusts, greater than 55 knots are susceptible to elevator damage and/or jamming. Airplanes suspected to have been subjected to these conditions must be inspected per the Aircraft Maintenance Manual prior to the flight. Operations Bulletin 80-2-017 (also issued by Boeing in 2020) provided operators methods to comply with the warning statement contained in FCOM Temporary Revision 80-2-153 and confirm before each flight that the elevators are not jammed in the trailing-edge-down position. The operations bulletin stated that, during the exterior inspection procedure, an elevator that is not faired with or above the trailing edge of the stabilizer can be verified as not jammed by moving the control column to the full aft stop and confirming (using an external observer) that the elevator moves in the trailing-edge-up direction. According to the bulletin, when the control column is pulled full aft, the elevator control tab moves during the first 95 percent (approximately) of control column travel, and the elevator moves during the last 5 percent. The bulletin stated that, if an external observer sees no elevator movement when the control column is pulled fully to its aft stop, a maintenance inspection of the elevators is required. Both Operations Bulletin 80-2-017 and the Boeing MD-80 FCOM Temporary Revision 80-2-153 established maintenance inspection requirements for airplanes exposed to wind of 55 kts or greater. This wind threshold lowered the previously established threshold of about 65 kts. Further, Operations Bulletin 80-2-017 included information about two previous jammed elevator events in 1999 and 2017 involving DC-9/MD-80 series airplanes that had been exposed to high winds and gusts while parked. The bulletin stated that, in both cases, the control column feel and travel were normal during the control checks performed during taxi. The 1999 event involved a successful rejected takeoff in Germany, and the 2017 event was a runway overrun accident in Ypsilanti, Michigan, investigated by the NTSB. As a result of the NTSB’s investigation of the Ypsilanti accident, the NTSB issued three safety recommendations to Boeing [Safety Recommendations A-19-1 through -3] and one to the FAA [Safety Recommendation A-19-5] that were specific to DC-9/MD-80 series airplanes and intended to prevent future occurrences. (Discussed in the “Previously Issued Safety Recommendations” section of this report.) Boeing made the operations bulletin available to airplane owners, operators, and maintenance, repair, and overhaul centers through its MyBoeingFleet website. According to a Boeing representative, the MyBoeingFleet system would also send an e-mail to the contact person for operators listed within the system to inform them of any new bulletins published for their specific aircraft. Everts was listed in the MyBoeingFleet system as an operator, and a review of select activity data for Everts between 2019 and 2021 identified numerous views and downloads of various technical publications from the system. Everts’ director of operations stated that he unaware of Operations Bulletin 80-2-017 before the accident, and the MyBoeingFleet activity data showed that an Everts representative first accessed the bulletin 4 days after the accident. No representative of 987 Investments, which was listed in MyBoeingFleet as an airplane owner, had ever accessed the system, and the maintenance manager was unaware of Operations Bulletin 80-2-017 and the maintenance inspection requirement for airplanes exposed to wind of 55 kts or greater. During interviews, an Everts representative stated that the 2017 jammed elevator event was discussed during pilot training and that the scenario was performed in the simulator. The captain stated that Everts’ jammed elevator training addressed only the effects of jammed elevator in flight. The first officer stated that he was not sure if he ever had training to deal with a jammed elevator. Another Everts pilot described that, in checking the elevators, “Generally…we just did the control checks in the airplane as we were taxiing. No binding, no stiffness, no anything like that….It seems like if [the elevators] were jammed, you wouldn’t be able to move the yoke.” Normal Takeoff Procedures The normal takeoff procedures in Everts’ MD-80 operating manual stated the following (in excerpt): o The pilot monitoring makes the “V1” callout when the airplane’s speed is about 5 kts below V1 and the “rotate” callout at Vr (rotation speed). o The pilot monitoring makes the “rotate” callout at Vr (rotation speed), and the pilot flying “verifies airspeed and smoothly rotates to initial takeoff attitude (maximum 20° pitch). Rotation rate should be approximately [2.5] seconds to liftoff (8° pitch) and [2.5] seconds from liftoff to takeoff attitude in one smooth, continuous pitch change.” o The captain will make the decision to abort, if necessary. Reduced Thrust Takeoff Procedures The reduced thrust takeoff procedures in Everts’ MD-80 operating manual stated (in part) that, when the airplane’s actual takeoff weight is less than the maximum allowable, the takeoff may be made with normal takeoff thrust or with reduced thrust, if the proper conditions are satisfied. Per the manual, when determining the flap setting and takeoff speeds for a reduced thrust takeoff, the flight crew should “[r]ead down the appropriate wind column to a weight equal to or greater than the actual takeoff weight.” Based on the flight release paperwork for the accident flight, the takeoff weight for the accident flight was 111,770 lbs (converted from 50,700 kgs), which was below the airplane’s maximum takeoff weight of 149,000 lbs. According to the captain, he chose a reduced thrust takeoff for the accident flight because the airplane’s low takeoff weight allowed it, and he preferred to use reduced thrust takeoffs whenever possible to help maintain the engines. He stated that, when determining the V speeds for the reduced thrust takeoff, the accident airplane’s takeoff weight fell between 110,000 lbs and 119,000 lbs (the increments available on the takeoff performance chart), so he used the numbers that corresponded with 119,000 lbs. Based on the chart, the captain determined that, for the accident flight, V1 was 129 kts, Vr was 132 kts, and V2 was 140 kts. The Everts MD-80 operating manual that the captain referenced was for an airplane equipped with Pratt & Whitney JT8D-217 engines, and the accident airplane was equipped with -219 engines. A Boeing review of airplane flight manuals (AFMs) for both -217 and -219 equipped airplanes identified minimal difference between the resultant calculated V speeds (such that rounding the results to the nearest knot yielded equivalent V speeds) when using the graphical takeoff performance charts and the accident airplane’s takeoff weight. Rejected Takeoff Procedures The rejected takeoff procedures in Everts’ MD-80 flight operation manual stated the following (in excerpt): The captain “has the sole responsibility for the decision to reject the takeoff…Rejecting the takeoff after V1 is not recommended unless the captain judges the airplane to be incapable of flight.” According to Everts’ general operations manual, if a flight crewmember “detects any malfunction during the takeoff run, call out the type of malfunction. The captain makes the decision, declares, and initiates the abort.” Emergency Evacuation Everts’ quick reference handbook’s “Emergency Evacuation” procedure for the airplane for the “on ground” phase of flight included (in excerpt) positioning the fuel levers to “off,” pulling the engine fire handles, initiating the evacuation command, confirming all passengers and crew are evacuated, and, if time and conditions permit, turning the battery switch “off.” Additional Information Postaccident Inspection of Other DC-9 Airplane Parked at TME The owner of the accident airplane owned another DC-9 (MD-87) airplane that was parked on the ramp at TME since before the accident airplane had last flown. According to the maintenance manager, after becoming aware of the maintenance inspection specified in Operations Bulletin 80-2-017 after the accident, he performed the inspection on the other airplane to verify that the elevators were not jammed. (The airplane was not in flying condition but its elevator system and controls had integrity sufficient to perform the inspection.) The maintenance manager said the inspection involved having a person in the cockpit manipulate the flight controls while a person outside the airplane on a lift observed the tail surfaces. He said the inspection worked well. This airplane, which had been parked near the accident airplane during the high-wind events at TME on May 18 and September 13-14, 2021, did not sustain jammed elevators. Everts’ Postaccident Actions Following the accident, Everts updated its manuals and developed an illustrated pilot training presentation that referenced this accident and the previous known elevator jamming events, the Boeing operations bulletins, and the flight crew preflight inspection procedure for the elevators. The presentation included photographs to show the visual difference (when viewed from the ground) between the faired and trailing-edge-down elevator positions and a video to show elevator movement. - Captain At the time of the accident, the captain worked for Everts as a simulator instructor and check airman. He previously worked as Everts’ chief pilot in the DC-9/MD-80 series airplanes for about 2.5 years until he turned 65 and was no longer eligible to fly under Part 121 regulations. The captain’s most recent Part 121 training events at Everts included recurrent ground and flight training in October and November 2020, respectively, a requalification proficiency check in June 2021, and emergency procedures training in October 2021. The captain resided in Las Vegas, Nevada. On October 16, 2021 (3 days before the accident), he was in Fairbanks, Alaska, and awoke about 0515 Alaska daylight time (AKDT) for a 0700 AKDT flight home, where he arrived about 1830 Pacific daylight time (PDT). He did not nap during the day, and he went to bed about 2130 PDT. The next day, he awoke between about 0600 and 0700 PDT, did routine personal errands throughout the day, and went to bed about 2200 PDT. The day before the accident, he awoke about 0630 PDT and had a 1000 PDT flight to Houston, where he arrived about 1530. He met the first officer for dinner, went back to the hotel to watch a football game, and went to bed about 2230 to 2245. On the day of the accident, he awoke about 0630, had breakfast, and arrived at the airport about 0800 The captain said he had no problems falling asleep at night and felt rested the morning of the accident. In the 72 hours preceding the accident, the captain did not consume any alcohol or other drugs, including prescription or nonprescription medications, that might have affected his performance. He had no major changes in his personal life, finances, or health in the previous 12 months. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on the captain’s blood identified no evidence of impairing drugs. First Officer The first officer worked for Everts since June 2019. Previous employment included flying corporate airplanes for several years in the United States and overseas. The first officer’s most recent Part 121 training events at Everts included recurrent ground and flight training in January and July 2021, respectively, a proficiency/qualification check in July 2021, and emergency procedures training in January 2021. The first officer resided in Bruce, South Dakota. On October 16, 2021 (3 days before the accident), he awoke between 0800 and 0900, did routine housework throughout the day, and went to bed between 2200 and 2300. The next day, he awoke between 0800 and 0900, did routine housework, and went to bed about 2200. The day before the accident, he awoke about 0530 and caught an 0800 flight to Houston, arriving at his hotel at 1438. He took a 45-minute nap, met the captain for dinner, the returned to the hotel to relax and watch TV before going to bed about 2130 to 2200. On the day of the accident, he awoke about 0700 and had breakfast before heading to the airport. The first officer said he usually fell asleep quickly at night and would sometimes toss and turn. He characterized his sleep as “pretty decent” in the days before the accident and said he felt rested on the day of the accident. In the 72 hours preceding the accident, the first officer did not consume any alcohol or other drugs, including prescription or nonprescription medications. He had no major changes in his personal life, finances, or health in the previous 12 months. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on the first officer’s blood identified no evidence of impairing drugs. Other Crewmembers According to the airplane’s owner, he acted as a cabin crewmember and performed such duties as setting out food, drinks, and blankets before the passengers arrived and providing the pretakeoff safety briefing, which included the use of the seatbelts and the emergency exits. (See the “Survival Aspects” section.) The owner knew all of the passengers on the accident flight (either personally or through business), and most had traveled on the airplane before. According to the captain, the owner typically provided the passenger safety briefings, was thorough, and ensured that everyone paid attention. According to the airplane’s owner, a mechanic (usually the maintenance manager) always traveled on board the airplane to be available in case any maintenance needs arose when the airplane was away from base. On the day of the accident, the maintenance manager was not feeling well enough to travel, but he went to the airport before the flight departed, met with the flight crew, and provided instructions to the on-board mechanic (who had not traveled with the accident airplane before). - After all the passengers boarded, the mechanic stowed the stairs, closed the main cabin door, and notified the pilots that the door was closed before he took a seat in the right crew room (at the front of the cabin) and fastened his seatbelt. The airplane’s owner stated that he ensured that all passengers were paying attention when he provided them with a safety briefing, which included the use of the seatbelts and the location of the emergency exits. According to the CVR transcript, about 12 minutes before takeoff, the CVR captured the owner’s voice speaking in a cadence consistent with that of a passenger briefing, detecting the word “forward” and a discussion of seat positioning. The owner said he walked through the cabin and ensured that all passengers were seated with their seatbelts fastened before he took a seat in the left crew room (at the front of the cabin) and latched the lap belt portion of his restraint. Emergency Evacuation During the accident sequence, two passengers who had removed their seatbelts during taxi were ejected from their seats but were not injured. The mechanic said he unbuckled his seatbelt during the accident sequence to be mobile and able to evacuate faster. As described in the “History of Flight” section, as soon as the airplane came to rest, the captain saw that it was on fire and commanded the evacuation. The captain said that his main concern was getting the passengers off the airplane and away from the fire. The first officer said he left the cockpit before the captain and saw that the forward-left door was already open, and passengers were evacuating. The first officer said he began walking aft through the cabin to ensure no one was still on board, but the captain told him to evacuate. The captain said he walked aft through the cabin but made it only about two-thirds of the way back before encountering dense smoke. The captain said he yelled to make sure no one was in the back of the airplane before he exited and that, just as he was exiting through the forward-left door, the first officer asked him if he had shut down the engines, and he responded that he had not. According to the captain, not shutting down the engines (per the emergency evacuation procedure) was an omission. Once the airplane came to a stop, passengers heard shouts indicating a fire and the need to evacuate. The mechanic said he ran to the forward-left door, looked out the window, and saw flames outside. As the mechanic moved to the forward-right door, a passenger came forward, opened the forward-left door, and jumped out before the evacuation slide inflated. The passenger said he felt a sharp pain in his ankle when he landed on the ground, but he was able to run away from the airplane. The mechanic said he saw the passenger jump out, and he went back to the forward-left door and “kicked the girt bar” to help the slide inflate “faster.” Passengers reported that the slide was fully inflated at the beginning of the evacuation but became less inflated as the evacuation continued. The mechanic exited through the forward-left door and assisted passengers as they came down the slide. A passenger who was seated near the left overwing exit opened it, experienced intense heat from the flames outside, then attempted to close it (with the help of another passenger) but was unsuccessful; she subsequently ran forward to use the forward-left door. The passenger who had assisted her moved to the right overwing exit, opened it, and exited through it, along with one other passenger. No other passengers or crew used the overwing exit. Two passengers who had first headed aft toward the tailcone exit turned around after observing smoke in the back of the airplane and exited through the forward-left door. One passenger, who was described as having a preexisting back injury that was exacerbated during the accident sequence, couldn’t walk and was assisted by the airplane’s owner and others in evacuating and moving away from the airplane. The airplane’s owner said he walked aft through the cabin to make sure no passengers were still on board before he exited through the forward-left door. Emergency Response The TME air traffic controller saw the airplane exit the runway into the trees and initiated the emergency response procedures. The airport manager also saw the event, ran into the terminal, and yelled for someone to call 911 then immediately drove to the scene. Emergency responders were dispatched about 1001, police officers arrived on scene about 1007, and the first firefighting vehicle arrived about 1013; responders noted an “intense” fire. Responders encountered passengers walking away from the airplane and toward the road, with about nine gathered at a locked gate to the pasture. Emergency responders used bolt cutters to open two locked gates to access the pasture, and a road grader working nearby assisted the airport director with forcing open a third. Responders placed the passenger with the back injury onto a backboard, and several passengers helped carry him to the emergency response vehicles. Ambulances transported this passenger and a passenger who sustained a lung injury (from the intense heat she encountered when she opened the left overwing exit) to a local hospital. Another passenger, who sustained a self-reported ankle fracture, later went to a local hospital via private transport. - Aircraft Performance According to dispatch information, the accident airplane’s gross takeoff weight was 111,770 lbs, and the center of gravity was at 22.8% of the mean aerodynamic cord, both of which were within the certified envelopes for the airplane. Based on these data and the weather and surface conditions for the accident flight, Boeing calculated that the distance for the airplane to accelerate to V1 (the captain’s calculated decision speed of 129 kts) and then be brought to a stop was 5,607 ft. The captain calculated that Vr (rotation speed) was 132 kts. (See “Reduced Thrust Takeoff Procedures” for more information.) Based on the NTSB’s aircraft performance study (which used both recorded FDR parameters and automatic dependent surveillance-broadcast data for the accident flight), during the takeoff roll, the first officer made the “rotate” callout at 0959:48.0, and a change in control column position (consistent with the captain’s attempt to rotate the airplane) began about 1 second later, when the airplane was traveling about 134 kts. However, both elevators remained in the nearly full trailing-edge-down position, and the airplane’s pitch never increased. A review of FDR data from the accident flight and airplane’s previous two takeoffs showed similar control column position behavior for all three flights. However, the elevator movement and airplane pitch behavior following control column movement during the accident takeoff were inconsistent with the airplane’s previous two takeoffs. The data showed that, generally, during the previous takeoffs, as the airplane accelerated down the runway, the elevator deflections gradually converged around or slightly below neutral until about 1 to 2 seconds after the initiation of control column position movement, at which point the elevators moved to a trailing-edge-up position, and the airplane’s nose-up pitch response began about 1 to 2 seconds later. The airplane performance study determined that, during the accident takeoff, the airplane’s speed was about 150 kts when the crew initiated the rejected takeoff about 0959:53.3, as evidenced by the increase in the left and right brake pressures and a reduction in engine thrust. At this point, about 1,500 ft of runway remained. The airplane reached a maximum speed of 158 kts at 0959:55 before it began decelerating. Boeing estimated that it would have taken 2,450 ft to stop the airplane from the maximum speed on a dry, paved runway for the given airplane configuration using maximum braking and reverse thrust (or 2,800 ft without the use of reverse thrust). The FDR data indicated that, about 0959:59, the left and right thrust reversers momentarily unlocked and the spoilers deployed but then the thrust reversers relocked. In the absence of valid data parameters for left and right thrust reverser position (separate parameters from the unlock data), the actual positions of the thrust reversers during the accident sequence could not be determined. The airplane performance study determined that the airplane’s speed was about 121 kts when it exited the paved surface about 1000:01; the FDR data became unreliable about 1000:03. During postaccident interviews, the captain stated that he pulled the thrust reverser levers “all the way up” to deploy the thrust reversers. The captain stated that he couldn’t recall where his hand was positioned after he deployed the thrust reverser levers but noted that he did not ever intentionally stow them or consciously push them down. The first officer described the runway excursion as “a pretty violent ride.” An airport maintenance worker located in a field adjacent to the runway reported that he saw the thrust reversers deploy and a puff of smoke from hard braking but lost sight of the airplane as it continued off the end of the runway. The airplane’s owner said he felt the heavy braking but did not hear the thrust reversers, and the mechanic said the thrust reversers may have come open but he did not hear them. - The airplane came to rest about 1,400 ft from the end of the runway. No parts of the airplane were found on the runway or south of the airport perimeter fence. The nose landing gear remained attached and was folded aft with damage to its supporting structure. The lower section of the left main landing gear, including the axle and wheels, was found separated in the debris field about 150 ft from the main wreckage. The right main landing gear was found in its respective wheel well. The airplane structure forward of the empennage was heavily damaged by fire. All of the upper fuselage structure (except for a small section of the upper nose structure and empennage) was consumed by fire. An outboard portion of the left wing was found separated due to contact with several trees. The inboard portion of the left wing was attached to the fuselage and showed heavy fire damage. Most of the right wing was partially attached to the fuselage and showed heavy fire damage near the wing root. The empennage was partially intact with the vertical and horizontal stabilizers, rudder, and elevators attached (see figure 3). Figure 3. View of the wreckage (from front left looking aft) showing heavy fire damage forward of the empennage. Elevators Postaccident examination found both elevators in a trailing-edge-down position, and attempts to move them upward (using hand pressure) were unsuccessful (see figure 4). Figure 4. Both elevators as found in the trailing-edge down position. Impact and fire damage precluded establishing control cable continuity for the elevator system. The control columns were consumed by fire, and the control cables from the cockpit to the tail were covered in melted metal and debris. Examination found that the inboard actuating cranks for both elevators’ geared tabs were bent, and their respective attachment linkages were bent outboard (see figure 5). Figure 5. Left and right elevator inboard geared tab linkages (left and right, respectively), viewed from underneath each elevator. Each linkage is bent outboard. The actuating crank and linkages were found locked overcenter beyond their normal range of travel. Once the actuating cranks were disconnected and the bent linkages removed, the elevators could be moved (using hand pressure) through their normal range of motion. No other elevator or pitch control system component anomalies were identified. Tests and examinations of the components removed from the system revealed no evidence of mechanical failures or damage, or any actions by the flight crew or maintenance personnel, that could have caused the overcenter condition. The first officer provided a photograph he took of the airplane on the morning of the accident, before the flight crew performed any manipulations of the cockpit flight controls. The photograph showed that the forward portion of each elevator’s outboard balance weight was visible above the top surface of the horizontal stabilizer, consistent with both elevators in a trailing-edge-down position (see figure 6). Figure 6. Accident airplane on the morning of the accident. Insets show the outboard balance weight for each elevator. Powerplants Both engines were found attached to their respective engine mounts and connected to the empennage in their normal orientation. The thrust reversers for both engines were found intact and stowed, and the leading edges of the lower doors showed no damage or scoring from contact with stationary objects. No damage or debris was found under the thrust reverser doors. An exhaust pattern of burned earth and singed grass extended about 90 ft behind the exhaust duct of the right engine, consistent with engine operation after the airplane came to rest. No such pattern was observed behind the left engine. Examination of the right engine and nacelle revealed minor impact damage. Examination of the left engine revealed impact damage to the lower right quadrant of the nacelle and the inlet duct assembly, most of which was found separated on the ground. The left engine’s fuel control unit and fuel pump were impact-damaged, with their internal components exposed. The last 500 ft of the airplane’s ground track included a cluster of trees on the left side that showed fractured and burned branches. The alignment of fire damage patterns observed on the left engine components was consistent with exposure to a ground fire. Seat Restraints and Exits Postaccident fire damage precluded documentation of the cabin seat restraints. The forward-left door was fire-damaged and found on the ground with the door hinge attached to the deformed door frame. The door and the handle were in the open position, and a portion of the evacuation slide was found under the door. The forward-right door and the surrounding fuselage structure were fire-damaged, and the lower portion of the door and door frame indicated that the door was closed; the evacuation slide was destroyed by fire. The tailcone exit was destroyed by fire, and its evacuation slide was in its packaging. Both overwing exits were destroyed by fire. -
Analysis
Accident Sequence The captain (who was the pilot flying) initiated the takeoff roll, and the airplane accelerated normally. According to the cockpit voice recorder (CVR) transcript, the first officer made the “V1” and then “rotate” callouts. According to the captain (in a postaccident interview), when he pulled back on the control column to rotate the airplane, “nothing happened,” and the control column felt like it “was in concrete” and “frozen.” The CVR captured that the first officer subsequently made the “V2” callout, then the captain said “come on” in a strained voice. Both pilots recalled in postaccident interviews that they both attempted to pull back on the controls, but the airplane did not rotate. The CVR captured that the first officer called out “abort.” The first officer pulled the thrust levers to idle and applied the brakes, and the captain deployed the thrust reversers. (See “Execution of Rejected Takeoff” for more information.) The airplane overran the departure end of the runway and continued through the airport perimeter fence and across a road, striking electrical distribution lines and trees before coming to rest in a pasture, where a postcrash fire ensued. The pilots, two additional crewmembers, and all passengers evacuated the airplane. Two passengers received serious injuries, and one received a minor injury. (See “Emergency Evacuation” for more information.) Postaccident examination of the airplane and the related flight data recorder (FDR) data revealed no evidence of preimpact malfunction of the engines or thrust reversers that would have precluded their normal operation. Examination of the elevators and a review of FDR data for elevator position determined that both elevators were jammed trailing-edge-down, which prevented the airplane from rotating during the takeoff roll. Jammed Elevator Condition The investigation determined that, at some point during the 6 months since the airplane was last flown, the inboard geared tab linkages for both elevators had moved beyond their normal range of travel into an overcenter position, resulting in the jammed condition of the elevators in the trailing-edge-down position. No evidence of any other mechanical malfunction, elevator or pitch control system failure, structural failure, or actions by the flight crew or maintenance personnel was identified that could have resulted in the jammed condition. Further, the jammed condition was not detectable during the flight control check the first officer performed during taxi; the elevator control system design is such that, even with this type of jammed elevator condition, the control column feel and travel would be normal during taxi (when the aerodynamic forces on the elevator control tabs would be minimal). Since the airplane was last flown, it was parked outside at the departure airport and exposed to two significant high-wind events: the passage of a squall line about 5 months before the accident (with gusts to 46 kts reported at the airport) and a tropical storm about 1 month before the accident (with gusts of 35 to 45 kts reported over a 5hour period). The possibility of elevator jamming on DC-9/MD-80 series airplanes as a result of exposure to certain high-wind conditions while parked is known and evidenced by two previous events – a rejected takeoff event in 1999 in Germany and a runway overrun accident in 2017 in Ypsilanti, Michigan. The NTSB’s investigation of the Ypsilanti accident determined that the airplane’s right elevator became jammed. Although The Boeing Company (the type certificate holder for the airplane) indicated that the MD-80 series airplane was designed to withstand a 65-kt horizontal ground gust from any direction while parked or taxiing, the jamming occurred even though the highest reported wind gust was 55 kts during the time that the airplane was parked. The investigation included a wind simulation study that determined that the airflow at that airplane’s parked location was affected by the presence of a large hangar (located upwind of the airplane) that generated localized turbulence with a dynamic, vertical component. Based on the wind simulation information, the NTSB developed an elevator test plan that determined that the vertical gust loads at the Ypsilanti accident airplane’s parked location were sufficient to enable the inboard geared tab linkages for the right elevator to move into an overcenter position and jam the right elevator. The investigation found that the airworthiness standard for transport-category airplanes specified that the airplanes must be designed for the limit loads generated when subjected to a 65-kt horizonal ground gust; however, the version of the standard that applied to MD-80 series airplanes allowed for the assumption of only static loads and did not require consideration of dynamic, vertical wind components. (In 2019, the NTSB issued a safety recommendation to the Federal Aviation Administration [FAA] related to the standard. See “Previously Issued Safety Recommendations” for more information.) The accident airplane (like the Ypsilanti accident airplane) had been parked near a hangar. Although the highest reported gust or sustained wind at the airport never exceeded 46 kts while the accident airplane was parked, the localized wind conditions in the immediate vicinity of the parked airplane may have differed from the wind conditions detected by the nearest weather sensor in speed or dynamic characteristics, or both. The presence of localized differences is further supported by the fact that another DC-9 (MD-87) airplane that was parked on the ramp near the accident airplane since the accident airplane had last flown did not sustain jammed elevators. Thus, the accident airplane’s jammed elevators resulted from the airplane’s exposure to high-wind conditions while parked, which likely included localized turbulence with a vertical component. Flight Crew Procedures and Training for Exterior Inspections of Elevators In 2019, the NTSB issued Safety Recommendation A-19-2 (as a result of its investigation of the Ypsilanti accident), which recommended that Boeing develop new preflight procedures or other mitigations for DC-9/MD-80 series airplanes that will enable a flight crew to verify before takeoff that the elevators are not jammed. In response to this recommendation, in 2020, Boeing published Operations Bulletin 80-2-017, “ELEVATORS NOT JAMMED VERIFICATION” and Temporary Revision 80-2-153 to the MD 80 Flight Crew Operating Manual (FCOM), both of which included a warning stating that, before every flight, the flight crew must confirm that the elevator surfaces are not jammed in the trailing-edge-down position. According to the warning, which was added as an update to the FCOM’s Exterior Inspection Procedures, confirmation involves visually verifying that the elevators are faired (even) with or above the stabilizer surface. This flight crew verification applied to every flight, regardless of the airplane’s ground wind exposure. The bulletin also explained that, for the previous known jammed elevator events, the control column feel and travel were normal during the control checks the crews performed during taxi. As a result of Boeing’s publication of this bulletin and revised procedures, the NTSB classified Safety Recommendation A-19-2 Closed—Acceptable Action. During postaccident interviews, the captain and the first officer indicated that they were unaware of the elevator inspection procedure. Although both elevators were visibly trailing-edge-down when the first officer performed a preflight inspection of the airplane (as was evident in a photograph he took of the airplane that morning), he did not recognize the condition as anomalous. Although the flight crew accepted the 14 CFR Part 91 accident flight as contract work for the operator, 987 Investments LLC, they were trained by and used the airplane manuals and procedures from their primary employer, Everts Air Cargo, a 14 Code of Federal Regulations (CFR) Part 121 cargo operator. Although Boeing had distributed Operations Bulletin 80-2-017 to Everts through its MyBoeingFleet system, and Everts was required (per 14 CFR 121.141) to keep its airplane flight manuals current, a review of Everts’ MyBoeingFleet activity data showed no evidence that any Everts personnel had viewed or downloaded the bulletin before the accident. As a result, the company had not updated the FCOM with the revised warning or updated its pilot training materials to include the new preflight exterior inspection procedures for visually confirming that the elevators are not jammed. In a postaccident interview, Everts’ director of operations stated that he was unaware of the Boeing operations bulletin until after the accident. Following the accident, Everts updated its manuals and developed a detailed pilot training presentation that included photographs and a video to show the visual difference between the faired and trailing-edge-down elevator positions when viewed from the ground. Execution of the Rejected Takeoff According to Everts’ procedures, the captain was responsible for deciding, declaring, and initiating a rejected takeoff. Before the takeoff, the captain briefed the first officer on the rejected takeoff criteria, stating that they would reject after V1 only if the airplane would not fly. (This procedure is consistent with longstanding FAA and industry guidance indicating that, generally, a takeoff rejected after V1 will result in a runway overrun.) Based on the NTSB’s airplane performance study and a review of the FDR data, the airplane’s lack of rotational response did not become apparent to the captain until after V1. The CVR transcript showed that the first officer made the “rotate” callout at 0959:48.0 (which was about 1 second after the “V1” callout). The FDR data showed that a change in the control column position began about 1 second after the “rotate” callout, consistent with the captain beginning his attempt to rotate the airplane. FDR data from the accident flight and the airplane’s two previous takeoffs showed similar control column position behavior for all three flights. The data showed that, during the two previous takeoffs, the airplane’s nose-up pitch response began about 2 to 4 seconds after the control column movement. However, during the accident flight, the control column response felt abnormal to the captain, and the airplane’s pitch did not increase. Following the first officer’s “rotate” callout, the captain pulled back on the control column (and was joined briefly by the first officer) before the first officer called out “abort” about 4 seconds later. Although, procedurally, the captain should have been the one to call for and initiate the rejected takeoff, the first officer recognized that the airplane was not going to fly and appropriately took action. Human performance research has shown that the average reaction time to an unexpected driving event is about 1.5 seconds. However, stress and increased task demands associated with an unexpected emergency (such as the abnormal control column feel and the airplane’s failure to rotate as usual) can increase a pilot’s reaction time and degrade a pilot’s ability to accurately assess how to respond. About the time that the first officer made the “abort” callout, pulled the thrust levers to idle, and applied the brakes, the airplane was traveling at 150 kts with only 1,500 ft of runway remaining (and a 600-ft runway safety area beyond that). The airplane reached a maximum speed of 158 kts at 0959:55 (about 2 seconds after the “abort” callout) before it began decelerating. Based on Boeing’s calculations, at this speed and position on the runway, an overrun was inevitable; Boeing calculated that it would have taken 2,450 ft to stop the airplane from the maximum speed on a dry, paved runway using maximum braking and reverse thrust. The FDR data showed the left and right thrust reversers momentarily unlocked and the spoilers deployed (consistent with the captain’s deployment of the thrust reversers) about 0959:59 but then the thrust reversers relocked. The airplane performance study determined that the airplane’s speed was about 121 kts when it exited the paved surface at 1000:01; the FDR data became unreliable at 1000:03. Actual thrust reverser positions during the accident sequence could not be determined from the FDR data (the thrust reverser position parameters were invalid for both the accident flight and previous flights). Although a witness stated that he saw the thrust reversers deploy before he lost sight of the airplane, the lack of damage on and debris inside the thrust reversers’ lower doors was consistent with them having been fully stowed by the time that the airplane began striking tree branches and other vegetation. In the absence of any mechanical anomaly or an intentional command by a crewmember to stow the thrust reversers, it is possible that a crewmember may have inadvertently pushed the thrust reverser levers down during the accident sequence. Emergency Evacuation According to the captain, once the airplane came to a stop, he saw flames out the left cockpit window and commanded for everyone to evacuate. The captain stated that his main concern was getting the passengers off the airplane and away from the fire. He inadvertently did not shut down the engines (per the emergency evacuation procedure), and the right engine continued to run throughout the evacuation. The investigation determined that damage to the fuel system sustained during the final seconds of the impact sequence resulted in the left engine’s power loss. The passengers and crew successfully evacuated the airplane despite the running engine and other challenges, including smoke and flames outside the airplane that deterred them from using some exits. The emergency response was timely and effective. Although the airplane’s cabin included two passenger seat positions not identified on the supplemental type certificate (STC) for the airplane’s cabin modification, the additional seats did not hinder the emergency evacuation. Previously Issued Safety Recommendations As a result of the NTSB’s investigation of the Ypsilanti accident, in 2019, the NTSB issued safety recommendations intended to prevent future occurrences. These included Safety Recommendation A-19-1, which recommended that Boeing modify DC-9/MD-80 series airplanes to prevent the possibility of elevator jamming due to exposure to high-wind conditions while parked or taxiing. However, that same year, Boeing responded that, due to airplane structural limitations, neither a physical travel stop on the elevator structure (to prevent a jammed condition) nor a sensor (to provide a cockpit indication of a jammed condition) was feasible. Based on Boeing’s response, the NTSB classified Safety Recommendation A-19-1 Closed—Reconsidered. Thus, the accident airplane was not equipped with any design feature that could prevent the possibility of elevator jamming or provide the flight crew with a cockpit indication that the elevators were jammed. The NTSB also issued Safety Recommendation A-19-3, which recommended that Boeing lower the ground gust criterion for requiring physical inspections and operational checks of the elevators of DC-9/MD-80 series airplanes by maintenance personnel. In response, in 2019, Boeing established a 55-kt ground wind exposure criterion (which lowered the previous inspection criterion of about 65 kts) that would require a maintenance inspection to ensure that the elevators were not jammed. Although the lowered wind exposure criterion was in effect before this accident, the reported wind at the airport never met nor exceeded the 55-kt criterion during the time that the airplane was parked since its last flight. Thus, no maintenance inspection of the elevators was required for the accident airplane before the accident flight. However, had such high wind conditions existed, neither the maintenance manager for 987 Investments nor the Everts personnel who provided him with maintenance information was aware that an inspection would have been required. In addition, NTSB Safety Recommendation A-19-5 (issued as a result of the Ypsilanti accident investigation) asked the FAA to ensure that operators of DC-9/MD-80 series airplanes have procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the specified ground gust criterion. At the time of the accident, the FAA had not yet completed its planned actions in response to Safety Recommendation A-19-5. (However, as stated above, the wind at the airport where the accident airplane was parked never met nor exceeded the ground gust criterion that would have required a maintenance inspection of the elevators.) On June 14, 2022, the FAA issued Safety Alert for Operators 22001, “Recommended Procedures for Operators of Boeing DC-9/MD-80 Series and B717 Model Airplanes When Wind/Ground Gusts Meet or Exceed Criteria Specified in the Applicable Aircraft Maintenance Manual.” According to the FAA (at the time of this report), it was developing a notice that will be included in FAA Order 8900.1, Flight Standards Information Management System, to ensure that operators have procedures within their Continuous Airworthiness Maintenance Program defining who is responsible for monitoring the wind that affects parked airplanes and who is responsible for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual. The FAA stated that it anticipated releasing the notice by December 31, 2023. At the time of this report, Safety Recommendation A-19-5 was classified Open—Acceptable Response. In addition, NTSB Safety Recommendation A-19-4 asked the FAA to determine whether the gust load limits specified in 14 CFR 25.415 adequately ensure that critical flight control systems are protected from hazards introduced by ground gusts that contain dynamic, vertical wind components. The FAA responded in June 2022 that the requirements of 14 CFR 25.415 were revised on December 11, 2014, to include consideration of dynamic loads, and the FAA determined that the ground gust limit loads specified for transport-category airplanes were adequate and appropriate for current and foreseeable future designs. The FAA also noted that the requirement for considering dynamic loads did not exist when the DC-9/MD-80 series airplanes were certified. Based on the FAA’s review of 14 CFR 25.415 and other related material and its determination that the current regulations were adequate, Safety Recommendation A19-4 was classified Closed—Acceptable Action.
Probable cause
The jammed condition of both elevators, which resulted from exposure to localized, dynamic high wind while the airplane was parked and prevented the airplane from rotating during the takeoff roll. Also causal was the failure of Everts Air Cargo, the pilots’ primary employer, to maintain awareness of Boeing-issued, required updates for its manuals, which resulted in the pilots not receiving the procedures and training that addressed the requirement to visually verify during the preflight checks that the elevators are not jammed.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MCDONNELL DOUGLAS
Model
DC-9-87 (MD-87)
Amateur built
false
Engines
2 Turbo fan
Registration number
N987AK
Operator
987 Investments, LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
49404
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-20T18:10:50Z guid: 104129 uri: 104129 title: WPR22FA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104148/pdf description:
Unique identifier
104148
NTSB case number
WPR22FA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-20T12:00:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2021-11-16T22:57:27.454Z
Event type
Accident
Location
Dunsmuir, California
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On October 20, 2021, about 1100 Pacific daylight time, a Cessna 150L, N5268Q, was substantially damaged when it was involved in an accident near Dunsmuir, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Multiple witnesses reported that the pilot was on a multi-leg cross-country flight that departed on October 19, 2021, from Sequim Valley Airport (W28), Sequim, Washington, about 1000 PDT, and was destined for Haigh Field Airport (O37), Orland, California. During a stop at Independence State Airport (7S5), Independence, Oregon, a witness reported the pilot charged the airplane battery, as he was having “issues” with the alternator. The witness offered the pilot assistance to find a replacement alternator, but the pilot refused. Witnesses reported that the pilot was “anxious” to get home and had a “get-there-itis" posture. After charging the battery at 7S5, the pilot departed for Ashland Municipal Airport-Sumner Parker Field (S03), Ashland, Oregon, and landed for an overnight rest stop. On October 20, the pilot departed S03 about 0940 PDT enroute to O37. The Federal Aviation Administration (FAA) issued an alert notification, or ALNOT, on October 20, at 1925 PDT, after a family friend became concerned as he had not heard back from the pilot, who was unreachable through the pilot’s cell phone. A search ensued and the airplane wreckage was subsequently discovered on a rising face of Mt. Bradley, about 725 ft below the summit, about 2 miles northwest of Interstate 5 near Dunsmuir, California. PILOT INFORMATION According to FAA records, the pilot had an expired student pilot certificate and reported civil flight experience that included 200 total hours and 0 hours in the six months before his last Aviation Medical Examiner examination on March 16, 1999. At that time, he reported no medication use or active medical conditions, and no significant issues were identified. A family member reported that he was a diabetic. Another witness added that the pilot has been flying as long as he has owned the airplane, which was about 20 years. METEOROLOGICAL INFORMATION There was no record of the pilot receiving a weather briefing or viewing weather imagery from Lockheed Martin Flight Service (LMFS), the Direct User Access Terminal Service (DUATS), or ForeFlight Mobile before departure. The pilot did not file a flight plan with ForeFlight Mobile. It is unknown whether the pilot retrieved weather graphics or text weather information from other internet sources. Weather Conditions at Time of Accident At 0840 PDT on the day of the accident, the weather at Rogue Valley International - Medford Airport (MFR), Medford, Oregon, elevation 1,335 ft, located about 15 nm from S03 (the last departure airport), included winds at 0 knots, visibility of 10 statute miles (sm), clouds broken at 6,500 ft, overcast at 8,500 ft, temperature and dewpoint at 9°/8°C respectively, and an altimeter setting of 29.96 inches of mercury. At 1050, the weather conditions recorded at Dunsmuir Municipal-Mott Airport (1O6), Dunsmuir, CA, elevation 3,261 ft, located about 3 nm northeast of the accident site, included winds from 100° at 4 knots, visibility 2 sm, light rain, clouds scattered at 700 ft, broken at 1600 ft, and overcast at 2,500 ft. The elevation of the accident site was about 5,314 ft. A power company lineman supervisor working near the Mt. Bradley lookout point on the day of the accident reported that a fog layer to the top of the mountain was present and allowed for a 200-ft visibility. Between 1100 to 1200, he heard a low-level airplane flying; he added that the engine sounded as if it was running but clarified that he did not hear the airplane impact terrain. He further reported that the fog was present for most of the morning and throughout the early afternoon. WRECKAGE IMPACT INFORMATION Examination of the accident site revealed that the airplane impacted a mountain about 5,290 ft mean sea level (msl). The airplane came to rest on a 15° slope on a heading of 350° magnetic. The first identified point of contact (FIPC) was identified by two 40-foot-tall pine trees and several broken tree branches, consistent with level flight. A debris path was marked by subsequent tree strikes that began about 75 ft forward of the FIPC and was oriented on a heading of 360° magnetic. The left wing was separated and found 20 ft southeast of the main wreckage. All major structures necessary for flight were accounted for at the accident site. Figure 1. Left picture: Location of wreckage site in relation to Dunsmuir, California. Right picture: Main wreckage location in relation to first identified point of impact.   The main wreckage marked the end of the debris path and was located about 225 ft beyond the FIPC. The nose, engine compartment, and the main landing gear came to rest inverted left of the cabin. The fuselage and cabin came to rest upright. The windscreen and both cabin doors separated. The cabin roof remained attached to the upper aft section of the fuselage. The cockpit had a bench seat installed. The instrument panel remained mostly intact and had impact damage. The split rocker-type master switch was in the OFF position (the left half controls the alternator, and the right half controls the battery). All other instrument switches were also in the OFF position. The ignition was in the BOTH position. The fuel selector lever was in the ON position. ADS-B was installed but not broadcasting due to the battery switch being in the OFF position. Both wings separated from their respective attachment points. The right wing separated from its respective root attachment point and came to rest upright, with its forward section partially resting on top of the tailcone. The right wing displayed a large area of compression damage on the leading edge starting 3 ft to 5 ft from its wing root, consistent with a tree strike. Its flight control cables cut through the upper skin up to midspan and displayed broom-straw failure, consistent with tension overload. The right wing tip was separated. Fuel was observed inside the right tank. The right aileron and flap remained attached and had impact compression damage. Flight continuity was confirmed from the aileron and the flap to its respective bellcrank. The left wing displayed compression wrinkles across the span of the wing. Two large areas of compression damage were displayed on its leading edge: one near the outboard and the other near inboard section of the wing, spanning about 3 ft each. The left wing tip was separated. The upper section of the left lift strut remained attached to the left wing while its lower section was separated from the fuselage. Fuel was observed inside the left tank. The left aileron and flap remained attached and displayed impact compression damage. Flight continuity was confirmed from the aileron and the flap to its respective bellcrank; flight control cables cut through the upper skin up to midspan and displayed broom-straw failure, consistent with tension overload. The left horizontal stabilator remained attached except for its tip and remained mostly undamaged. The right stabilator remained attached but displayed leading edge compression damage. The vertical stabilizer remained attached to the tailcone but was displaced to the left; compression damage was displayed on the left side of the tailcone near at the base of the vertical stabilizer. The rudder remained attached with minimal impact damage. Its respective cables remained attached to the bellcrank with the bellcrank displaced from impact damage. The elevator remained attached to its respective bellcrank; elevator trim continuity was confirmed. Both elevator and elevator trim cables displayed damage consistent with overload. The engine was displaced to the left of the fuselage and was inverted. The engine remained attached to the fuselage. All four cylinders remained attached. Each bottom spark plug was removed, and each spark plug was oily, with black deposits of carbon; each electrode was intact. Examination of the lower section of each cylinder revealed that each piston, wall, and upper spark plug remained intact. Each piston displayed carbon buildup and each upper spark plug had its electrodes intact with carbon buildup. The position of the engine did not allow the inspection of the upper section of the engine. The exhaust remained attached and secured. The oil sump remained attached and was removed; it was intact and had oil inside. The carburetor and its hoses, mixture lever, and throttle lever were secured and remained intact. After its removal, no anomalies were discovered. The vacuum pump remained attached and was removed; its coupling was attached and intact in one piece. The fuel filter bowl was examined; fuel was present inside the bowl with the filter screen free of debris. Both left and right magneto remained attached and secured along with their corresponding sparkplug wires. Each was removed and both couplings were attached and engaged when the gear was rotated. The battery remained attached with its connectors secured. The alternator remained attached and secured; it was removed, and the fan rotated freely and its wires remained attached and secured. The voltage regulator remained attached to the firewall with its connector and wires secured. According to the manufacturer’s owner manual, the alternator functioned to provide electrical power to the airplane and charge the battery. The 12-volt battery can also supply power to the aircraft; however, the manufacturer recommends that lone battery usage should be limited to checking the airplane’s electrical equipment during preflight. If the alternator switch is in the off position, the entire electrical load is placed on the battery. In an instance where the alternator does not function, the ammeter would indicate the discharge rate of the battery. Examination of the alternator revealed that there was no electrical continuity. The two McCauley blades were attached to the engine at the propeller hub with both blades bent aft about midspan. The crankshaft was slightly displaced to the left from impact damage. One blade displayed some chordwise scratches. The other blade was underneath the engine and could not be inspected. The examination did not reveal any evidence of mechanical malfunction or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION The pilot’s autopsy was performed by a pathologist contracted by the County of Siskiyou Office of the Sheriff/Coroner, Yreka, California. According to the pilot’s autopsy report and a supplemental report from the Office of the Sheriff/Coroner, the pilot’s cause of death was exsanguination, and his manner of death was accidental. The Federal Aviation Administration's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens recovered from the pilot. The pilot’s postmortem toxicological testing detected the potentially sedating antihistamine medication diphenhydramine in urine and at 174 ng/mL in heart blood. The over-the-counter stomach acid suppression medication famotidine was detected in heart blood and urine; famotidine is not generally considered impairing. Hemoglobin A1c (HbA1c) was elevated at 8.6%. Glucose was measured at 5 mg/dL in vitreous and 1051 mg/dL in urine. Diphenhydramine, marketed under the trade name Benadryl, is an antihistamine used to treat allergies. Famotidine, marketed under the trade name Pepcid, is used to prevent, and treat heartburn due to acid indigestion, usually caused by eating or drinking certain foods. Witnesses reported that the pilot self-medicated with diphenhydramine and famotidine to alleviate an upset stomach. -
Analysis
The non-certificated pilot departed on a cross-country flight that required multiple fuel stops. The weather forecast called for clouds near the accident site. During the fuel stops, the pilot recharged the battery and, at one instance, refused assistance from witnesses to find and replace his alternator. Witnesses stated that he sparingly used the battery power for takeoff and landing and continued his cross-country flight with a known inoperable alternator. Postaccident examination of the cockpit revealed that the master switch was in the OFF position. With the master switch in the OFF position, the electrical system was not powered, and the airplane was not able to transmit its aircraft positions over its automatic dependent surveillance-broadcast (ADS-B) system. The field examination of the airplane wreckage did not reveal any mechanical malfunctions or failures that would have precluded normal operation. A witness near the top of the mountain reported that clouds and fog were present and provided a visibility of about 200 ft. He added that, about the time of the accident, he heard a low-flying airplane and was able to distinguish noise consistent with a running engine but did not hear the airplane’s impact with terrain. He further reported that the fog was present for most of the morning, lasting through the early afternoon. The pilot was likely flying the airplane low over the interstate to stay out of the clouds. He then likely entered instrument meteorological conditions as the airplane approached the mountain valley and turned back towards the departure airport before impacting trees in a wings-level attitude. No record was found indicating that the pilot received a preflight weather briefing; however, it could not be determined if the pilot obtained weather information using other sources. The pilot’s toxicology results indicate that he may have been experiencing impairing effects of diphenhydramine, such as sedation, at the time of the crash, and may also have been experiencing mild symptoms of uncontrolled diabetes, such as fatigue or blurry vision. However, the pilot’s decision to attempt the risky flight is unlikely to have been directly affected by these medical factors. Thus, given that the airplane was in controlled flight at the time of its collision with visually obscured terrain, there is low likelihood that the pilot’s diphenhydramine use or uncontrolled diabetes contributed to the crash.
Probable cause
The non-certificated pilot’s improper decision to continue the flight under visual flight rules into instrument meteorological conditions which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150L
Amateur built
false
Engines
1 Reciprocating
Registration number
N5268Q
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15073168
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-16T22:57:27Z guid: 104148 uri: 104148 title: ERA22FA024 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104145/pdf description:
Unique identifier
104145
NTSB case number
ERA22FA024
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-21T17:31:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-11-19T02:23:42.511Z
Event type
Accident
Location
Holly Ridge, North Carolina
Airport
HOLLY RIDGE/TOPSAIL ISLAND (N21)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 1 serious, 1 minor
Factual narrative
The FAA Weight and Balance Handbook, FAA-H-8083-1, stated:   Most modern aircraft are so designed that, when all seats are occupied, the baggage compartment is full, and all fuel tanks are full, the aircraft is grossly overloaded. This type of design requires the pilot to give great consideration to the requirements of each specific flight. If maximum range is required, occupants or baggage must be left behind, or if the maximum load must be carried, the range, dictated by the amount of fuel on board, must be reduced. Overloading an aircraft can create a variety of problems: • The aircraft needs a higher takeoff speed, which results in a longer takeoff run. • Both the rate and angle of climb are reduced. • The service ceiling is lowered. • The cruising speed is reduced. • The cruising range is shortened. • Maneuverability is decreased. • A longer landing roll is required because the landing speed is higher. • Excessive loads are imposed on the structure, especially the landing gear. The POH or AFM includes tables or charts that give the pilot an indication of the performance expected for any weight. An important part of careful preflight planning includes a check of these charts to determine if the aircraft is loaded so the proposed flight can be safely made. According to FAA Advisory Circular AC-61-23C, Pilot’s Handbook of Aeronautical Knowledge: The effect of torque increases in direct proportion to engine power, airspeed, and airplane attitude. If the power setting is high, the airspeed slow, and the angle of attack high, the effect of torque is greater. During takeoffs and climbs, when the effect of torque is most pronounced, the pilot must apply sufficient right rudder pressure to counteract the left-turning tendency and maintain a straight takeoff path. According to the airplane’s pilot operating handbook, Section IV, Normal Procedures, Before Takeoff: 14. Wing Flaps – TAKEOFF (15°) - Review of maintenance records revealed that the airplane’s most recent annual inspection was completed on February 21, 2021, at 3,248.57 total aircraft hours. The tachometer showed 3,252.42 total aircraft hours at the accident site. The weight and balance condition of the airplane at the time of the accident was estimated with full fuel tanks and at half-full tanks, and the actual weights of the occupants. The estimates showed that, with the fuel tanks filled to half capacity, the airplane’s gross weight was about 2,668 lbs and its center of gravity was about 48 inches. Fueled to capacity, the airplane’s gross weight was about 2,860 lbs and the center of gravity about 48 inches. The airplane’s maximum allowable gross weight was 2,740 lbs, and the aft center of gravity limit was 50.1 inches. The accident airport was not equipped with fuel services, and the airport manager stated that most pilots in the area obtained fuel at nearby Henderson Field (ACZ), Henderson, North Carolina. A request for fueling receipts from ACZ for the accident airplane revealed that the airplane was serviced with 47 gallons of 100LL aviation fuel on September 17, 2021. - On October 21, 2021, at 1631 eastern daylight time, a Mooney M20J, N3933H, was substantially damaged when it was involved in an accident at Holly Ridge/Topsail Island Airport (N21), Holly Ridge, North Carolina. The commercial pilot and one passenger were fatally injured, one passenger was seriously injured, and one passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   Radar data obtained from the Federal Aviation Administration (FAA) revealed the pilot and the front-seat passenger had completed a 30-minute local flight at 1603. Then, two additional passengers boarded the airplane before departing on the accident flight.   Review of a video recorded by a witness at N21 revealed that the airplane started its takeoff roll for the accident flight on the 3,591-ft-long grass runway. After lift-off, the airplane’s wings wobbled as it climbed, turned left, and descended into a wooded area about two-thirds the distance down the runway. A video recorded by a surviving passenger revealed that the engine continued to operate throughout the accident sequence and sounds consistent with a stall warning horn were heard before impact. - The recovered pilot’s logbook was identified as “Logbook 3”. The first entry was dated October 23, 2006. The last entry was dated September 17, 2021. Between those dates, the pilot annotated 436 hours of flight experience, all but 2.2 hours of which were in the accident airplane. The pilot completed a flight review on September 17, 2021; that flight was the only flight recorded in the logbook during the 14 months before the accident. - Acoustic and vibration analysis of the audio portions of video recorded by a witness on the ground and the passenger in the airplane was performed by both the manufacturer of the airplane’s propeller and an National Transportation Safety Board performance engineer. Their separate and individual findings estimated the engine was running at or about its 2,700 rpm takeoff power setting. The engine sounds were smooth and continuous throughout the entirety of each video. - The airplane came to rest on a heading of 081°; the empennage rested against a tree in a vertical, nose-down attitude. All major components of the airplane were accounted for at the accident site. The left wing was fractured at the wing root and separated from the fuselage, laying about 12 ft to the right, with the left wing tip and aileron separated from the wing and located about 40 ft east of the main wreckage. The right wing and fuel tank remained attached to the fuselage and contained about 15 gallons of fuel. The left wing fuel tank was breached.   Flight control continuity for the left wing was confirmed from the separation point of the wing to the aileron and flap. Continuity of the remaining flight controls was confirmed from the flight control surfaces to the cockpit. Measurement of the flap actuator jackscrew revealed a flap setting of 0°, or fully retracted.   The engine was partially disassembled to facilitate examination. The propeller was cut from the engine to allow for engine rotation. The crankshaft was rotated by turning the propeller hub and continuity of the crankshaft to the rear gears and to the valvetrain was observed. Compression and suction were confirmed at all four cylinders using the thumb method. The engine-driven fuel pump was actuated by hand and pumped air from the outlet port. The fuel flow divider was partially disassembled, the rubber diaphragm was undamaged, and fuel was observed in both the pump and the flow divider. The magneto drive was rotated with an electric driver and produced spark at all ignition towers. -
Analysis
The pilot and three passengers were departing from a 3,591-ft-long grass runway when the accident occurred. Review of a video recorded by a witness on the ground revealed that, after becoming airborne, the airplane’s wings wobbled as it climbed, turned left, and descended into a wooded area about two-thirds down the runway. Onboard video recorded by a surviving passenger revealed that the engine continued to operate throughout the accident sequence and sounds consistent with a stall warning horn were heard before impact. The amount of fuel onboard the airplane at the time of the accident was not determined. The airplane’s weight and balance at the time of the accident was estimated using the actual weights of the occupants and both full fuel tanks and half-full fuel tanks. With the fuel tanks filled to half capacity, the airplane was about 72 lbs under its maximum allowable gross weight and about 2 inches forward of the aft center of gravity limit. Sound spectrum analysis of the audio portions of each video revealed that the engine was operating at or near its maximum takeoff power setting of 2,700 rpm, and engine sound was smooth and continuous throughout. Examination of the airframe and engine revealed no preimpact mechanical anomalies that would have prevented normal operation. The wing flaps were found retracted; the pilot’s operating handbook for the airplane indicated that flaps should be extended to 15° for takeoff.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack, which resulted in a stall/mush during takeoff and initial climb. Contributing to the accident was the pilot’s loading the airplane near its maximum allowable gross weight and near its aft cg limit.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20J
Amateur built
false
Engines
1 Reciprocating
Registration number
N3933H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-0981
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-19T02:23:42Z guid: 104145 uri: 104145 title: ANC22LA003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104149/pdf description:
Unique identifier
104149
NTSB case number
ANC22LA003
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-22T09:42:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-11-03T22:02:32.384Z
Event type
Accident
Location
Juneau, Alaska
Airport
JUNEAU INTL (JNU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 22, 2021, about 0842 Alaska daylight time, a Cessna 208B airplane, N754KP, sustained substantial damage when it was involved in an accident at Juneau International Airport, Juneau, Alaska. The pilot and five passengers were not injured. The airplane was operated by Kalinin Aviation dba Alaska Seaplanes as a Title 14 Code of Federal Regulations Part 135 scheduled passenger flight.   The pilot reported that she completed a preflight inspection and taxied the airplane to the active runway for departure, making both left and right turns. She completed the before takeoff checklist, which included a flight control check. The airplane was cleared for takeoff on runway 8 from the taxiway C intersection. Once the airplane reached the runway, the pilot increased engine power, and the airplane began to accelerate down the centerline of the runway. About the time that the airplane reached rotational speed, the airplane veered “abruptly” to the right. To correct the veer, the pilot applied left rudder, but the control travel “felt limited,” and the airplane continued to the right toward a float pond that was parallel to the runway. The pilot thought that the distance to the float pond would not be adequate to safely stop, so she continued the takeoff and, once airborne, maneuvered the airplane toward the runway for an emergency landing. Once the pilot determined that a safe landing could be made, she pulled the manual firewall fuel shutoff valve and moved the master switch to the OFF position. During the emergency landing, the right main landing gear and nose wheel collapsed, and both wings sustained substantial damage.   A passenger in the right front seat reported that his seat was moved aft and that his feet were on the floor near the control pedestal with his knees pointed toward the passenger door to preclude inadvertent interference with any flight control movements. A postaccident examination of the nosewheel steering and the brake and flight control systems revealed no mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The pilot reported that, during takeoff about the time that the airplane reached rotational speed, the airplane veered abruptly to the right. To correct the veer, she applied left rudder, but the control travel felt limited, and the airplane continued to the right. The pilot thought that there was not adequate distance for the airplane to safely stop, so she continued the takeoff and maneuvered the airplane toward the runway for an emergency landing. When the pilot determined that a safe landing could be made, she shut down the engine. During the emergency landing, the right main landing gear and nosewheel collapsed, and both wings sustained substantial damage. A postaccident examination revealed no mechanical malfunctions or anomalies that would have precluded normal operation. The cause of the pilot’s loss of directional control on the runway could not be determined based on the available evidence for this investigation.
Probable cause
The pilot’s loss of directional control for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
208B
Amateur built
false
Engines
1 Turbo prop
Registration number
N754KP
Operator
Alaska Seaplanes
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
208B1264
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-03T22:02:32Z guid: 104149 uri: 104149 title: ERA22FA026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104150/pdf description:
Unique identifier
104150
NTSB case number
ERA22FA026
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-22T16:57:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2021-11-06T20:04:42.352Z
Event type
Accident
Location
Walterboro, South Carolina
Airport
LOWCOUNTRY RGNL (RBW)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
Fuel Consumption A review of automatic dependent surveillance - broadcast (ADS-B) data and ATC information from the accident flight indicated that the pilot had made multiple changes in altitude during the flight. He initially climbed to 6,000 feet msl and entered cruise. He then climbed to 10,000 feet and entered cruise. He then descended to 8,000 feet and entered cruise. He then descended to 6,000 feet and entered cruise, and then descended to 4,000 feet and entered cruise, before climbing back up to 6,000 feet and entered cruise. He then descended to 1,600 feet and entered cruise before the loss of engine power occurred, and the airplane descended to impact. Further review indicated that the accident flight took about 3 hours, during which the airplane flew about 351 nautical miles, at an average ground speed of 116 knots. Fuel Consumption Calculations At the request of the NTSB, Piper Aircraft’s Flight Operations Department was asked to review the accident flight and determine possible fuel consumption. During the review, it was assumed that when the airplane was climbing, the power was set to the maximum continuous power available. In cruising flight, it was assumed that the power setting was constant while the airplane was maintaining altitude. When the airplane was descending, it was assumed that the power was not reduced as the average ground speed increased significantly during the descent. The review showed that had the pilot operated the engine at 75% power during cruise flight, with the fuel air mixture leaned for best performance, the engine would have consumed about 56.7 gallons during the flight. With the fuel air mixture leaned for best economy, the engine would have consumed about 51.5 gallons during the flight. Had the pilot operated the engine at 55% power during cruise flight, with the fuel air mixture leaned for best performance, the engine would have consumed about 47.7 gallons during the flight. With the fuel air mixture leaned for best economy, the engine would have consumed about 41.8 gallons during the flight Pilot’s Handbook of Aeronautical Knowledge According to the Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25C), the fuel quantity gauges indicate the amount of fuel measured by a sensing unit in each fuel tank and is displayed in gallons or pounds. Aircraft certification rules require accuracy in fuel gauges only when they read “empty.” Any reading other than “empty” should be verified. Do not depend solely on the accuracy of the fuel quantity gauges. Always visually check the fuel level in each tank during the preflight inspection, and then compare it with the corresponding fuel quantity indication. It goes on to say in part that, regardless of the type of fuel selector in use, fuel consumption should be monitored closely to ensure that a tank does not run completely out of fuel. Running a fuel tank dry does not only cause the engine to stop, but running for prolonged periods on one tank causes an unbalanced fuel load between tanks. Running a tank completely dry may allow air to enter the fuel system and cause vapor lock, which makes it difficult to restart the engine. On fuel-injected engines, the fuel becomes so hot it vaporizes in the fuel line, not allowing fuel to reach the cylinders. Civil Air Regulations (CARs) Prior to 14 CFR Part 23, which addresses airworthiness standards for normal category airplanes, the CARs were the basis for establishing the design requirements for aircraft. Eventually CAR 3, which addressed airplane airworthiness for normal, utility, acrobatic, and restricted purpose categories, grew to become the regulatory guidance specific to small airplanes. The requirements for fuel quantity indicators at the time were for the indicator to be calibrated to read zero during level flight when the quantity of fuel remaining in the tank was equal to the unusable fuel supply. The airplane design was originally certificated under these regulations. - Maintenance Records A review of partial copies of the airplane’s maintenance logbook entries had revealed that the engine had accumulated 2083.76 hours at the time of the most recent annual inspection dated August 5, 2021. According to maintenance records, the airplane's most recent annual inspection was completed on August 5, 2021. At the time of the inspection, the airplane had accrued about 6,050 total hours of operation, and the engine had accrued about 2,084 hours since major overhaul.” Fuel System The fuel system consisted of two interconnected tanks in each wing, having a combined capacity of 49 U.S. gallons, for a total capacity of 98 U.S. gallons (94 usable). Fuel flow was indicated on a gauge located in the instrument panel. A fuel quantity gauge for each wing system was also located in the instrument panel, which indicated the amount of fuel remaining as transmitted by the electric fuel quantity sending units located in the wing tanks. An exterior sight gauge was installed in the inboard tank of each wing so fuel quantities could be checked on the ground during the preflight inspection of the airplane. Fuel was drawn through a finger screen located in the inboard fuel tank and routed to a three-position fuel selector valve and filter unit which was located aft of the main spar. The valve had “OFF,” “LEFT,” and “RIGHT” positions that were remotely selected by means of a torque tube operated by a handle located in the pedestal. The handle had a spring-loaded detent to prevent accidental selection to the “OFF” position. From the selector valve the fuel would go to the electric fuel pump, which also was mounted aft of the main spar and then would go forward to the engine-driven fuel pump, which forced the fuel through the injector unit into the engine. Guidance for Fuel Tank Selection According to the Pilot’s Operating Handbook (POH) for the airplane, to keep the airplane in best lateral trim during cruise flight, the fuel should be used alternately from each tank at one-hour intervals. The POH also stated, “Always remember that the electric fuel pump should be turned ‘ON’ before switching tanks and should be left on for a short period thereafter. To preclude making a hasty selection, and to provide continuity of flow, the selector should be changed to another tank before fuel is exhausted from the tank in use. The electric fuel pump should be normally ‘OFF’ so that any malfunction of the engine driven fuel pump is immediately apparent. If signs of fuel starvation should occur at any time during flight, fuel exhaustion should be suspected, at which time the fuel selector should be immediately positioned to a full tank and the electric fuel pump switched to the ‘ON’ position.” - On October 22, 2021, about 1557 eastern daylight time, a Piper PA-32R-300 airplane, N1652H, was destroyed when it was involved in an accident near Walterboro, South Carolina. The pilot was seriously injured, and the passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The airplane departed on an 802 nautical mile flight from Shannon Airport (EZF), Fredericksburg, Virginia, about 1256 destined for Miami Executive Airport (TMB), Miami, Florida. Before departure, the pilot brought the airplane’s fuel tanks up to their total fuel capacity of 98 gallons by adding 78.81 gallons of 100LL aviation gasoline. The flight was uneventful until about 2 hours and 53 minutes into the flight, when the airplane was in cruise at 6,000 feet above mean sea level (msl). The pilot advised air traffic control (ATC) that he wanted to divert to Lowcountry Regional Airport (RBW), Walterboro, South Carolina, for fuel, and then resume his IFR flight plan to TMB. The air traffic controller then cleared the pilot to fly direct to RBW and approved him to leave the frequency to get the current weather and NOTAMS for the airport. When the pilot reported that he was back on frequency, the air traffic controller instructed him to maintain 3,000 feet msl and to state his approach request. The pilot requested the visual approach to runway 23. The air traffic controller then instructed the pilot to maintain 1,600 feet msl, and subsequently instructed him to fly heading 190° to the RBW Airport. The airplane was approximately nine miles north of RBW when the airplane began to descend without a clearance. The pilot then declared “Mayday” and reported a “lagging engine” to which the air traffic controller advised that RBW was at one o’clock and seven miles, and to maintain present heading and altitude. The minimum safe altitude warning then activated at the air traffic controller’s station as the airplane descended through 1,000 feet msl. The air traffic controller queried the pilot if they were reporting a rough running engine, to which there was no response. The airplane continued descending while in a left turn to the northeast and was last observed by ATC radar at an altitude of 100 feet msl. There was no further communication with the pilot. According to a witness, he heard an airplane “sputter and stop.” He looked in the direction of the airplane, and continued to hear sputtering, before the sound of an engine cut out, and then sputtering again. The airplane kept flying and then went out of sight. According to two other witnesses, about 1556, they began to hear an engine noise. They observed [the accident airplane] almost directly above the tree line behind their neighbor’s house. It appeared to be in a left turn, and then they next heard a loud “pop” from the airplane and the engine noise ceased. According to the pilot, once he arrived at the airport, he pulled the airplane out of the hangar with his tug, loaded their baggage, boarded the airplane, and then started the engine. He then taxied to the fuel pumps. He filled both wing tanks all the way up (just below the caps). He then took off. The weather was VMC and he had filed an instrument flight rules flight plan. He planned to cruise at 6,000 feet and he could not remember if he changed altitude at any time during the cruise portion of the flight. He had filed the flight as one leg. About 1.5 hours into the flight, he decided to land for fuel due to the headwinds he encountered. He had also made the decision to get fuel early, as he would be landing at his destination at night. He received the weather for the diversion airport and, as he was proceeding to the airport, he received a clearance to descend to 1,600 feet. He began the descent and pulled the power back. When he reached 1,600 feet, he pushed the throttle forward, but the engine did not respond. He then pulled it back towards idle to try and match the throttle to where the engine was operating. The engine surged (went up and back down). He pushed the throttle forward, but there was no response. He then pitched the airplane to get the speed to about 90 knots (towards best glide). He then declared an emergency and when they were about 100 feet above the trees, he lowered the landing gear. He told the passenger to “Brace” as they were going to crash and transmitted: “Mayday, Mayday, Mayday” before the airplane contacted the trees. He could not remember anything after hitting the trees. The next thing he remembered was being in the hospital. The pilot reported that he had his lap belt on, but the shoulder harness was broken, and had been that way since when he purchased the airplane. The passenger had her lap belt on, but he could not remember if she had her shoulder harness on. He did not try to check the magnetos or switch tanks after the loss of engine power. He stated that fuel management was not an issue as he would set the timer on his Garmin unit every 15 minutes, and if the fuel tank he was on was higher than the other one he would stay on that tank. He would determine the quantity by looking at the fuel gauges to estimate what fuel he had. He also stated that he was at the halfway point and should have had enough fuel to make it, or close. He could not remember what tank he was on when the accident occurred. He added that he just wanted to configure the airplane for landing and all he saw was trees. - Synoptic conditions The National Weather Service Surface Analysis Chart for 1700 for the eastern United States depicted a low-pressure system at 1012 hectopascals over the Virginia and North Carolina border, with a cold front extending southwestward into North and South Carolina, Georgia, and into the Florida panhandle. The front then became a warm front and extended westward along the gulf coast. The accident site was located in the vicinity of the cold front. The station models in the vicinity of the accident site indicated westerly winds of 10 knots, clear to scattered clouds over the area with temperatures in the 80's °F, with dew point temperatures in the 60's °F. No significant weather or obstructions to visibility were identified surrounding the accident site. Observations The accident airplane was diverting to Lowcountry Regional Airport (RBW), Walterboro, South Carolina, which listed an elevation of 101 ft msl, with a magnetic variation of 7° W based on the sectional chart for the area. The airport had an Automated Weather Observation System (AWOS), which was not augmented by any human observers. The following conditions were reported at the approximate time of the accident: Routine weather observation for RBW at 1555 included wind from 280° true at 10 knots gusting to 17 knots, visibility 10 statute mile or more, scattered clouds at 5,000 ft agl, scattered clouds at 7,000 ft, and scattered at 9,500 ft, temperature 30° C (86° F), dew point temperature 20° C (68° F), altimeter setting 29.82 inches of mercury. Sounding A High-Resolution Rapid Refresh (HRRR) numerical model data was obtained from the National Oceanic and Atmospheric Administration Oceanic Air Resource Laboratory archive using the closest grid point to the accident site coordinates. The HRRR model data was then plotted on a standard skew T log P diagram using analysis software for 1600 on October 22, 2021. The sounding depicted an elevation of 105 ft over the grid point, with a near surface temperature of 27.2°C (81° F), with a dew point temperature of 16.4°C (61.5° F), a relative humidity of 52%, with a density altitude of 1,756 ft. The lifted condensation level was identified at 4,490 ft agl, the level of free convection at 4,490 ft agl, and the convective condensation level at 6,407 ft agl. The freezing level was identified at 13,112 ft which was above the accident airplane’s cruising level at 6,000 ft. The precipitable water content was 1.09 inches. The atmosphere was characterized as conditional unstable with a Lifted Index of -2.9. At 6,000 ft the sounding depicted a temperature of 12° C, a dew point temperature of 1.4° C, with a relative humidity of 45%, with the wind from 260° at 22 knots. The HRRR wind profile indicated the mean 0 to 6 kilometer (or 18,000 ft) wind was from 255° at 25 knots. During the portion of the flight when the accident airplane’s enroute cruise was at 6,000 feet the winds were from 260° at 21 knots with a temperature of 12° C. - At the time of the accident, the pilot was a colonel in the United States Air Force, was rated as a command pilot, and had flown the T-37A, T-38A, C-130E, AT-38B, F-16C, A-10A, and A-10C. According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. His most recent FAA second-class medical certificate was issued on October 20, 2021. At the time of the accident, he had accrued approximately 1,968 total flight hours, of which about 76 hours were in the accident airplane make and model. - Examination of the accident site revealed that the airplane first contacted an approximately 70-foot-tall pine tree, and then continued to travel through about 100 yards of forest on a magnetic heading of about 072°, striking multiple trees while descending on an approximate 20° flight path angle. The postaccident examination of the airplane revealed that both wings and the right side of the stabilator had separated from their mounting locations during the impact sequence with the trees. There was no evidence of pre-impact fire, and all impact damage was consistent with tree and terrain impact. The fuselage was mostly consumed by a postimpact fire. Examination of the burn pattern indicated that the postimpact fire appeared to initiate from the area of the right wing. Residual fuel was found in the right outboard fuel tank. Fuel staining was also present around the fuel filler port for the right wing. Minimal thermal damage on the inboard leading edge of the left wing was present, but residual fuel, and fuel staining, were not evident. The landing gear was in the down position, and the landing gear dump lever was stowed. The throttle, propeller, and mixture were all in the full forward position. The fuel selector valve was in the right fuel tank position. Flight control continuity was established from the cockpit controls to the breaks in the system and from the breaks in the system to the control surfaces. The wing flaps were in the up (0°) position. The left wing outboard and inboard fuel tanks were breached. There was no evidence of vegetation blight nor residual odor of fuel in the vicinity of the wing. The right-wing outboard fuel tank was breached (but still contained residual fuel), and the right inboard fuel tank had separated from the wing. Both the left and right fuel filler caps were still attached to their receptacles. About 1.5” of pitch trim jack screw threads were exposed from the top of the trim barrel assembly, which was indicative of a “near full nose up” stabilator trim setting. The postaccident examination of the aluminum 3-bladed constant-speed propeller and spinner revealed that the propeller had remained attached to the propeller flange, and no rotational deformation was present on the impact damaged spinner. Impact damage was noted to the propeller hub and all three blades. There was no leading-edge damage or chord-wise abrasions noted on the propeller blades. The postaccident examination of the engine revealed that the engine had remained attached to its mount which had partially separated from the fuselage. Both the engine and its mount exhibited impact and thermal damage. The exhaust system was impact damaged but remained attached to its respective cylinder attach points. No internal obstructions or deformations were noted in the exhaust system. The single drive, dual magneto installation, and the engine-driven fuel pump were thermally destroyed. The spark plugs exhibited dark gray, sooty coloration, and worn normal condition. The Nos.3 top, 5 top, 1 bottom, 2 bottom, 3 bottom and 5 bottom spark plugs were oil soaked, consistent with how the engine came to rest. Thumb compression and suction were obtained, and crankshaft and camshaft continuity to the rear gears was established. The interiors of the cylinders were observed with a lighted borescope and no anomalies were observed. Oil was observed within the sump; the oil pump suction screen was clear of debris, and the oil filter media was charred. No metallic debris was observed between the folds of the media. One tooth was found to be fractured on the oil pump drive gear, and its driving idler gear exhibited abrasions on several consecutive teeth. The fractured gear tooth was retrieved from the oil sump. The oil pump could not be rotated by hand. Examination of the oil pump by the NTSB Materials Laboratory indicated that the drive gear failed from a tooth that fractured in overstress while engaged with the adjacent idler gear. The directions of the fracture surface features and adjacent damage to the drive gear and idler gear, suggested the forces were in the direction of rotation and were consistent with the failure occurring during the impact sequence. The examination of the engine fuel system revealed that the fuel injector servo remained attached to the engine and exhibited soot and discoloration consistent with exposure from the postimpact fire. The throttle cable rod end remained attached to the servo throttle arm. The arm was positioned at the full throttle position. The mixture cable rod end remained attached to the servo mixture control arm. The arm was positioned at a mid-range position. The mixture control stop screw was not observed. The servo fuel regulator section was partially disassembled; the hub stud was still in place, and the rubber diaphragms were destroyed by fire. The fuel screen was clean. The fuel flow divider remained attached to the engine and exhibited soot and discoloration consistent with exposure to the post-impact fire. The fuel injector lines were secure. The flow divider was partially disassembled, and no evidence of fuel was found in the flow divider. The rubber diaphragm was destroyed by fire. The fuel injector nozzles remained attached to the engine and the fuel lines were secure. All six nozzles were found to be unobstructed. -
Analysis
The airplane departed from its home airport for an airport about 802 nautical miles away with the airplane’s fuel tanks filled to their total fuel capacity of 98 gallons. The pilot planned for the flight to only be a single leg, but about 1.5 hours into the flight he decided to land for fuel due to the 20-knot headwind, which he had not accounted for during his flight planning. About 2 hours and 53 minutes into the flight, the pilot advised air traffic control (ATC) that he wanted to divert for fuel and then resume his instrument flight rules (IFR) flight plan to his destination. The air traffic controller cleared the pilot to fly direct to a diversion airport. When the airplane was approximately nine miles north of the diversion airport, at an assigned altitude of 1,600 feet msl, the pilot declared “Mayday” and reported a “lagging engine.” The pilot described that, when he reached 1,600 feet, he pushed the throttle forward to level off from the preceding descent, but the engine did not respond. The engine then surged (went up and back down), but it would not respond to his throttle inputs. The airplane subsequently impacted trees short of the diversion airport. During the impact sequence, the pilot was seriously injured and the passenger was fatally injured. The pilot had flown for about 3 hours, and 351 miles of the 802-mile flight, at the time of the accident. Fuel consumption calculations indicated that, depending on the power setting, more than half of the fuel load of 94 gallons of usable fuel would have been consumed before the accident (about 47.7 to 56.7 gallons, depending on power setting). This was greater than the usable fuel amount in each wing (47 gallons per side). While the pilot stated that he checked the fuel gauges every 15 minutes and would continue flying on the fuel tank that had the higher fuel indication, the Pilot’s Operating Handbook (POH) for the airplane, advised that to keep the airplane in best lateral trim during cruise flight, the fuel should be used alternately from each tank at one-hour intervals. The POH also stated, “Always remember that the electric fuel pump should be turned "ON" before switching tanks and should be left on for a short period thereafter. To preclude making a hasty selection, and to provide continuity of flow, the selector should be changed to another tank before fuel is exhausted from the tank in use. If signs of fuel starvation should occur at any time during flight, fuel exhaustion should be suspected, at which time the fuel selector should be immediately positioned to a full tank and the electric fuel pump switched to the "ON" position.” Postaccident examination of the airplane at the accident site revealed the postimpact fire had a burn pattern that appeared to initiate from the area of the right wing. Residual fuel was found in the right outboard fuel tank, and fuel staining was also present around the fuel filler port for the right wing. However, minimal thermal damage was present on the inboard leading edge of the left wing, and residual fuel and fuel staining were not evident. This physical evidence suggests that little or no fuel was present in the left wing fuel tanks, and that the majority of the fuel onboard the airplane at the time of the accident was in the right wing tanks. The postaccident examination of the engine did not reveal evidence of any preimpact failures or malfunctions that would have precluded normal operation. Based on this information, it is likely that the loss of power was due to the left wing having little or no usable fuel available, which subsequently introduced air into the fuel lines. Thus, after the loss of power, the fuel in the right wing would not have been a reliable source of fuel to quickly restore engine power. Based on the available evidence, the circumstances of the accident are consistent with fuel starvation resulting from the pilot’s mismanagement of the fuel system during the flight.
Probable cause
The pilot’s inadequate fuel planning and fuel management, which resulted in a loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32R-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N1652H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-7780168
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-06T20:04:42Z guid: 104150 uri: 104150 title: ERA22LA027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104154/pdf description:
Unique identifier
104154
NTSB case number
ERA22LA027
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-22T18:50:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2021-11-08T05:45:59.141Z
Event type
Accident
Location
Orlando, Florida
Airport
ORLANDO INTL (MCO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 22, 2021, at 1750 eastern daylight time, an Embraer EMB-500 airplane, N925DR, was substantially damaged when it was involved in an accident in Orlando, Florida. The airline transport pilot and four passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he completed a stable RNAV/GPS approach to a landing on runway 36L at Orlando International Airport (MCO). He had lowered a wing and was using the rudder to compensate for the crosswind. After touchdown, he applied brakes, but “only the right brake activated,” and the airplane’s nose went to the right. He then released the brakes and stated that he “may still have had a little left rudder in from the crosswind landing.” The airplane “came aggressively” back to its left, and the right wing began to lift. The pilot then decided to complete the landing roll into the grass rather than risk over-controlling the airplane by trying to remain on the runway. The pilot stated that he asked for a “wind check” before landing and was told the wind was from 120° at 14 knots (kts). He said that the airplane landed on the runway centerline, after which he applied the brakes. He added, “[The airplane] Pulled to the right. Released brakes. Stepped on left rudder to come back towards centerline. Over corrected.” The pilot stated that, as he tried to steer the airplane toward the runway centerline, the wing was “lifted by wind.” He “eased up on the controls” and the airplane departed the left side of the runway. The pilot further reported that he did not customarily apply brakes after touchdown, and if there was adequate runway available, he would “let the airplane roll out” and add brakes after it had slowed. He stated that, during the accident landing, he “got on the brakes pretty soon, and I don’t know why I did that.” One passenger described the airplane “rocking back and forth aggressively” after landing. Another passenger stated that it felt like the airplane was “fishtailing” before it departed the runway surface. After departing the runway, the airplane impacted a sign, dragged the right wing, and ultimately came to rest upright facing perpendicular to the landing runway, resulting in substantial damage to the right wing. The pilot reported having 26,000 total hours of flight experience, of which 80 hours were in the accident airplane make and model. Examination of the airplane’s maintenance records revealed that its most recent continuous airworthiness program inspection was completed October 17, 2021, at 1,767.3 total aircraft hours. The airplane’s combination cockpit voice recorder/flight data recorder and components and modules of the braking system were retained for further examination. Data downloaded from the flight recorder revealed the airplane touched down at 87 kts airspeed. Lateral acceleration deviations were recorded shortly after touchdown, before any displacement of the brake pedals occurred. As the airplane slowed, about 8 seconds after touchdown, right brake pressure increased, with corresponding changes to the right brake pedal position. Lateral accelerations to the right and left were recorded beginning about the time of the right brake input, before the airplane yawed left and continued to yaw left until the end of the data. No warnings or cautions were recorded. The manufacturer’s Functional Test Instructions were followed when testing the brake control unit (BCU), and that the BCU passed all tests. Download of the BCU’s non-volatile memory revealed there was “no unusual braking behavior or issues with the BCU at the time of the incident.” The recorded wind at 2153 (about 3 minutes after the accident) was from 090° at 12 kts, gusting to 16 kts, which would have resulted in a 90° crosswind for the landing runway. The 120°, 14-kt wind reported to the pilot just before the accident would have resulted in a right quartering tailwind, with a tailwind component of about 7 kts and a crosswind component of about 12 kts. The airplane’s maximum demonstrated crosswind component was 17 kts (this value is not considered to be limiting), and its maximum allowed takeoff and landing tailwind component was 10 kts. -
Analysis
The pilot was landing the light jet with a right quartering tailwind. He stated that only the right brake activated when he applied the brakes during the landing roll. The airplane veered right so he released the brake pressure and used left rudder pressure to steer the airplane back toward the centerline. The airplane turned “aggressively” to the left, the right wing rose, and the pilot chose to continue into the grass rather than risk overcontrolling the airplane. The right wing impacted terrain, resulting in substantial damage, and the airplane came to rest upright perpendicular to the landing runway. One of the passengers stated that the airplane was “fishtailing” before it continued off the runway into the grass. The airplane’s flight data recorder showed an increase in right brake pressure and right brake pedal position starting 8 seconds after touchdown, with no corresponding increase in left brake pressure or pedal position, consistent with application of right brake only. Upon application of the right brake, the airplane entered a series of lateral accelerations, yawing right and left, consistent with the “fishtailing” described by the passenger; then entered a left yaw that continued until the end of the recorded data. No warnings or brake fault indications were recorded, and the brake control unit operated nominally during postaccident testing. The pilot reported that he did not customarily apply brakes during the landing roll when adequate runway was available to let the airplane decelerate. Based on the available information, it is likely that the pilot inadvertently applied right brake during the landing roll, which resulted in a loss of directional control and subsequent runway excursion.
Probable cause
The pilot's inadvertent application of the right brake during the landing roll, which resulted in a loss of directional control and a subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EMBRAER
Model
EMB500
Amateur built
false
Engines
2 Turbo fan
Registration number
N925DR
Operator
Scout About, LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
50000059
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-08T05:45:59Z guid: 104154 uri: 104154 title: ERA22LA029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104156/pdf description:
Unique identifier
104156
NTSB case number
ERA22LA029
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-23T14:34:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-11-03T22:35:21.897Z
Event type
Accident
Location
Westhampton Beach, New York
Airport
Francis S Gabreski (FOK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 23, 2021, about 1334 eastern daylight time, a Cessna 172S, N1188L, was substantially damaged when it was involved in an accident near Francis S Gabreski Airport (FOK), Westhampton Beach, New York. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot, who was conducting a cross-country flight, reported that he heard a “pop” when the airplane was at an altitude of 3,000 ft mean sea level. Afterward, the engine lost all power, but the propeller continued to windmill. The pilot diverted to FOK, which was about 5 miles west of the airplane’s position. He also attempted to restart the engine but was unsuccessful. During the glide to FOK, the airplane impacted trees before reaching runway 24 and came to rest upright against the airport perimeter fence. Postaccident examination of the wreckage revealed substantial damage to the right wing and fuselage. Examination of the engine found that the top spark plugs, once removed, had electrodes that were intact and light gray in color. When the propeller was rotated by hand, crankshaft, camshaft, and valve train continuity were confirmed to the rear accessory section of the engine. Thumb compression was attained on all cylinders, and borescope examination of each cylinder revealed no anomalies. Both magnetos produced spark at all leads when rotated by hand. Additionally, about 35 gallons of fuel were drained after the accident, and fuel remained throughout the fuel system. The examination revealed no preimpact mechanical malfunctions that would have precluded normal engine operation. -
Analysis
During a cross-country flight, the engine lost all power when the airplane was at an altitude of 3,000 ft mean sea level; however, the propeller continued to windmill. The pilot diverted toward an airport located about 5 miles west of the airplane’s position. He also attempted to restart the engine but was unsuccessful. During the glide to the diversion airport, the airplane impacted trees just before the intended landing runway and came to rest upright against the airport perimeter fence. Postaccident examination of the engine and its accessories revealed no preimpact mechanical malfunctions that would have precluded normal operation. Additionally, about 35 gallons of fuel were drained after the accident, and fuel remained throughout the fuel system. As a result, the cause of the loss of engine power could not be determined based on the available evidence for this investigation.
Probable cause
A total loss of engine power during cruise flight for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N1188L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
172S10370
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-03T22:35:21Z guid: 104156 uri: 104156 title: CEN22FA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104152/pdf description:
Unique identifier
104152
NTSB case number
CEN22FA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-23T15:40:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2021-10-25T18:46:35.091Z
Event type
Accident
Location
Marengo, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Based on available maintenance documentation, the airframe total time since new was 2,345.9 hours. The factory rebuilt engine and new propeller accumulated 16.9 hours since they were installed on the airplane on September 21, 2021. A review of the maintenance logbooks revealed no unresolved discrepancies or maintenance actions. - On October 23, 2021, about 1440 central daylight time, an American Champion Aircraft 8KCAB airplane, N843AC, was destroyed when it was involved in an accident near Marengo, Wisconsin. The pilot and his passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot’s sister-in-law reported that she received a phone call from the pilot about 5 minutes before the accident, during which the pilot told her to wait outside because he intended to fly over her house. The airplane overflew her position multiple times at a low altitude before she saw the airplane “doing a loop” shortly before she heard the airplane crash. The pilot’s sister-in-law used her mobile phone to capture several “live” photos of the airplane while it maneuvered near her house during the final minutes of the flight. These “live” photos consisted of several frames of video with sound to create a short movie clip. One of these movie clips showed the airplane as it flew over a residential yard at a low altitude, as shown in figure 1. Another movie clip showed the airplane in a steep nose-down descent in the moments before the accident, depicted in figure 2. A review of the sound spectrum extracted from the movie clip that captured the final descent determined the fundamental propeller blade passage was about 80 Hz, which corresponded to 2,400 rpm for the 2-blade propeller installed on the airplane. Figure 1. Airplane flying low over the ground (still image extracted from a video that was recorded by a witness) Figure 2. Airplane descending during final low altitude maneuver (still images extracted from a video that was recorded by a witness) Another witness was driving when he saw the airplane flying “pretty low” about 200 - 400 ft above the ground. The witness stated that the airplane dove toward the ground while flying to the west before it “went back up going upside down” while flying to the south. The airplane then descended and crashed in a residential yard while flying north. A postaccident review of the passenger’s mobile phone determined that it contained a video recording of the flight. The phone, which was hand-held by the passenger who was seated in the rear seat of the airplane, frequently changed its view throughout the recording. However, in general, the camera’s field of view was out of the airplane’s right-and-left rear seat windows. The airplane’s general ground track in the vicinity of the accident location was constructed based on recovered video footage and is depicted in figure 3. The airplane’s bank angle with respect to the visible horizon was estimated for several turns, with each turn chronologically numbered 1 - 6 and annotated in figure 3. Additionally, the airplane’s maximum bank angle during each turn is listed in table 1. Figure 3. The airplane’s estimated ground track in the minutes before the accident, with red numbers indicating where the bank angles were measured during each turn Table 1. Estimated maximum bank angle during turns Based on the passenger’s video recording, the final maneuver began with the airplane rolling into a wings-level attitude before it pitched up into slight climb for about 3 seconds. The pilot then pitched the airplane into a negative G maneuver during which the passenger stated “Whooooa.” About 2 seconds later, the pilot increased airplane pitch into a rapidly positive G maneuver. The pilot then rolled the airplane into a steep (at least 80°) left-wing-down bank before the camera view panned into the interior of the airplane and showed the rear control stick in a neutral roll and slightly nose-up pitch input. About a second later, the rear control stick showed a nose-up pitch input, which was quickly followed by a right roll input in addition to the nose-up pitch input. During the final 3 seconds of the flight, the airplane’s stall warning horn was audible, the passenger was laughing, and the pilot stated an expletive. The pilot maintained the slight nose-up pitch input with a moderate right roll input until the video concluded with the sound of the airplane impacting the ground. There was no video evidence that the passenger interfered with the airplane’s flight controls during the flight. - An autopsy of the pilot was completed at the request of the Dane County Medical Examiner, McFarland, Wisconsin. According to the autopsy report, the pilot died as result of blunt force injuries. From histology sections of the myocardium, the medical examiner reported the pilot had acute myocarditis of probable viral etiology; his postmortem nasopharyngeal swab sample was positive for SARS-CoV-2 RNA (the virus that causes COVID-19). No other significant natural disease was identified. Toxicology testing performed for the medical examiner’s office was positive for caffeine in the pilot’s pleural blood. Federal Aviation Administration toxicology testing did not detect any carboxyhemoglobin, ethanol, or tested-for drugs. - A postaccident examination determined the airplane’s right-wing leading edge impacted the roof of a house before the fuselage impacted the ground in a nose-down pitch attitude. The main wreckage came to rest in the backyard of the house on a north heading. The main wreckage consisted of the fuselage, empennage, engine, and propeller. Both wings separated from the upper fuselage during impact and were found about 20 ft north of the main wreckage. All structural components and flight control surfaces were located at the accident site. Flight control cable continuity could not be established; however, all observed separations were consistent with impact-related damage. The wreckage examination revealed no evidence of a preimpact mechanical malfunction or failure that would have precluded normal operation. -
Analysis
The pilot and passenger were conducting a personal flight. The pilot’s sister-in-law received a phone call from the pilot about 5 minutes before the accident, during which the pilot told her to wait outside because he intended to fly over her house. The airplane then overflew her position multiple times at a low altitude before she saw the airplane “doing a loop” shortly before it descended into terrain. Another witness saw the airplane flying “pretty low” about 200 - 400 ft above the ground. The witness stated that the airplane dove toward the ground while flying to the west before it “went back up going upside down” while flying to the south. The airplane then descended and crashed in a residential yard while flying north. Based on video footage, the pilot completed several low passes and steep turns while flying near his sister-in-law’s house; there was no video evidence that the pilot attempted an aerobatic loop maneuver. Further review of on-board video footage indicated the airplane’s bank angle exceeded 80° left-wing-down, and the stall warning horn was audible in the seconds before the accident. Another video, captured by the pilot’s sister-in-law on the ground, showed the airplane in a steep nose-down descent in the moments before the accident. Based on the available information, it is likely that the pilot did not maintain adequate airspeed during a steep turn, which resulted in the airplane exceeding its critical angle of attack and an inadvertent aerodynamic stall at a low altitude. The low altitude at which the aerodynamic stall occurred likely prevented a successful recovery. Postaccident examination of the airplane and engine revealed no evidence of a preexisting mechanical malfunction or failure that would have prevented normal operation of the airplane. Although the pilot’s autopsy revealed he had acute myocarditis, likely due to COVID-19, there was no evidence of impairment based on the on-board video footage. Additionally, toxicological testing did not reveal any impairing substances.
Probable cause
The pilot’s failure to maintain adequate airspeed during the steep turn, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Also causal was the pilot’s decision to conduct steep turns without sufficient altitude to safely recover from an inadvertent aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
American Champion Aircraft
Model
8KCAB
Amateur built
false
Engines
1 Reciprocating
Registration number
N843AC
Operator
One Two Kilo Delta Corporation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
843-99
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-25T18:46:35Z guid: 104152 uri: 104152 title: ANC22LA004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104158/pdf description:
Unique identifier
104158
NTSB case number
ANC22LA004
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-23T19:25:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-10-25T20:12:03.976Z
Event type
Accident
Location
Willow, Alaska
Airport
MINUTEMAN STRIP (AK68)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On October 23, 2021, about 1825 Alaska daylight time, an experimental, amateur-built PA-18 Replica airplane, N368G, sustained substantial damage when it was involved in an accident near Willow, Alaska. The commercial pilot was fatally injured, and the passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed from Anderson Lake Airport, Wasilla, Alaska, and was returning to Minuteman Strip Airport (AK68), Willow, when the accident occurred. According to the passenger, while on final approach to the runway, the airplane impacted something, which she presumed was a tree, at the same time the tail became “squirrely.” She could not remember the exact order of the events. The next thing she remembered was being slumped over after the airplane had come to rest. A witness located about .3 nautical miles to the southeast of AK68 observed the airplane fly over his location and reported that the engine appeared to be at a low power setting, as it was fairly quiet, which he thought was unusual. The airplane subsequently made a turn and disappeared from view. He then heard an increase in engine power followed by the sound of an impact. He stated that he did not hear any unusual sounds from the airplane and that the engine appeared to be operating normally. The airplane impacted in a near-vertical attitude at an elevation of about 274 ft, resulting in substantial damage to the fuselage and wings. All major components of the airplane were located at the main accident site. No significant tree impacts were observed on the airframe. The flaps were found in the fully extended position. A postaccident examination of the airframe and engine revealed no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation. According to the owner of the company that manufactured the kit from which the accident airplane was built, the accident pilot requested numerous design changes into the wings, ailerons, and flaps. The owner of the company stated that he was not comfortable with and recommended against some of these changes; however, the kit was manufactured to the pilot’s specifications. The designer of the wing flaps installed on the airplane stated that he remembered working with the pilot on his build request and saw several “red flags.” He stated that too many changes were being made to the design without the knowledge of how these changes would affect each other. He strongly recommended against the requested changes. A note found in the airplane’s maintenance records described the stall characteristics of the airplane and stated in part: “Stalls - The nose drops like a rock.” The note went on to say: “Another anomaly I have seen is the big flaps kind of shadow the rudder when at slow speeds. So I suggest retract flaps on stall recoveries. Obviously this will be at altitude for stall/slow flight maneuvers.” -
Analysis
The pilot was landing his experimental, amateur-built airplane at a private airport when the airplane impacted terrain in a nose-down, near-vertical attitude short of the runway. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. No significant tree impacts were observed on the airframe. Based on the available information, it is likely that the pilot exceeded the airplane’s critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall and loss of control. At the pilot’s request, numerous design changes were incorporated into the wings, ailerons, and flaps of the accident airplane. The manufacturer of the kit and the designer of the flaps stated that they told the pilot and builder that the design changes were not recommended; however, the kit was built to the pilot’s specifications. It is likely that the design changes affected the stall characteristic of the airplane; however, the role those changes played in the accident sequence could not be determined.
Probable cause
The pilot's exceedance of the airplane’s critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GREGG ORIGER
Model
PA-18 REPLICA
Amateur built
true
Engines
1 Reciprocating
Registration number
N368G
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1801
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-25T20:12:03Z guid: 104158 uri: 104158 title: ERA22LA031 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104165/pdf description:
Unique identifier
104165
NTSB case number
ERA22LA031
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-27T00:23:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-10-28T14:44:49.557Z
Event type
Accident
Location
Folkston, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On October 26, 2021, about 1914 eastern daylight time, a Vans Aircraft RV-12, N525AT, was destroyed when it was involved in an accident near Folkston, Georgia. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) data obtained from the Federal Aviation Administration (FAA), the airplane departed Winter Haven Regional Airport (GIF), Winter Haven, Florida, at 1725. About 1900, after about 1 hour and 35 minutes of flight on a generally northbound track, the airplane made a right turn toward Davis Field Airport (3J6), Folkston, Georgia. The airplane crossed over the middle of the runway at 3J6 at 575 ft above ground level (agl), then completed a descending left turn. The airplane again crossed over the runway, this time at 100 ft agl, and made a descending right turn, while the airspeed decreased from 76 knots to 47 knots. The airplane contacted a utility pole and came to rest next to a road. Figure 1 depicts the flight track as the airplane maneuvered in the vicinity of 36J. Figure 1 – The airplane’s ADS-B-derived flight track while maneuvering near 3J6. A witness stated that he and his wife had just parked their car in their driveway when his wife looked up and saw the accident airplane fly over. He then walked inside his house and received a phone call from a neighbor at 1914. The neighbor said that the airplane just flew over his house, toward the east, and he noticed that the right navigation light was not operating. During the phone call, the witness heard the airplane impact and could hear the engine running “like it was hitting something.” The witness and his wife drove in their car to the accident site, which took about 30 seconds. The airplane impacted the ground next to a road and the engine was on fire when the witness pulled the pilot from the airplane. The witness also stated that the runway lights at 3J6 did not work and that there was a published NOTAM regarding the inoperative lights. A family member of the pilot stated that the pilot had difficulty with his vision and finding airport runways during the daytime. He believed the pilot was not supposed to be flying at night. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed that the cabin, cockpit, and instrument panel were destroyed by postimpact fire. The right wing was folded back and separated from the fuselage. The left wing remained attached to the fuselage; however, the outboard portion was damaged due to impact forces. The empennage remained attached and displayed minor damage. The engine remained attached to the fuselage, but the three blades on the propeller were separated. According to the Astronomical Application Department of the United States Naval Observatory, sunset occurred at 1845, the end of civil twilight was at 1909, and moonrise was at 2303. The phase of the moon on the day of the accident was waning crescent, with 66.1% of the moon’s visible disk illuminated. 3J6 was located 3 miles southwest of Folkston, Georgia, at an elevation of 68 feet msl. It had one runway, designated as 1/19, which was 2,500 ft long by 50 ft wide. At the time of the accident, a NOTAM was active indicating that the runway 1/19 runway edge lights were inoperative. An autopsy was performed on the pilot by the Office of the Office of the Medical Examiner, Gainesville, Florida. The report listed the cause of death as blunt force trauma. Toxicology testing was not performed on the pilot due to the length of his stay in the hospital before his death. -
Analysis
Flight track information indicated that, about 1 hour and 35 minutes after departure, in night conditions, the airplane was maneuvering in the vicinity of an airport. The pilot crossed over the runway twice while descending, maneuvered near a roadway, and the groundspeed decreased before the airplane contacted a utility pole beside the road and then impacted terrain. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. A family member reported that the pilot had difficulty with his vision during the day, and especially at night. Additionally, a witness stated, and a published NOTAM confirmed, that the runway edge lights at the airport were inoperative. Given the airplane’s maneuvering in the vicinity of the airport and its decreasing speed similar to an approach to landing phase of flight, it is possible that the pilot was maneuvering in an attempt to locate the runway and land when the airplane struck the utility pole.
Probable cause
The pilot’s low altitude maneuvering, which resulted in a collision with a utility pole.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS AIRCRAFT INC
Model
RV-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N525AT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12065
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-10-28T14:44:49Z guid: 104165 uri: 104165 title: ERA22LA033 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104171/pdf description:
Unique identifier
104171
NTSB case number
ERA22LA033
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-27T18:50:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-11-02T00:09:29.896Z
Event type
Accident
Location
Ballston Spa, New York
Airport
SARATOGA COUNTY (5B2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 27, 2021, at 1750 eastern daylight time, a Beech BE-23 airplane, N2353Z, was substantially damaged when it was involved in an accident near Ballston Spa, New York. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot checked the fuel levels during the preflight inspection, measuring 1 inch of fuel in the right tank and 3 inches of fuel in the left tank with a ruler. Based on his calculations of the airplane’s fuel consumption during the 3-day, multi-leg flight home from Texas after purchasing the airplane, he determined that each inch represented 1 hour and 15 minutes of flying, and therefore they had 5 hours of flying time. The student and instructor departed Saratoga County Airport (5B2), Saratoga Springs, Florida, around 1530. They flew in the practice area then around a nearby lake before returning to 5B2, where they completed eight touch-and-go takeoffs and landings. About 2 hours and 20 minutes into their flight, after turning to final approach on the ninth landing, the engine sputtered, stopped producing power, and the propeller continued to windmill. The instructor took control of the airplane, established the best glide speed, and performed a quick check of the mixture, carburetor heat, ignition, and master switches, but was unable to restore engine power. He selected an area for a forced landing and as the airplane descended, he noted power lines in their flightpath. He pitched the airplane up to avoid power lines and heard the stall horn sound. The airplane missed the power lines, descended to the ground, and landed hard, fracturing the nose landing gear. The airplane then nosed over and slid to a stop. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest upright in a nose-down attitude. The right wing was substantially damaged where the right main landing gear pushed up into the wing. There was no evidence of fuel in the left-wing tank and the right-wing tank was about 1/8 full. The flight instructor stated that they used fuel solely from the left tank, did not switch fuel tanks during the flight, and leaned the mixture during the cruise portions of the flight. Postaccident examination of the airplane revealed that the left fuel tank gauge needle indicated “E” and the right fuel tank gauge needle indicated just above “E” when the airplane’s electrical master switch was selected ON. Both right and left fuel caps were secure and the fuel vents were unobstructed. No fuel was present in the left tank, and about 1 inch of fuel was present in the right tank. All fuel lines from the left and right fuel tanks to the fuel selector, gascolator, both fuel pumps and the carburetor were intact and devoid of fuel. No fuel was found in the gascolator bowl or the electric fuel pump. The examination revealed no other preimpact anomalies or malfunctions that would have precluded normal operation. The airplane’s pilot’s operating handbook (POH) stated, “do not take off when the Fuel Quantity Gages indicate in the yellow band or with less than 11 gallons in each main tank.” A cockpit placard specified a capacity of 26 gallons for the left fuel tank and 26 gallons for the right fuel tank; however, the student reported that the airplane’s tanks held 60 total gallons of fuel. In follow-up interviews with the flight instructor and student about fuel planning, the student indicated that they were leaning the fuel mixture and had a tailwind when returning home from Texas and calculating the airplane’s fuel consumption rate. Both indicated that the fuel measured 9 inches when full. When asked about the fuel planning performed before the accident flight, the instructor responded, “Neither of us did and that's the problem.” -
Analysis
The student pilot measured 1 inch of fuel in the right tank and 3 inches of fuel in the left tank using a stick during the preflight inspection. Based on fuel consumption calculations from a multi-day flight home after purchasing the airplane out of state, he determined that the fuel measurements represented 5 hours of flying time. After about 2 hours and 20 minutes of flight in the practice area and performing eight touch-and-go takeoffs and landings, all while using the left fuel tank, the engine lost total power, and the propeller continued to windmill. The flight instructor took control of the airplane but was unable to restore engine power. During the forced landing, the instructor pitched up to avoid power lines, heard the stall warning horn, and the airplane then descended to the ground and landed hard, substantially damaging the right wing. Examination of the wreckage revealed no evidence of fuel in the left tank, fuel lines, gascolator, or fuel pump. The right fuel tank contained about 1 inch of fuel. No other preimpact anomalies or malfunctions that would have precluded normal operation were observed; therefore, it is likely that the engine lost power when the fuel in the left tank was exhausted. The pilots’ previous calculation of the airplane’s fuel burn rate during a previous cross-country flight did not take into consideration prolonged flight without leaning the mixture or the multiple landings on the accident flight. The flight instructor stated that neither he nor the student performed the appropriate preflight fuel planning.
Probable cause
The flight instructor’s and student pilot’s inadequate preflight fuel planning and improper in-flight fuel management, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
23
Amateur built
false
Engines
1 Reciprocating
Registration number
N2353Z
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1963
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-02T00:09:29Z guid: 104171 uri: 104171 title: CEN22FA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104170/pdf description:
Unique identifier
104170
NTSB case number
CEN22FA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-27T19:17:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-10-29T05:29:27.842Z
Event type
Accident
Location
Lena, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Hypoxia occurs when a person is deprived of adequate oxygen. Impairing effects from hypoxia can include confusion, disorientation, diminished judgment and reactions, worsened motor coordination, difficulty communicating and performing simple tasks, and a false sense of well-being. The brain is particularly sensitive to hypoxia, and it can be difficult for a pilot to recognize the danger of hypoxia and take protective action before impairment or incapacitation occurs. Failure to take protective action can be fatal. - The airplane was not pressurized, but it was equipped with an onboard oxygen system that included a 76.5-cubic ft oxygen cylinder installed below the front seats and fitted with an altitude compensating regulator. The cylinder shutoff valve was controlled by a push-pull knob on the lower portion of the instrument panel. The oxygen supply was routed to receptacles on the left and right cockpit sidewalls for the pilot and copilot/front seat passenger, respectively. Receptacles were also located in the center cabin for any rear seat passengers. A gauge indicating the pressure within the oxygen system was located on the left cockpit sidewall, but the airplane had no independent indication of low oxygen system pressure. A pulse-demand oxygen delivery module in the airplane was connected to the right sidewall (copilot) oxygen receptacle. The module was fitted with two nasal cannulas, and first responders reported the pilot was found wearing one. The module was set to the “F10” mode, which supplied an oxygen flow rate equivalent to 10,000 ft above the pressure altitude sensed by the unit. The oxygen delivery module incorporated several annunciations, which included a flow fault, an apnea event, and low-battery warnings. The flow fault provided a red light indication and an aural alarm if no oxygen was flowing to the unit. An apnea event provide an amber light indication and an aural alarm when a “valid inhalation event” was not detected within 30 seconds. Neither warning was intended to indicate to the pilot that the system was out of oxygen. The NTSB did not perform an evaluation of the salience of the audible alarms when presented in the cockpit with background engine noise and when a pilot was using an aviation headset. According to the mechanic that had performed the most recent annual inspection, the pilot contacted him a few weeks before the accident to inquire about an annual inspection. The mechanic was expecting the pilot to bring the airplane to his facility in Camdenton, Missouri, on the day of the accident. There was no record that showed when the oxygen system was last serviced, refilled, or used. A specific maintenance record is not required when refilling the oxygen cylinder. Similarly, routine use of the system during flight is not required to be logged. Although that airplane was equipped with an autopilot, there was no data specific to its use during the flight, or any modes that may or may not have been selected. - On October 27, 2021, at 1817 central daylight time, a Beech B36TC airplane, N75RM, was substantially damaged when it was involved in an accident near Lena, Wisconsin. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed from Fort Worth Meacham Airport (FTW), Fort Worth, Texas, about 1357 and proceeded on a northeasterly course. The pilot’s mechanic stated that the airplane was destined for Camdenton Memorial – Lake Regional Airport (OZS), near Camdenton, Missouri, so that the airplane could undergo an annual inspection. About 1427, the airplane leveled off near 15,500 ft mean sea level (msl). About 1451, the airplane entered a climb; shortly afterward, its flightpath began to deviate as the airplane approached a line of storms. About 1519, the airplane leveled off about 24,500 ft msl and returned to a northeasterly course. Air traffic control attempted to contact the pilot after the airplane climbed through 18,000 ft and into class A airspace, but these attempts were not successful. About 1756, the airplane entered a descent from 24,500 ft msl; at the time, the airplane was about 25 miles west of Green Bay, Wisconsin. About 1758, the airplane’s course became slightly erratic as the descent continued; about 6 minutes later, the airplane returned to the northeasterly course and became established in a steady descent of about 1,000 ft per minute, which continued until the data ended. The final data point was recorded at 1817:11. The airplane impacted a cornfield about 480 ft northeast of the final recorded data point. The impact path was aligned with the final portion of the flightpath. - The 67-year-old male pilot had his last aviation medical examination on October 5, 2017. He reported having occasional asthma symptoms associated with seasonal allergies. He reported using fluticasone/salmeterol, a combination of two asthma medications which generally are not considered impairing. The aviation medical examiner (AME) noted that the pilot met the Conditions AMEs Can Issue (CACI) criteria for his asthma. No significant issues were identified. The Office of the Dane County Medical Examiner performed the pilot’s autopsy. According to the autopsy report, his cause of death was blunt force injuries. and the manner of death was accident. A summary comment from the Medical Examiner who performed the autopsy stated: “It is my medical opinion that [the pilot] died as a result of blunt force injuries of the head, torso and extremities complicating hypertensive and atherosclerotic heart disease. The minimal injuries and hemorrhage present at autopsy suggest that the decedent died of natural causes before the crash. However, the contribution of these injuries to an unconscious state, and immediate death, cannot be excluded. As such, the manner of death in this case is ruled accident.” The autopsy identified an enlarged heart. The heart weighed 530 grams (upper limit of normal is roughly 510 grams for a male of the pilot’s body weight). The thicknesses of the left ventricular wall, right ventricular wall, and interventricular septum of the heart were 1.6 cm, 0.4 cm, and 1.6 cm, respectively (upper limits of normal are roughly 1.6 cm, 0.6 cm, and 1.8 cm, respectively). The remainder of the heart examination was unremarkable; cross sections of the coronary arteries revealed no atherosclerosis. The kidneys showed chronic changes typical of high blood pressure. The lungs showed evidence of pulmonary hypertension, with plexiform lesions of the bifurcation to the pulmonary arteries. The autopsy examination did not identify other significant natural disease. Toxicology testing by NMS Labs detected delta-9-tetrahydocannabinol (commonly known as THC) at0.63 ng/mL in the pilot’s subclavian blood; no THC metabolites were detected. Toxicology testing by the Federal Aviation Administration Forensic Sciences Laboratory detected loratadine (a nonsedating antihistamine medication) and its metabolite desloratadine in the pilot’s subclavian blood and urine; no THC or THC metabolites were detected. - The National Weather Service composite radar mosaic at 1450 depicted a line of rain showers and thunderstorms across the airplane’s flightpath. The line ran from near Wichita, Kansas; southeast to Tulsa, Oklahoma; and past Hot Springs, Arkansas. Individual thunderstorm cell tops were indicated from 20,000 to 24,000 ft msl. - The pilot’s logbook was not located during the investigation. As a result, the pilot’s most recent flight experience and flight review could not be determined. At the time of the pilot’s most recent airman medical examination, conducted in October 2017, the pilot reported total civil flight time of 2,465 hrs. The pilot’s third-class medical certificate expired in 2019. In July 2020, the pilot completed a BasicMed comprehensive medical examination checklist and a BasicMed course. - After impacting the cornfield, the airplane slid about 150 ft before coming to rest. The landing gear and wing flaps were retracted. The lower fuselage structure was damaged due to impact from the airplane nose to the mid-cabin area. Flight control continuity was confirmed from each control surface to the cockpit. An engine examination revealed no anomalies consistent with the engine’s inability to produce rated power. Both fuel tanks appeared to be intact. About 35 gallons of fuel remained in the left tank; no fuel remained in the right tank. The cockpit fuel selector was found set to the right tank. Examination of the onboard oxygen system revealed that the oxygen cylinder was intact. The altitude compensating regulator and overpressure relief valve attachment fittings were damaged due to impact. The cylinder valve was in the ON position, and the control cable from the cylinder valve to the instrument panel control knob was intact and continuous. The oxygen lines appeared intact with the exception of a right-angle fitting common to the left (pilot) sidewall receptacle. With the system pressurized, a noticeable leak was identified behind the left sidewall. The fitting was cracked at the supply end. Metallurgical examination of the fitting revealed that one side of the fracture surface exhibited an area with Teflon thread sealant embedded onto the surface. The sealant was in the area of the first three threads and did not extend along the full width of the crack. A portion of the fracture surface was smooth and showed no fracture features, such as ductile dimples, which was consistent with a casting defect in that area. The remaining portion of the fracture surface exhibited ductile dimples, consistent with an overstress fracture. Examination of the oxygen cylinder valve revealed no anomalies. Examination of the altitude compensating regulator revealed that the regulator exhibited minor deviations from the test requirements; however, none of these discrepancies were consistent with the system’s inability to provide the required oxygen. Examination and testing of the pulse-demand oxygen delivery module and associated in-line pressure regulator revealed no anomalies from the required test parameters. Testing of the oxygen system pressure gauge located on left cockpit sidewall revealed no anomalies. When oxygen pressure was applied, the gauge indicated the correct supply pressure. -
Analysis
The flight departed from an airport near Fort Worth, Texas, and proceeded on a northeast course. The airplane was enroute to Missouri for an annual inspection. About 30 minutes after takeoff, the airplane leveled off near 15,500 ft mean sea level (msl). About 24 minutes after leveling off, as the airplane approached a line of thunderstorms, the airplane started to climb, and the flight path began to deviate consistent with an attempt by the pilot to maneuver around those thunderstorms. Isolated thunderstorm tops in the area were 20,000 ft to 24,000 ft. About 28 minutes after the climb started, the airplane leveled off about 24,500 ft msl and returned to a northeast course. Attempts by air traffic control to contact the pilot after the airplane climbed through 18,000 ft msl were not successful. After about 2 hours and 37 minutes, the airplane entered a descent from about 24,500 ft msl. About 2 minutes later, the airplane course became slightly erratic as the descent continued; however, the airplane ultimately returned to the northeast course. At that time, the airplane was in a stabilized descent of about 1,000 ft per minute (fpm), which continued until the data ended. The airplane impacted a cornfield about 480 ft northeast of the final recorded data point. The impact path was aligned with the final portion of the flightpath. The airplane impacted a corn field and slid about 150 ft before coming to rest. The landing gear and wing flaps were retracted. Flight control continuity was confirmed, and an engine examination did not reveal any anomalies consistent with an inability to produce rated power. Both fuel tanks appeared to be intact and about 35 gallons of fuel remained in the left tank; however, no fuel remained in the right fuel tank. The cockpit fuel selector was set to the right tank at the time of the on-scene examination. These findings were consistent with a loss of engine power due to fuel starvation. Just under 2.5 hours after the airplane reached 24,500 feet msl, the airplane was intercepted and the pilot was observed to be incapacitated. The time when the pilot most likely became incapacitated could not be determined. Nevertheless, flightpath deviations around weather and the pilot’s lack of communication with air traffic control during the climb indicated performance deficiencies that were inconsistent with the pilot’s skill and experience. Thus, the pilot likely became impaired when the airplane was below 18,000 ft but might not have been incapacitated when the airplane climbed into class A airspace. In other words, the pilot likely became impaired at an altitude below 18,000 feet, and later became incapacitated. The airplane was not pressurized, but it was equipped with an onboard oxygen system. Examination of the onboard oxygen system revealed a cracked fitting behind the left (pilot) sidewall, which caused a leak when the system was pressurized. Metallurgical examination of the fitting determined that it had a localized casting defect and that a portion of the fracture contained thread sealant embedded onto the surface, indicating that a crack was present at the time the fitting was installed. The investigation was unable to determine the oxygen supply onboard before the accident flight and was, therefore, unable to make any determination of whether the pilot was being adequately supplied with oxygen during the flight. Given the altitudes at which the airplane was operating and the accident circumstances, the possibility of altitude-related hypoxia must be considered. If the airplane’s onboard oxygen system was properly functioning and properly used, the system would have generally been expected to prevent significant hypoxia in a pilot operating below 18,000 feet. Even with the nasal cannula instead of a mask at 24,500 feet, a pilot would generally not likely experience significant hypoxia if the oxygen system was functioning properly. However, an impaired or incapacitated pilot might have a diminished ability to use the nasal cannula effectively. In addition, if the supplemental oxygen supply became exhausted while the airplane was at altitude, due to the crack in the fitting, hypoxia would have resulted. An average, healthy pilot’s performance is mostly unaffected by cabin altitudes below 10,000 ft but may seriously deteriorate within 15?minutes at a cabin altitude of 15,000 feet. The time of useful consciousness is the maximum time available for an average, healthy pilot to take protective action against hypoxia at a given cabin altitude. This time decreases rapidly with increasing cabin altitude; at 18,000 feet, it is 20 to 30 minutes; at 25,000 feet it is 3 to 5 minutes. Although the pilot’s toxicology results indicated that he had used a cannabis product, the THC level in his blood was very low and there were no detectable THC metabolites in his blood or urine, making it unlikely that cannabis effects contributed to the accident. The accident pilot’s impairment and/or subsequent incapacitation could plausibly have resulted from known effects of hypoxia. Hypoxia might have resulted from supplemental oxygen depletion, diminished altitude tolerance due to disease, or a combination of those factors. If the supplemental oxygen supply was exhausted while the aircraft was at altitude, hypoxia would have resulted, as the pilot did not take action to descend. The aircraft was at 24,500 ft for almost 2.5 hours before the pilot was seen to be incapacitated. At that altitude, the time of useful consciousness without supplemental oxygen for an average, healthy pilot is about 3 to 5 minutes. The pilot’s autopsy identified cardiopulmonary disease that conveyed increased susceptibility to hypoxia as well as some increased risk of experiencing an impairing or incapacitating cardiovascular event such as arrhythmia or ischemic stroke. Without knowing the pilot’s usual altitude tolerance or when the supplemental oxygen supply was exhausted, there is no way to determine the likelihood that the pilot’s cardiopulmonary disease contributed to the accident. Given the airplane’s flight path after the pilot deviated around weather, it is likely that the autopilot was engaged during most of the final portion of the flight. The pilot likely became impaired at some point during the flight below 18,00 ft and subsequently became incapacitated. The exact timing and underlying cause of those events could not be determined. Based on the flight path after the pilot’s deviation around weather, it is plausible the airplane completed most of the final portion of the flight with the autopilot engaged. Once the fuel supply in the selected tank was exhausted, the engine lost power and the airplane entered an extended glide that continued until the airplane impacted the cornfield.
Probable cause
Impairment and subsequent incapacitation of the pilot for reasons that could not be determined. The incapacitation resulted in a loss of engine power due to fuel starvation. Likely contributing was pilot hypoxia due to altitude exposure, possibly worsened by effects of undiagnosed pulmonary hypertension, by premature depletion of the supplemental oxygen supply, or by a combination of those factors.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B36TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N75RM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
EA-402
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-10-29T05:29:27Z guid: 104170 uri: 104170 title: WPR22FA023 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104178/pdf description:
Unique identifier
104178
NTSB case number
WPR22FA023
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-28T10:11:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-11-09T06:52:09.627Z
Event type
Accident
Location
Snoqualmie, Washington
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the previous owner, the airplane underwent an annual inspection on September 22, 2021. The airframe, engine, and propeller logbooks were provided to the pilot by the previous owner at the time of the sale and were not located during the investigation. The previous owner surmised that the logbooks were on board the airplane at the time of the accident. - On October 28, 2021, about 0911 Pacific daylight time, a Mooney M20M, N40KA, was substantially damaged when it was involved in an accident near Snoqualmie, Washington. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot had purchased the airplane just days before the flight and was flying it from the purchase location of Arlington Municipal Airport (AWO), Arlington, Washington, to Magic Valley Regional Airport (TWC), Twin Falls, Idaho. The morning of the flight, the pilot filed an IFR flight plan from AWO to TWC, and he received a ForeFlight weather briefing that identified moderate icing conditions along the planned route of travel. The relative humidity during the planned time along the route of flight was 98%. The weather briefing indicated that during the planned flight time, the base freezing level was 5,000 ft msl and the top freezing level was 22,000 ft msl. A review of air traffic control (ATC) communications and radar data revealed that the airplane departed AWO about 0842. The pilot initiated an eastbound turn, which was abnormal for departures from AWO airport, and the controller questioned the pilot about the abnormal turn and subsequently issued the pilot a heading to the south. The pilot advised ATC that the turn was not intentional and that the autopilot may have been the issue. The pilot corrected course; however, at 0900, the airplane made a hard right turn to the northwest in the opposite direction of the planned route of flight. The airplane’s altitude was about 14,000 ft msl when a handoff was made from the Seattle Terminal Radar Control Approach facility to the Seattle Air Route Traffic Control Center. The pilot established communication with the ARTCC controller and stated that he had an issue with the autopilot and that he was correcting to the southeast. The airplane’s altitude was about 14,000 ft msl when the pilot made a left turn to the southeast, and the controller acknowledged the heading correction and subsequently cleared the airplane to depart 14,000 ft msl and climb to 17,000 ft msl. The controller made the pilot aware of multiple pilot reports (PIREPs) for moderate rime icing conditions between 12,000 ft msl and 18,000 ft msl. The controller offered the pilot an altitude of 19,000 ft msl to get above the ice, and the pilot accepted. At 0903, the airplane’s altitude was 16,000 ft msl when the controller informed the pilot that he was about 20° left of course and to maintain his present heading. About 0904, after climbing to an altitude of 16,300 ft msl, the airplane began a rapid descent with a series of tight spiral turns. Communication between the controller and the pilot became broken and unreadable. The controller solicited an airplane in the area to attempt communication with the accident airplane on the emergency frequency 121.5 and to relay the controller’s instructions. After multiple attempts to communicate, the relaying airplane informed the controller that the pilot of the accident airplane reported that the airplane was out of control. The airplane descended through 5,400 ft msl when a simultaneous loss of radar contact and communication occurred shortly after 0910. The airplane was the subject of an alert notice and was located by search and rescue personnel in the Snoqualmie National Forest, Snoqualmie, Washington, about 1 mile southeast of Calligan Lake. - A review of the meteorological conditions that existed surrounding the time of the accident revealed instrument meteorological conditions. AIRMET Z was active for light to moderate rime icing and the presence of clear ice conditions. PIREPs confirmed the icing conditions and low-level turbulence in the vicinity of the accident site. The northwest section of the Surface Analysis Chart at 0800 depicted a low-pressure system over the Washington Pacific coastline associated with a frontal wave, with a warm front extending southeastward over Washington and in the immediate vicinity of the accident site. A secondary trough of low pressure extended southeastward from the front across Washington, northeast Oregon, and into western Idaho. A high-pressure system was located over central Idaho. The station models in the vicinity of the accident site depicted light winds, obscured skies in rain and fog, with temperatures ranging from 50°F in the Seattle area to near 37° F immediately southeast of the accident site at Ellensburg, Washington. Temperature-dew point spreads were less than 2° F over the area with light rain and fog. To determine the conditions over the accident site, a high-resolution rapid refresh (HRRR) numerical model was obtained from the National Oceanic and Atmospheric Administration Air Research Laboratory archive for the nearest grid point to the accident site about the time of the accident. The HRRR sounding depicted an accident site elevation near 3,681 ft, with cloud tops estimated at 20,000 ft msl. The freezing level was identified at 6,000 ft msl and indicated a high potential for light-to-moderate clear icing and rime ice from the freezing level through 20,000 ft msl. - According to a friend of the pilot, the pilot transitioned from the use of a paper logbook to ForeFlight’s pilot logbook. Foreflight indicated that the pilot had amassed 1,561.4 hours of flight experience. Following a 6-year hiatus from flying, the pilot resumed flying 5 months before the accident and had amassed 13.4 hours of flight experience in a Cessna 172. Further, the Foreflight track log identified six flights in the accident airplane that were not documented in the pilot’s logbook. The six flights were conducted over the 3 days before the accident and totaled 5.1 hours of flight time. The pilot’s logbook contained no record of a flight review or an instrument proficiency check since the pilot had resumed flying. - The airplane wreckage was located in densely wooded, mountainous terrain and distributed within a 21 ft by 15 ft area. Damage to the outboard left and right wings was consistent with the airplane initially impacting two trees about 20 ft above the base of the trees. The northwestern border of the wreckage consisted of the engine and propeller sections, which sustained thermal damage. The Nos. 1 and 2 cylinders were liberated from engine block, and the three propeller blades were liberated from the propeller hub. The cabin and fuselage were consumed by the post-impact fire. The airplane’s tail section including the rudder and elevators, formed the southwestern border of the wreckage. An examination of the engine and airframe revealed no anomalies or mechanical malfunctions that would have precluded normal operations. The airplane’s anti-ice and de-ice systems had sustained significant thermal damage. The TKS ice protection panels affixed to the leading edges of the vertical and horizontal stabilizers were present and had sustained thermal damage. The windshield spray-bar that provided de-ice protection and the propeller slinger ring that also provided de-ice protection were not visibly identifiable. The propeller blades were equipped with de-icing boots and had sustained thermal damage. The supplement to the pilot’s operating handbook and the airplane flight manual contained a warning that stated, “INTENTIONAL FLIGHT INTO KNOWN ICING IS PROHIBITED.” -
Analysis
After a 6-year hiatus from flying, the pilot had just purchased the airplane. The morning of the accident flight, he filed an instrument flight rules (IFR) flight plan and received a weather briefing that identified icing conditions along the planned flight route. The pilot departed the airport about 0842 and planned to climb to an altitude of 17,000 ft mean sea level (msl). About 0901, the controller cleared the pilot to depart 14,000 ft msl and climb to 17,000 ft msl. Subsequently, the controller informed the pilot of multiple PIREPs for icing conditions from 12,000 ft msl to 18,000 ft msl and offered the pilot an altitude of 19,000 ft msl to get above the icing, which the pilot accepted. About 0904, after climbing to an altitude of 16,300 ft msl, the airplane began a rapid descent with a series of tight spiral turns. Communication between the controller and the pilot became broken and unreadable. An airplane operating in the area relayed to the controller that the pilot reported being out of control. Shortly after 0910 radar contact was lost, and the airplane impacted terrain. It is likely that the accident airplane encountered structural icing and that the erratic turns coupled with a rapid descent rate were indicative of the pilot’s loss of airplane control, which resulted in a collision with terrain. Postaccident examination of the engine and airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The supplement to the pilot’s operating handbook and the airplane flight manual contained a warning that stated, “INTENTIONAL FLIGHT INTO KNOWN ICING IS PROHIBITED.” The pilot’s logbook contained no record of a recent instrument proficiency check.
Probable cause
The pilot’s decision to fly the airplane into known icing conditions, which resulted in a loss of airplane control and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20M
Amateur built
false
Engines
1 Reciprocating
Registration number
N40KA
Operator
ANOTHER GREASER LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
27-0171
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-09T06:52:09Z guid: 104178 uri: 104178 title: WPR22FA022 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104177/pdf description:
Unique identifier
104177
NTSB case number
WPR22FA022
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-28T14:11:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2021-11-02T01:10:10.264Z
Event type
Accident
Location
Ukiah, California
Airport
Ukiah Municipal Airport (UKI)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The San Francisco Bay and surrounding areas had received significant rainfall during the week leading up to the accident. The events broke multiple daily precipitation records, with Santa Rosa and Napa receiving 7.83 and 5.35 inches of rain, respectively, 4 days before the accident. The airplane was stored outside at Napa County Airport during those rain showers. A flight instructor who had performed the logbook endorsement for the accident flight stated that he flew the airplane earlier in the morning. During the preflight inspection, he found a small quantity of water in the gascolator. He was surprised because although he had often seen water contamination in other airplanes, this was the first time he had seen it in the accident airplane. The airplane and engine performed without issue on that flight. On the accident flight, just before departure, the accident pilot requested the airplane be fueled to capacity. The line technician who serviced the airplane stated that he added 7 gallons of 100 low-lead aviation gasoline, and as he was reeling the fuel line back into the fueling truck, he noticed the pilot checking the fuel quantity at the filler caps, and then collecting a fuel sample at the wing tank drains. A photo recovered from the pilot’s phone taken at 1158, 21 minutes before departure while on the airport ramp, showed a “fuel-check” sumping tool, held by the pilot. It contained clear light-blue fluid that looked like aviation gasoline. Below the blue fluid there was a small clear globule that appeared to be water. The manager of the fixed base operator that supplied the fuel stated that no pilots of other aircraft supplied from the same fuel truck came forward to report any issues with the fuel. Additionally, fueling logs did not indicate the presence of water or contaminants present in the fuel tank farm or truck. Visual examination of a sample recovered from the drain of the fuel truck indicated that it was clear and bright, with no evidence of either entrained water or water slugs. - The airplane was owned and operated by Mike Smith Aviation, a Part 61 flight school. The owner of the flight school performed most of the airplane’s maintenance, including the annual and 100-hour inspections. - The pilot had installed a GoPro HERO digital camera to a suction mount on the left side of the windshield. The unit was connected to the airplane’s intercom and the pilot’s headset, such that it recorded the microphone audio as well as radio traffic communication. It recorded the preflight checks, takeoff and enroute segments, along with the landing approach. The video was reviewed by a specialist from the National Transportation Safety Board Vehicle Recorders Division. It showed that after reaching the runup area, the pilot recited the before take-off checklist, which included a confirmation that the seatbelts were buckled. Before takeoff he exclaimed irritation that he had lost his pencil, and after takeoff he became animated, stating that he had lost and then found his pen. He continued to talk throughout the flight, citing reporting points and airplane parameters, and about 12 minutes after takeoff he turned the camera off. The camera began recording again as the airplane approached Ukiah. Two airplanes were already in the traffic pattern, and the pilot reported his location while communicating with them. During the downwind landing leg, the pilot of the airplane ahead reported that he was extending the downwind leg to accommodate landing traffic. As the accident pilot began to recite the before landing checklist, and after reaching the carburetor heat and flaps section, he was interrupted and briefly alarmed as the airplane flew close to a bird. He then stopped talking, and the completion of the checklist items, which included confirmation that the seatbelts were buckled, was not heard. As the airplane continued the left downwind leg for runway 15, a helicopter pilot reported that they were departing. The accident pilot transmitted that he had the traffic in sight and that he would extend his downwind leg. About 35 seconds later, he transmitted that he was turning left base. During the final approach leg, he stated, “alright, flap’s in, carb heat’s out, lights on, seventy.” The landing approach to runway 15 was nominal, and the airplane appeared to flare just over the runway numbers. After reaching the 1000-ft runway markings, the camera captured a stroboscopic effect of the propeller, consistent with an increase in engine speed, and the pilot transmitted, “Cessna 172 going around.” The airplane began to climb until 5 seconds later the stroboscopic effect of the propeller changed, and the airplane stopped climbing. The nose of the airplane then pitched down slightly, and the pilot stated, “whoa, whoa, whoa.” The recording then ended. - On October 28, 2021, at 1311, a Cessna 172M, N1870V, was substantially damaged when it was involved in an accident in Ukiah, California. The student pilot, the sole occupant, was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The pilot was making a solo cross-country flight as part of his requirements in pursuit of a private pilot's license and had planned for a full stop landing at Ukiah Municipal Airport. According to FAA automatic dependent surveillance–broadcast (ADS-B) data, the airplane departed Napa County Airport at 1219 and flew a direct course to Ukiah, arriving in the traffic pattern from the southeast at 1308. About that time, a witness, who was located near the north end of Runway 15 on the west side of the airport, noticed the airplane “porpoising” at the approach (north) end of Runway 15. He watched as the pilot initiated a go-around, and the airplane climbed with the flaps deployed. He did not think much more of it and looked away. A security camera located about midfield on the west side of the runway captured the airplane during the initial climb phase of the go-around. The video revealed that the airplane climbed to about 60 ft agl and then assumed a level attitude, while still tracking over the runway. After reaching midfield, the airplane pitched down and descended toward the runway. The airplane’s nose struck the ground, separating the nosewheel, and the airplane continued to travel along the runway, until it passed out of the camera’s field of view behind a building. The engine could be heard operating throughout, and the airplane was not trailing smoke or vapors at any time during the video (figure 1). Figure 1 - Composite image of flight path from security video – Runway 15, left to right A witness located on the east side of the airport did not initially see the airplane but saw a cloud of dust appear at the end of Runway 15. He then watched as the tail of the airplane lifted up into view as it pitched down on its nose and rolled over onto its roof. - Bennet Omalu Pathology performed the pilot’s autopsy at the request of the Mendocino County Sheriff-Coroner. The cause of death was head and face injury. According to the autopsy report, the pilot had heart disease and identified plaque causing a 90-95% narrowing of the proximal portion of the left anterior descending coronary artery. No other significant natural disease was identified. Central Valley Toxicology, Inc., performed toxicological testing of blood and vitreous specimens from the pilot at the request of Bennet Omalu Pathology. No tested-for substances were detected. The FAA Forensic Sciences Laboratory also performed toxicological testing of specimens from the pilot, detecting codeine in urine at 47 ng/mL and morphine in urine at 90 ng/mL. Neither codeine nor morphine was detected in heart blood. Codeine and morphine are opioid substances that may be medicinal, illicit, or associated with poppy seed consumption. Morphine is a metabolite of codeine. Both codeine and morphine have potential to cause cognitive and psychomotor impairment. Medicinally, codeine and morphine are available by prescription to treat pain, cough, and diarrhea. An open prescription for codeine or morphine is generally disqualifying for FAA medical certification, although certification may be granted by FAA decision in certain cases of infrequent use for acceptable medical conditions. Regardless, the FAA states that a pilot should not fly after using either medication until adequate time has elapsed for it to be eliminated from the pilot’s system. Both codeine and morphine may be used illicitly, and both are metabolites of the illicit opioid drug heroin. Also, because codeine and morphine occur naturally in the poppy plant, both might be detected in the urine of a person who has consumed poppy seeds. The pilot’s wife stated that she was not aware of her husband ever using prescription pain medication and that he had eaten a bagel with poppy seeds during the days leading up to the accident. - The pilot started his flight training in July 2021, about 3 months before the accident. He had accrued a total of 31.3 flight hours, all of which were in the same make and model as the accident airplane. The accident flight was the pilot’s fifth solo flight and his second solo cross-country flight. - The airplane came to rest inverted, and the pilot, who had been seated in the left seat, was partially ejected through the upper section of the windshield. The pilot’s seat was found locked in place about the midrange position on the seat rails; its locking pins were intact and unbent; and the roller assemblies were within tolerance. The seat did not show any evidence of preimpact movement. The pilot’s seat was equipped with a 3-point harness. Although the shoulder harness was attached to the center lap buckle, the lap buckle was found unlatched, and its strap was in the fully extended position. Examination of the seat belt and buckle did not reveal any indications of damage or failure. The tongue could be latched into the buckle assembly with a positive click and released at a repeatable latch angle, and there was no evidence that the belt had stretched, bunched, or frayed. Damage within the cabin was limited to the lower section of the left instrument panel, which included the circuit breaker panel, ignition and master switches, and fuel primer, all of which had sustained forward bending damage. The overhead speaker assembly in the forward cabin roof had sustained crush damage, and its plastic cover was broken on the left side. A series of tests was performed to determine if the damage could be attributed to contact with the pilot during the accident sequence. The tests revealed that if the pilot had been securely buckled into his seat, he would not have been able to move forward and contact the damaged areas. The pilot’s flight instructor stated that in addition to adherence to the standard pre-landing and pre-takeoff checks, his students are taught the “GUMPS” pre-landing flow, specifically: “Gas (quantity checked and fuel selector on both), Undercarriage - confirmed down, Mixture - rich, Propeller - set for downwind leg/or high RPMs on final for constant speed propellers as appropriate, Seatbelts - seatbelts and shoulder harnesses on and secure, Switches - lights on.” He stated that the pilot always wore his seatbelt and flying without it was not an option. The pilot’s wife also stated that he always used his seatbelt when driving and was insistent that others wore them too. - Video Study The security camera video was analyzed by a specialist from the NTSB Vehicle Performance Division. The results indicated that by the time the airplane had reached midfield it was traveling at a ground speed of 52 kts and maneuvering about 50 ft above the runway. Over the next 7 seconds, the airplane accelerated to about 60 knots and climbed to 68 ft. With about 2,000 ft of runway remaining, it then began a 1,350 ft per minute descent, striking the ground about 1,670 ft from the runway end while traveling at a speed of 77 kts. The airplane continued to travel along the ground over the runway and out of view for a further 20 seconds until the sound of the engine stopped. Audio analysis indicated that the engine and propeller speed during the flight segment varied between 2,415 and 2,505 rpm, and after the ground collision, the engine continued to operate at a speed of about 2,150 rpm. - The airplane came to rest inverted on a grass verge adjacent to a diagonal taxiway on the right side of runway 15. Damage to the airframe was limited to the vertical stabilizer, rudder, leading edge tip of the left wing, and the windshield, which had shattered. The propeller exhibited evidence of runway contact including tip curl and multi-directional gouges and scratches. Examination of the runway surface revealed a tire skid mark and gouge on the centerline about two thirds of the way down the 4,423-ft-long runway. The gouge matched the shape of the nose wheel rim and fork, which had detached and was recovered 350 ft downrange from the gouge. From the initial gouge, a scrape mark, along with 20 slash marks that matched the propeller blade tips continued 700 ft, progressively moving to the right of the runway centerline, and ending at the main wreckage (figure 2). Figure 2 - Airplane flight track (red), ground track (blue). Runway damage, and airplane at accident location. Following the accident, 1 ounce of water was drained from the gascolator, and 3 ounces of water were drained from the fuel tank drain in the left wing. The complete contents of both fuel tanks were then drained, and an additional 3 ounces of water were found in the left tank. The flaps were in the retracted position: the elevator trim was set for takeoff: and the carburetor heat control and corresponding air door were in the off positions. Examination of the airframe and engine revealed a series of maintenance discrepancies. These included seat rails worn beyond serviceable limits; an inoperative throttle friction lock; engine camshaft-lobe wear with accompanying metallic debris in the engine oil screen; and degraded and worn spark plug ignition cables and P-lead wires. Fuel Tanks Examination of the left tank revealed a leak had developed around the left fuel tank filler neck adapter assembly. The outboard tank strap had snapped, and there was extensive brown staining trailing aft of the fuel filler cap. The gasket that sealed the filler neck adapter to the tank had degraded and was no longer providing a seal. Silicon sealant was present in multiple areas inside the top wing skin consistent with an attempted leak repair. The forward tank support pads had worn away, such that the lower wing skin stringer rivets were in direct contact with the tank. This contact had resulted in fretting damage to the underside of the tank. There was a buckle in the lower tank skin that had resulted in a 3/16-inch-deep, 2 1/2-inch-long, and 3-inch-wide raised area just forward of the fuel supply screen (figure 3). The buckled area inside the tank had a pronounced fold that was discolored in a manner consistent with corrosion. A fuel level dipstick was found moving free within the left tank, and a fuel cap chain was found in the right tank. Figure 3 – Inboard side of left fuel tank. Cessna Single Engine Service Bulletin SEB 92-26, revision 1, provided a modification for installing additional fuel drains in the wing fuel tanks. The modification was designed to assist in the detection and removal of water or other contaminants in the wing fuel tanks. Although Cessna stated that compliance was mandatory, FAA regulations do not require adherence to service bulletins for Part 91 operations, and the bulletin had not been applied to the accident airplane. -
Analysis
The student pilot was making his second solo cross-country flight. The pilot used an onboard camera to record the ground run, takeoff, and initial cruise segments of the flight and then turned it off. The recordings showed those portions of the flight were uneventful, but he was heard talking to himself about dropping a pen and a pencil. The pilot turned the camera back on as he approached the destination airport, which was moderately busy with multiple aircraft in the traffic pattern. During the approach, the pilot’s performance of the pre-landing checklist was interrupted due to a close encounter with a bird, and he did not complete the step of checking that his seatbelt was fastened. During the landing flare, the pilot transmitted on the local frequency his intention to perform a go-around. The airplane began to climb and reached about 60 ft above ground level (agl) when a change in the stroboscopic effect of the propeller was recorded, which likely indicated an engine speed change. The airplane leveled off, and the pilot said, “whoa, whoa, whoa,” before the recording ended. Airport security video footage revealed that after reaching midfield, the airplane pitched down and struck the ground in a nose-low attitude, collapsing the nose gear. Thereafter, the propeller struck the ground, and the airplane continued under power for an additional 700 ft until it nosed over in a grass area and came to rest inverted. Sound spectrum analysis of the security video revealed that the engine was operating throughout the video and continued to operate after impact. The airplane’s cabin sustained minimal damage during the accident sequence; however, the pilot, who was not restrained by a seat belt, was partially ejected through the windshield and sustained fatal injuries. The pilot was likely incapacitated from the initial impact and therefore unable to reduce engine power after the nose gear collapsed. During the week before the accident, the airplane was stored outside during heavy rain. Postaccident examination revealed water in the left tank and the gascolator, although both the accident pilot and the pilot who flew the airplane earlier in the day followed the correct procedure for draining contaminants. Examination of the left fuel tank revealed that a longstanding leak in the left fuel tank filler neck assembly had allowed water into the tank. Pre-accident internal damage and buckling of the tank’s lower skin appeared to have trapped water and prevented it from reaching the drain port. It is likely that this water moved and entered the engine’s fuel supply system as the pilot maneuvered the airplane in the traffic pattern. The change in the stroboscopic effect of the propeller observed shortly after the pilot began the go-around was consistent with a power interruption due to water entering the engine. With sufficient runway remaining, the pilot likely decided to abort the go-around and land. The airplane manufacturer had issued a service bulletin that recommended the installation of additional drains in the fuel tanks. If installed, these drains may have revealed the water; however, the additional drains had not been installed, nor was this required per Federal Aviation Administration (FAA) regulations. The engine did not experience a total loss of power at any point during the video-recorded portions of the flight. Examination revealed that the cam lobes of the engine exhibited excessive wear; however, such damage is progressive in nature and typically occurs over an extended period. The wear would have resulted in a gradual reduction in engine performance over that time, rather than an immediate or intermittent power loss. According to the pilot’s flight instructor and his spouse, the pilot was a strong advocate of seatbelt usage. Although the reason for his failure to wear a seatbelt could not be determined, it is possible that when he dropped his writing implements during the flight, he released his seat belt to recover them and failed to resecure it. When his pre-landing checklist was interrupted due to the proximity of a bird, he became preoccupied by the busy airport environment and did not finish the checklist. Autopsy results indicated that the pilot had severe coronary artery disease; however, based on available medical and operational evidence, it is unlikely that the heart disease contributed to the accident. Although toxicology samples revealed codeine and morphine in the pilot’s urine, there was no detectable codeine or morphine in his blood, and it is unlikely that effects of those substances contributed to the accident.
Probable cause
A power interruption due to water-contaminated fuel, which resulted in the student pilot aborting the takeoff and landing hard. Contributing to the accident were a leak in the left fuel tank that allowed water to enter and damage to the fuel tank that prevented water from being properly drained during the preflight inspection.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N1870V
Operator
Mike Smith Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17263776
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-02T01:10:10Z guid: 104177 uri: 104177 title: RRD22LR002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104181/pdf description:
Unique identifier
104181
NTSB case number
RRD22LR002
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-29T05:02:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Event type
Accident
Location
Houston, Texas
Injuries
null fatal, null serious, null minor
Probable cause
In progress
Has safety recommendations
true

Vehicle 1

Railroad name
WATCO
Equipment type
Yard/switching
Train name
WATCO-202
Train type
FRA regulated freight
Total cars
25
Total locomotive units
2
Findings
creator: NTSB last-modified: 2023-10-25T04:00:00Z guid: 104181 uri: 104181 title: ERA22LA037 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104185/pdf description:
Unique identifier
104185
NTSB case number
ERA22LA037
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-29T17:00:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2022-06-01T15:19:35.583Z
Event type
Accident
Location
Waverly, Tennessee
Airport
Humphrey's County (0M5)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 29, 2021, about 1600 central daylight time, a Piper PA-30, N30SH, sustained substantial damage when it was involved in an accident near Waverly, Tennessee. The pilot and the two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot said he departed Music City Executive Airport (XNX), Gallatin, Tennessee, about 1540, on a cross-county flight in his twin-engine airplane and set the fuel selector to the auxiliary tanks. About 7-10 minutes into the flight, the auxiliary tanks ran out of fuel and the pilot switched the fuel selector handles to the main tanks, which the fuel gauge indicated were a ¼-full. The pilot elected to divert and land at the Humphrey’s County Airport (0M5), Waverly, Tennessee, for fuel. When the airplane was on a four-mile final approach to land, the left engine stopped producing power, and the pilot feathered the engine. About 30 seconds later, the right engine stopped producing power. The pilot was unable to maintain altitude and made a forced landing to a field. The airplane struck a hay bale, which resulted in substantial damage to the fuselage and wings. On-scene examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed the right wingtip fuel tank, auxiliary fuel tank, and main fuel tank were not breached and were absent of fuel. The left wingtip fuel tank separated (but was not breached) with the portion of the wing and was empty of fuel. The left auxiliary and main fuel tanks were not breached and empty of fuel. Each of the tanks respective fuel caps were secure. After the airplane was recovered from the accident site and the wings were removed, the inspector re-examined the airplane and noted the fuel line fitting to the right auxiliary tank was loose, stained blue/green, consistent with a fuel leak. The amount of fuel lost due to this leak could not determined. The staining was traced down the main wing spar to where it exited at the wing root area and a large fuel stain was observed on the exterior of the wing root. No other evidence of fuel leakage was observed. The airplane was equipped with three fuel tanks in each wing: a main tank (30 total/26 useable), 15-gallon auxiliary tank, and a 15-gallon wingtip tank, for a total of 120 gallons total (114 useable). Each tank was independent of each other, so the leak in the right auxiliary fuel tank would have only affected the fuel level in that tank. The pilot reported that based on his recent fueling and flight history in the airplane, that he had about 55 gallons of fuel onboard when he departed. He said the airplane burned an average of 15 gallons per hour. Based on this information, if the right auxiliary tank was empty due to the leak, there still should have been about 40 gallons of fuel onboard (or about 2.6 hours of fuel).   The pilot said that he did not visually check the fuel quantity prior to flight because the airplane “…does not have a way to visually check the fuel and know how much fuel you have in the tanks.” However, the Pilot Operating Handbook (POH) (section 4 – Normal Procedures – Walk Around Inspection) states, that the pilot should visually check the fuel supply in each tank before flight and to make sure each fuel cap is adjusted and secure. The pilot also reported that the fuel gauges for the main tanks were still indicating a ¼-full just before they both lost power. The pilot said he was relatively new to flying this make/model airplane and thought the fuel gauges were fairly accurate. The pilot said that he would not have flown the airplane if he knew the right-wing auxiliary fuel line was leaking or that the fuel gauges were not indicating properly. -
Analysis
The pilot departed on a cross-county flight in his twin-engine airplane and set the fuel selector to the auxiliary tanks. About 7-10 minutes into the flight, the auxiliary tanks ran out of fuel and the pilot switched the fuel selector handles to the main tanks, which the fuel gauge indicated were a ¼-full. The pilot then decided to land and purchase fuel. When the airplane was on a four-mile final approach to the diversion airport, the left engine stopped producing power. About 30 seconds later, the right engine stopped producing power. The pilot was unable to maintain altitude and made a forced landing to a field. The airplane struck a hay bale, which resulted in substantial damage to the fuselage and wings. Postaccident examination of the airplane revealed six fuel tanks were intact and empty of fuel. A fuel line fitting to the right auxiliary tank was observed to be loose, stained blue/green, and most likely had been actively leaking fuel. The amount of fuel lost due to this leak could be not determined. The airplane was equipped with three fuel tanks (main, auxiliary and tip tank) in each wing, for a total of 120 gallons total (114 useable). Each tank was independent of each other, so the leak in the right auxiliary fuel tank would have only affected the fuel level in that tank. The pilot reported there was about 55 gallons of fuel onboard when he departed, and the airplane consumed an average of 15 gallons per hour. Based on this information, if the right auxiliary tank (15 gallons total) was empty due to the leak, there still should have been about 40 gallons of fuel onboard (or about 2.6 hours of fuel). The pilot said that he did not visually check the fuel quantity prior to flight because the airplane “…does not have a way to visually check the fuel and know how much fuel you have in the tanks.” However, the Pilot Operating Handbook states, that the pilot should visually check the fuel supply in each tank before flight. As such, even though the pilot thought he had sufficient fuel to complete his flight, postaccident examination of the airplane revealed the fuel tanks were not breached and empty of fuel. A loose fuel line fitting in the right auxiliary fuel tank likely contributed to some unquantifiable loss of fuel from that tank. Had the pilot used the preflight checklist, and visually looked in all six fuel tanks, he would have seen that there was insufficient fuel in all of the tanks to complete the flight. As a result, both engines lost total power due to fuel exhaustion 20 minutes after takeoff, which resulted in a forced landing to field.
Probable cause
The pilot’s improper pre-flight fuel planning, which resulted in a total loss of engine power to both engines due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N30SH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-1262
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-01T15:19:35Z guid: 104185 uri: 104185 title: CEN22LA027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104205/pdf description:
Unique identifier
104205
NTSB case number
CEN22LA027
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-30T15:37:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-11-05T21:12:43.259Z
Event type
Accident
Location
La Porte, Texas
Airport
LA PORTE MUNI (T41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 30, 2021, about 1437 central daylight time, a Bellanca 7ECA airplane, N86612, was substantially damaged when it was involved in an accident near LaPorte, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while operating in the airport traffic pattern, the engine lost power and did not respond after he applied full throttle and carburetor heat. The pilot performed a forced landing during which the airplane impacted fence poles, which resulted in damage to both wings. Examination of the airplane revealed that when the fuel valve was turned on, fuel ran continuously through the carburetor and out of the bottom of the engine. The carburetor was removed and shipped to a repair facility, where it was determined that a pontoon had detached from the carburetor’s float assembly arm. Without a pontoon attached to the float assembly arm, excess fuel/flooding was possible in the float chamber. The detached pontoon was an older brass style that was subject to service bulletins for replacement due to a history of mechanical failures. -
Analysis
The pilot reported that, while operating in the airport traffic pattern, the engine lost total power and he performed a forced landing, during which the airplane impacted fence poles and sustained substantial damage. Examination revealed that when the fuel valve was turned on, fuel ran continuously through the carburetor and out the bottom of the engine. Examination of the carburetor float assembly revealed a detached pontoon, which likely resulted in the loss of engine power due to excess fuel/flooding. The detached pontoon was an older brass style that was subject to service bulletins for replacement due to a history of mechanical failures.
Probable cause
A total loss of engine power due to the failure of the carburetor float assembly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7ECA
Amateur built
false
Engines
1 Reciprocating
Registration number
N86612
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1008-74
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-05T21:12:43Z guid: 104205 uri: 104205 title: CEN22LA036 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104257/pdf description:
Unique identifier
104257
NTSB case number
CEN22LA036
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-30T20:10:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-03T21:31:47.634Z
Event type
Accident
Location
Hudson Oaks, Texas
Airport
PARKER COUNTY (WEA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 30, 2021, about 1910 central daylight time, a Cessna 177 airplane, N29615, was substantially damaged when it was involved in an accident near Parker County Airport (WEA), Weatherford, Texas. The pilot and four passengers were not injured. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The flight departed from Guthrie-Edmond Regional Airport (GOK), Guthrie, Oklahoma, about 1733 and was destined for WEA. The pilot stated that the flight was uneventful until the airplane was descending from 10,500 ft mean sea level for landing. At that time, engine power was reduced, carburetor heat was applied, the mixture was enrichened, and the pilot “cleared” the engine by adding and reducing power periodically. The pilot reported that the descent was then “entirely normal” until the last 15 to 20 seconds of flight. The pilot stated that he added “a slight amount” of power, but the engine did not respond. The pilot attempted to restore engine power but was unsuccessful. While maneuvering for a forced landing, the airplane collided with power lines and terrain, resulting in substantial damage to the fuselage, right wing, and vertical stabilizer. The pilot reported that a sudden loss of engine power (stop or change in rpm) did not occur and that the engine ”simply stopped responding to throttle inputs.” Postaccident examination of the accident site found that the airplane tanks did not appear to contain fuel and that fuel had not leaked from the tanks. The pilot reported that the airplane should have contained at least 10 gallons of fuel. Postaccident examination of the airplane and engine was conducted. Accident damage to the engine section prevented documentation of the throttle cable’s full range of travel. The cabling remained properly attached to the carburetor, and no restriction to the throttle arm was noted. No preimpact anomalies were found with the airframe or engine. The pilot mentioned that carburetor icing could have caused the loss of engine power during the accident flight. A review of the Carburetor Icing Probability Chart located in the Federal Aviation Administration’s Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, dated June 30, 2009, showed that the conditions in which the airplane was operating were conducive to the formation of serious icing at glide power. -
Analysis
During a personal flight, the pilot was descending the airplane for landing and added throttle, but the engine did not respond. The pilot decided to make a forced landing, during which the airplane collided with power lines and terrain, resulting in substantial damage to the airplane. Postaccident examination of the airplane and engine found damage in the engine area that precluded documentation of the throttle cable’s full range of travel. Examination of the accident site found no evidence of fuel in the tanks, but fuel did not appear to have leaked from the tanks. The pilot reported that the airplane should have contained at least 10 gallons of fuel. Thus, the pilot’s fuel calculations could have been incorrect, resulting in fuel exhaustion. In addition, the airplane was operating in an area conducive for the formation of serious icing at glide power. However, the pilot stated that he applied carburetor heat and enrichened the mixture when he began descending. The postaccident airplane and engine examination revealed no preimpact anomalies that would have precluded normal operation. As a result, and based on the available evidence, the reason for the partial loss of engine power was most likely the result of fuel exhaustion.
Probable cause
The partial loss of engine power due to fuel exhaustion. Contributing was the pilot’s improper fuel planning.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177
Amateur built
false
Engines
1 Reciprocating
Registration number
N29615
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17700993
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-03T21:31:47Z guid: 104257 uri: 104257 title: CEN22LA024 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104189/pdf description:
Unique identifier
104189
NTSB case number
CEN22LA024
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T10:37:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2021-11-01T18:42:33.868Z
Event type
Accident
Location
Forrest City, Arkansas
Airport
Forrest City Muni Airport (FCY)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
On October 31, 2021, about 0937 central daylight time, a Cessna 150L airplane, N6713G, was substantially damaged when it was involved in an accident near Forrest City, Arkansas. The pilot was fatally injured, and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the passenger, there were no issues found with the airplane during the preflight inspection and the airplane was running well. When the airplane touched down on runway 36, the pilot pushed the yoke forward to lower the nose landing gear to the runway surface. After the nose landing gear touched down the airplane veered to the left and exited the runway surface. The pilot asked the passenger if he was on the rudder pedals, to which the passenger stated that he was not. The airplane struck a fence and came to rest upright. The passenger observed the pilot outside of the airplane near the right main landing gear. According to the passenger, the pilot never liked wearing his seat restraints. The passenger, seated in the left seat, was wearing the installed 3-point restraint system. The pilot, seated in the right seat, was not wearing the installed restraint system. He was ejected from the airplane and was fatally injured. Wheel mark impressions were visible in the grass beginning next to the runway. The main wheel marks continued through the grass for about 650 ft to the accident site. The grass area alongside the runway was about 120 ft wide between the runway and the airport perimeter fence. The wheel marks in the grass gradually curved to the left for about 100 ft before they began to curve back to the right and then nearly parallel to the airport perimeter fence. About 400 ft from the point where the airplane left the runway, the main wheel marks could be seen in the grass, but the nose wheel mark was no longer visible. A series of deep gouges in the grass were observed. The tail tie down hook was found packed with mud and grass. Flight control continuity was established from the ailerons to the control column. Elevator control continuity was established from the forward spar to the control surfaces. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. Examination of the main landing gear and associated brake assemblies did not reveal any pre-impact anomalies. Postaccident examination of the airplane revealed that the airplane was in poor mechanical condition. The aft elevator bellcrank was severely corroded and the bearing exhibited a rough or ratchet-type movement. An insect nest was observed inside the separated aileron piece. The rudder stop-bolts and associated hardware appeared to be the original size and were severely corroded. The elevator trim actuator chain remained engaged on the actuator sprocket. The chain appeared dry and corroded. There did not appear to be fresh grease on any chains, pulleys, or hinges. The airplane paint was faded and peeling. Bird feces covered the airframe and engine, and insect nests were found in the cabin, wings, and tail cone. All exposed hardware on the airplane was severely corroded. Neither the pilot logbooks nor the airplane maintenance records were available for review during the investigation. The pilot’s most recent FAA medical examination was on February 17, 1993. At that time, the pilot reported civil flight experience of 130 total hours. An autopsy of the pilot was performed by the Arkansas State Crime Laboratory Medical Examiner. According to the autopsy report, the cause of death was multiple injuries, and the manner of death was accident. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the pilot. This testing detected diphenhydramine at 269 ng/mL in heart blood. Diphenhydramine was also detected in urine. Diphenhydramine is a sedating antihistamine medication widely available over the counter in multiple sleep aids and cold and allergy products. Diphenhydramine can cause cognitive and psychomotor slowing and drowsiness. It often carries a warning that it may impair performance of tasks like driving and operating heavy machinery. The FAA states that pilots should not fly within 60 hours of using diphenhydramine to allow time for it to be cleared from circulation. -
Analysis
According to the passenger, the airplane started to veer to the left once the pilot lowered the nosewheel onto the runway. The pilot asked the passenger if he was on the rudder pedals and the passenger responded that he was not. The pilot then stated that he could not slow the airplane down. The airplane veered off the left side of the runway into the grass and impacted a chain link fence that was parallel to the runway. The pilot was not wearing his seat restraints. He was ejected from the airplane and sustained fatal injuries. The airplane sustained substantial damage to both wings. Examinations of the airplane’s flight controls, and brake assemblies did not reveal any pre-impact anomalies. The pilot’s toxicology results indicate that he had used diphenhydramine and might have experienced some impairing cognitive effects from it at the time of the accident. Diphenhydramine’s potential for postmortem redistribution complicates more precise interpretation of the drug’s concentration in heart blood, although it is unlikely that the pilot followed Federal Aviation Administration (FAA) guidance to wait 60 hours after using the drug before flying. The pilot’s lack of medical certification, the unairworthy condition of his airplane, and his decision not to wear his restraints indicate a chronic pattern of tolerating unsafe levels of risk. His diphenhydramine use might be a manifestation of that pattern, but it could not be determined if it significantly contributed to the accident.
Probable cause
The pilot’s loss of control during landing. Contributing to the pilot’s injuries was his ejection from the airplane resulting from him not wearing his available seat restraints.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150L
Amateur built
false
Engines
1 Reciprocating
Registration number
N6713G
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15072213
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-01T18:42:33Z guid: 104189 uri: 104189 title: WPR22LA025 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104194/pdf description:
Unique identifier
104194
NTSB case number
WPR22LA025
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T12:50:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-11-02T15:34:32.005Z
Event type
Accident
Location
Rexburg, Idaho
Airport
Rexburg-Madison County (RXE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 31, 2021, about 1150 mountain daylight time, a Cessna 172K airplane, N1082V, was substantially damaged when it was involved in an accident near Rexburg, Idaho. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot reported that the intent of the flight was to meet the requirements for the solo cross-country flight for his private pilot certificate. While the airplane was on final approach to land at an altitude of about 400 ft above ground level, the student pilot added throttle to correct for a low approach angle, and the engine “just died.” He cycled the engine ignition switch twice while at full throttle but did not turn on the electric fuel pump. The propeller continued to rotate after the engine lost power. The student pilot realized that, while attempting to restart the engine, the airplane had lost about one-half of its altitude. He declared an emergency and focused his attention on where to land the airplane. He elected to land on a street. During the landing roll, the right wing struck a street light pole, and the landing gear struck the street curb, resulting in substantial damage to the wing and fuselage undercarriage. The student pilot further reported that, during the summer of 2021, the engine had lost power “about 8 times.” The loss of engine power occurred after he engine had warmed up. The airplane underwent maintenance after one of these engine power losses. The student pilot reported that the engine lost power again after the maintenance had been performed. According to the student pilot, the accident flight was the only in-flight loss of engine power. A review of the engine maintenance logbook revealed that, on October 8, 2021, when the engine had accumulated 1,629 engine hours, an entry was made stating in part, the following: Engine dies on rollout after landing with the throttle all the way to idle…. Found engine to be excessively rich and the low side fuel pressure was 5.5 PSI [pounds per square inch]. Ran engine, multiple times and set all settings within specs. Low un-metered fuel set to 7.2 psi. Idle set to 750RPM with 40 RPM rise on shutoff, and high side metered set to 16.2 PSI. All work IAW [in accordance with] Continental Motors SID97-3G. The airplane was signed off as airworthy with respect to the work performed and approved to return to service. During a postaccident engine run performed by a mechanic at a hangar at Rexburg-Madison County Airport (RXE), Rexburg, Idaho, the engine started and ran smoothly for about 2 minutes. During the engine run, the mechanic checked the magnetos and the mixture, which were “normal.” The mechanic performed the engine run and the magneto and mixture checks without the Federal Aviation Administration or the National Transportation Safety Board (NTSB) present. The mechanic indicated that he did not touch the fuel selector switch or any other engine component. He added that about 30 gallons of fuel was removed from the airplane’s wings during the recovery. The NTSB’s postaccident examination of the wreckage revealed that the fuel selector lever was jammed in between the “both” position and the right tank position, and the lever could not be rotated in either direction with moderate force. The section of floor underneath the fuel selector lever had been deformed upward. An engine run was not conducted by the NTSB due to propeller damage and the engine run conducted by the mechanic, which precluded a thorough engine examination. -
Analysis
The student pilot reported that, during final approach to land on a solo flight, the engine lost total power while the airplane was about 400 ft above ground level. The student pilot elected to conduct an off-airport landing on a street. During the landing roll, the right wing struck a street light pole, and the nose landing gear struck the street curb, resulting in substantial damage to the wing and fuselage undercarriage. The student pilot reported that, before the accident, the airplane had lost power on multiple occasions after the engine was warmed up and at idle. Maintenance had been performed to correct the issue and the airplane was signed off as airworthy with respect to the work performed and was approved to return to service; however, the power loss occurred at least once after the maintenance but before the accident. No maintenance entries were identified in the logbook to indicate that further maintenance was accomplished. The student pilot elected to operate the airplane on the day of the accident, even though the engine issue was not fully resolved. After the airplane was recovered, a mechanic ran the engine and reported that it ran smoothly for about 2 minutes. The mechanic also stated that magneto and mixture checks were “normal.” The mechanic performed the engine run and the magneto and mixture checks without government oversight. Postaccident examination of the wreckage revealed that the fuel selector switch was jammed between the “both” and right tank positions likely due to the damage to the floor, which was deformed upward, during the accident sequence. The cause of the total loss of engine power could not be determined based on the available evidence for this investigation.
Probable cause
A total loss of engine power for reasons that could not be determined based on the available evidence. Contributing to the accident was the pilot’s decision to operate the airplane with a known mechanical issue.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
R172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N1082V
Operator
Dean N. Jordan
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
R1722110
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-02T15:34:32Z guid: 104194 uri: 104194 title: ERA22FA036 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104184/pdf description:
Unique identifier
104184
NTSB case number
ERA22FA036
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T14:20:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2021-11-09T02:21:01.749Z
Event type
Accident
Location
Chattahoochee, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On October 31, 2021, about 1320 eastern daylight time, an experimental, amateur-built Vans RV-4, N479JJ, was destroyed when it was involved in an accident near Chattahoochee, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed Tallahassee International Airport (TLH), Tallahassee, Florida, about 1303 destined for Monroe County Aeroplex Airport (MVC), Monroeville, Alabama. After departure, an air traffic controller terminated radar services and approved the pilot to change radio frequencies. About 17 minutes later, radar contact was lost. According to automatic dependent surveillance-broadcast (ADS-B) data obtained from the Federal Aviation Administration (FAA), the airplane climbed northbound to about 3,000 ft mean sea level (msl) after departure, then it turned right about 90° to the east, then back to the north. The airplane descended to about 2,500 ft and overflew Lake Jackson then headed westbound before turning northwest bound. The airplane’s altitude varied between about 2,000 and 2,500 ft. As the airplane flew about .70 nautical miles southwest of Mount Pleasant, it began to lose groundspeed and began turning left and descending, then gaining groundspeed while continuing to descend. Radar contact with the airplane was lost about 17 minutes after takeoff. The last data track showed the airplane at 650 ft and a groundspeed of 172 knots. An off-duty law enforcement officer was doing yardwork at his house when the airplane’s bubble-style canopy fell in his yard (the airplane was equipped with a buddle-style canopy that was hinged on the side). The canopy was about 1.5 miles away from the main wreckage. WRECKAGE AND IMPACT INFORMATION The accident site was in a wooded area and the wreckage path was about 550 ft long. The airplane was heavily fragmented and scattered along a debris path on a heading of about 220° magnetic. The outboard portion of the right wing, including the aileron, was separated and found in the vicinity of an initial tree strike. Small pieces of sheet metal, wheel pants, pieces of the carburetor, fuel tank wing sections and stringers were located along the wreckage path for about 400 ft. The empennage was leaning against a tree with impression marks about 15 ft up the tree. The inboard section of the left wing was found about 500 ft along the wreckage path. The fuel tank was breached, and the left wing was fire damaged. The engine, propeller, pieces of the landing gear, and parts of the instrument panel were located at the end of the wreckage path. Both propeller blades were impact separated. The canopy was impact damaged and the frame was bent in several areas. The canopy handle was found in the open position with the locking pin damaged and bent at its tip. The locking mechanism on the canopy could not be tested. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology testing performed by the FAA’s Forensic Services Laboratory did not reveal any evidence of alcohol or other impairing drugs. An autopsy was performed on the pilot by the Office of the Office of the Medical Examiner, District Two, Tallahassee, Florida. The report listed the cause of death as blunt traumatic injuries. -
Analysis
The pilot departed the airport for a cross country flight. Shortly after departure, radar services were terminated by air traffic control and the pilot was cleared for a radio frequency change. Seventeen minutes later, radar contact was lost. Automatic dependent surveillance-broadcast data obtained from the Federal Aviation Administration revealed the airplane climbed to about 2,500 ft mean sea level and made a few turns to the north and northeast before heading northwest. The airplane began to lose groundspeed, turned to the left and descended, then gained groundspeed as it continued to descend. The last data track showed the airplane at 650 ft and a groundspeed of 172 knots. A witness was outside at his house when the canopy from the airplane fell in his yard. The canopy was about 1.5 miles away from the main wreckage. The accident site was in a wooded area and the wreckage path was about 550 ft long. The airplane was heavily fragmented and scattered along a debris path. The canopy handle was found in the open position with the looking pin damaged and bent at its tip. It is likely that the canopy was not locked correctly before takeoff and that it opened in flight and departed the airplane. The airplane then made a gradual slow left descending turn and continued to gain airspeed until it contacted trees and the ground at a high rate of speed. Based on the available evidence, it could not be determined if the canopy contacted and incapacitated the pilot when it separated from the airplane, which then resulted in a loss of control.
Probable cause
The pilot’s failure to properly secure the canopy before takeoff, allowing the canopy to open and then separate in flight, which resulted in the pilot’s failure to maintain control of the airplane for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV4
Amateur built
true
Engines
1 Reciprocating
Registration number
N479JJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
79
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-09T02:21:01Z guid: 104184 uri: 104184 title: CEN22FA023 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104188/pdf description:
Unique identifier
104188
NTSB case number
CEN22FA023
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T14:34:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2021-11-04T22:54:27.801Z
Event type
Accident
Location
Harrison, Nebraska
Weather conditions
Unknown
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane featured two 40-gallon wing fuel tanks with 74 gallons of usable fuel. At 65% of maximum continuous power, the airplane’s range would have been up to about 800 nautical miles and the endurance about 5.5 hours of flight time. The airplane was not equipped with any anti-icing or de-icing equipment, which would have been required for flight into known icing conditions, in accordance with 14 CFR 91.527, Operating in icing conditions. The day of the accident was the last day before an annual inspection was required to be completed. According to the airplane mechanic, the airplane was scheduled to undergo an annual inspection on November 1, 2021, the day after the accident. - On October 31, 2021, about 1334 mountain daylight time (all times MDT), a Beech P35 Bonanza airplane, N8625M, was substantially damaged when it was involved in an accident near Harrison, Nebraska. The pilot, passenger, and a dog were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal cross-country flight. The airplane departed Marion Municipal Airport (MNN), Marion, Ohio, about 0600 for the first leg of the flight and was destined for Marshalltown Municipal Airport, (MIW), Marshalltown, Iowa, which was about 454 nautical miles (nm) away. The pilot had filed an IFR flight plan for the first leg and was in contact with ATC. The airplane landed at MIW about 0930 and the pilot added 49.5 gallons of aviation gasoline. There was no flight plan filed for the second leg from MIW to Converse County Airport (DGW), Douglas, Wyoming, which was about 555 nm from MIW. Recorded ATC communications revealed that the controllers experienced difficulty communicating with the pilot en route. At 1011, a few minutes after he departed from MIW, the pilot called ATC at 4,500 ft msl and requested VFR flight following and then reported that the frequency was breaking up. At 1015, the pilot checked in with another controller and reported to the controller that he was VFR at 4,500 ft msl. At 1143, the controller changed the pilot to a different frequency, but the pilot did not respond. At 1144, the controller broadcasted for the pilot, but there was no response. The controller then coordinated with an adjacent ATC sector for a communication relay through another airplane. At 1148, the accident pilot reported on the controller’s frequency, then the controller advised that radar contact was lost. In the next 10 minutes, the controller requested that the pilot recycle the transponder and advised that the airplane was still not visible on radar. Finally, at 1205, the controller terminated VFR flight following. Automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed MIW at 1004 with an en route cruise altitude between 4,400 ft and 5,300 ft msl and about 140 kts groundspeed. There were several areas along the route of flight that were not recorded by any radar or ADS-B sources. A witness reported that while flying his airplane about 15 miles south of Valentine, Nebraska, about 1215 to 1230, he observed a white V-tail Bonanza with red stripes. (Note: This area was along the accident airplane’s estimated route of flight.) The airplane was headed west toward the weather and passed above him about 5,000 ft msl. He was aware of two active airman’s meteorological information (AIRMETs) advisories for icing conditions to the west and southwest of his location, and he tried to radio the accident pilot to warn him of the icing conditions, but he did not receive a response. At 6,500 ft msl, the outside air temperature was 28° F where he had previously encountered trace to light icing before he had descended to 4,500 ft msl where the temperature was 38° F. At 13:33.18, ADS-B data showed the accident airplane at 5,275 ft msl and descending toward rising terrain. From 13:33.30 to 13:33.37 the airplane was about the same altitude as the terrain, as seen in Figure 1, and then began a climb to 5,500 ft msl (320 ft agl), about 125 kts groundspeed. The final data point was recorded at 13:33.52 at 5,400 ft msl (250 ft agl) and 150 kts groundspeed. Figure 1. End of accident flight path and accident site, Google Earth view. The flight track descends toward rising terrain, which increases in elevation by 800 to 1,000 ft. - An autopsy of the pilot was performed by the Western Pathology Consultants, Regional West Medical Center, Scottsbluff, Nebraska. The autopsy report was reviewed by the National Transportation Safety Board Investigator-In-Charge. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident. The laceration the right hand was consistent with a [flight] control injury. Toxicology testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences Laboratory on the pilot’s blood and urine detected quinine, which is not generally considered impairing. - The night before the accident, the pilot obtained a ForeFlight weather briefing and filed an IFR flight plan for the first leg of the flight but did not file a flight plan for the second leg. The pilot reviewed several ForeFlight weather products at that time and a general route briefing was generated. The pilot also entered several route strings from MIW to DGW from 2,500 ft msl through 6,000 ft msl but did not generate a weather briefing for the accident route. There were no records that indicated the pilot received any other updates from ForeFlight on October 31, 2021. There was no record of any updates from the contract Flight Service Station provider, Leidos, or any other third-party vendors for any weather briefings, inflight contacts, or flight plans. The National Weather Service (NWS) Weather Prediction Center (WPC) 12-hour Surface Forecast chart depicted a high-pressure system over Nebraska with the stationary front to the southwest over Colorado with little change in position. A mixed band of freezing precipitation and snow was depicted over western Nebraska, northern Colorado, and Wyoming, and extended over the accident site. The NWS Aviation Weather Center (AWC) issued inflight weather advisories in the form of AIRMETs for IFR conditions over the accident site and for moderate icing conditions from the freezing level to 21,000 ft. The NWS graphical forecasts for aviation and inflight weather advisories included warnings of IFR conditions and icing conditions applicable to the accident site at the time of the accident. A witness, who was located southeast of Crawford, Nebraska, and about 10 miles south of the accident airplane’s flight path, stated that he heard a low flying airplane between 1330 and 1400. The weather conditions included an overcast cloud layer about 200 ft agl, one mile of visibility, and “heavy freezing drizzle with ice particles.” Weather data indicated low ceilings with light freezing rain over the accident site, which was confirmed by two weather reporting sites in Harrison, Nebraska, and two witnesses. The data depicted light-to-moderate clear icing below 5,500 ft with rime icing conditions above through 11,000 ft, which was the estimated top of the nimbostratus type clouds. The pilot reports over the region confirmed light-to-moderate rime and mixed icing reported about the time the accident flight was in the area. The closest recorded weather station was Chadron Municipal Airport (CDR), Chadron, Nebraska, located about 40 miles east of the accident site and along the route of flight at an elevation of 3,298 ft msl. The airport’s automated surface observation system was not augmented by any human observers. At the time the airplane passed about 4 miles south of CDR, the following conditions were reported: Weather observation for CDR at 1253 MDT, automated, wind from 100° at 4 kts, visibility 10 miles or more, ceiling overcast at 4,500 ft agl, temperature 2° Celsius (C), dew point temperature -4° C, altimeter setting 30.35 inches of mercury (inHg). Remarks: automated station with a precipitation discriminator, sea-level pressure 1030.7-hPa, temperature 1.7° C, dew point -4.4° C. - The pilot’s logbook showed that the pilot had accumulated 1,269.6 total hours, and that he just recently started flying again in April 2021. Before that he had not flown since 1978. As of September 10, 1978, he had accumulated 1,215.3 total hours. As of April 23, 2021, when the pilot started flying again, he had accumulated 54.3 total hours, all of which were in the accident airplane. From September 9 to 11, 2021, he completed 3 IFR training flights for a total of 4.9 hours, 3.4 of which were simulated instrument instruction. During those simulated instrument flights he completed holding procedures, several instrument approaches, and other IFR-related procedures. - The remote accident area consisted of small rolling hills at an elevation of 5,140 ft msl. The accident site was defined by an initial impact crater and a debris field about 700 ft long at 5,160 ft msl elevation. There was airplane debris scattered from the initial impact point to the main wreckage. The engine and propeller and a few pieces of debris were found southwest of the main wreckage. The airplane impacted the ground with the wings relatively level and at a shallow descent angle. Figure 2 shows the final locations of the airplane, engine, and propeller within the debris field. Figure 2. Aerial image of the accident site (Source: Sioux County Sheriff’s Office). The rudder and elevator control cables were continuous from the cockpit controls to the respective flight control surfaces with no separations or anomalies. The rudder interconnect torque tube between the left and right pedals was broken on both sides and impact damaged. The aileron control cables had been cut at the wing roots during the wreckage recovery process. One arm of the left aileron bellcrank was separated due to impact forces. Otherwise, the aileron controls were continuous with no anomalies. The elevator trim actuator was found near neutral. Both flap actuators were in a retracted position. The pitot heat switch was found OFF, the defrost switch was OFF, and the cabin heat knob was pulled out slightly. The vertical speed indicator needle was seized and was positioned to -5,500 fpm descent. The airspeed indicator was indicating about 200 kts. The engine had separated from the firewall and came to rest southwest of the main wreckage. The bottom of the engine sustained significant impact damage and most of the oil sump was impact separated. The propeller had separated from the crankshaft flange and the bolts were all sheared. The blades were both bent aft about midspan. One blade exhibited significant leading edge impact gouges and scoring. The engine’s crankshaft was unable to rotate due to impact damage. The crankshaft was visible from the bottom of the case with the oil sump removed. The inside of the case, crankshaft, and camshaft appeared intact with no anomalies noted. There were no preimpact mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. -
Analysis
The night before the accident, the instrument-rated pilot received a weather briefing for the first leg of a multi-leg cross country flight and filed an instrument flight rules (IFR) flight plan. The next morning, the pilot and passenger completed the first leg and serviced the airplane with 49.5 gallons of aviation gasoline. The pilot had not received a weather briefing or filed a flight plan for the second leg of the flight but was in contact with air traffic control (ATC) and received visual flight rules (VFR) flight following for the first portion of the flight. The controllers experienced difficulty communicating with the pilot and the radar coverage was intermittent. About 2 hours into the flight, the controller advised that the airplane was still not visible on radar and terminated VFR flight following. Recorded flight track information revealed that the airplane continued west toward the destination airport. About 15 to 30 minutes later, the pilot of another airplane observed the accident airplane headed west. Since he knew there were icing conditions and bad weather ahead, he attempted to radio the pilot but did not receive a response. About an hour later, the airplane’s flight track descended toward rising terrain, where it was briefly at the same elevation as the terrain, then climbed to about 320 ft above ground level (agl). The final flight track point showed the airplane at 250 ft agl and 150 kts groundspeed. The airplane impacted open terrain with a shallow descent angle and the wings relatively level, then came to rest upright about 700 ft later. The end of the debris field was defined by the engine and propeller, which had separated from the airplane during the accident sequence. General fragmentation and the length of the wreckage debris field were indicative of a high-speed impact. Postaccident examination of the airplane did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane was likely operating in instrument meteorological conditions and in mixed freezing precipitation and snow at the time of the accident. If the pilot had obtained an adequate weather briefing, he likely would have been made aware of the adverse conditions and could have been able to alter his course to avoid the conditions. The conditions at the airport with the closest recorded weather station, directly along his route of flight, could have been a safe alternate airport. Based on the flight track and weather conditions at the time of the accident, it is likely that the pilot was attempting to avoid instrument and icing conditions; he unknowingly descended toward rising terrain, then rapidly climbed to avoid the terrain, which resulted in a loss of control.
Probable cause
The pilot’s decision to continue the flight into instrument and icing conditions, which resulted in loss of control and impact with terrain. Contributing to the accident was the pilot’s failure to obtain a timely weather briefing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
P35
Amateur built
false
Engines
1 Reciprocating
Registration number
N8625M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-7298
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-04T22:54:27Z guid: 104188 uri: 104188 title: ERA22LA039 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104187/pdf description:
Unique identifier
104187
NTSB case number
ERA22LA039
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T17:40:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2021-11-13T01:47:01.333Z
Event type
Accident
Location
Zelienople, Pennsylvania
Airport
ZELIENOPLE MUNI (PJC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 31, 2021, about 1640 eastern daylight time, a Bell 47D1 helicopter, N132BR, was substantially damaged when it was involved in an accident in Zelienople, Pennsylvania. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 solo instructional flight. According to the pilot, an annual inspection was just completed on the helicopter at Zelienople Airport (PJC), and he met his flight instructor there to continue the training necessary to add a rotorcraft-helicopter rating to his pilot certificate. He serviced the helicopter with about 10 gallons of fuel, and they departed on the instructional flight to Butler Air Show Airport (3G9), Butler, Pennsylvania, where they landed, shut down the helicopter, and the instructor endorsed the pilot’s logbook for solo flight. The pilot and instructor then returned to PJC, where the instructor disembarked while the engine continued to run, and the pilot departed back to 3G9. About 3 to 4 miles east of PJC, the engine “sputtered,” and there was a “drop” in both the engine and main rotor rpms. The pilot performed a 180° turn back toward PJC, and when he leveled the helicopter, engine and rotor rpm “returned.” The pilot continued in the direction of PJC for about 2 miles before the helicopter lost total engine power. He entered autorotation and maneuvered the helicopter for a “flat” open area but lacked the altitude and rotor rpm to reach it. The pilot landed on sloped terrain, which resulted in the destruction of the main rotor blades and substantial damage to the landing gear and tailboom. The pilot stated that there was nothing wrong with the performance and handling of the helicopter before the loss of engine power. The pilot reported 334 total hours of flight experience, of which 54 hours were in helicopters, and 14 hours were in the accident helicopter make and model. Examination of FAA and maintenance records revealed that the helicopter was manufactured in 1951 and was powered by a Franklin 6U-335-A, 210-horsepower, carbureted engine. Its most recent annual inspection was completed October 21, 2021, at 3,863.2 total aircraft hours. Examination of the helicopter by FAA aviation safety inspectors revealed that the 28-gallon fuel tank contained about 5 gallons of fuel. The accessory drive case at the bottom of the vertically mounted engine was found fractured. The tachometer generator, the engine-driven oil pump, and one magneto were all separated from the engine, but remained attached to the helicopter by associated wires and hoses. Fractured pieces of the accessory case were collected and forwarded to the National Transportation Safety Board Materials Laboratory in Washington, DC for examination. Examination of the accessory case fragments revealed that the features displayed by the fracture surfaces were consistent with overstress fracture due to impact. Other than the fractured accessory case, the initial wreckage exam revealed no evidence of mechanical anomalies. The helicopter’s subsequently owner blocked access to the wreckage and no additional examination of the helicopter was performed. Examination of the weather reported in the area at the time of the accident revealed atmospheric conditions conducive to serious carburetor icing at glide power. -
Analysis
The pilot receiving instruction and the flight instructor picked up the helicopter following maintenance and performed a brief instructional flight. The instructor disembarked while the helicopter’s engine continued to run, and the pilot subsequently departed for a solo flight to the home airport. Shortly after departure, the engine “sputtered,” and there was a “drop” in both the engine and main rotor rpms. The pilot performed a 180° turn back toward the departure airport, and when he leveled the helicopter, engine and rotor rpm “returned.” However, soon after, the helicopter lost total engine power. The pilot entered autorotation and maneuvered the helicopter for a “flat” open area but lacked the altitude and rotor rpm to reach it. He landed on sloped terrain, which resulted in the destruction of the main rotor blades and substantial damage to the landing gear and tailboom. Initial examination of the wreckage by Federal Aviation Administration inspectors revealed a fragmented engine accessory case. Examination of the accessory case fragments revealed that the fracture surface features were consistent with overstress due to impact. Other than the fractured accessory case, the initial wreckage examination revealed no evidence of mechanical anomalies. The helicopter’s owner blocked access to the wreckage, and no further examination of the helicopter could be performed. Weather conditions reported in the area at the time of the accident was conducive to the development of serious carburetor icing at a glide power setting. It is possible that carburetor ice may have developed during the time the helicopter was operating on the ground while the instructor disembarked; however, the pilot’s use of carburetor heat was not determined, and other reasons for the loss of engine power could not be ruled out due to the lack of a more extensive examination of the helicopter. Therefore, the reason for the loss of engine power could not be determined based on the available information.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
47D1
Amateur built
false
Engines
1 Reciprocating
Registration number
N132BR
Operator
STEINHEISER TERRY N
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
51-332
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-13T01:47:01Z guid: 104187 uri: 104187 title: ERA22LA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104196/pdf description:
Unique identifier
104196
NTSB case number
ERA22LA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-10-31T20:00:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-03T18:42:12.005Z
Event type
Accident
Location
Orleans, Massachusetts
Airport
Chatham Municipal Airport (CQX)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On October 31, 2021, about 1900 eastern daylight time, a Piper PA-28-236 airplane, N2186U, was presumed destroyed when it was involved in an accident near Orleans, Massachusetts. The private pilot was not located and presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a fuel receipt, the pilot fueled the airplane with 53.8 gallons of 100LL aviation fuel at Freeman Municipal Airport (SER), Seymour, Indiana, at 1203. Automatic Dependent Surveillance-Broadcast (ADS-B) track data provided by the Federal Aviation Administration (FAA) indicated that the airplane departed SER at 1256. At 1623, the airplane landed at Reading Regional Airport/Carl A Spaatz Field (RDG), Reading, Pennsylvania, where it was fueled with 48.6 gallons of 100LL aviation fuel. The airplane departed RDG on the accident flight at 1653.   During the flight, the autopilot-equipped airplane flew at an altitude of about 8,000 ft mean sea level (msl), in a straight line, until it began the descent toward Chatham Municipal Airport (CQX), Chatham, Massachusetts. Continuing its established flight track, the airplane descended to and maintained 1,000 ft msl, and then the flight path turned slightly before the airplane overflew CQX on a 080° heading. The airplane continued past the airport, and the altitude began to vary between 1,100 ft and 750 ft. The airplane turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. At 1849:26, the airplane began a descending right turn from about 1,025 ft msl before track data was lost at 1849:33, at an altitude of 675 ft msl. The following figure provides an overview of the final portion of the accident flight track, CQX, and the location of the debris field. The flight track is depicted in green. The airport is depicted by the pin labeled CQX, and the location of the debris field is depicted by the airplane labeled N2186U. Figure – Flight track information A debris field was located on November 3, 2021, at a water depth of about 80 ft about 2.5 miles from the Cape Cod National Seashore and 7 miles from CQX; however, the airplane was not recovered. The FAA did not provide any air traffic control services to the pilot during the accident flight. According to the airport manager at CQX, the airport lighting system was tested the day of the accident and the day after the accident and was fully functional. According to FAA airman records, the pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued November 12, 2019. At that time, he reported 300 total hours of flight experience, of which 75 hours were within the previous 6 months. The pilot did not hold an instrument rating. The pilot reported no concerns on his recent medical application and no significant issues were identified by the aviation medical examiner. According to FAA airworthiness records, the airplane was powered by a Lycoming O540 series engine equipped with a Hartzell propeller. Review of maintenance records revealed that the airplane’s most recent annual inspection was completed on January 14, 2021, at a total time of 3,336.4 airframe hours and 1,291.6 hours since major overhaul of the engine.   According to astronomical data, on the day of the accident, the sunset was at 1735 and the end of civil twilight was at 1803. Moonrise was at 0150 and moonset was at 1547. The phase of the moon was waning crescent, with 20% of the moon’s visible disk illuminated; however, at the time of the accident, the position of the moon was under the horizon.   The 1852 recorded weather observation at CQX included wind from 230 at 6 knots, 10 miles visibility, clear skies, temperature 13°C, dew point 18°C; and an altimeter setting of 29.63 inches of mercury. The FAA's Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25B) stated that: Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which combinations of normal motions and forces can create convincing illusions that are difficult to overcome. The Handbook also advised, "unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible." -
Analysis
The private pilot departed on a cross-country flight, and after takeoff, the airplane flew in a straight line at an altitude about 8,000 ft mean sea level (msl). It began a descent toward a presumed destination airport in dark night visual meteorological conditions. Continuing on the established track, the airplane descended to and maintained 1,000 ft msl. The flightpath turned slightly before the airplane overflew and continued past the destination airport, turned northeast and flew over the Atlantic Ocean, then made a 270° left turn to the southeast. During the overwater portion of the flight, the airplane’s altitude varied between 750 ft and 1,100 ft msl. Before track data were lost, the airplane began a descending right turn from about 1,025 ft to 675 ft msl. The debris field located about 2.5 miles offshore and 7 miles from the destination airport. The airplane was not recovered. The uniformity of the flight track and altitude data for most of the flight suggests that the pilot was using the airplane’s autopilot. After overflying the airport, the airplane’s track and altitude variations were consistent with the pilot having disengaged the autopilot to hand-fly the airplane; however, continued flight over the ocean would have resulted in a near absence of cultural lighting and external visual references, requiring the use of instruments to maintain control. The pilot was neither qualified nor proficient to conduct the flight by reference to instruments and would have been vulnerable to the onset of spatial disorientation during the overwater portion of the flight. It is likely that, while maneuvering over the ocean, the pilot became spatially disoriented, resulting in a loss of control and impact with the water.
Probable cause
The pilot’s spatial disorientation and subsequent loss of airplane control while maneuvering over water in dark night conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-236
Amateur built
false
Engines
1 Reciprocating
Registration number
N2186U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-7911121
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-03T18:42:12Z guid: 104196 uri: 104196 title: WPR22FA026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104201/pdf description:
Unique identifier
104201
NTSB case number
WPR22FA026
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-03T12:30:00Z
Publication date
2023-12-06T05:00:00Z
Report type
Final
Last updated
2021-11-12T21:13:28.692Z
Event type
Accident
Location
Shafter, California
Airport
SHAFTER-MINTER FLD (MIT)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On November 3, 2021, about 1130 Pacific daylight time, a Thrush Ayers Corporation S-2R airplane, N8960Q, was destroyed when it was involved in an accident near Shafter, California. The pilot was fatally injured. The airplane was operated by Inland Aviation, Inc., as a Title 14 Code of Federal Regulations Part 91 repositioning flight prior to conducting aerial application activity. A witness who spoke with the pilot before the flight stated that the pilot said the fog had cleared for a few moments and that he had missed his “window to leave.” About 20-30 minutes later he heard the pilot’s airplane start and take off. Another witness who spoke with the pilot reported that the pilot had been in and out of the office to use the phone and to check weather. His last comment to the witness was, “…you just have to get high enough over the top of the weather to get in the clear.” A third witness who was at his house about 6 miles west of the airport stated that around 1220 the visibility was 1/2 to 1 mile, with patchy fog and low ceilings of about 400 ft above ground level (agl). According to the post-accident meteorology report, weather conditions along the accident pilot’s flight path was IMC. The accident pilot’s flight in IMC might have led to his inability to see outside visual references. When there are no outside visual references, pilots must rely on use of flight instruments to understand their position in space. If a pilot does not reference the aircraft flight instruments and there are no outside visual references, the pilot might experience spatial disorientation. In this case, the aircraft was not equipped with equipment that would be necessary for IFR flight, and therefore the accident pilot likely did not have all the required flight instruments to adequately assess his position in flight in IMC, and he likely experienced spatial disorientation. It is likely the accident pilot was not referencing his flight instruments or was experiencing an increase in workload because of spatial disorientation, and he did not recover the aircraft from its descent into terrain. According to the operator, the purpose of the flight to New Cuyama Airport (L88), California, was to load the accident airplane with dry seed to disperse at a farm near L88. The pilot attempted to depart Shafter Airport-Minter Field (MIT), Shafter, California, earlier in the morning but had canceled the flight due to the overcast conditions at MIT. The pilot departed on the accident flight about 1130. MIT was situated at an elevation of 424 ft above mean sea level (msl). It was equipped with three paved runways. The runway used, designated 8/26, which measured 3,680 ft by 60 ft, was not equipped with an air traffic control tower. Postaccident examination of the accident site revealed that the airplane impacted level, fallow terrain about 1 1/4 miles northwest of runway 26 at MIT. The debris field was about 800 ft in length on a westerly heading. The airplane impacted terrain and collided with an irrigation standpipe located near the middle of the debris field. A postimpact fire ensued. The single-seat, low-wing, fixed-gear airplane was configured for aerial application operations with an aerial spray system. The airplane was not equipped with any instruments required for instrument flight. The accident pilot did not request weather information from Leidos Flight Service on the day of the accident. A search of archived ForeFlight information indicated that the accident pilot did not request weather information from ForeFlight on the day of the accident. The accident site was in an area of relatively high surface pressure, calm wind conditions, and moist surface conditions. In addition, two temperature inversions were located above the accident site, one inversion below 3,000 ft msl and another inversion below 5,000 ft msl. At 1125, an automated weather observing system (AWOS) located at MIT, reported wind from 160° at 3 knots, visibility was 1/2 statute mile, overcast ceiling at 200 ft agl, temperature 14°C, dew point temperature of 14°C, and an altimeter setting of 30.20 inches of mercury. The Geostationary Operational Environmental Satellite-17 (GOES-17) provided visible imagery from 1130 PDT indicating cloud cover above the accident site and southeastward towards Meadows Field Airport (BFL), Bakersfield, California. The cloud cover was decreasing in areal coverage with time. Figure 1-GOES-17 visible image at 1130 PDT. KBFL was the closest airport to the accident site (9 miles southeast of the accident site) with an National Weather Service Terminal Aerodrome Forecast (TAF). The KBFL TAF that was valid at the time of the accident expected calm wind, 1/2 mile visibility, fog, and an overcast ceiling at 400 ft agl. -
Analysis
The instrument-rated commercial pilot departed from the airport and was planning to conduct a visual flight rules aerial application flight in an airplane that was not equipped for instrument flight rules (IFR) operations. Shortly after departure, the airplane entered instrument meteorological conditions (IMC). The airplane impacted terrain about 1 1/4 mile from the departure airport. The wreckage field was about 800 ft in length. A postaccident examination of the airframe and engine revealed no mechanical anomalies that would have prevented normal operation. A witness who spoke with the pilot before the flight reported that the pilot said that the fog had cleared for a few moments and that he had missed his opportunity to depart the airport. About 20-30 minutes later the pilot departed the airport with a 200 ft cloud ceiling and 1/2 mile of visibility. Another witness who spoke with the pilot stated that the pilot had checked the weather. Multiple weather sources indicated low ceilings and the presence of fog, which is conductive to low IFR conditions, before and at the time of the accident for the area near the accident site. Given the weather data and witness statements, the airplane likely flew into an area of fog and low clouds during departure and just before the accident. Based on the wreckage distribution, which was consistent with a high-speed impact, and the low visibility and ceiling present at the time of the accident, it is likely that the pilot experienced spatial disorientation and lost airplane control.
Probable cause
The pilot’s decision to depart into instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AYRES CORPORATION
Model
S-2R
Amateur built
false
Engines
1 Turbo prop
Registration number
N8960Q
Operator
Max A. Hanner
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
2450R
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-12T21:13:28Z guid: 104201 uri: 104201 title: ERA22LA045 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104203/pdf description:
Unique identifier
104203
NTSB case number
ERA22LA045
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-04T10:47:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-05T23:35:54.712Z
Event type
Accident
Location
Decatur, Georgia
Airport
Dekalb-Peachtree (PDK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On November 4, 2021, about 0947 eastern daylight time, a Cessna 172A, N172XX, was substantially damaged when it was involved in an accident near Decatur, Georgia. The student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The student pilot stated that, before takeoff, he added 1 quart of oil, bringing the total quantity to 8 quarts (full capacity). The airplane departed from Dekalb-Peachtree Airport (PDK), Atlanta, Georgia. While the airplane was at an altitude of 1,500 ft mean sea level, the student pilot noted that the engine began running roughly, which was followed by a total loss of engine power. The student pilot pitched the airplane for best glide airspeed and declared an emergency with air traffic control. He subsequently attempted a forced landing to a four-lane road, but the airplane struck powerlines and came to rest inverted on the road. The accident site was located about 5 miles south-southwest of PDK.   Postaccident examination of the airplane at the accident site revealed that the exterior surface of the bottom fuselage skin was coated in oil from the engine compartment to the tailcone, and a hole was noted in the crankcase above the No. 6 cylinder. Examination of the airframe and engine after recovery revealed fresh oil on the cockpit floor behind the firewall. In the rear portion of the engine, the oil filter adapter and its attached base had separated from the engine accessory case. The adapter did not appear to be safety wired, per the instructions in the manufacturer’s service bulletin. The separated portion of the oil filter, which was safety wired, exhibited impact damage. The oil suction screen contained some ferrous material, but no contamination was observed in the oil filter element. About 4 to 5 ounces of oil were drained from the oil sump, which contained metal. Examination of the accessory case revealed that the lower portion of the opening, into which the oil filter adapter threads, was fractured away. None of the smeared threads of the accessory case accepted the oil filter adapter, but some of the damaged threads of the oil filter adapter would have threaded into the accessory case. A review of the maintenance records revealed that the airplane’s last annual inspection was completed in January 2014, more than 7.5 years before the accident. The Federal Aviation Administration inspector assigned to this investigation reported that the oil filter adapter was installed “sometime in 2020,” but this installation was not documented in the maintenance records. As part of the National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident report, the student pilot indicated the following: There was evidence of the spin on adapter being over torqued upon installation that cracked the accessory housing, which in turn never leaked but broke free on rotation at PDK. This dumped all eight quarts [of oil] out of a hole over an inch in diameter starving the crank and causing the [connecting] rods to seize. The spin on was installed by the [airframe and powerplant mechanic] that did the 100hr inspection. -
Analysis
The student pilot reported that, before takeoff, he added 1 quart of oil, bringing the oil quantity to full capacity. Shortly after takeoff, while the airplane was at an altitude of 1,500 ft mean sea level, the pilot noted that the engine began running roughly, which was followed by a total loss of engine power. He pitched the airplane to attain its best glide airspeed. He descended the airplane for a forced landing to a four-lane road, during which the airplane struck powerlines and came to rest inverted on the road. Postaccident examination of the engine found that crankcase was breached consistent with a catastrophic failure. Additionally, a substantial amount of oil was covering the exterior of the bottom fuselage skin from the engine compartment to the tailcone, fresh oil was noted in the cockpit floor area, and only a minimal amount of oil remained in the engine. Given this information it is most likely that the total loss of engine power occurred due to oil exhaustion, that was precipitated by an oil leak. At the rear portion of the engine, the oil filter adapter and its attached base had separated from the accessory case. Although it is possible that the oil leak emanated from this location, the available evidence for this investigation precluded a definitive determination of the source for the oil leak.
Probable cause
Oil exhaustion due to an oil leak that resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N172XX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
47123
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-05T23:35:54Z guid: 104203 uri: 104203 title: ERA22LA046 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104208/pdf description:
Unique identifier
104208
NTSB case number
ERA22LA046
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-04T20:30:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-20T00:26:41.684Z
Event type
Accident
Location
Margarettsville, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 4, 2021, at 1930 eastern daylight time, a Cessna 150M, N704HQ, was substantially damaged when it was involved in an accident near Margarettsville, North Carolina. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after descending to about 1,600 ft mean sea level, while on the localizer approach to runway 34 at the Emporia-Greensville Regional Airport (EMV), Emporia, Virginia, the engine began to “sputter.” He applied the carburetor heat, the engine “got a little surge of power,” and he pushed the carburetor heat back in (OFF). The engine sputtered again, and he re-applied the carburetor heat. He then raised the nose to gain altitude, and the engine stopped completely. He turned the airplane toward a road he had recently overflown, declared an emergency, and landed in the tree canopy about 10 nautical miles southeast of EMV. A postaccident examination of the airplane revealed that the throttle, mixture, and carburetor heat controls remained intact and functioned normally. Fuel drained from the carburetor was blue in color with no water or debris present. The top sparkplugs were removed; their electrodes were grey in color and appeared “worn normal” when compared to a Champion Check-a-Plug Chart. Fuel was plumbed into the engine from an external fuel tank to the carburetor. The engine was primed, started, ran at idle without anomalies, and responded to throttle inputs. The 1935 weather observation reported at EMV included a temperature of 6°C and dew point of 5°C. A review of a carburetor icing probability chart revealed that in those conditions, the probability of carburetor icing was “serious” at cruise power. -
Analysis
During a flight at night and in visual meteorological conditions, after descending to about 1,600 ft mean sea level on a localizer approach, the engine began to “sputter.” The pilot applied the carburetor heat, and the engine “got a little surge of power” and he pushed the carburetor heat back in (OFF). The engine sputtered again, and he re-applied the carburetor heat. He then raised the nose to gain altitude, and the engine stopped completely. The pilot attempted to perform a forced landing to a road; however, the airplane came to rest in a tree canopy about 10 nautical miles southeast of the airport. The airplane sustained substantial damage to both wings, the right aileron, and the horizontal stabilizers. A postaccident examination of the wreckage, and a test run of the airplane’s engine, revealed no evidence of pre-impact mechanical malfunctions or failures that would have precluded normal operation. Review of weather conditions indicated the potential for serious icing at cruise power for the reported temperature and dew point; therefore, it is likely that the loss of engine power was the result of carburetor ice.
Probable cause
The pilot’s delayed application of carburetor heat during the descent, which resulted in a total loss of engine power due to carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N704HQ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15078627
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-20T00:26:41Z guid: 104208 uri: 104208 title: CEN22FA029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104207/pdf description:
Unique identifier
104207
NTSB case number
CEN22FA029
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-05T10:37:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-11-10T00:16:19.06Z
Event type
Accident
Location
Harrison, Michigan
Airport
CLARE COUNTY (80D)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On November 5, 2021, about 0937 eastern daylight time, an amateur-built Van’s RV-6 airplane, N16TG, was destroyed when it was involved in an accident near Harrison, Michigan. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. ADS-B data indicated that the airplane departed runway 27L at Oakland International Airport (PTK), Pontiac, Michigan at 0846. After departure the airplane made a climbing right turn and flew northwest for about 12 nm, then turned north for about 5 nm, then back to a northwest heading. The airplane reached a cruise altitude of about 3,000 ft mean sea level and remained on the northwest heading until track data was lost about 0905. The last ADS-B position was about 56 nm and 143° from the accident site. Discrete radar beacon returns showed that the airplane continued a straight-line course for another 60 nm after the loss of ADS-B data. The radar data showed that the airplane was in straight and level flight before the end of the data. The accident site was located about 1 nm south of the approach end of runway 36 at the Clare County Airport (80D), Harrison, Michigan. The pilot was in communication with air traffic control facilities during the flight, having requested and received flight-following after his departure from PTK. Air traffic control did not receive any distress calls from the pilot. Figure 1. Plot of ADS-B track data for the entire flight. Figure 2. Plot of the final portion of the accident flight. The airplane impacted the back yard of a residence. Impact signatures indicated that the airplane struck the ground about 45º nose low. The initial impact point was located directly beneath the airplane. The airplane remained predominately intact with all major airframe components still connected. The engine was partially attached to the fuselage. The three-blade wood core propeller was attached to the engine. One blade was broken off near the blade root. None of the propeller blades were splintered and they were predominately intact, consistent with low or no engine power at impact. Figure 3. Airplane at accident scene. The engine’s crankshaft could be rotated using the propeller. Compression and suction were verified on all cylinders during engine rotation. Accessory gear and camshaft continuity was verified. The engine’s carburetor was partially disassembled, and no anomalies were noted. The engine was equipped with dual electronic ignition systems. One ignition system was damaged due to impact forces and could not be tested. This system relied on airplane electrical power for all operation. The second ignition system utilized airplane electrical power for starting and low (idle) power running and had an internal alternator to support ignition at higher engine rpm. The unit was designed to automatically switch from airplane electrical power to the internal alternator as necessary during operation and could maintain engine ignition if airplane electrical power was interrupted. Functional testing of the ignition was performed and no preimpact anomalies were detected. The airplane was equipped with a GRT Avionics MX100-01, and a Horizon EFIS HX MFD-03- 070801. Both units were removed from the airplane for possible download of data. Subsequent research revealed that neither unit was cable of storing data internally. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operations. No manufacturer published glide ratio data were found for the accident model airplane; however, builder data from online sources indicated that a glide ratio of about 7:1 was achievable. The distance and altitude from the last radar return to the accident site would have required a glide ratio of about 23:1. According to the Western Michigan University, School of Medicine, Medical Examiner and Forensic Science autopsy report prepared for the Clare County Medical Examiner, the cause of the pilot’s death was multiple blunt force injuries and the manner of death was accident. No significant natural disease was identified. Federal Aviation Administration Forensic Sciences Laboratory toxicology testing detected the sedating antihistamine diphenhydramine in the pilot’s cavity blood at 18 nanograms per milliliter (ng/mL) and in his liver tissue. The non-impairing antihistamine loratadine, commonly marketed as Claritin, and its metabolite desloratadine were also detected in the pilot’s cavity blood and liver tissue. -
Analysis
Flight track data indicated that the airplane was on a cross-country flight in level cruise flight until track data were lost. The airplane impacted the back yard of a residence. Impact signatures indicated a 45° nose-low impact angle, consistent with an aerodynamic stall. The airplane’s wood core propeller was not splintered, indicating low or no engine power at impact. Examination of the airframe, engine, and related systems did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operations. The accident site was located about 7.3 nautical miles (nm) to the east of the last recorded track and about 1 nm south of the approach end of an airport runway. The location of the accident site suggests that the pilot had diverted from his original course and was attempting to land at the nearby airport. The loss of automatic dependent surveillance-broadcast (ADS-B) flight track data and discrete radar beacon returns indicated an interruption of transmission of the data from the airplane. Based on the available information, it is likely that the pilot was diverting to the airport near the accident site. The pilot had been in communication with air traffic control, but no distress calls were received. This along with the interruption of ADS-B track data and discrete radar beacon returns suggest a possible interruption in airplane electrical power. However, loss of electrical power would not explain the lack of engine power at impact since one of the ignition systems could operate independently without aircraft electrical power. Additionally, the distance from the final radar return to the accident site was not consistent with the achievable glide ratio of the airplane, suggesting that the engine did not lose power at the point where the final discrete beacon return was received. Therefore, the reason the airplane was diverting to the alternate airport could not be determined. The impact signatures indicated that the pilot likely failed to maintain the proper airspeed, leading to an exceedance of the airplane’s critical angle of attack and subsequent aerodynamic stall and loss of airplane control. Based upon the results from the toxicology, the pilot likely had taken allergy, cold, or sleep-aid medications. However, pilot performance does not appear to be an issue. Thus, while diphenhydramine was detected during the toxicology, it is unlikely that the effects from the pilot’s use of diphenhydramine contributed to this accident.
Probable cause
The pilot’s failure to maintain adequate airspeed and exceedance of the airplane’s critical angle of attack during landing approach, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV
Amateur built
true
Engines
1 Reciprocating
Registration number
N16TG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25730
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-10T00:16:19Z guid: 104207 uri: 104207 title: ERA22FA047 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104210/pdf description:
Unique identifier
104210
NTSB case number
ERA22FA047
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-05T20:26:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-11-07T04:04:12.167Z
Event type
Accident
Location
Rock Hill, South Carolina
Airport
ROCK HILL/YORK COUNTY/BRYANT FLD (UZA)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the Piper Turbo Twin Comanche ‘C’ PA-30 Owner’s Handbook, the stalling speed with gear and flaps down was 69 mph, and the stalling speed with gear and flaps up was 76 mph. Vortex generators were installed on the airplane’s wings and vertical fin in 2002, in accordance with a supplemental type certificate. The handbook also stated the following: The gear indicating lights are located conveniently by the gear selector switch. The green indicating light below the selector switch shows that all gear and down and locked. The amber light above the gear selector switch is the gear up indication.... The white light indicates that the landing gear is in transit. The gear up warning horn will sound when power is reduced (below approximately 12 inches of manifold pressure) on both engines and the gear is not down and locked.... GEAR INDICATION LIGHTS ARE DIMMED WHILE THE INSTRUMENT LIGHTS ARE ON. The handbook’s “Instructions for Emergency Extension of Landing Gear” stated the following: 1. Reduce power – airspeed not to exceed 100 MPH. 2. Place Landing Gear Selector Switch in “GEAR DOWN LOCKED” position. 3. Disengage motor – Raise motor release arm and push forward thru full travel. 4. Remove gear extension handle from stowage. If left socket is not in clear position, place handle in right socket. Engage slot and twist clockwise to secure handle. Extend handle and rotate forward until left socket is in clear position. Remove handle and place in left socket and secure. Extend handle. Rotate handle FULL forward to extend landing gear and to engage emergency safety lock. 5. Handle locked in full forward position indicates landing gear is down and emergency safety lock engage. Gear ‘DOWN LOCKED’ indicator light should be ‘ON.’ A laminated, commercially purchased checklist found in the airplane listed the following manual gear extension instructions: AIRSPEED – 87 KIAS (100 MPH) OR LESS LOWER GEAR LEVER OR IF 3 POSITION SWITCH – CENTER OFF DISENGAGE MOTOR – RAISE RELEASE ARM & PUSH FORWARD PLACE HANDLE IN LEFT SOCKET – LOCK AND EXTEND HANDLE If Left Socket Not Clear Use Right Socket, Twist Clockwise to Lock, Then Left Socket. ROTATE FORWARD FULL TRAVEL – VERIFY GREEN LIGHT - On November 5, 2021, about 1926 eastern daylight time, a Piper PA-30, N8924Y, was substantially damaged when it was involved in an accident near Rock Hill (York County) Airport-Bryant Field (UZA), Rock Hill, South Carolina. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Earlier in the day, the pilot was a passenger in a friend’s airplane that departed UZA for Savannah-Hardin County Airport (SNH), Savannah, Tennessee, where the accident pilot would pick up the accident airplane, which he had recently purchased. The mechanic who had performed the last annual inspection on the airplane received a call from the pilot while he was at SNH; during the call, the pilot told the mechanic that he would be making his first flight in the Piper PA-30 Twin Comanche and asked him about the fuel tanks. The pilot indicated that he was going to fly to Hartselle-Morgan County Regional Airport (5M0), Hartselle, Alabama, to pick up the airplane’s logbooks. The pilot later called the mechanic from 5M0; according to the mechanic, the pilot stated, “well, I made my first flight in the Twin Comanche” and “everything went great.” The pilot further stated that he had picked up the airplane’s logbooks and that his next stop was LaGrange-Callaway Airport (LGC), LaGrange, Georgia, before returning to UZA. Fuel purchase receipts indicated that 35.8 gallons of 100 low-lead aviation gasoline were purchased at LGC about 1620. Automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane departed LGC about 1636 and flew in a northeasterly direction, climbing to a cruise altitude between about 3,000 and 3,500 feet mean sea level (msl). About 1835 and about 4 nautical miles from UZA, the airplane began a descent to 2,000 ft msl. The pilot called the mechanic from the airplane about 1838 to report that he was near UZA and that the landing gear circuit breaker kept popping. ADS-B data showed that the airplane was maneuvering southwest of UZA at an altitude between 1,000 and 2,000 ft msl while the mechanic provided guidance on the manual gear extension process. The calls repeatedly dropped, but the final call began about 1913 and dropped about 1926 after the pilot stated that he needed to add “some power.” ADS-B data at that time showed the airplane at an altitude of 1,025 ft msl and a groundspeed of 63 knots. The last flight track data point showed the airplane at 625 ft msl near the accident site. The airplane impacted a wooded area about 3.5 nautical miles south of UZA. The airplane came to rest in an upright, nose-down attitude oriented on a true heading of 297°. All major components of the airplane were located at the accident site. - Review of the pilot's logbook revealed that he had logged a total of 62 hours of multiengine flight time at the time of the accident. The pilot’s logbook included two entries regarding flights in the accident airplane make and model: a multileg flight on May 20, 2020, with a reported duration of 15 hours and a flight on March 23, 2021, with a reported duration of 5 hours. Both of these flights were conducted at Pickens County Airport (LQK), Pickens, South Carolina. The flight on May 20, 2020 (which included time from a flight conducted the day before) was confirmed, but ADS-B information for March 23, 2021, revealed only a 54-minute local flight at Goshen Municipal Airport (GSH), Goshen, Indiana. According to the mechanic who had spoken with the pilot during the accident flight, the pilot asked him earlier in the day about the locations of the main tanks and the auxiliary tanks. The mechanic responded that there were eight fuel tanks on the airplane but that, to return home, the pilot would need to fill only the main and auxiliary tanks. The pilot then responded that he wanted to fill only the main tanks and asked which ones those were. The mechanic provided the requested information to the pilot, but the conversation concerned the mechanic. He encouraged the pilot to leave the airplane at SNH and return to the airport the following week so that he could be checked out on the airplane, but the pilot indicated that he needed to get back to UZA. - The airplane came to rest upright in a nose-down attitude oriented on a true heading of 297°. All major components of the airplane were located at the accident site. Examination of the wreckage revealed that the airplane’s nose was impact crushed upward and aft and that the nose and cockpit area were fragmented. The fuselage was fractured aft of the wing roots and displaced upward. The empennage was found resting on the right wing. The stabilator and rudder were intact, but the empennage was fractured about 2 ft aft of the baggage door and deformed over the top of the fuselage. The right wing was accordion crushed aft and fractured about 9 ft from its root, with the outer wing section laying on top of the inboard section. The left-wing leading edge was impact damaged. The right main landing gear remained attached to the wing and was noted to be in the down-and-locked position. The left main landing gear was noted to be in the down-and-locked position with its fractured oleo tube deformed aft at the fractured area. Flight control continuity was established from all flight control surfaces to the cockpit area. The stabilator and rudder trims were neutral, and the flaps were in the retracted position. The right engine compartment and engine were intact, but the propeller was impact separated from the engine at the crankshaft flange and was mostly buried in the soil. The main landing gear remained attached to the wing and was noted in the “down and locked” position. The left wing leading edge was impact damaged. The left engine compartment and engine were intact with the propeller attached to the crankshaft flange. Examination of both the right and left propellers revealed leading-edge damage, twisting, and chordwise scratches. The left main landing gear was noted in the “down and locked” position with its fractured oleo tube deformed aft at the fractured area. Both engines were rotated via the crankshaft flange, and thumb compressions, valve action, and crankshaft continuity were confirmed. All magnetos were impulse coupled and sparked at all towers. All spark plugs remained installed and displayed normal coloration compared with the Champion AV-27 chart except for the right engine’s No. 1 bottom spark plug, which was impact destroyed. Oil was found in various oil lines throughout the engines and rocker covers. The oil filters were opened and found to have minor carbon, ferrous, and nonferrous material. Examination of both engines revealed no preimpact anomalies or malfunctions that would have precluded normal operation. There was an odor consistent with aviation fuel at the accident site. Fuel was found within the gascolator bowls, engine-driven fuel pumps, fuel lines, and fuel servos. Recovered fuel tested negative for water contamination. Flight control continuity was established from all flight control surfaces to the cockpit area. The stabilator and rudder trims were neutral, and the flaps were in the retracted position. Fuel was found within the gascolator bowls, engine driven fuel pumps, fuel lines, and fuel servos. Recovered fuel tested negative for water contamination. The nose landing gear transmission exposed no threads, consistent with the gear in the down position. Field testing of the transmission with a drill motor revealed no obstructions or resistance. Field testing of the gear motor in the “down” position with a DC power source determined that the motor was functional. The landing gear lights (up, in transit, and down locked) were field tested with a DC power source. The amber “up” and white “in transit” lights were determined to be functional, but the green “down locked” light was found not to be functional. Further examination revealed the “down locked” light’s element was fragmented. Radiograph of the green landing gear light revealed that the bulb filament was fractured into several pieces and that no hot filament stretching was present, consistent with either the bulb burning out before impact or not being illuminated at the time of impact. The timing of the filament fracture could not be determined. -
Analysis
The pilot had recently purchased the airplane and departed on a multileg flight to pick up the airplane and its logbook and return to the pilot’s home airport. Automatic dependent surveillance-broadcast (ADS-B) data showed that about 2 hours into the last leg of the flight, the pilot descended and began to maneuver several miles from the intended airport. At that time, the pilot initiated several phone calls to a mechanic to report that the landing gear circuit breaker kept popping. The mechanic provided guidance on the manual gear extension process. About 45 minutes later, during the final call to the mechanic, the pilot stated that he needed to add “some power,” and then the call dropped. At that time ADS-B data showed the airplane at an altitude of 1,025 ft mean sea level (msl) and a groundspeed of 63 knots. Examination of the engines and airframe revealed no evidence of any preimpact mechanical malfunctions that would have precluded normal operation. All landing gear were in the downand-locked positions at the time of the accident. Laboratory testing of the green landing gear “down locked” light bulb revealed that the bulb filament had fractured and that no hot filament stretching was present, indicating that the bulb was either burned out before impact or not illuminated at the time of impact. The timing of the filament fracture could not be determined. Given the burned-out light bulb and the position of the landing gear at the time of the accident, it is likely that the landing gear indication (the popped circuit breaker) was erroneous and that the gear was down and locked while the pilot was attempting to manually lower the landing gear. Given that ADS-B data showed that the airplane was at 1,025 ft msl and 63 knots groundspeed at the time that the pilot indicated that he needed to add power, it is likely that, with his focus on the manual gear extension process and phone calls, the pilot failed to monitor his airspeed. The airplane likely slowed below its stall speed, resulting in an exceedance of the airplane's critical angle of attack, which led to an aerodynamic stall from which the pilot could not recover because of the airplane’s low altitude.
Probable cause
The pilot’s exceedance of the airplane's critical angle of attack while troubleshooting a landing gear indication, which resulted in an aerodynamic stall at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA30
Amateur built
false
Engines
2 Reciprocating
Registration number
N8924Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-1997
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-07T04:04:12Z guid: 104210 uri: 104210 title: ERA22FA050 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104216/pdf description:
Unique identifier
104216
NTSB case number
ERA22FA050
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-08T14:57:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2021-11-09T16:20:22.747Z
Event type
Accident
Location
Villa Rica, Georgia
Airport
EARL L SMALL JR FLD/STOCKMAR (20GA)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the pilot’s logbook, the airplane accumulated at least 66.3 hours of flight time since its last annual inspection. The amount of fuel on the airplane before the accident could not be determined from the available evidence for this investigation. The airplane owner’s manual indicated that the aerodynamic stall speeds at gross weight varied according to bank angle and flap setting, as shown in figure 3. Figure 3. Stall speeds shown in airplane owner’s manual. - On November 8, 2021, about 1257 eastern standard time, a Mooney M20F, N3284F, was substantially damaged when it was involved in an accident near Earl L. Small Jr. Field/Stockmar Airport (20GA), Villa Rica, Georgia. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a friend of the pilot, the purpose of the flight was to “warm up the oil” because he and the pilot planned to change the engine oil and check the cylinder compression in preparation for an upcoming annual inspection. According to automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration, the airplane departed 20GA at 1253:49. About 1 minute later, the airplane departed the airport traffic pattern area and flew about 2 miles north on a 360° heading. A review of the data downloaded from the airplane’s JPI 700 engine data monitor revealed that the exhaust gas temperatures and the cylinder head temperatures were climbing within the normal operating range. At 1255:20, the temperatures began to decrease gradually for 40 seconds and then began climbing again until the end of the data at 1256:12. At 1256:25, the airplane flew west on a 273° heading for about 1 mile, entered a spiraling left descent, and impacted a wooded area about 3.3 miles from the airport. The last ADS-B return, at 1257:23, showed that the airplane was about 100 ft above ground level and 80 ft from the accident site.  Figures 1 and 2 show the airplane’s flightpath and ground speeds, respectively. During the final 10 seconds of the flight, the airplane’s ground speed decreased from 71 to 51 mph, increased back to 71 mph, decreased to 49 mph, and increased to 96 mph. GPS data from the airplane’s Garmin 396 GPSMap device were similar to ADS-B data. Figure 1. Accident airplane’s flightpath and altitude. Figure 2. Accident airplane’s ground speeds (in mph) during final 40 seconds of ADS-B data. The pilot’s friend did not hear any distress calls on the airport common traffic advisory frequency about the time of the accident. According to home surveillance videos that captured the final moments of the accident flight, the airplane was in steep left bank before impacting the ground, and engine noise could be heard until the sound of impact. - According to his wife, the pilot had flown the accident airplane since he was 16 years old. - The airplane came to rest in a heavily wooded area at an elevation of 1,020 ft. The airplane was upright and in a level attitude on a 240° heading. All major components of the airplane were located near the main wreckage. Multiple trees near the main wreckage exhibited no impact damage. There was no smell of fuel at the accident site. The fuselage remained intact and was impact crushed. Flight control continuity was established from all flight control surfaces to their respective flight controls in the cockpit. The empennage remained attached to the fuselage and was twisted to the left. The horizontal stabilizers and elevators exhibited a small amount of wrinkling damage. The rudder and vertical stabilizer remained attached to the empennage. The vertical stabilizer was wrinkled. The wings remained attached to the fuselage, and both fuel tanks were breached. Both flaps were extended. The engine remained attached to the airframe. Crankshaft and valvetrain continuity were confirmed when the crankshaft was rotated through 360° of motion. Thumb compression and suction were obtained on all cylinders. Fuel was found in the fuel lines, fuel servo, fuel pump, and fuel manifold. The fuel injectors were removed, and none of them were obstructed. The spark plugs were removed, and all exhibited severe wear and were light gray in color compared with the Champion Check-A-Plug Chart. The magnetos were removed and provided sparks on all towers. The oil filter was removed and disassembled, and no debris was noted in the filter. The propeller remained attached to the engine. Both propeller blades remained attached to the hub. One propeller blade exhibited bending at the tip. The other propeller blade was curled, its tip was torn off, and the blade exhibited chordwise scratching. In addition, a root in the ground near that propeller blade was cut at a 45° angle. -
Analysis
The pilot was performing a personal flight. The airplane departed the traffic pattern, flew 2 miles north, and then turned and flew west for 1 mile. During the final 2 minutes of the flight, the airplane’s ground speed slowed from 102 to 49 mph. After the ground speed decreased to about 55 mph, the airplane abruptly turned left and rapidly descended. The final data return was recorded when the airplane was about 100 ft above ground level and 80 ft from the accident site. A home surveillance video that captured the final moments of the accident flight showed that the airplane was in a steep descending left bank before impacting the ground. Another home surveillance video captured the sound of the engine until impact. Postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions that would have precluded normal operation. The propeller signatures, cut tree roots, audio recording, and engine data were all consistent with the engine producing power at the time of impact. The weight and balance of the airplane and flap configuration (either extended flaps of 15° or 33°) could not be determined. Nevertheless, according to the airplane owner’s manual, the airplane’s stall speed likely ranged from 62 to 68 mph. The exact weight and balance of the airplane and flap configuration between extended flaps of 15° or 33° could not be determined. Thus, the available evidence for this accident (the automatic dependent surveillance-broadcast (ADS-B) data, GPS data, and surveillance videos) showed that the pilot likely allowed the airplane’s airspeed to decay below the aerodynamic stall speed for any configuration, which caused the airplane’s critical angle of attack to be exceeded. As a result, the airplane entered an aerodynamic stall and spin from which the pilot was unable to recover.
Probable cause
The pilot’s failure to maintain proper airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall and spin.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20F
Amateur built
false
Engines
1 Reciprocating
Registration number
N3284F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
670377
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-09T16:20:22Z guid: 104216 uri: 104216 title: ERA22FA051 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104218/pdf description:
Unique identifier
104218
NTSB case number
ERA22FA051
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-08T18:20:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-25T00:04:52.474Z
Event type
Accident
Location
Malone, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to the Aerovee 2.1 Assembly and Installation document, ACV-R02, Revision AE dated April 27, 2021, applicable to the accident engine serial number, the maximum allowed cylinder head temperature (CHT) and oil temperature readings were 450° F and 240° F, respectively. The document indicated that the gap for the upper and lower spark plugs were 0.018 inch and 0.032 inch, respectively. According to the Notes section of a document which was the likely continuation of his pilot logbook, on October 30, 2021, during takeoff in the accident airplane, the CHT was 452° F, the exhaust gas temperature was “high” and the oil temperature was 206° F with a corresponding “red flashing light” during takeoff requiring an immediate landing on an adjacent runway. The next entry, dated November 3, 2021, read, “[re-adjusted] timing & mixture OK!! Finally.” The maintenance actions were not recorded in the maintenance records. - On November 8, 2021, about 1620 central standard time, an experimental, amateur-built Sonex airplane, N432SX, was substantially damaged when it was involved in an accident near Malone, Florida. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot told a friend of his that the engine had experienced total losses of engine power on two occasions during a flight earlier that day. The friend questioned the pilot to get more details, but the conversation was interrupted, and the pilot did not explain what actions he performed to restore engine power. Another individual who spoke with the pilot before the accident flight reported that the pilot stated that he thought that he had found “the problem” and he was planning to remain in the airport traffic pattern at Marianna Municipal Airport (MAI), Marianna, Florida, during the accident flight. The witness reported that the pilot departed from runway 36 and continued straight-out after departure. He then diverted his attention and did not witness the accident. A witness, who was located about .65 nautical miles (nm) south-southwest of the accident site reported that he was in the cab of a tractor plowing a field when he observed an airplane that he thought was a “crop duster” flying in a westerly direction at high speed toward the ground. He did not hear any sound associated with the airplane from inside the tractor cab. The airplane disappeared behind trees, and about 1 to 2 seconds later, he saw a big ball of black smoke. Before seeing the black smoke, he did not notice any erratic movements, nor did he see anything trailing the airplane. - Since purchasing the airplane on March 21, 2021, the pilot logged 9 flights excluding the accident flight; however, his total flight experience in the accident airplane was not determined. - The airplane impacted federal property that was formerly a United States Coast Guard facility. The accident site was located about 9.4 nm north of the departure end of runway 36 at MAI. The airplane impacted the top of an oak tree about 25 feet above ground level; the tree was located near the east end of an abandoned runway. The airplane then impacted the ground about 154 ft later on a magnetic heading of 273°. The ground scar was oriented on a magnetic heading of 290°. The main wreckage, which comprised the fuselage, attached but partially fractured left wing, and horizontal and vertical stabilizers with attached primary and secondary flight controls, came to rest inverted on a magnetic heading about 279° and about 275 ft from the impacted tree. Fire damage was noted to the adjacent grass to the west, north, and northeast of the main wreckage. The cockpit exhibited extensive heat damage which precluded determination of switch positions. Pieces of windshield, engine air filter, propeller blade pieces/fragments, other engine parts consisting of a pushrod housing, and yellow paint specks were noted immediately aft of the heavy ground scar location. The right wingtip, and red colored lens (associated with the left wing navigation light) were located on the left side of the energy path. Further examination of a window piece recovered near the initial impact point revealed heavy/coarse scratches consistent with contact with the asphalt surface. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. The rudder control cables were continuous from the control surface to each clevis in the cockpit. The left wing exhibited tree contact about midspan, while a semi-circular indentation about 3 to 4 inches in diameter was noted on the leading edge of the right wing about 2 ft from the wingtip. Correlation of the indentation with the tree limb revealed an approximate left bank of 40 to 45° if the airplane was upright when the contact was made. Located on the ground near the right wing were several tree limbs with live leaves consistent with the species of the impacted tree; one tree limb was about 4 inches in diameter. A 2-inch diameter tree limb with 45° slash that penetrated about 1/2 inch into the limb was also located on the ground in close proximity to the main wreckage. The firewall and remains of the engine were located about 1 ft forward of the flap torque tube. The nose landing gear wheel was deformed, likely by heat damage. The fuel tank was destroyed; the outlet finger screen was clean and the fuel shutoff valve was in the open position. The engine crankcase was nearly consumed by the postcrash fire, exposing the crankshaft, camshaft, lifters, pushrods, oil pump gears, cast iron oil pump cover, steel band clamps, and other small steel parts. Cylinder Nos. 1 and 2 were displaced from their normal orientation while the Nos. 3 and 4 cylinders were still in their proper orientation. All pushrods for cylinder Nos. 3 and 4 were straight, while two of the four pushrods for the Nos. 1 and 2 cylinders were bent. The Nos. 1 and 2 pistons were destroyed by the fire, while the Nos. 3 and 4 pistons were nearly consumed. The intake for the cylinders remained attached but the intake for the Nos. 1 and 2 cylinders was heat damaged. The exhaust valve for the No. 2 cylinder (left forward) was separated from the cylinder and found on the ground. The rocker arms for the Nos. 1 and 2 cylinders intake and exhaust valves were fractured. The crankshaft and camshaft were not fractured. All piston rings except from the No. 3 cylinder were observed; all observed piston rings were in place which no evidence of ring breakage in any cylinder. The exhaust was tightly attached to cylinder Nos. 3 and 4. The ignition, fuel metering, and oil cooler systems were extensively heat damaged. An examination of the spark plugs revealed the following: No. 1 Top - Plug snug, light tan color. Plug Gap at Specification No. 1 Bottom – Could not remove No. 2 Top – White Color. Plug Gap at Specification No. 2 Bottom - Could not remove No. 3 Top - Light Tan. Ground electrode touching center electrode No. 3 Bottom - Light Tan. Plug gap 0.006 inch greater than Specification No. 4 Top - Plug snug, Gray Color. Plug Gap 0.001 inch greater than Specification No. 4 Bottom - Light Tan. Plug gap 0.002 inch less than Specification Examination of the cylinders revealed the following: No. 1 - Valves appeared satisfactory. Rings in place No. 2 - Intake valve in place exhaust valve separated. Rings in cylinder No. 3 - Valves appeared satisfactory. The piston was in the cylinder barrel and the rings were not observed. Piston dome had re-solidified aluminum. Piston appeared satisfactory. No. 4 - Valves satisfactory. Rings in place. Piston extensively heat damaged. One large piece of piston removed. Resolidified aluminum adhering to remaining portion of piston. There was no evidence of any lubrication issue. The oil pump gears which were recovered and examined revealing no broken or damaged teeth. The oil filter was separated from the engine and was extensively heat damaged. The oil filter element and oil cooler were extensively heat damaged. The propeller was destroyed by the postimpact fire. -
Analysis
On the day of the accident, the pilot reported to a friend that the engine had lost power twice during a previous flight that day, but he informed another individual before departing on the accident flight that he had discovered what the problem was and would remain in the airport traffic pattern during the next flight. The pilot departed and proceeded north of the airport, where a witness near the accident site noted that the airplane flying in a westerly direction at high speed toward the ground. About 1 to 2 seconds after the airplane disappeared from his view, he saw black smoke. The airplane had impacted a tree adjacent to an abandoned runway while flying in a westerly direction, then impacted the ground and came to rest inverted. Postaccident examination of the wreckage revealed no evidence of preimpact failure or malfunction of the flight controls. Examination of the power train of the engine revealed no evidence of preimpact failure or malfunction. Although several of the spark plug gap measurements did not meet specification, these conditions likely existed when the flight departed and likely would not have resulted in a total loss of engine power. Extensive thermal damage to the engine precluded examination of the ignition and fuel metering system components. Therefore, it could not be determined whether there was a loss of engine power during the accident flight, or if the pilot was attempting to perform forced landing to the abandoned runway when the collision with the tree occurred.
Probable cause
An in-flight collision with a tree for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Issitt Greg
Model
Sonex
Amateur built
true
Engines
1 Reciprocating
Registration number
N432SX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1044
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-25T00:04:52Z guid: 104218 uri: 104218 title: ERA22LA054 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104230/pdf description:
Unique identifier
104230
NTSB case number
ERA22LA054
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-09T18:05:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-11-30T22:42:34.529Z
Event type
Accident
Location
Sarasota, Florida
Airport
SARASOTA/BRADENTON INTL (SRQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 9, 2021, about 1605 eastern standard time, a Piper PA-28-151, N40831, was substantially damaged when it was involved in an accident near Sarasota, Florida. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot reported that he was returning to his home airport at the end of a roundtrip cross-country flight. While turning from left downwind leg to left base leg for runway 14 at Bradenton International Airport (SRQ), with 10° flap extension, he noticed that the throttle lever was stuck at the 2,000 rpm position. He then turned on to final approach with 25° flap extension and realized that the descent rate was too great and that the airplane was not going to make it to the runway. He completely retracted the flaps to reduce drag and checked the throttle friction lock to loosen the throttle but this had no affect. In an effort to avoid houses at the approach end of the runway, the pilot elected to turn right and ditch in an adjacent bay. The student pilot subsequently egressed and the airplane sank. The wreckage was recovered from the bay and examined by a Federal Aviation Administration inspector. The inspector noted substantial damage to the right wing. He also observed that the throttle cable was jammed inside its housing. The throttle cable was forwarded to the National Transportation Safety Board Materials Laboratory, Washington, DC. Metallurgical examination of the cable revealed that the Teflon liner, which supported the inner cable and prevented metal to metal contact with the helical coil of the cable housing, was worn. Six of the seven wires of the inner cable had separated due to metal to metal contact wear. The seventh (single central) wire did not have the capacity to resist compressive and torsional loading of the cable, which led to collapse and torsional unfurling of the cable (for more information, see Materials Laboratory Factual Report for this accident in the public docket). The airplane was manufactured in 1973 and had accrued about 14,000 hours of operation at the time of the accident. There were no life limited components on the make and model airplane and no published schedule to replace them. Review of the maintenance manual for the 100-hour (500-hour, and 1,000-hour) inspections for the make and model airplane revealed a checklist item (item 37) in the engine group section related to the throttle cable. It stated, “Inspect throttle, carburetor heat, and mixture controls for security, travel, and operating condition.” Review of maintenance records dating back 2 years before the accident did not reveal any problems with the throttle. -
Analysis
The student pilot was turning from downwind to base in the traffic pattern, with 10° flap extension, when he noticed that the throttle lever was stuck with the engine operating at 2,000 rpm. He turned onto final approach with 25° flap extension and realized that the descent rate was too great and that the airplane was not going to make it to the runway. He retracted the flaps to 0° to reduce drag, turned right to avoid houses at the approach end of the runway, and landed the airplane in an adjacent bay. Metallurgical examination of the throttle cable revealed a worn Teflon liner. When intact, the liner supported the inner cable and prevented metal-to-metal contact with the helical coil of the cable housing. Six of the seven wires of the inner cable had separated due to metal-to-metal contact wear. The seventh (single central) wire did not have the capacity to resist compressive and torsional loading of the cable, which led to collapse and torsional unfurling of the cable. The airplane was manufactured 48 years before the accident and had accrued about 14,000 hours of operation. There were no life-limited components on the make and model airplane and no requirement to replace the throttle cable at a scheduled interval. Review of maintenance records dating back 2 years before the accident did not reveal any problems with the throttle.
Probable cause
A partial loss of engine power due to a failed throttle cable.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N40831
Operator
CIRRUS AVIATION INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7415092
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-30T22:42:34Z guid: 104230 uri: 104230 title: ERA22FA056 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104235/pdf description:
Unique identifier
104235
NTSB case number
ERA22FA056
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-10T12:03:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-18T22:09:58.698Z
Event type
Accident
Location
Oak Hill, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On November 10, 2021, about 1003 eastern standard time, an experimental amateur-built Zenith CH601, N22XF, was destroyed when it was involved in an accident near Oak Hill, Florida. The pilot/builder/owner was fatally injured. No flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91. There were no witnesses to the accident and the pilot was not communicating with air traffic control. A review of radar data revealed the airplane departed Massey Ranch Airpark (X50), New Smyrna Beach, Florida, at 1000. The airplane traveled south for about 3 minutes at an altitude of 200 ft above ground level before it made a left turn to the east. The last radar return was at 1003, and the airplane was traveling on a heading of 070° at a ground speed of 98 knots. The airplane wreckage was located within the immediate vicinity of the last radar return. PILOT INFORMATION The pilot held a foreign-based Federal Aviation Administration (FAA) private pilot certificate for airplane single-land airplane. He completed a BasicMed training course and Comprehensive Medical Examination Checklist on February 28, 2021. A review of the pilot’s flight logbook revealed that his last logged flight was on November 3, 2021. At that time, he had a total of 177.3 total flight hours, of which, 5.1 hours were in the accident airplane. AIRPLANE INFORMATION The pilot had recently completed building the airplane and was issued an FAA special airworthiness certificate on September 29, 2021. The airplane and engine had accrued a total of about 8 hours at the time of the accident. WRECKAGE INFORMATION The airplane came to rest in heavily wooded and jungle-like terrain on private property. An on-scene examination revealed the airplane impacted trees then the ground. There was no post-impact fire despite a strong odor of aviation fuel around the impact area. All major components of the airplane were located at the accident site. The engine was buried about 2 ft into the ground and the empennage was folded forward over the cockpit area. The two-blade wooden propeller was fragmented and pieces were located in the impact crater with the engine. The left wing was separated about three feet from the wing root but remained connected by the aileron control cables. Both wings sustained extensive leading edge impact damage. Flight control continuity was established for all major flight components from the flight control surface to the cockpit though there were some breaks in the system due to impact forces and postaccident recovery efforts by rescue personnel. The horizontal stabilator was separated from the empennage and was lying to the left of the main wreckage. The flying rudder had also separated and was lying behind the main wreckage. The electronic elevator trim servo was damaged from impact and a trim setting could not be determined. No mechanical deficiencies were observed with the airframe or flight controls that would have precluded normal operation at the time of impact. The engine sustained impact damage and all four cylinders were pushed slightly aft. The No. 2 and No.4 push rods were also damaged. The top spark plugs were removed, and the interior of each cylinder was examined via borescope. No anomalies were noted with the tops of each piston, the cylinders wall or their respective valves. The top spark plugs appeared normal when compared to the Champion Check-A-Plug chart. All the accessories remained attached to the engine and were removed to facilitate engine rotation. The alternator was pushed into the case, was locked, and would not turn freely. Both magnetos were placed on a test bench, and spark was produced at all terminals. The starter was unremarkable. The oil filter was crushed and filled with mud; however, light colored oil was observed throughout the engine. When the engine’s crankshaft was manually rotated via the propeller flange, it would not turn more than 270 degrees. The impact damaged No. 2 and No. 4 push rods were removed, and the crankshaft rotated freely. Compression was established on each cylinder and valve train continuity was observed on the No. 1 and No. 3 cylinders. The carburetor was disassembled. The fuel finger screen exhibited some light debris. The bowl was empty of fuel and the metal floats had collapsed. The electric fuel pump functioned normally when power was applied. No mechanical deficiencies were observed that would have precluded normal engine operation at the time of impact. The airplane was equipped with a dash mounted attitude and heading reference system (AHRS). The unit was destroyed from impact forces and the memory card that could have contained non-volatile memory from the accident flight was not located. MEDICAL AND PATHOLOGICAL INFORMATION The Volusia County District 7 Medical Examiner’s Office performed the pilot’s autopsy. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident. Two labs performed toxicological testing of postmortem specimens from the pilot. One lab detected ethanol at 0.017 g/dL in cavity blood. The other lab detected ethanol at 0.014 g/dL in blood, 0.017 g/dL in heart tissue, 0.028 g/dL in brain tissue, and 0.122 g/dL in muscle tissue. That lab also detected n-butanol in muscle tissue. -
Analysis
According to radar data, after takeoff, the pilot flew for about 3 minutes at an altitude of about 200 ft above ground level before making a left turn at a ground speed of 98 knots. Shortly after the turn, the radar data ended. The wreckage was located in heavily wooded, jungle-like terrain, in the immediate vicinity of the last radar return. An on-scene examination revealed the airplane likely impacted trees then the ground in a steep nose-down attitude at a high rate of speed. There was a strong odor of aviation fuel around the impact area. All major components of the airplane were located at the accident site. The engine was buried about 2 ft into the ground and the empennage was folded forward over the cockpit area. The two-blade wooden propeller was fragmented but located in the impact crater with the engine. Examination of the airplane wreckage and engine revealed no evidence of any preimpact mechanical deficiencies that would have precluded normal operation at the time of impact. As such, it could not be determined why the airplane descended to ground impact. Toxicological testing of postmortem specimens from the pilot were positive for ethanol and n-butanol. Detection of these substances was most likely due to postmortem production (rather than consumption) and likely did not contribute to the accident.
Probable cause
A loss of airplane control while maneuvering at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
CH601
Amateur built
true
Engines
1 Reciprocating
Registration number
N22XF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6-3611
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-18T22:09:58Z guid: 104235 uri: 104235 title: ERA22FA058 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104237/pdf description:
Unique identifier
104237
NTSB case number
ERA22FA058
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-11T12:48:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2021-11-26T22:57:13.273Z
Event type
Accident
Location
Branchville, New Jersey
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On November 11, 2021, about 1048 eastern standard time, a Cessna 172S, N90559, was destroyed when it was involved in an accident near Hampton Township, New Jersey. The flight instructor and a private pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. A witness in the vicinity of the accident site reported that he heard an airplane maneuvering near his home and noticed various engine pitch changes. He listened to the airplane for a few minutes before returning home. Upon his return, emergency vehicles were in his driveway, prompting him to report what he heard to the authorities. An airplane performance study was conducted using data from the airplane's Garmin G1000 integrated flight instrument system. The G1000 recorded time, position, altitude, attitude, airspeed, acceleration, and engine parameters. The data indicated that the flight departed Essex County Airport (CDW), Caldwell, New Jersey, around 1029. The airplane climbed to a cruise altitude of about 6,400 ft and maintained a northwesterly heading for the first 17 minutes of the flight. At 10:46:30, the airspeed began to decrease due to a power reduction from about 2,400 rpm to 1,300 rpm. Shortly before 1047, the airplane pitched nose up, reaching a maximum pitch attitude of about 37° at 10:47:04 as the airspeed slowed to 28 knots indicated. At 10:47:10, the airplane reached a left-wing-down bank angle of 102° and a nose-down pitch attitude of 79°. The G1000 recorded the airplane’s descent rate at over 8,000 ft/minute 3 seconds later. The recorded airplane data indicated that the pilot initiated a recovery attempt between 10:47:10 and 10:47:30. The pitch attitude increased to 32°, the rate of climb rose to over 2,000 ft/minute, and the airplane was wings-level for 20 seconds as power was increased to 2,400 rpm. However, airspeed only momentarily recovered at 10:47:16. The G1000 did not capture load factors for the final seconds of the flight, likely due to buffering between volatile and non-volatile memory (See “NTSB Vehicle Performance Study” in the public docket). A surveillance video from a camera located at the Sussex County Sheriff’s Communications Center showed the airplane in a very steep spiral turn, continuing this maneuver until it was out of view of the surveillance camera. PILOT INFORMATION A review of the private pilot's logbook revealed that the flight instructor had provided training for the "steep spiral turn" maneuver on numerous occasions during the private pilot's flight training. The "steep spiral turn" is a maneuver requiring specific techniques, and if not executed correctly, common errors can occur. These errors are outlined in the Airplane Flying Handbook (FAA-H-8083-3C), Chapter 10, Performance Maneuvers. Understanding and addressing these potential errors are crucial for safe flight operations. Section 4, Normal Procedures, of the Cessna 172 Pilot Operating Handbook, page 4-40, explains the procedure for spin training and exiting spins. WRECKAGE AND IMPACT EXAMINATION The airplane came to rest oriented on a magnetic heading of 330°, and all major components of the airplane were located at the accident site. The fuselage, from the firewall to the empennage, revealed crush and other related impact damage. The instrument panel and cockpit were destroyed by impact forces. Both wings remained partially attached to the fuselage, and the ailerons and flaps were impact damaged. Flight control surface cable continuity was observed from the flight surfaces to the cockpit controls. The horizontal stabilizers and vertical stabilizer remained attached to the empennage; however, they displayed damage consistent with impact. Both elevators were impact-damaged and remained partially attached to the horizontal stabilizers. The rudder remained attached to the vertical stabilizer and displayed impact damage. Examination of the engine did not reveal any pre-impact mechanical malfunctions or failures that would have precluded normal operation. The propeller remained attached to the engine and displayed chordwise scoring and aft bending. Tree branches showing fresh cuts consistent with propeller slash marks were noted on several trees at the accident site. MEDICAL AND PATHOLOGICAL INFORMATION Certified flight instructor According to the autopsy report by the County of Morris Medical Examiner, Morristown, New Jersey, the cause of death for the flight instructor was multiple injuries and the manner of death was accident. Toxicological testing detected THC in the flight instructor’s blood at 1.5 and 9.3 ng/mL. THC-COOH was detected in one blood specimen at 2.7 ng/mL, another testing facility found the specimen unsuitable for testing. THC and THC-COOH were not detected in vitreous fluid. The flight instructor’s peripheral blood was also positive for caffeine and cotinine. Private pilot According to the autopsy report, the cause of the private pilot’s death was multiple injuries and the manner of death was accident. Toxicological testing did not detect any ethanol or tested-for drugs in the private pilot’s blood. -
Analysis
While on an instructional flight, control of the airplane was lost during a flight maneuver, and the airplane impacted the terrain in a heavily wooded area. Data recovered from the Garmin G1000 integrated flight instrument system revealed that the airplane climbed to a cruise altitude of about 6,400 ft and remained on a northwesterly heading for the first 17 minutes of the flight. The airplane’s airspeed began to decrease due to an engine power reduction from 2,400 rpm to 1,300 rpm. The airplane began to pitch nose up, ultimately reaching a maximum pitch attitude of about 37° as the airspeed slowed to 28 knots indicated. The airplane reached a left-wing-down bank angle of 102° and a nose-down pitch attitude of 79°. The G1000 recorded the airplane’s descent rate at over 8,000 ft/minute 3 seconds later. A surveillance security video showed the airplane in a very steep spiral turn that continued until the airplane was out of view of the camera. Based on the data recovered from the G1000, the reduction of power was intentional, and the aerodynamic stall was induced. The flight instructor’s logbook and receipts from previous flights show the flight instructor and private pilot had practiced steep spiral turns on several occasions. All the major airplane components were located at the accident site. Examination of the airplane and the engine did not reveal any anomalies with the flight controls that would have precluded normal operation. Although toxicological testing of the flight instructor’s blood was positive for THC and the THC metabolite THC-COOH, given the circumstances of this accident and the low concentration found in his blood, it is unlikely that the flight instructor’s performance was impaired by THC at the time of the accident.
Probable cause
The flight instructor’s failure to recover from a steep spiral turn during an instructional flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N90559
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S11076
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-26T22:57:13Z guid: 104237 uri: 104237 title: ENG22LA004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104339/pdf description:
Unique identifier
104339
NTSB case number
ENG22LA004
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-12T11:02:00Z
Publication date
2024-03-08T05:00:00Z
Report type
Final
Last updated
2022-04-27T20:09:15.992Z
Event type
Occurrence
Location
Bellefontaine, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 12, 2021, at 0902 eastern standard time, a Beech F-33A, registration N9035Q, reported an autopilot malfunction while enroute to Bellefontaine, Ohio. There were no injuries to the pilot, the sole occupant. The airplane was registered to Brown Vintage Airlines, LLC. and operated as a 14 Code of Federal Regulations Part 91 flight. The flight originated from Mansfield, Ohio and was destined for Bellefontaine, Ohio. The pilot reported that he departed Mansfield (MFD) at about 0900 on a visual flight rules (VFR) trip and climbed to 4,000 feet mean sea level. Once established at a stable altitude, the pilot engaged the autopilot. The pilot reported an “immediate, pitch down attitude” from the autopilot. The pilot responded by disconnecting the autopilot via the disconnect switch on the yoke. He reported hearing an aural signal but no change in airplane attitude. He then reduced the engine power, disconnected the autopilot on the forward panel and then opened the autopilot circuit breaker. Finally, he was able to bring the airplane nose-level by use of the manual trim wheel on the forward panel. After returning the airplane to 4,000 feet the pilot reengaged the autopilot, but the autopilot reacted in the same manner with another uncommanded nose down movement. After regaining control, the pilot did not reengage the autopilot for the remainder of the flight. The pilot assessed that the airplane could still be flown without the autopilot. After completion of the flight to Bellefontaine, the pilot returned the airplane to Mansfield and brought it to the avionics company that had originally installed the autopilot for troubleshooting. The autopilot’s uncommanded nose down trim was repeated in several instances. In addition to the occurrence flight, the autopilot repeated the nose down trim during troubleshooting at the avionics facility that had installed the autopilot. When the NTSB conducted an autopilot examination on the airplane, the uncommanded nose down trim movement occurred repeatedly. Only after the Garmin GSA 28 autopilot servo actuator in the pitch position was replaced did the uncommanded nose down trim movement cease. Airplane Information The airplane was fitted with a Garmin GFC 500 Autopilot System. The system included the Garmin G5 Electronic Flight Instrument, the GMC 507 Auto Pilot Mode Control Panel, and four GSA 28 servo actuators. The G5 can function as either an attitude display indicator and/or horizontal situation indicator. See Figure 1. Figure 1. Garmin 500 Auto Flight Control System general schematic (courtesy of Garmin, taken from the G5 Electronic Flight Instrument Pilot's Guide for Certified Aircraft). The airplane had the four GSA 28 servo actuators installed in the pitch, pitch trim, roll, and yaw positions. The pitch servo actuator was connected to the elevator surface while the pitch trim servo actuator was connected to the elevator trim surface. The servo actuators are linked via a Controller Area Network (CAN) bus. When the autopilot is engaged, the pitch trim servo will act based on information reported by the primary pitch servo received via the CAN bus. When the autopilot is disengaged, the pitch trim servo can be commanded through a switch on the flight control yoke for manual electric pitch trim. (The occurrence airplane also had a pitch trim wheel on the forward flight panel.) The autopilot was installed in 2019. In August 2021, the GSA 28 servo in the pitch trim position was removed and replaced. According to the paperwork provided by the avionics facility that completed the replacement, the servo was removed because the “pitch trim servo was found to be inoperative.” Only the servo in the pitch trim position was replaced. Wreckage and Impact Information The pilot reported the following minor damage to the airplane: the left elevator trim tab was bent at the actuator arm location and the pitch trim cable was stretched. Tests and Research The NTSB conducted two examinations as part of the investigation – an examination of the airplane’s autopilot, as installed, and an examination of a Garmin GSA 28 servo actuator removed from the airplane. The examination of the airplane’s Garmin 500 GFC Autopilot System was conducted in a hangar at the avionics company that had originally installed the autopilot system. For the tests, the airplane was connected to an air data test set to simulate airspeed and altitude. With the air data test set simulating 130 knots and 4,000 feet altitude and the airplane’s pitch trim in a neutral position, the autopilot was engaged. In response, the autopilot immediately commanded nose down pitch trim to the stop limits. This was repeated several times with the same, nose down trim response. When the trim would reach the stop limit, the autopilot would disengage, with a red “X” on the flight display and an aural alert. (During the NTSB’s autopilot examination in the airplane, the “Monitor Pitch Torque” message was displayed. Garmin indicated that, in flight, the autopilot’s pitch torque monitor could trip after an uncommanded pitch trim movement for five seconds and disconnect the autopilot. The autopilot disconnect would be accompanied by red “AP X” text and an aural warning. However, the “Monitor Pitch Torque” message itself would not be annunciated.) When the autopilot commanded the full nose down pitch trim, the command could be stopped by grabbing the trim wheel and by disconnecting the autopilot via the control wheel switch. During the testing, several of the autopilot system components were replaced with a new or other unit. The GMC 507 Autopilot Mode Controller and the Garmin GSA 28 servo actuator in the pitch trim position were each separately replaced. In each case, when the autopilot was engaged, a full nose down pitch trim was commanded. The GMC 507 and GSA 28 units were replaced with the original units to return the autopilot configuration to its original configuration. When the Garmin GSA 28 servo actuator in the pitch position was removed and replaced with another GSA 28 servo, the autopilot did not command pitch trim when the autopilot was engaged. At the end of the examination, the GSA 28 servo installed in the pitch position was retained by the NTSB for further examination. The GSA 28 servo actuator removed from the pitch servo position was examined at the Garmin facility in Olathe, Kansas. The unit was hand carried to Garmin by the NTSB. The servo was attached to a Garmin automatic test equipment (ATE) test bench and tested against the Garmin GSA 28 Minimum Performance Specification Test. The test ran normally and to completion. The results of the test indicated that the servo failed several of the test elements, including elements related to monitoring of the pitch servo torque. Following completion of the Minimum Performance Specification Test, the unit was dis-assembled to access the servo’s circuit board. The purpose of the visual examination was to look for evidence of sulphuration on the circuit board. Garmin indicated that sulphuration of components on the circuit board was the root cause of the failed servos identified in Service Bulletin 2063. The circuit board was removed from the servo and the padding protecting the reverse/bottom side of the board was removed. The components on the board were examined under magnification. Garmin identified that at least two resistors (R540 and R536, parts of the torque monitoring circuitry) exhibited damage or evidence of sulphuration. The pitch servo was submitted to the NTSB Materials Laboratory for further documentation of the sulphuration. Following the GSA 28 pitch servo actuator examination, Garmin indicated that a review of the resultant test data lead to the determination that an internal failure within the pitch servo can cause the pitch trim servo to run for five seconds before a monitor in the GMC 507 Autopilot Mode Controller detects the failure and disconnects the autopilot. If this occurred, the message shown to the pilot would be a red “AP” annunciation against a black background, indicating an “autopilot abnormal disconnect” accompanied by an aural alert. Garmin also noted that the condition of the tested GSA 28 servo was a unique condition that was different from the failure modes observed on other unit with sulphuration. Garmin determined that the that the servo did not fail test elements like servos that had been returned to Garmin for the sulphuration issue. Additional Information – Garmin Release of Service Documents and FAA Notice of Proposed Rulemaking Following the examination of the GSA 28 servo at their facility, Garmin issued the following service information: 1. Service Alert Number 22109, Date: November 21, 2022 (Revision B of the document was issued on January 11, 2023.) Subject: Automatic Pitch Trim Products Affected:Garmin GFC 500 Autopilots with GSA 28 pitch trim servo Action: Before further flight either disable the GFC 500 by pulling the AUTOPILOT circuit breaker and placard “Inoperative” or contact a Garmin dealer to disable the pitch trim. 2. Aviation Service Document Notification, Date: November 21, 2022 Subject: Disabling Electric Pitch Trim Products Affected:Garmin 500 Autopilot Systems using STC SA01866WI Purpose: The notification provided an alert to the Service Alert Bulletin 22109 3. Service Bulletin 22123, Date January 3, 2023 Subject: Automatic Pitch Trim Enable To:GFC 5009 Autopilot System Owner and Operators Action: The service bulletin authorized a software update that would allow pitch trim to be enabled for the affected autopilot systems. On October 3, 2023, the Federal Aviation Administration issued a Notice of Proposed Rulemaking (NPRM) to issue an Airworthiness Directive (AD) for airplanes modified with a configuration of the Garmin GFC 500 Autopilot System. (The NPRM is Docket Number FAA-2023-1990, Project Identifier AD-2023-00734-A.) If adopted, the AD’s list of affected airplanes would include the occurrence airplane. The AD would require updating the applicable Garmin GFC 500 Autopilot System software and prohibit installing earlier versions of the software. The software update would be required within 12 months of the effective date of the AD. -
Analysis
The pilot reported an uncommanded nose down pitch trim movement. The nose down pitch trim occurred immediately following the pilot’s engagement of the autopilot. The uncommanded nose down trim was repeated when the pilot engaged the autopilot later in the occurrence flight as well as during postflight troubleshooting. During the NTSB’s autopilot examination on the airplane, the uncommanded nose down pitch trim movement occurred repeatedly upon autopilot engagement. When the Garmin GSA 28 pitch servo actuator was removed and replaced with another GSA 28 servo, the uncommanded nose down pitch trim movement ceased. The pitch servo actuator examination at Garmin resulted in test element failures (related to monitoring of the pitch servo torque) that, with the servo installed as part of the airplane’s autopilot, would have caused the autopilot pitch down movement, and, after several seconds, an automatic disconnect. Garmin’s analysis showed that an internal failure on the pitch servo actuator circuit card could cause uncommanded autopilot pitch trim movement before the autopilot would automatically disconnect. As a result of the investigation, the FAA issued a notice of proposed rulemaking (NPRM) for various airplanes modified with the Garmin 500 GFC Autopilot System. The proposed Airworthiness Directive (AD) would require a mandatory software upgrade to the system.
Probable cause
The internal failure of the autopilot pitch servo actuator that caused the autopilot to command a nose down movement of the pitch trim.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
F33
Amateur built
false
Engines
1 Reciprocating
Registration number
N9035Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
CE-310
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2022-04-27T20:09:15Z guid: 104339 uri: 104339 title: WPR22FA033 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104238/pdf description:
Unique identifier
104238
NTSB case number
WPR22FA033
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-12T16:13:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-11-16T07:18:50.764Z
Event type
Accident
Location
Randsburg, California
Airport
Goler Heights Airstrip (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Although friends or family members could not provide specific details regarding the reason for the flight, social media posts indicated that the passenger was camping at the Kern Valley Airport (L05). The pilot sent a route plan to him the night before the accident. The route included multiple airports, backcountry airstrips, and waypoints all within the northern Mojave Desert east of Inyokern. The first waypoint was Goler Heights Airstrip. - According to the kit manufacturer, the airplane was developed as an "off-airport" STOL airplane designed with the capabilities of an ultralight aircraft. The design also met the definition of a light sport aircraft (LSA) for operation under the FAA's Sport Pilot/LSA category. The airplane was issued its airworthiness certificate in 2015, and, according to the airplane’s previous owner, the pilot purchased it from him about 5 months before the accident. The airplane was equipped with leading-edge wing slats, but according to friends of the pilot, they had been removed during the preceding year to increase the airplane’s speed. The kit manufacturer stated that, while the airplane could be flown with the slats removed, the pilot should be aware that the glide ratio would be lower, thus increasing the area required for landing. The airplane’s maintenance logbooks were not located. - The airstrip was located within Bureau of Land Management land and was not identified on any FAA chart or the FAA Airport Facilities Directory. Kern Valley Airport had prepared an unofficial, “SoCal Backcountry Airstrip Guide.” The guide advised a traffic pattern altitude of 3,300 ft msl (830 ft agl), and recommended landing and taking off to the west, weather permitting, due to terrain. - The Appareo Stratus 3 device sustained thermal damage and was sent to the NTSB Vehicle Recorders Division for data extraction. The data indicated that the unit was turned on while in motion, and because accuracy of multiple parameters is dependent on the device being calibrated while it is stationary, many of the recorded parameters were determined to be invalid. However, date/time, GPS position and ground speed appeared to be valid. - On November 12, 2021, about 1413 Pacific standard time, an experimental, amateur-built Zenith STOL CH-701, N984LD, was destroyed when it was involved in accident near Randsburg, California. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The accident occurred at Goler Heights Airstrip, which was located within a 1,500-ft-wide valley at an elevation about 2,450 ft mean sea level (msl). The runway was oriented on a southwesterly heading, with rising terrain to the north, a box canyon in line with the landing approach to the east, and a parallel ridgeline to the south, which fell away to an open desert expanse. A witness, who was located on a camping spot about ½ mile to the west and overlooking the runway, stated that he had camped at that location many times before, and was familiar with aircraft landing on the airstrip. About 1410, he heard the typical sound of an airplane in the traffic pattern and saw a high-wing airplane flying northeast along the ridgeline about 300 ft over the runway. He stated that it was flying in a manner that seemed appropriate for an airplane approaching the southwest runway for landing. A short time later, he heard the sound of increasing engine speed, and when he looked up, the airplane was at the north end of the runway, flying northeast. The airplane was wobbling, and it then began to bank left. Its bank angle reached about 60° such that he could see the full wing profile; the nose then dropped, and the airplane descended rapidly to the ground. Another witness, who was located within the runway valley, stated that his attention was drawn to an airplane flying northeast over the ridgeline. It was flying about 50 ft above the ridge and appeared to be bouncing in a manner that he attributed to the airplane encountering turbulence. He was concerned and continued to watch the airplane as it began a left turn consistent with an approach to land on the southwest runway. The airplane’s bank angle then rapidly increased, reaching what he estimated to be about 90°. The nose of the airplane then suddenly dropped, and the airplane rapidly descended and collided with the ground, erupting in flames. Both witnesses reported that they did not see the airplane emitting smoke or vapors at any time prior to the impact. Data from an onboard Appareo Stratus 3 unit showed that the airplane initially departed from Kern Valley Airport (L05), Kernville, California, at 1134 on the day of the accident, and flew 15 miles north along the Kern River Valley. It then turned around and flew a 65-mile meandering track to the south, before heading northeast and landing at Inyokern Airport (IYK), Inyokern, California, at 1311 (see figure 1). Fuel receipts indicated that at 1331, the pilot purchased 7 gallons of 100 low-lead aviation gasoline. Figure 1 – Flight track. Morning of accident (red), accident flight track (yellow). The airplane departed from IYK on the accident flight at 1349 and climbed to an altitude of about 3,100 ft msl (650 ft above ground level [agl]). The airplane then began a left turn to the southwest in the general direction of Goler Heights, and for the next 18 minutes, gradually climbed to about 5,000 ft msl while maintaining a groundspeed between 55 and 65 kts. At 1409, the airplane had passed over the Red Rock Canyon State Park Mountain Range and was about 3 miles northwest of, and 2,500 ft above the airstrip. Over the next 2 ½ minutes, the airplane began a descending left turn until it reached the parallel ridgeline of the left downwind leg. The airplane maintained a groundspeed of about 60 knots during the decent, with descent rates varying between about 500 and 1,450 ft per minute (see figure 2). Figure 2 – Accident flight track By the time the airplane had reached the downwind leg, it was about 800 ft laterally from the runway and had slowed to a groundspeed of 47 kts. The airplane continued on the downwind leg along the ridgeline about 50 ft agl (125 ft above the runway), as the speed decreased to 40 kts. Shortly after the airplane passed the landing threshold, it began a 25° left turn consistent with the first stage of a base turn. As the runway centerline approached, the airplane’s turn began to tighten, and its groundspeed began to increase to 65 kts, as it overshot the runway centerline and continued toward rising terrain. The airplane’s last position was recorded five seconds later, by which time the airplane had reached the runway heading, but had overshot the centerline by 300 ft. The wreckage was located about 150 ft beyond, and 100 ft below the last recorded position (see figures 3 and 4). Figure 3 –Descent path into traffic pattern. Figure 4 –Plan view of flight track. - Pilot Kern County Sheriff-Coroner’s Office performed the pilot’s autopsy and reported his cause of death as multiple blunt force trauma. The autopsy identified an enlarged, dilated heart and moderate-to-severe aortic atherosclerosis, with no other significant natural disease. Toxicological testing by the FAA Forensic Sciences laboratory detected dextromethorphan and its metabolite dextrorphan, loratadine and its metabolite desloratadine, and carvedilol in cavity blood and liver tissue. Pilot Rated-Passenger The passenger’s most recent second-class FAA medical certificate was issued on February 15, 2019. At that time, he reported no medication use or active medical conditions. According to his autopsy report, the cause of death was multiple blunt force trauma. - One witness to the accident stated that wind was variable and gusting between 20 and 25 knots. He did not see any dust devils or dust disturbance on the ground. Another witness described the wind as gusting and generally out of the north. The airstrip was equipped with a windsock at its west end, just south of the runway. At the time of the accident, it was not in use, having been blown over during a recent storm. A pilot who routinely visited the airstrip stated that he landed shortly after the accident and although the windsock was immobilized, there were multiple campers and off-highway vehicles all flying flags in the recreational area surrounding the airstrip. He estimated that, by the time he landed, the wind was about 10 kts out of the southeast, which he stated was extremely unusual for the area, as they were predominantly out of the west or the southwest. - Pilot The pilot held a commercial pilot certificate with a glider rating and a sport pilot endorsement for airplane single-engine land. He had not applied for FAA medical certification, nor was he required to based on his glider and sport pilot license. The pilot’s flight logbooks were damaged during the post-accident fire, and his flight experience could not be determined. The logbook remnants indicated 549 total flights, the majority of which were in gliders, with 112 total flights in the accident airplane since October 15, 2020. A friend of the pilot stated that he typically flew the airplane two to three times per week, and he had accumulated between 100 and 200 hours of flight experience in it. There was no documentation in the pilot’s logbook indicating he had landed at the accident airstrip before the day of the accident. His flight instructor stated that they had not flown to the airstrip together, and he believed the pilot had limited experience flying into remote airstrips. He stated that the pilot was planning to use the airplane to fly into wilderness spots to go camping and fishing. The pilot was flying the airplane from the left seat, which was the only position that included wheel brake controls. Pilot-Rated Passenger The pilot was a US Navy-trained aviator. In addition to his Navy experience as a helicopter pilot, he held a commercial pilot certificate with airplane, glider, and rotorcraft-helicopter ratings, as well as a flight instructor certificate with a glider rating. He regularly flew the tow airplane for a glider club, and it was through this club that he met the accident pilot. The passenger’s logbooks were current through May 2020. It could not be determined how often the pilot and passenger flew together; however, a social media post provided by family members indicated that they had flown together before in the accident airplane. - The airplane came to rest inverted on a heading of about 035°, in the foothills of the rising terrain of the Red Rock Canyon State Park to the north, about 700 ft short of the southwest runway landing threshold. The first identified point of impact was a ground disruption that contained fragments of propeller blades and three equally-spaced indentations that matched the lateral dimensions of the nose and main landing gear. The disruption continued on a heading of about 215° true for 75 ft to the main wreckage. The entire fuselage through to the leading edge of the horizontal stabilizer, along with most of the right wing and the inboard section of the left wing, sustained extensive crush damage and thermal damage that melted most of the aluminum structure. The horizontal stabilizer and rudder/vertical stabilizer assembly remained intact and came to rest in line with the burnt fuselage remnants. The leading-edge wing slats were not located and appeared to have been previously removed. There was no evidence of preexisting failure to any of the flight controls that had not been thermally destroyed. The flap position could not be determined, and the flight instruments were destroyed by fire. The propeller blades had separated from the hub and were located in the debris field; both exhibited evidence of chordwise rotation. The engine was largely intact and remained attached to the airframe. Internal inspection did not reveal any evidence of catastrophic failure. The engine throttle controls and butterfly valve within the throttle body were at the high-power position. There was no evidence of birdstrike to any of the fuselage or fractured canopy components. The burnt remnants of both seat belts indicated that the belt latches and tongues were locked. -
Analysis
The pilot and pilot-rated passenger planned to fly the experimental, amateur-built short take-off and landing (STOL) airplane to a series of desert airports and backcountry airstrips. The accident airstrip was the first stop on their itinerary. They had flown together at least once before in the accident airplane, but this was the first time the pilot, who was the owner of the airplane, had landed at a remote, backcountry airstrip. The accident airstrip was located within a bowl-like feature in the foothills of a mountain range. Published information about the airstrip recommended a traffic pattern altitude of about 825 ft above ground level (agl); however, flight track data indicated that the airplane’s altitude on the downwind leg was about 50 ft above the ridge that ran roughly parallel to the airstrip, and about 125 ft above the runway surface, with very little lateral separation from the runway. Witnesses observed the airplane fly low over the ridgeline while on the downwind leg, during which it appeared to encounter turbulence. The airplane then began a left turn onto the base leg of the traffic pattern and overshot the runway centerline toward rising terrain as it continued in a left turn onto final approach. The airplane’s bank angle increased to between 60° and 90° as it turned from base to final, and the airplane then rapidly descended, consistent with an aerodynamic stall. The airplane impacted the ground about 700 ft short of the runway threshold and about 300 ft right of the runway centerline. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation, and damage to the propeller blades indicated that the engine was producing power at impact. Witness accounts regarding the direction and velocity of the wind at the time of the accident varied; however, information from a GPS unit onboard the airplane recorded an increased groundspeed on the base leg of the traffic pattern, suggesting crosswind conditions that would have resulted in a tailwind while on the base leg. This likely contributed to the pilot overshooting the runway extended centerline, which placed the airplane closer to rising terrain on the other side of the runway. The runway overshoot, combined with the proximity to rising terrain, likely resulted in the pilot’s steep turn in the direction of the runway as reported by witnesses before the airplane’s descent into terrain. It is likely that, during that turn, the pilot exceeded the airplane’s critical angle of attack, resulting in an accelerated aerodynamic stall. Although the airport windsock was inoperative at the time of the accident, there were flags present at a campsite within the airport valley that would have indicated the direction of the wind. Additionally, the pilot was likely aware of the wind during the downwind leg because the airplane maintained a relatively straight track, which would have required control inputs to compensate for the crosswind conditions. Even without the crosswind, the airplane’s reduced lateral separation from the runway during the downwind leg would have required an aggressive turn onto final to avoid overshooting the runway. The investigation could not rule out the possibility that the pilot-rated passenger was flying the airplane at the time of the accident; however, the airplane’s owner was seated in the left seat, which was the only seat equipped with wheel brake controls. Given that the accident occurred during the approach to land, it is likely the owner was flying the airplane. The terrain surrounding the accident airstrip would have provided an unusual sight picture during the landing approach, likely compounded by the pilot’s decision to fly the traffic pattern at a very low altitude. It is likely that the pilot’s limited experience flying into remote, backcountry airstrips such as the accident airstrip contributed to his failure to establish a stabilized approach to the runway in the presence of unfamiliar topography. The airplane was originally equipped with leading edge slats to enhance short field takeoff and landing performance, but they had been removed. The airplane could be flown without them, and a safe landing at this airstrip could still have been accomplished if a stabilized approach was performed. Although autopsy of the pilot revealed cardiovascular disease, operational evidence indicates that it is unlikely that he experienced a sudden medical event.
Probable cause
The pilot’s improper landing approach, which failed to account for wind conditions, and his exceedance of the airplane’s critical angle of attack following an overshoot of the runway extended centerline, resulting in an accelerated aerodynamic stall. Contributing to the accident was the pilot’s lack of experience flying into challenging backcountry airstrips.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
STOL CH701
Amateur built
true
Engines
1 Reciprocating
Registration number
N984LD
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7-8819
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-16T07:18:50Z guid: 104238 uri: 104238 title: CEN22FA031 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104239/pdf description:
Unique identifier
104239
NTSB case number
CEN22FA031
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-13T15:49:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2021-11-15T06:53:18.471Z
Event type
Accident
Location
Beaver Island, Michigan
Airport
WELKE (6Y8)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 1 serious, 0 minor
Factual narrative
The airplane was a twin-engine, high-wing, strut-braced monoplane with a fixed tricycle landing gear arrangement. It was configured to accommodate 10 people, including the flight crew, with additional baggage capacity behind the passenger seats. The airplane load manifest indicated that the airplane was operating at a weight of 5,903 lbs., and the center of gravity was at 25.3 inches aft of the datum, within the manufacturer’s prescribed weight and center of gravity limits. According to the operator, all passengers and baggage were weighed on a scale before flight. According to the airplane flight manual, for a weight of 6,000 lbs. with flaps down, the stall speed was listed as 42 knots (48 mph). - On November 13, 2021, at 1349 eastern standard time, a Britten Norman BN-2A airplane, N866JA, was substantially damaged when it was involved in an accident near Beaver Island, Michigan. The pilot and three passengers were fatally injured, and one passenger received serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 air taxi flight.   The ADS-B data showed that the airplane departed Charlevoix Municipal Airport (CVX), Charlevoix, Michigan, at 1332. After departing CVX, the airplane turned north and proceeded directly toward Welke Airport (6Y8), Beaver Island, Michigan. The enroute portion of the flight was conducted about 1,500 ft above mean sea level (msl), and the airplane remained at this altitude until it was about 3 nautical miles (nm) from 6Y8. At this point, the airplane descended and maneuvered toward a straight-in approach to runway 35 at 6Y8. The ADS-B data ended about 0.24 nm south of the accident site. The track data from a handheld GPS that was used in the airplane coincided with the ADS-B data but recorded additional data that ended at the accident site. Figure 1: Overview of the accident flight. ADS-B flight track depicted in blue, GPS flight track depicted in red.   Figure 2: Plot of ADS-B and GPS flight track data for the final portion of the accident flight. ADS-B data depicted in blue. GPS data depicted in red.   The GPS recorded position, heading, altitude, and ground speed among other data. The airplane’s airspeed was calculated from the GPS groundspeed considering the recorded winds at the Beaver Island Airport (SJX), located about 2 nm southwest of the accident site. When the airplane was 1,200 ft from the runway threshold, the calculated airspeed was 58 knots, and when 600 ft from the threshold the airspeed was 54 knots. The final recorded data point coincided with the wreckage location and the recorded airspeed was 33 knots. Figure 3 depicts the plotted airspeed during the final portion of the accident flight. The chief pilot for the operator witnessed the accident. He stated that he heard the pilot announce that he was at “Sand Bay”, a location that the operator’s pilots use as a reporting point about 5 minutes from the airport. He stated that he left his house, which is adjacent to the airport, to meet the airplane and he could see the airplane was flying very slowly, in a near stall position. He stated that it appeared to be flying nose-up with no power. He realized that the pilot only had a few seconds to lower the nose and add power before the airplane stalled. His first reaction was that the airplane was “wallowing” and no one was flying the airplane. He stated that the airplane did not recover from the nose-high attitude, then stalled and impacted the ground about 100 ft from the runway. Figure 3. Airspeed during the final portion of the flight. - According to the operator’s report, the pilot had accumulated 2,949 hours of total flight experience with 136 hours in the accident airplane make and model. The pilot was hired by the operator on March 20, 2021, and the operator's training records indicated that the pilot completed the company indoctrination, aircraft ground training, emergency training, crew resource management training, special subjects training, flight training, and differences training between March 21 and July 13, 2021. He passed the airman competency/proficiency check in accordance with 14 CFR Parts 135.293, 135.297, and 135.299 on July 21, 2021. The pilot's flight duty summary indicated that his last duty day before the day of the accident was on November 1, 2021, 12 days before the accident. On that day the pilot was on duty for about 9.3 hours, logged 5.5 hours of flight time, and completed 17 landings. - The airplane impacted the ground about 110 ft east of the extended centerline of runway 35, and 320 ft south of the runway threshold. The turf runway was 3,500 ft long and had a displaced threshold just beyond its intersection with paved runway 9/27. Impact signatures indicated that the airplane struck the ground in a left-wing-low, nose-low attitude. The front of the fuselage was crushed upward and aft.   Figure 4. Overall view of the airplane wreckage at the accident site.   All major components of the airplane were located at the accident scene. Flight control continuity was established from the cockpit controls to each respective control surface except for cuts made by first responders for occupant extraction. Engine control continuity was established from the cockpit to each engine except for cuts made by first responders for occupant extraction. The wing flaps were found in an extended position. Examination of the airframe, engines, and propellers did not reveal any preimpact mechanical malfunction or failures that would have precluded normal operation. -
Analysis
A pilot-rated witness observed the airplane during the final approach to the destination airport and stated that the airplane was flying slowly, with a high pitch attitude, and was “wallowing” as if nobody was flying. The airplane stalled and impacted the ground about 300 ft from the runway. GPS and automatic dependent surveillance-broadcast (ADS-B) data captured the accident flight, but the ADS-B data ended about 0.24 miles before the accident. GPS data showed that the airplane’s speed was at or near the published stall speed for the airplane’s given loading condition. The airplane sustained substantial damage to the fuselage and both wings. Examination of the airplane verified flight and engine control continuity. No preimpact anomalies were found with respect to the airplane, engines, or systems. The pilot allowed the airspeed to decrease during the approach, increased pitch attitude, and exceeded critical angle of attack, which resulted in an aerodynamic stall and spin into terrain.
Probable cause
The pilot's exceedance of the airplane's critical angle of attack during final approach, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BRITTEN-NORMAN
Model
BN-2A
Amateur built
false
Engines
2 Reciprocating
Registration number
N866JA
Operator
MCPHILLIPS FLYING SERVICE INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
185
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-15T06:53:18Z guid: 104239 uri: 104239 title: WPR22LA039 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104272/pdf description:
Unique identifier
104272
NTSB case number
WPR22LA039
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-14T15:15:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2021-12-15T21:16:38.937Z
Event type
Accident
Location
North Las Vegas, Nevada
Airport
NORTH LAS VEGAS (VGT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 14, 2021, about 1315 Pacific standard time, an IAI 1125 Westwind Astra airplane, N771DX, was substantially damaged when it was involved in an accident near Las Vegas, Nevada. The pilot and passenger were uninjured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported to the Federal Aviation Administration that he departed the North Las Vegas Airport (VGT), Las Vegas, Nevada, and remained in the traffic pattern during the flight. He said that the nose landing gear indicator light was intermittent when the landing gear was extended before landing. The pilot aborted the first landing and reentered the pattern for a second attempt. Security video shows the airplane touching down with the landing gear fully extended with about 2,000 ft of runway remaining. The airplane’s thrust reversers were not deployed, and the airplane exited the departure end of the runway. The examination of the accident site revealed that the airplane landed at about the 2,000 ft runway marker, skidded about 965 ft down the runway and into the runway safety area. The airplane traveled over a concrete culvert, separating the nose landing gear and main landing gear. The wings sustained substantial damage. The cockpit voice recorder (CVR) was removed from the airplane and sent to the National Transportation Safety Board for download. The CVR unit had internal damage and did not record during the accident flight. The owner of the airplane reported that there was a potential buyer who was interested in the airplane, and that he provided the names of two pilots who were type rated in the accident airplane to the potential buyer. The potential buyer gave authorization for both pilots to conduct the pre-buy flight. The first pilot reported that, on the day of the accident, the passenger seated in the front right seat was not a pilot, but instead was a friend of his family. The second pilot approved to conduct the flight was in Florida on the day of the accident. According to the airplane’s type certificate, the airplane requires a minimum of two pilots for flight operations. -
Analysis
The pilot and a passenger departed on a local flight in an airplane that requires a minimum crew of 2 pilots. The airplane landed about halfway down the runway, with about 2,000 ft of runway remaining. The pilot did not deploy the thrust reversers and the airplane skidded about 965 ft down the runway and into the runway safety area. The airplane collided with a culvert, resulting in the separation of the landing gear and substantial damage to both wings.
Probable cause
The pilot landed long and failed to deploy the thrust reversers, which resulted in a runway overrun and impact with terrain. Contributing to the accident was the pilot’s decision to operate the airplane as a single pilot instead of the required minimum crew of two pilots.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
IAI
Model
1125 Westwind Astra
Amateur built
false
Engines
2 Turbo jet
Registration number
N771DX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
077
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-15T21:16:38Z guid: 104272 uri: 104272 title: WPR22LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104273/pdf description:
Unique identifier
104273
NTSB case number
WPR22LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-14T16:23:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2021-12-15T21:16:11.853Z
Event type
Accident
Location
Boulder City, Nevada
Airport
BOULDER CITY MUNI (BVU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 14, 2021, about 1423 Pacific standard time, a Piper PA-28R-200 airplane, N5057S, was substantially damaged when it was involved in an accident at the Boulder City Municipal Airport (BVU), Boulder City, Nevada. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that after receiving the airplane from the paint shop, he conducted two takeoffs and landings in the local traffic pattern to check that the landing gear retracted and extended properly. Once the maintenance check flight was completed, he and his passenger departed on the accident flight to BVU. During the approach to BVU, the right main landing gear would not extend. The pilot cycled the landing gear and made several abrupt, high-G maneuvers to try and free the right main landing gear from its retracted position. Despite his actions, the right main landing gear would not extend. The pilot decided to land with the left main landing gear and the nose landing gear extended. As the airplane slowed during the landing roll, the right wing dropped to the runway surface and the airplane veered off the right side of the runway. The airplane came to rest over a small ditch and sustained substantial damage to the aft fuselage and right wing. The pilot reported that the right main landing gear was retracted, and the landing gear door was opened about 1 to 2 inches. He said that he positioned himself in the ditch below the landing gear and pulled hard on the door to extend the gear. After a couple of attempts, the landing gear suddenly dropped down into place. During a postaccident examination, the airplane was lifted up on jacks and the airplane’s landing gear was examined. The emergency gear extension functioned normally, and both the nose landing gear and main gear fell into the down and locked position. Mechanical damage was found on the right main landing gear wheel well near the right gear door rod-end bolt travel area. The mechanical damage was consistent with the threaded end portion of the bolt. The right main landing gear door rod-end bolt had about 4 additional threads than the bolt used on the left main landing gear. The bolt was removed, and its length was 1-4/25 inch, which was about 1/8 inch longer than the correctly installed bolt, which measured 1-1/32 inch. Figure 1-Landing gear linkage and wheel well damage. The paint shop reported that the gear doors were never removed from the landing gear structure during the painting process. They reported that on this type of aircraft they do not remove the gear doors. -
Analysis
During an approach to the airport, the right main landing gear would not extend. The pilot cycled the landing gear and made several abrupt, high-G maneuvers to try and free the right main landing gear from its retracted position. Despite his actions, the right main landing gear would not extend. During the landing, the airplane sustained substantial damage to the aft fuselage and right wing. During the postaccident examination of the airplane, the right main landing gear wheel well exhibited mechanical damage consistent with contact from the threaded end of the right gear door rod-end bolt. The right main landing gear door rod-end bolt had about 4 additional threads than the bolt used on the left main landing gear. The bolt was removed, and its length was 1-4/25 inch, which was about 1/8 inch longer than the correctly installed bolt, which measured 1-1/32 inch. It is likely that during the accident flight, the right main landing gear could not fully extend due to the right gear door rod-end bolt positioning itself on the inside of the landing gear wheel well, preventing the landing gear from extending.
Probable cause
The installation of an improper right main landing gear door rod-end bolt, which resulted in the right main landing gear not extending during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N5057S
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-35784
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-15T21:16:11Z guid: 104273 uri: 104273 title: CEN22LA039 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104265/pdf description:
Unique identifier
104265
NTSB case number
CEN22LA039
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T09:45:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-11-24T18:48:22.58Z
Event type
Accident
Location
Rockport, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On November 15, 2021, about 0745 central standard time, a Beech A36TC airplane, N1805D, sustained substantial damage when it was involved in an accident near Aransas County Airport (RKP), Rockport, Texas. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before departure, the airplane contained a total of 70 gallons of fuel: 20 gallons in each wing tip tank (40 gallons) and about 15 gallons in each main tank (30 gallons). The pilot estimated that the cross-country flight to RKP would take about 45 minutes. Shortly after departure, the pilot switched the fuel selector from a main tank to the left tip tank. About 20 minutes into the flight, the pilot noticed “a trail of fuel being sucked out of both the left and right main [tank] gas caps.” The pilot decided to continue with the flight because, at that time, the airplane was about halfway to RKP and the weather was favorable. About 30 miles from RKP, the pilot switched to the left main fuel tank to prepare for a visual approach and landing. When the airplane was at an altitude of 1,200 ft and was about 4 miles from the runway, the engine “sputtered a couple of times and quit completely.” The pilot switched to the right main fuel tank, which indicated 1/2 fuel, and attempted an engine restart that was unsuccessful. The pilot switched back to the left main fuel tank, which also indicated 1/2 fuel. The pilot realized that the airplane was not going to make it to the runway, so he ditched the airplane into Copano Bay, 1.5 miles short of RKP. The airplane impacted the water and came to rest upright. Postaccident examination showed that the airplane sustained substantial damage to the fuselage, both wings, and ailerons. Due to water immersion, the engine could not be functionally tested. The enginedriven fuel pump was removed; residual fuel, consistent with aviation gasoline, drained from the fuel pump, and the drive spline was intact. The magnetos were water damaged and thus were unable to be tested. Mechanical continuity throughout the engine was noted when the propeller was rotated by hand. The fuel selector was found in the left main fuel tank position. Compressed air was applied to the fuel system to verify integrity of the fuel lines and system. The test revealed that air was venting from both the left and right fuel caps; no additional anomalies were noted with the fuel system. Both the left and right fuel caps showed evidence of water corrosion, and the cap O-rings appeared dry and pliable. -
Analysis
The private pilot stated that, before departure for the 45-minute flight, the airplane contained 70 total gallons of fuel: 20 gallons in each wing tip tank and about 15 gallons in each main tank. Shortly after departure, the pilot switched the fuel selector from a main tank to the left tip tank. About 20 minutes into the flight, the pilot noticed “a trail of fuel being sucked out of both the left and right main [tank] gas caps.” The pilot decided to continue the flight because, at that time, the airplane was about halfway to the destination airport and the weather was favorable. In preparation for the visual approach, the pilot switched the fuel selector to the left main fuel tank. When the airplane was at an altitude of 1,200 ft and was about 4 miles from the runway, the engine “sputtered a couple of times and quit completely.” The pilot switched to the right main fuel tank, which indicated 1/2 fuel and attempted an engine restart that was unsuccessful. The pilot switched back to the left main fuel tank, which also indicated 1/2 fuel. The pilot recognized that the airplane was not going to make it to the runway, so he ditched the airplane into the water about 1.5 miles short of the runway. The airplane sustained substantial damage to the fuselage, both wings and ailerons. Postaccident examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The fuel selector was found in the left main fuel tank position. The engine and magnetos could not be functionally tested due to water immersion/damage. The enginedriven fuel pump was removed; residual fuel, consistent with aviation gasoline, drained from the fuel pump, and the drive spline was intact. Application of compressed air to the fuel system revealed the venting of air from the left and right fuel caps; no additional anomalies were noted with the fuel system. Both the left and right fuel caps showed evidence of water corrosion, and the cap O-rings appeared dry and pliable. Although the pilot reported observing fuel draining from the fuel caps, he also reported the airplane fuel tank indicators showed about one-half of the fuel capacity in each main fuel tank when the engine lost power. As a result, the reason for the total loss of engine power could not be determined based on the available evidence for this investigation.
Probable cause
The total loss of engine power for reasons that could not be determined based on available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N1805D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
EA-233
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-24T18:48:22Z guid: 104265 uri: 104265 title: WPR22LA034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104243/pdf description:
Unique identifier
104243
NTSB case number
WPR22LA034
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T10:19:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2021-11-16T20:57:09.978Z
Event type
Accident
Location
Molalla, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 15, 2021, about 0819 mountain daylight time, a Bell OH-58A helicopter, N103WC, was substantially damaged when it was involved in an accident near Molalla, Oregon. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 rotorcraft external load flight. The pilot reported that he was on an external sling load flight, relocating Christmas trees. About 30 minutes into the flight, while enroute to refuel, the master caution light and the fuel boost light illuminated. He landed the helicopter without incident. While on the ground, prior to hot refueling, he reduced the engine power setting to idle and attempted to reset the master caution light and cycled the fuel boost switch and circuit breakers, but the lights remained illuminated. After the helicopter was refueled, the pilot increased the engine power setting to 100% and recycled the fuel boost switch and circuit breakers again and the lights extinguished. The pilot added that the operator reminded him that the fuel boost light would intermittently illuminate and extinguish. The pilot then hovered the helicopter and verified that the master caution and fuel boost lights did not illuminate. Shortly after, he maneuvered the helicopter to the loading site and trees were hooked to the external sling. The pilot lifted off and as the helicopter climbed through 60 ft above the ground, he heard a change in sound from the engine and felt the helicopter yaw. Immediately after he verified that the people on the ground were clear, he released the external load. The helicopter lost altitude and the pilot heard the main rotor speed decay, so he initiated an autorotation. As the helicopter approached the ground, the pilot raised the collective while maintaining heading. The skids contacted the water-soaked soil, and the helicopter rocked nose-low, bounced, and came to rest upright. Subsequently, the main rotor blade struck the tailboom and separated the tail rotor and tail rotor gear box assembly. Postaccident examination of the engine revealed no evidence of preimpact fire or postimpact damage. Fuel continuity was established from the fuel tank to the fuel nozzle; no fuel leaks were noted. A subsequent ground idle engine run was performed. The engine was started using battery power and a normal start sequence, which included use of the airframe mounted boost pump. The engine started normally and ran at ground idle without hesitation for approximately 5 minutes. The FUEL BOOST light on the annunciator panel remained extinguished during the entire time. After 5 minutes, the fuel boost pump was turned off, the FUEL BOOST light illuminated, and the engine continued to run at ground idle with no observed anomalies for approximately 4 additional minutes. The operator reported that the fuel boost caution light illuminated randomly, independent of whether the boost pump was operating, even after the helicopter’s most recent inspection. According to the helicopter manufacturer’s hover performance charts, at 100% N2, at a skid height of 50 ft, at a gross weight of about 2350 pounds, and at a pressure altitude of 250 ft and 15°C, the helicopter would need about 58% torque to hover. The estimated gross weight of the helicopter was 2,350 pounds. No preimpact mechanical anomalies were observed when the engine was run in a test cell using the manufacturer’s acceptance test procedure. The Fuel Control Unit was bench tested in accordance with manufacturer overhaul manual procedures and it tested successfully by meeting serviceable limits. A compressor case half was removed to facilitate visual assessment of the compressor flow path. No pre-existing conditions were found that would have precluded normal operation. A breakaway valve CT scan showed that the breakaway mechanism was intact, and the valve was open. The breakaway valve did not show any anomalies during a fuel flow test. -
Analysis
The helicopter pilot was lifting off with an external load of Christmas trees. As the helicopter climbed above 60 ft above the ground (agl), the pilot reported that he simultaneously heard a change in sound from the engine and felt the helicopter yaw, but could not remember which direction the helicopter yawed. After he released the external load, the helicopter lost altitude and he heard the main rotor speed decay. He initiated an autorotation and raised the collective while maintaining heading in the landing flare. The skids contacted the water-soaked soil and the helicopter rocked nose-low, bounced, and came to rest upright. Subsequently, the main rotor blade struck the tailboom and separated the tail rotor and tail rotor gearbox assembly. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunction or failure that would have precluded normal operation. The engine functioned normally during two separate tests and the intermittent operation of the fuel boost pump annunciator light could not be replicated. According to the helicopter manufacturer, under the given conditions, at a gross weight of 2,350 pounds and a height of 50 feet, a hover out of ground effect can be accomplished. The reason for the loss of engine power was undetermined.
Probable cause
The loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
OH-58A
Amateur built
false
Engines
1 Turbo shaft
Registration number
N103WC
Operator
EDGEFIELD AVIATION LLC
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
External load
Commercial sightseeing flight
false
Serial number
69-16083
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-16T20:57:09Z guid: 104243 uri: 104243 title: ERA22LA064 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104268/pdf description:
Unique identifier
104268
NTSB case number
ERA22LA064
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T12:12:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-12-13T04:43:28.509Z
Event type
Accident
Location
Tampa, Florida
Airport
Peter O Knight (TPF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 15, 2021, about 1012 eastern standard time, a Mooney M20M, N21890, was substantially damaged when it was involved in an accident near Tampa, Florida. The private pilot and one passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.    The pilot stated that he flew the airplane earlier that day on an uneventful 15-minute flight from Peter O Knight Airport (TPF), Tampa, Florida, to Lakeland Linder International Airport, Lakeland, Florida. After landing he picked up his passenger and departed for Gainesville Regional Airport, Gainesville, Florida. At 3,000 ft mean sea level (msl) with the mixture control full rich and the engine operating at 32 inHg and 2,400 rpm., he noted the turbine inlet temperature (TIT) was in the red range. At the same time of the high TIT reading, he noticed liquid on the bottom portion of the windshield. He confirmed that the mixture control was full rich and reduced engine power, which decreased the TIT reading, but there was still liquid on the windshield. While at 4,000 ft msl, he advised air traffic control of the higher temperature and diverted to TPF, maintaining 4,000 ft msl until on the downwind leg of the airport traffic pattern where he reduced power, extended the landing gear and lowered the 1st notch of flaps. He turned onto the base leg, and at 1,200 ft above ground level before turning onto final, he added throttle, but the engine did not respond. He pushed the mixture, propeller, and throttle controls full forward, which at full throttle automatically turned on the auxiliary fuel pump, but noted the propeller was windmilling. At 800 ft msl, he realized he would be unable to make the runway and told his passenger about the impending ditching. He retracted the landing gear and maintained a nose-up wings level attitude ditching the airplane. Both occupants exited the airplane and were transported to land. The underside of the fuselage was substantially damaged during the ditching. Following recovery of the airplane, examination of the fuel lines in the engine compartment revealed the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Pressure testing of the fuel supply system was performed with the b-nut in the as-found position revealed fuel leaked at the b-nut. After the b-nut was tightened, no leakage was noted at the b-nut. Inspection of the threads of the fitting and of the flexible fuel hose revealed no discrepancies. Torque stripes were noted on the fuel injector nuts at the manifold valve. Review of the maintenance records revealed that nearly 2 months before the accident, fuel system components consisting of the engine-driven fuel pump, servo fuel injector, manifold valve, and fuel injectors were removed for testing and overhaul. The components were installed and according to the pilot, the airplane had been operated about 12 hours over 3 or 4 flights since installation. There was no record of any subsequent engine work after the overhauled components were installed. The mechanic who installed the components after testing and/or overhaul reported that the airplane owner helped with the installation. The mechanic also indicated that he normally would have applied a torque stripe to the inlet hose at the manifold valve. -
Analysis
While in cruise flight, the pilot noticed the turbine inlet temperature (TIT) was about 100° F above the maximum reading and that liquid was on the windshield. He reduced engine power, which lowered the TIT reading and then diverted to his home airport. While on the base leg of the airport traffic pattern at 1,200 ft above gound level, he advanced the throttle, but the engine did not respond. At 800 ft msl he noted he would be unable to reach the airport and ditched the airplane. Both occupants exited the airplane and were transported to land, and the airplane’s fuselage was substantially damaged during the ditching. Following recovery of the airplane, the inlet fuel line at the manifold valve was 7.5 flats of the b-nut from being hand tight against the inlet fitting. There was no provision for safety wiring the b-nut and there was no torque stripe on the b-nut or inlet fitting. Fuel leakage was noted at the loose b-nut during pressure testing, but no leakage occurred after tightening the b-nut. There was no damage to the b-nut or fitting that would have precluded obtaining the proper torque. The manifold valve was overhauled and installed nearly 2 months earlier. The mechanic who signed off the installation indicated he normally would have applied a torque stripe on the b-nut. Based on this information, it is likely that the overheating of the engine and the subsequent loss of engine power was likely due to a fuel leak at the fuel manifold valve, resulting an excessively lean fuel to air mixture. It is also likely that the loose b-nut had not been properly tightened during the reinstallation of the manifold valve.
Probable cause
The total loss of engine power due to the failure of maintenance personnel to properly tighten the fuel supply line b-nut at the manifold valve during installation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20M
Amateur built
false
Engines
1 Reciprocating
Registration number
N21890
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
27-0293
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-13T04:43:28Z guid: 104268 uri: 104268 title: WPR22LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104244/pdf description:
Unique identifier
104244
NTSB case number
WPR22LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T13:30:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2021-12-03T03:55:57.2Z
Event type
Accident
Location
Laveen Village, Arizona
Airport
HANGAR HACIENDAS (AZ90)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On November 15, 2021, about 1130 mountain standard time, an experimental amateur-built Sonex Waiex-B airplane, N535D, was substantially damaged when it was involved in an accident near Laveen Village, Arizona. The pilot was not injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he had been flying for about 48 minutes when the engine began to run rough. He said the airplane did not have enough power to maintain altitude and he initiated a forced landing to an airstrip. The pilot realized he was not going to make the airstrip and landed on desert terrain, impacting rocks and a barbed wire fence which caused the airplane to nose over which resulted in substantial damage to the wings, stabilizers, and ruddervators. The pilot was able to exit the cabin area through the broken canopy. Examination of the airplane revealed that the No. 4 cylinder exhaust valve rocker arm swivel housing and swivel pad separated from its screw body. The screw body remained secured to the rocker arm. The swivel pad and swivel housing were found loose in the rocker cover. The swivel pad remained loose in the swivel housing and impact damage was visible on the swivel housing fracture surface. The rocker assembly for No. 3 and 4 cylinders and the separated swivel housing and swivel pad (see figure) were sent to the National Transportation Safety Board Materials Laboratory for forensic examination. The examination revealed a damaged fracture surface of the swivel housing and the screw body. The spherical outboard side of the swivel pad had a rough surface consistent with scoring and galling damage. The damage pattern had circular patterns on two sides with linear features in between, consistent with rotating contact within the swivel housing. The swivel housing had scoring and galling that mirrored the damage patterns observed on the swivel pad with a circular pattern on two sides and linear scratches between. The interior of the swivel housing had worn away, producing a space for the swivel pad to be recessed within the housing. This worn area was located near the facture surface of the swivel housing and screw body. Figure - Overall view of the rocker assembly showing the inboard side of the rocker arms including the fractured No. 4 exhaust valve adjuster. Review of the airplane’s maintenance records revealed that the engine was assembled on May 9, 2018. The last inspection was completed on October 12, 2021, with about 110 hours of engine operation since the engine had been assembled. At this time, the cylinders were torqued, and the valves were adjusted. The airplane flew another 25 hours before the accident. -
Analysis
The pilot reported the engine began running rough during cruise flight, and the airplane could not maintain altitude. The pilot initiated a forced landing to an airstrip and during the descent realized that he was not going to make the airstrip, so he elected to landed on the desert terrain. The airplane impacted rocks and a barbed wire fence which caused the airplane to nose over, which resulted in substantial damage to the wings, stabilizers, and ruddervators. Postaccident examination of the engine revealed that the No. 4 exhaust rocker assembly swivel housing separated from the screw body, likely due to wear of the swivel and the swivel pad housing. This wear likely occurred because of either incorrect spacing between the pad and valve, or corrosion.
Probable cause
Failure of the rocker swivel assembly due to either wear or corrosion, which resulted in a loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Sonex
Model
WAIEX B
Amateur built
true
Engines
1 Reciprocating
Registration number
N535D
Operator
AIR-SPACES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
WXB0010
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-03T03:55:57Z guid: 104244 uri: 104244 title: CEN22LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104267/pdf description:
Unique identifier
104267
NTSB case number
CEN22LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T13:50:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2021-11-30T01:57:42.277Z
Event type
Accident
Location
Abilene, Texas
Airport
ABILENE RGNL (ABI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On November 15, 2021, about 1150 central standard time, a Beech 23 airplane, N8701M, was substantially damaged when it was involved in an accident near Abilene Regional Airport (ABI), Abilene, Texas. The flight instructor received serious injuries and the student pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that on the morning of the accident, 4.19 gallons of fuel were added to the right fuel tank; no additional fuel was added due to an issue with the self-service fuel pump. After fueling, the instructor estimated that the airplane contained about 15 gallons in each the left and right tanks. The first instructional flight was 1 hour, and the airplane consumed an average of 8 gallons per hour in cruise flight. He estimated that after the first flight there would have been about 15 gallons remaining in the left tank and 7 gallons in the right tank. The second instructional flight was about 1.1 hours, during which they completed maneuvers in the local area then returned to ABI for practice landings. During this flight they used both fuel tanks equally, switching between tanks about every 30 minutes, and there would have been about 11 gallons remaining in the left tank and about 3 gallons in the right tank. They had completed one touch-and-go landing at ABI, then after takeoff, about 500 ft above ground level (agl), the engine sustained a loss of power. The flight instructor took control of the airplane and requested that the student pilot complete the emergency checklist for a loss of engine power. They were unable to restart the engine and made an emergency landing to an area of mesquite trees. The student pilot stated that, after the initial loss of engine power, he followed the checklist and switched the fuel selector from the left to the right fuel tank. He stated the engine started but sputtered like it was not getting fuel. The airplane owner stated that he had leased the airplane to two pilots who intended to use it for their flight instruction business. He estimated that on the morning of the accident there would have been about 32 gallons of fuel in the airplane. The responding Federal Aviation Administration Inspector reported that the fuel tanks were breached and there was no sign or smell of residual fuel at the accident site. The fuel line from the fuel pump to the carburetor was void of fuel. The carburetor bowl was intact, but the position of the wreckage prevented an examination of the contents of the bowl at the accident site. The airplane sustained substantial damage to the wings, fuselage, and empennage. Postaccident examination of the airplane revealed that the fuel selector handle was positioned to OFF, and when actuated, it moved through LEFT, RIGHT, and OFF positions without issue. Air was blown through the fuel selector in the LEFT and RIGHT positions with no obstructions noted. The fuel strainer was intact and attached to the airplane, and it did not contain any fuel or contaminants. The engine-driven fuel pump was intact and attached to the engine. The fuel pump actuated with no anomalies noted. The carburetor was found partially fractured near the butterfly valve area. There was no fuel in the carburetor bowl and no anomalies noted with the unit. The fuel tank filler ports were not placarded with any information. The fuel selector valve displayed placards that indicated 29 gallons of (usable) fuel for each tank. In 1974, Beechcraft Service Instructions No. 0624-281, Fuel System – Replacarding to indicate minimum fuel for takeoff and increase amount of unusable fuel, was issued for the accident airplane. The pilot’s operating handbook revealed that the total unusable fuel increased from 1 gallon to 7.6 gallons (3.8 gallons per tank). The instructions had not been complied with since there were no updated placards to indicate 26 gallons of usable fuel for each tank. A fuel consumption estimation was completed based on the available evidence, which used only information recalled by the owner and pilots and could not be validated with any recorded data or other evidence. The estimation concluded that there could have been up to 7.79 gallons of usable fuel available. The flight instructor later stated that he thought the airplane was equipped with a 59.8-gallon system and was not aware that the usable fuel was only 52.2 gallons. He added that accident was possibly a result of fuel exhaustion. -
Analysis
The flight instructor completed about a 1-hour instructional flight with a student pilot, then was able to add only 4.19 gallons of fuel due to an issue with the airport’s fuel pump. The flight instructor then completed another 1-hour flight with a second student pilot. During this flight they used both fuel tanks, switching between tanks about every 30 minutes, and the flight instructor thought there would have been about 11 gallons remaining in the left tank and about 3 gallons in the right tank. They had completed one touch-and-go landing, then after takeoff, about 500 ft above ground level, the engine sustained a loss of power. The flight instructor took control of the airplane and requested that the student pilot complete the emergency checklist for a loss of engine power. They were unable to restart the engine and made an emergency landing to an area of mesquite trees. The airplane sustained substantial damage to the wings, fuselage, and empennage. The initial postaccident examination revealed that the wing fuel tanks were breached during the impact with trees and there was no sign or smell of residual fuel at the accident site. A detailed examination of the engine and fuel system did not reveal any residual fuel in the fuel system or engine components, and there were no anomalies found that would have precluded normal operation. The airplane manufacturer issued service instructions in 1974 that increased the amount of total unusable fuel from 1 gallon to 7.6 gallons (3.8 gallons per tank). The instructions had not been complied with since there were no updated placards to indicate 26 gallons of usable fuel for each tank. A postaccident fuel consumption estimation was completed based on the available evidence, which concluded that there could have been up to 7.79 gallons of usable fuel available. Since there was no recorded engine data, fuel quantity data, fuel at the accident site, or fuel remaining the airplane, the investigation was unable to determine the exact amount of usable fuel available, if any, when the loss of engine power occurred. It is likely that the flight instructor’s misunderstanding of the usable fuel quantity, and his inadequate management of the available fuel, resulted in fuel starvation and a loss of engine power.
Probable cause
The flight instructor’s inadequate fuel management, which resulted in a loss of engine power due to fuel starvation. Contributing to the accident was the missing placard showing the usable fuel quantity.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
23
Amateur built
false
Engines
1 Reciprocating
Registration number
N8701M
Operator
Lytle Aviaiton
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
M-485
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-30T01:57:42Z guid: 104267 uri: 104267 title: CEN22FA032 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104245/pdf description:
Unique identifier
104245
NTSB case number
CEN22FA032
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T14:45:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-11-22T19:20:47.142Z
Event type
Accident
Location
Boyne City, Michigan
Airport
BOYNE CITY MUNI (N98)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane had been modified numerous times since 1973 and was equipped with Honeywell TPE331-10 engines, McCauley 5-bladed propellers, and Garmin avionics. The aircraft was the original test vehicle for the Honeywell engine and McCauley propeller supplemental type certificate (STC) development. The airplane was the first of two modified by the STC. The owner/pilot of the second STC airplane reported that a rapid deceleration on final approach would occur when propeller levers were moved to the high rpm (forward) position, so he normally waited until the airplane was on short final to do so. A different pilot who flew the accident airplane observed it rapidly decelerate from 135 to 100 knots during level off on one occasion. This pilot normally flew jets and the rapid deceleration was surprising to him. Another pilot who flew the accident airplane stated he normally landed with partial engine power on to avoid the airplane decelerating prematurely. According to FAA flight testing that was conducted in conjunction with the STC, the stall speed with landing gear down and 0° flaps was 89 knots indicated airspeed. Flight testing results were determined to be satisfactory. The airplane flight manual included the following caution about icing: Stalling airspeeds should be expected to increase when ice has accumulated on the airplane due to distortion of the wing airflow. Keep a comfortable margin of airspeed above the normal stall airspeed with ice on the airplane. Maintain a minimum of 140 knots during icing conditions to prevent ice accumulation on unprotected surfaces of the wing. - On November 15, 2021, about 1245 eastern standard time, a Beech E-90, N290KA, was destroyed when it was involved in an accident near Boyne City, Michigan. The airline transport pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. A review of automatic dependent surveillance-broadcast (ADS-B) data revealed the airplane departed Oakland County International Airport (PTK), Pontiac, Michigan, at 1150 and climbed to a cruise altitude of 16,000 ft mean sea level (msl) enroute to Boyne City Municipal Airport (N98), Boyne City, Michigan. The airplane descended toward N98 and air traffic control cleared the pilot for the RNAV GPS Rwy 27 approach. While established on final approach, the airplane gradually slowed from 129 to 88 knots groundspeed over a period of one minute. The last recorded ADS-B data showed the airplane at 88 knots groundspeed, about 3.2 nautical miles from the runway, and about 600 ft above ground level. The airplane impacted the ground about 600 ft beyond the last recorded ADS-B data. The nearest surface winds located about 12 miles north were 360° at 3 knots. - An airman’s meteorological information (AIRMET) for moderate icing was valid for the accident location, which the pilot received during a weather briefing from Leidos. The accident site was influenced by northwesterly winds flowing across the Great Lakes that resulted in increased moisture. When combined with the low-level trough, bands of lake effect rain and snow shower activity were occurring. The destination did not have weather reporting capability. The observations of the nearest airports indicated visual flight rules (VFR) to marginal VFR conditions with scattered snow. Visibility conditions were reported as low as ¼ mile when areas of snow moved across the region during the early morning of the accident. Two witnesses located about ¼ mile southeast of the accident site heard the airplane fly overhead, followed by a loud thud of the accident. The witnesses observed very heavy sleet with low visibility conditions for about 10 minutes prior to and after the accident. The sleet had a high liquid content and would melt quickly after ground impact. Another witness located near the final approach flightpath, about 2 miles before the accident site observed the airplane fly past his position below an overcast cloud deck. The witness reported that no precipitation was present as the airplane flew by his position. - The pilot primarily flew a Bombardier Challenger 604 jet, although he had not flown this airplane since June 2021 due to maintenance work on the engines. The pilot completed Challenger 601 recurrency training with CAE in a flight simulator from November 5-8, 2021. The pilot flew about 700 hours in Beech E-90 airplanes. About 3 years prior to the accident, the pilot started managing the accident airplane, and he last flew the airplane during recurrent flight training on March 22, 2021. The airplane required one pilot to be operated. The passenger in the cockpit’s right seat was a student pilot interested in becoming a professional pilot and was along for the ride. - The airplane impacted into forested terrain on a westerly heading, with broken tree limbs indicating a steep descent of about 70°. The nose was crushed aft and the tail was bent up and over the top of the fuselage like a scorpion. A postimpact fire did not occur. Multiple propeller-cut tree limbs were found immediately east of the accident site. The power levers, speed/propeller levers, and fuel cutoff levers were found at the accident site in the full forward position. The position of the cockpit deice switches were unable to be determined due to impact damage. The landing gear was in the down position. Three of the four flap actuators indicated a flaps 5° position. No preimpact anomalies were observed with flight control continuity. Examination at a recovery location revealed the impeller vanes of both engines were bent in the direction opposite of rotation, consistent with ingestion of foreign debris during engine operation. The third stage turbine shrouds of both engines were rotationally scored and the nozzles vanes of both engines displayed metal spray deposits on the convex side of the vanes, consistent with engine rotation, normal internal airflow and an existent combustion process. Witness marks on both propellers indicated blade angles were 20° to 40° during ground impact. The blade bending, twisting, and overall assembly damage of both propellers was consistent with deformation during the impact sequence. Left and right propeller mounting holes were elongated, the direction of which was consistent with the correct rotational direction. The deicing system was examined at the recovery location, and the bleed air regulator valve, de-ice distributor valve, and an 8-inch section of the left wing surface de-ice manifold assembly were removed for further testing. No preaccident mechanical failures or malfunctions were observed that would have contributed to the accident. -
Analysis
While on final approach, the airplane gradually slowed to near its stall speed. About 600 ft beyond the last recorded data, the airplane impacted the ground in a nosedown attitude that was consistent with a stall. Postaccident examination revealed no preaccident mechanical failures or malfunctions that would have contributed to the accident. Witnesses near the accident site reported very heavy sleet with low visibility conditions, whereas a witness located near the final approach flightpath, about 2 miles before the accident site observed the airplane fly by below an overcast cloud layer with no precipitation present. Based on the witness accounts and weather data, the airplane likely entered a lake effect band of heavy sleet during the final portion of the flight. The airplane was modified with 5-bladed propellers, and other pilots reported it would decelerate rapidly, especially when the speed/propeller levers were moved to the high rpm (forward) position. The pilot usually flew a larger corporate jet and had not flown the accident airplane for 8 months. The passenger was a student pilot with an interest in becoming a professional pilot. The pilot’s poor airspeed control on final approach was likely influenced by a lack of recency in the turboprop airplane. The workload of inflight deicing tasks may have also contributed to the poor airspeed control. The aerodynamic effects of the heavy sleet that was encountered near the accident site likely contributed to the stall to some degree.
Probable cause
The pilot’s failure to maintain sufficient airspeed and his exceedance of the airplane’s critical angle of attack while in icing conditions, which resulted in an aerodynamic stall and subsequent ground impact.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
E-90
Amateur built
false
Engines
2 Turbo prop
Registration number
N290KA
Operator
N290KA LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
LW59
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-22T19:20:47Z guid: 104245 uri: 104245 title: CEN22LA038 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104263/pdf description:
Unique identifier
104263
NTSB case number
CEN22LA038
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-15T19:30:00Z
Publication date
2023-04-05T04:00:00Z
Report type
Final
Last updated
2021-11-23T00:34:34.284Z
Event type
Accident
Location
West Union, Ohio
Airport
ALEXANDER SALAMON (AMT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 15, 2021, about 1730 eastern standard time, a Piper PA-22-160, N3463Z, was substantially damaged when it was involved in an accident near West Union, Ohio. The student pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. The student pilot reported that he was completing a solo cross-country flight when the accident occurred. After descending from 5,500 ft to 2,500 ft, the airplane began to roll left unless the pilot continuously held right aileron input. The use of rudder did not null the left roll tendency. Due to the left roll and lower cloud bases ahead, he elected to divert. After an initial attempt to land on runway 5, he entered left traffic for runway 23. During the landing flare, the airplane continued the left roll and touched down hard past the 1,000 ft runway markers. The airplane bounced and touched down a second time before departing the left side of the runway, where it impacted a ditch and nosed over, resulting in substantial damage to the fuselage and engine mount. During a postaccident examination, control cable continuity and routing were verified from the rudder pedals to the rudder, and full rudder travel was observed. The aileron system was inspected, and control cable continuity and routing were verified from the control column to each aileron. Full travel of each aileron was observed. The aileron/rudder interconnect was also verified and found to be operational with no restrictions. The aileron control yoke was found to be misrigged so that when the ailerons were even with the wingtips, the yoke was approximately 200 offset to the left, and when the yoke was placed in a neutral position, the aileron positions corresponded to a right turn. -
Analysis
The student pilot reported that he was conducting a solo cross-country flight when the airplane began to roll left unless he continuously held right aileron input. The pilot elected to divert, and during the landing flare, the airplane continued the left roll and touched down hard past the 1,000-ft runway markers. The airplane bounced and touched down a second time before departing the left side of the runway, where it impacted a ditch and nosed over, resulting in substantial damage to the fuselage and engine mount. A postaccident examination did not reveal any flight control anomalies that would have caused the left rolling tendency, and the reason for the malfunction could not be determined based on the available information.
Probable cause
A malfunction of the flight controls for reasons that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N3463Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
22-7385
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-23T00:34:34Z guid: 104263 uri: 104263 title: CEN22FA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104254/pdf description:
Unique identifier
104254
NTSB case number
CEN22FA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-16T20:36:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Last updated
2021-11-30T00:32:03.285Z
Event type
Accident
Location
Estes Park, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Download of the Flight Data Acquisition Storage and Transmission System showed decreasing indicated airspeed and increasing engine interstage turbine temperature, gas producer speed, propeller speed, engine torque, and fuel flow toward the end or the recording. - On November 16, 2021, about 1836 mountain standard time, an Air Tractor Inc. AT-802A, N802NZ, was substantially damaged when it was involved in an accident near Estes Park, Colorado. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial firefighting flight. The purpose of the flight was to drop chemical retardant on the Kruger Rock fire in mountainous terrain. The pilot was using night vision goggles during the flight. Video footage of the airplane showed the airplane’s wings rocking as it approached the intended drop location. Two witnesses stated that they saw the airplane roll inverted but did not see it descend into terrain. One of the witnesses, who was in radio communication with the pilot, stated that he did not hear the pilot report any problems with the airplane nor make any distress calls before the accident. - The autopsy report stated the pilot died of multiple blunt force injuries. The Federal Aviation Administration Forensic Toxicology Report was negative for all substances tested. - The National Weather Service (NWS) Surface Analysis Chart valid for 1700 depicted a low-pressure system over Nebraska with a cold front extending southwestward across northern Colorado to another low-pressure system along a frontal wave over northeastern Utah. A high-pressure system was located over southwestern Colorado with a mesoscale ridge extending northeastward over the general vicinity of the accident site. The accident site was located immediately south of the cold front in an area with a strong pressure gradient. The station models immediately surrounding the accident site depicted west winds at 20 to 40 knots, clear to scattered clouds, and temperatures ranging from 60°F ahead of the front to 39°F over southern Wyoming northwest of the accident site and on the cold-air side of the front. The next NWS Surface Analysis Chart for 2000 depicted the low-pressure system over Nebraska having moved southward into eastern Colorado with the cold front extending westward across Colorado and located south of the accident site. The station models surrounding the accident site depicted west-northwest winds at 40 knots, scattered to broken skies to the west and northwest of the accident site, and temperatures at 51°F immediately east and 32°F to the northwest of the accident site. The closest official weather reporting site was Vance Brand Airport (LMO), Longmont, Colorado, located about 18 miles southeast of the accident site at an elevation of 5,055 ft. The routine weather observation for LMO at 1835 reported wind from 200° at 11 knots gusting to 17 knots, wind direction variable from 170° to 230°, visibility 10 miles or more, scattered clouds at 11,000 ft above ground level (agl), temperature 17°C, dew point temperature -8°C, and altimeter setting 29.78 inches of mercury. A review of the observations at LMO indicated west winds gusting from 20 to 35 knots from about 0955 to 1500 and winds backing or changing anti-cyclonically to the southwest with decreasing wind speeds through 1600. Winds further decreased in speed to less than 10 knots between 1600 and 1815 and shifted direction to the east. Winds again shifted to the south to west-southwest at 1835 with wind speeds increasing again immediately before the accident with gusts to 29 knots at 1915 before decreasing again at 2115. The area was also reviewed for any available Remote Automated Weather Stations (RAWS) operated by the United States Forestry Service, other land management agencies, and the Colorado Department of Transportation (CDOT). Lily Lake (CO045), a CDOT station at an elevation of 8,960 ft, about 3.3 miles southwest of the accident site, reported the following conditions at 1849: Temperature: 41°F Max 24-hr Temperature: 49°F Dew Point: 15°F Min 24-hr Temperature: 45°F Relative Humidity: 36% Wind: 225° 7 knots Peak Gust: 28 knots Max Gust: 38 knots at 1748 Estes Park (ESPC2) at an elevation of 7,892 ft, about 4.3 miles west-northwest of the accident site, reported the following conditions at 1824: Temperature: 44°F Max 24-hr Temperature: 57°F Dew Point: 21°F Min 24-hr Temperature: 44°F Relative Humidity: 39% Wind: 260° 11 knots Peak Gust: 28 knots Max Gust: 39 knots at 1424 Boulder County Fire (BCFC2) at an elevation of 6,674 ft, about 9.6 miles southwest of the accident site, reported the following conditions at 1742: Temperature: 51°F Max 24-hr Temperature: 61°F Dew Point: 19°F Min 24-hr Temperature: 51°F Relative Humidity: 28% Wind: 280° 7 knots Peak Gust: 32 knots Max Gust: 43 knots 1642 The Geostationary Environmental Satellite number 16 (GOES-16) infrared image for 1836 depicted an area of low- to middle-level clouds to the west of the accident site in a general north-to-south orientation pattern similar to transverse banding or trapped lee waves. The GOES-16 image also showed a relatively clear gap (or foehn gap) over and east of the accident site and a band of enhanced higher clouds further east through southeast of the accident site. When observed at high levels, transverse bands, which are bands of clouds oriented perpendicular to the flow in which they are embedded, may indicate severe or extreme turbulence. Transverse bands observed at low levels often indicate the presence of a temperature inversion as well as directional shear in the low- to mid-level winds. A foehn gap is a break in an extensive cloud deck or cloud shield, usually parallel to and downwind of a mountain ridge line. Especially visible in satellite imagery, this cloud-free zone results from the strong sinking motion on the lee side of a mountain barrier during mountain wave activity or strong downslope winds. The GOES-17 infrared image for 1836 showed similar features of a transverse cloud pattern associated with orographic clouds over the area. An animation of the satellite imagery showed that most of the clouds west and east of the accident site did not propagate eastward with time with the mean wind but remained relatively stationary. The low cloud bands immediately south of the accident site also remained relatively stationary and were consistent with rotor clouds. Rotor (or roll) clouds are a turbulent cloud formation found in the lee of some mountain barriers when winds cross the barrier at high speed. The NWS had SIGMET Uniform 15 current over the area for moderate to occasional severe turbulence below 18,000 ft due to strong low-level winds. SIGMET Xray 4 was current for severe turbulence between 25,000 and 42,000 ft due to wind shear associated with the jet stream and mountain wave activity. The NWS also had Graphic-AIRMET Tango for moderate turbulence from the surface to 18,000 ft and low-level wind shear below 2,000 ft agl over the region at the time. - The airplane wreckage was upright and displayed features of a low-speed, nose-down impact with sloping and wooded terrain. There was no ground scarring that preceded the wreckage. The wreckage did not display asymmetric wing damage consistent with yaw/bank on impact, and there was no lateral displacement of the empennage consistent with yaw on impact. The airplane sustained substantial damage to the fuselage, wings, and empennage. The propeller exhibited torsional bending/twisting consistent with the engine producing power at the time of impact. Postaccident examination of the wreckage revealed no mechanical anomalies that would have precluded normal operation. -
Analysis
The aerial firefighting flight was approaching the intended drop location when the airplane rolled inverted, descended, and impacted terrain. The airplane wreckage displayed features of a low-speed, nose-down impact with the engine producing power. The airplane sustained substantial damage to the fuselage, wings, and empennage. Recorded data showed decreasing indicated airspeed and increasing engine power toward the end of the flight. Postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation. The accident site was located on the eastern slope of a high mountain range, and west winds gusting to near 30 knots were reported near the time of the accident. An animation of satellite imagery showed that most of the clouds west and east of the accident site did not propagate eastward with time with the mean wind but remained relatively stationary, which was consistent with mountain wave activity. Low cloud bands immediately south of the accident also remained relatively stationary and were likely rotor clouds, a type of cloud associated with severe or greater turbulence. It is likely the airplane encountered severe to extreme low altitude turbulence associated with rotor clouds, which resulted in the loss of control.
Probable cause
The airplane’s encounter with severe to extreme turbulence associated with mountain wave rotor cloud activity, which resulted in loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-802A
Amateur built
false
Engines
1 Turbo prop
Registration number
N802NZ
Operator
CO Fire Aviation Inc
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
802A-0593
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-30T00:32:03Z guid: 104254 uri: 104254 title: WPR22FA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104278/pdf description:
Unique identifier
104278
NTSB case number
WPR22FA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-19T13:40:00Z
Publication date
2024-02-21T05:00:00Z
Report type
Final
Last updated
2021-12-06T20:14:16.155Z
Event type
Accident
Location
Carlsbad, New Mexico
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On November 19, 2021, about 1130 mountain standard time, a Cessna 182Q Skylane, N91AZ, was destroyed when it was involved in an accident near Carlsbad, New Mexico. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. The pilot departed Odessa Airport-Schlemeyer Field (KODO) Odessa, Texas, about 0930 central standard time for an aerial pipeline and oil well survey, with an intended destination of Gaines County Airport, (KGNC), Seminole, Texas. The operator reported that the pilot had experience with this pipeline survey flight. According to automatic dependent surveillance–broadcast (ADS-B) data, about 2.5 hours into the flight, the airplane entered a modified, single-grid flight track that started 12 nautical miles (nm) northwest of the accident site at an altitude of 400 ft agl. The airplane continued to maneuver west to east, in a south to north grid pattern (Figure 1). 12 nm Figure 1. View of ADS-B flight track showing single grid flight track. About 40 minutes later, at an altitude of 325 ft agl, the airplane skirted around an FM tower to the south before it maneuvered back to the north to continue its aerial survey. About 6 minutes later, the airplane turned right to the southwest about 9 nm from the tower and at an altitude of about 447 agl. The airplane continued southwest towards the tower and impacted the tower’s guy line at an altitude of about 500 agl and impacted terrain. A postcrash fire ensued, and the fuselage sustained substantial thermal damage. The tower, which was about 17 nm northeast of the Cavern City Air Terminal (CNM), Carlsbad, New Mexico, was annotated on a FAA sectional chart as an obstruction marked at 715 ft agl (Figure 2). The tower was marked with a light for night operations. 17 nm Figure 2. Excerpt of sectional depicting tower in relation to Cavern City Air Terminal (CNM) WRECKAGE AND IMPACT INFORMATION The accident airplane was found about 12 nm northwest of Carlsbad, New Mexico, on a dirt field at a field elevation of about 3,300 ft mean sea level. All four corners of the airplane were accounted for at the accident site. The first identified contact point was identified by a 50-foot-long section of a radio tower and several broken guy wires attached to their respective ground anchor about 240 ft north of the radio tower. The right wing was in two sections; the outboard section of the right wing was located about 60 ft north of the tower while the inboard section was located about 620 ft west of the tower (Figure 3). The debris path was marked by broken pieces of tower structure and red colored light bulb covers, also from the tower, that were scattered throughout the debris field from the tower to the main wreckage site. An impact scar was in the debris path about 30 ft north of the main wreckage. Figure 3. View of map depicting location of main wreckage components in relation to the FM tower. The main wreckage comprised of the fuselage, empennage, left wing, propeller, and engine, sustained thermal damage (Figure 4). The fuselage was fractured into several pieces and the tail section was separated from the fuselage, connected only by flight control cables to the cockpit area. Remnants of the main landing gear were found within the cockpit area. Most of the left wing had impact damage and significant thermal damage. The propeller was located within the impact scar about 30 ft north of the fuselage. The propeller hub was fractured consistent with impact damage. Both blades were found adjacent the hub and displayed no bending to blade No.1 and minimal bending to blade No.2; both blades had chordwise scratches on the face and bottom of each blade. The pitot tube was found in line with a shallow impact scar that spanned about 174 inches, consistent with the impact of the left-wing leading edge. The engine came to rest inverted, adjacent to the cockpit. Figure 4. View of main wreckage and FM tower. Postaccident examination of the airplane and engine did not reveal any preimpact mechanical anomalies. MEDICAL AND PATHOLOGICAL INFORMATION The pilot’s autopsy was performed by a medical investigator from the University of New Mexico, Office of the Medical Investigator. According to the pilot’s autopsy report, the cause of death was blunt force injuries, and the manner of death was accidental. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens recovered from the pilot. The pilot’s postmortem toxicological testing did not detect any ethanol or drugs. -
Analysis
The pilot was conducting an oil and pipeline aerial observation flight. The airplane maneuvered and skirted around a Frequency Modulation (FM) tower to the south and continued a left turn to the northwest, clearing the tower, as the pilot resumed his pipeline observation. The tower’s height, as depicted on a Federal Aviation Administration (FAA) sectional chart, was 715 ft above the ground (agl) and was lit for nighttime operations. Shortly after, the airplane maneuvered to the southwest towards the same tower and the airplane struck a guy wire about 500 ft agl. The airplane impacted terrain and a postcrash fire ensued. A postaccident examination of the airplane wreckage did not reveal any mechanical malfunctions or failures that would have precluded normal operation. The pilot was likely headed towards the local airport and did not see the tower guy lines.
Probable cause
The pilot's failure to maintain separation from an FM tower guy wire while on an aerial survey flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182Q
Amateur built
false
Engines
1 Reciprocating
Registration number
N91AZ
Operator
GULF COAST HELICOPTERS INC
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
18265784
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-06T20:14:16Z guid: 104278 uri: 104278 title: ERA22LA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104277/pdf description:
Unique identifier
104277
NTSB case number
ERA22LA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-19T14:04:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-22T21:03:31.256Z
Event type
Accident
Location
Glens Falls, New York
Airport
FLOYD BENNETT MEML (GFL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On November 19, 2021, at 1204 eastern standard time, a Piper PA-28R-200, N2305T, was substantially damaged when it was involved in an accident at the Floyd Bennett Memorial Airport (GFL), Glens Falls, New York. The pilot and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the preflight inspection, engine start, engine run-up and takeoff were all normal. After liftoff, the pilot retracted the landing gear, and during the initial climb, about 500 ft above the ground, the engine power “rolled back” but the propeller continued to windmill. The pilot stated he lowered the nose and began a gradual turn back toward the runway. The airplane landed on the grass and struck the airport’s perimeter fence, resulting in substantial damage to the fuselage and wings. Data downloaded from the onboard engine monitor revealed fuel flow fluctuated before it dropped to zero. An examination of the fuel-injected engine and the airplane’s fuel system supervised by a Federal Aviation Administration inspector revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot stated that the preflight inspection, engine start, engine run-up and takeoff were all normal, and there was no indication of any problems with the engine. After liftoff, when the airplane was about 500 ft above the ground, the engine stopped producing power, but the propeller continued to windmill. The pilot lowered the nose and began a gradual turn back toward the runway. The airplane landed on the grass and struck the airport’s perimeter fence, resulting in substantial damage to the fuselage and wings. Data downloaded from the onboard engine monitor indicated a fluctuation in fuel flow prior to the loss of power. Postaccident examination of the fuel-injected engine and the airplane’s fuel system revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Therefore, the reason for the total loss of engine power was not determined.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N2305T
Operator
WARREN COUNTY FLYING CLUB INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7135193
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-22T21:03:31Z guid: 104277 uri: 104277 title: HWY22FH001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104282/pdf description:
Unique identifier
104282
NTSB case number
HWY22FH001
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-19T18:02:00Z
Publication date
2023-10-10T04:00:00Z
Report type
Final
Event type
Accident
Location
Big Spring, Texas
Injuries
3 fatal, 7 serious, 43 minor
Probable cause
TBD
Has safety recommendations
false

Vehicle 1

Traffic unit name
Ford F-350 pickup truck
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2005 MCI motorcoach
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 3

Traffic unit name
2018 Freightliner Coachliner
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-10-10T04:00:00Z guid: 104282 uri: 104282 title: WPR22FA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104283/pdf description:
Unique identifier
104283
NTSB case number
WPR22FA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-20T18:56:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-07T08:02:48.14Z
Event type
Accident
Location
Big Bear City, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
ADS-B data for the accident flight revealed that, after the time the airplane leveled off between about 9,500 to 9,600 ft, its altitude indicated 8,000 ft on three occasions. The first descent was about 1630 and lasted for a duration of 10 minutes. The second descent was about 1651. Shortly thereafter the airplane was climbed back to 9,000 ft. The last descent was about 1654, and the airplane maintained for the remainder of the data. During these altitude changes, the airplane’s airspeed, vertical velocity, and heading data parameters remained virtually unchanged. In addition, the descents to 8,000 ft took place in less than 1 second. Furthermore, the ADS-B geometric altitude remained unchanged after the airplane initially leveled off and did not reflect any descents in altitude during cruise; all consistent with anomalous data rather than an actual descent to 8,000 ft. The FAA defines controlled flight into terrain (CFIT) as an event that "occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain … with inadequate awareness on the part of the pilot of the impending collision." In April 2003, the FAA published Advisory Circular (AC) 61-134, entitled " General Aviation Controlled Flight Into Terrain Awareness." The AC stated that, "in visual meteorological conditions, the pilot in command (PIC) is responsible for terrain and obstacle clearance (See and Avoid) …" and identified several CFIT risks, including: - Loss of situational awareness - Breakdown in good aeronautical decision making - Failure to comply with appropriate regulations - Failure to comply with minimum safe altitudes The AC recommended that, during VFR flight, pilots maintain a minimum of 1,000 ft above the highest terrain while operating in non-mountainous areas, and 2,000 ft above the highest terrain when operating in mountainous areas. - The airplane was a high-performance, low wing, composite monoplane. The airframe and engine maintenance logbooks were not located. An individual who worked on the airplane reported that it was equipped with an autopilot and a Garmin 496 GPS unit. - On November 20, 2021, about 1656 Pacific standard time, an experimental, amateur-built Glasair III, N291KT, was destroyed when it was involved in an accident near Big Bear City, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A friend of the pilot reported that the pilot commuted to work in the accident airplane between Los Angeles, California, and Phoenix, Arizona, about twice per week. Review of ADS-B data revealed that the airplane departed Camarillo Airport (CMA), Camarillo, California, on the night of the accident. The airplane climbed to an altitude between about 9,500 to 9,600 ft msl on a heading of about 095°. The last 5 minutes of data showed relatively constant parameters in the airplane’s airspeed, altitude, and heading. The last data point indicated that the airplane’s heading was about 095°, and the groundspeed was about 219 knots. The pilot was reported missing the following day, and a search for the airplane was initiated. The wreckage was subsequently located on a mountainside at an elevation about 9,720 ft msl, near the summit of San Bernardino Peak. - The San Bernardino County Sheriff’s Department Coroner Division, San Bernardino, California, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “multiple blunt force injuries.” Toxicology testing performed by the FAA’s Forensic Sciences Laboratory on the pilot’s muscle specimen detected doxylamine. Doxylamine is a sedating antihistamine medication that is available over-the-counter as a sleep aid and as an ingredient in various cold and allergy products. Sedating antihistamines can cause drowsiness and may have impairing effects on task performance. Doxylamine is acceptable for pilots if used occasionally for a time-limited condition. The FAA states that pilots should not fly within 60 hours of using doxylamine, to allow time for it to be eliminated from circulation. - Visual flight rules (VFR) conditions were reported over the region. A review of National Composite Radar Mosaic depicted no meteorological echoes over southwestern California. A sounding model over the accident site indicated surface wind from the northeast at 7 knots (kts), and wind at 8,000 ft from 035° at 11 kts. No significant turbulence or mountain wave conditions below 12,000 ft were depicted. The closest weather reporting station to the accident site was Big Bear City Airport (L35), Big Bear City, California, at an elevation of 6,752 ft msl. The 1655 automated observation included calm wind, visibility of 10 statute miles or more, clear skies below 12,000 ft above ground level (agl), and an altimeter setting of 30.26 inches of mercury. There were no pilot reports (or PIREPs) near the accident site. No SIGMETs, convective SIGMETs, or National Weather Service advisories were active for the area of the accident site. AIRMET Sierra was valid for instrument flight rules (IFR) conditions along the Pacific coast and AIRMET Tango was valid for turbulence below 12,000 ft north of the accident site. At the time of the accident, the Sun was 3.8° below the horizon at an azimuth of 248°. Moonrise was at 1739, and the moon was -9.7° below the horizon at an azimuth of 52°. - The pilot held an airline transport pilot certificate with a rating for airplane multiengine land, and commercial privileges for airplane single-engine land. His most recent Federal Aviation Administration (FAA) first-class airman medical certificate was issued on October 21, 2021, without limitations. On the application for that certificate, the pilot reported 18,000 total hours of flight experience and reported his occupation as a pilot for a major airline. - The airplane impacted rocky, tree-covered terrain on a 45° slope about 9,720 ft mean sea level (msl). Fragments of the wings and fuselage were located in this area. The only portion of the airplane that was relatively intact was the tail section, which was also found in this area. All the flight control surfaces on the vertical stabilizer and horizontal stabilizers remained attached. Fragments of the airplane were scattered about 200 ft upslope from the main wreckage and about 100 ft below the site. The engine, which sustained substantial impact damage, separated from the fuselage and was located about 100 ft upslope of the main wreckage. The propeller blades and hub had separated. Damage to the airplane, the debris dispersal pattern, and impact markings, were all consistent with impact in a high-speed, wings-level attitude. The airplane wreckage was located in remote mountainous terrain and was not recovered. -
Analysis
The pilot departed on a cross-country flight in the experimental, amateur-built airplane under day visual meteorological conditions. He was reported missing the following day, and the wreckage was subsequently discovered along the route of flight near the summit of a mountain at an elevation about 9,720 ft mean sea level (msl). Automatic dependent surveillance – broadcast (ADS-B) data revealed that the pilot departed and climbed the airplane to an altitude about 9,500 ft msl on an easterly heading and roughly maintained this heading and altitude for the duration of the flight until impact. Both the ADS-B data and distribution of the wreckage were consistent with controlled flight into terrain in a near-level attitude with a high forward velocity and revealed no evidence of evasive action before impact. The scope of the wreckage examination was limited due to the location of the accident site; however, all major components of the airplane were identified at the site. Additionally, ADS-B data was not consistent with the pilot experiencing a flight control or engine anomaly before the accident. Whether the pilot may have experienced physiological incapacitation or impairment during the flight could not be determined based on the available information. No blood samples were available for toxicological testing; therefore, carboxyhemoglobin levels could not be determined. Testing of available muscle tissue indicated the pilot’s use of the sedating antihistamine doxylamine; however, this result could not be used to determine whether the drug had sedating or impairing effects that may have contributed to the accident.
Probable cause
The pilot’s failure to maintain clearance from mountainous terrain for reasons that could not be determined based on the available information, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JAHNKE LIONEL G
Model
GLASAIR III
Amateur built
true
Engines
1 Reciprocating
Registration number
N291KT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3141
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-07T08:02:48Z guid: 104283 uri: 104283 title: ANC22LA007 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104287/pdf description:
Unique identifier
104287
NTSB case number
ANC22LA007
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-20T19:55:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2021-12-04T05:35:35.454Z
Event type
Accident
Location
Bethel, Alaska
Airport
BETHEL (BET)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 20, 2021, about 1755 Alaska standard time, a Cessna 207 airplane, N9794M, sustained substantial damage when it was involved in an accident near Bethel, Alaska. The pilot and five passengers were not injured. The airplane was operated by Yute Commuter Service as a Title 14 Code of Federal Regulations Part 135 scheduled passenger flight. The purpose of the flight was to transport five passengers and cargo to Kwethluk, Alaska, which is located about 12 miles east of Bethel. The pilot reported that shortly after departure, he noticed that the red emergency locator transmitter (ELT) light on the instrument-panel-mounted remote switch had illuminated. The pilot then asked the Bethel tower operator if they were hearing an ELT signal, and the tower operator responded that no signal was being received. Moments later, the pilot began to smell an electrical burn smell and elected to return to Bethel. The pilot said that about 1 minute later, the electrical burn smell intensified, which was followed by visible smoke in the cockpit, and he then declared an emergency to the Bethel tower. The pilot then turned off the airplane’s master electrical switch, and subsequently opened his side window for ventilation and smoke removal. He said he briefly turned the master switch back on to again declare an emergency with Bethel tower, and to inform the tower operator that he was planning to land on runway 1L. The pilot said that during the landing roll, he realized that the nosewheel steering system and brake system were both inoperative. After the airplane rolled to a stop on the left side of runway 1L, he ordered all the passengers to evacuate the airplane. The pilot reported that after all the passengers had safely departed the airplane, heavy smoke filled the cockpit and passenger compartment, and he saw a candle-like flame behind the pilot and co-pilot seats, just beneath the floorboards of the airplane. Moments after all the passengers and pilot had exited the airplane, it was immediately engulfed in flames. See figure 1. Figure 1 Photo of accident airplane while still on Runway 1L. Examination of the maintenance records showed that on January 27, 2011, the Capstone system, phase 1, was installed on the accident airplane under Federal Aviation Administration (FAA) Supplemental Type Certificate (STC) number STC2154AK. The Capstone Program is a voluntary safety demonstration involving the installation, at FAA expense, of avionics suites in approximately 200 aircraft operated in western Alaska. The avionics suites, manufactured by UPS Aviation Technologies, consist of an MX-20 multifunction display (MFD), a GX-60 GPS nav/com, a Universal Access Transceiver (UAT), and an installation kit with all necessary cables, antennas, and mounting hardware, and an instruction book. A National Transportation Safety Board (NTSB) postaccident examination of the airplane wreckage revealed the origin of the fire to be centered behind the pilot’s row of seats, where a wire harness, which was discovered to be part of the Capstone Program equipment, was found improperly installed on top of the aft fuel line from the left fuel tank. The fuel line exhibited chafing and thermal damage. Following removal of the fuel line, a small pinhole was detected in the fuel line utilizing a flashlight. NTSB Materials Laboratory examination of the wire harness found a range of thermal and electrical damage, from thermal discoloration and sooting to beading and welding in areas on individual conductors. The damage was consistent with the wire being energized at the time the damage occurred. During the on-scene NTSB examination of the accident airplane wreckage, a second Cessna 207, which was purchased at the same time as the accident airplane, was examined in the operator’s hangar. The NTSB IIC, along with the entire investigative team, discovered that the same Capstone wire harness condition found in the accident airplane existed in the second Cessna 207 in the same location. As a result of the NTSB investigation, the FAA issued a notification letter to alert registered aircraft owners and operators of the need to inspect the area inside inspection panels from the rear door frame forward under the pilots and passengers’ floorboards at the next maintenance function, 100 hour, or Annual inspections. FAA database records indicate there is over 200 aircraft that had the CAPSTONE phase 1 equipment installation under STC2154AK and therefore need to be inspected. -
Analysis
The pilot was conducting a scheduled air taxi flight with five passengers onboard. Shortly after departure, the pilot began to smell an electrical burn odor, and he elected to return to the airport. About 1 minute later, the electrical burn smell intensified, which was followed by visible smoke in the cockpit, and the pilot declared an emergency to the tower. After landing and all the passengers had safely departed the airplane, heavy smoke filled the cockpit and passenger compartment, and the pilot saw a candle-like flame just behind the pilot and co-pilot seats, just beneath the floorboards of the airplane. Moments later, the airplane was engulfed in flames. Postaccident examination of the airframe revealed the origin of the fire to be centered behind the pilot’s row of seats, where a wire harness was found improperly installed on top of the aft fuel line from the left tank. Examination of the wire harness found a range of thermal and electrical damage consistent with chafing from the fuel line. It is likely that the installation of the wire harness permitted contact with the fuel line, which resulted in chafing, arcing, and the subsequent fire.
Probable cause
The improper installation of an avionics wire harness over a fuel line, which resulted in chafing of the wire harness, arcing, and a subsequent fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
207A
Amateur built
false
Engines
1 Reciprocating
Registration number
N9794M
Operator
Paklook Air Inc
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
20700730
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-04T05:35:35Z guid: 104287 uri: 104287 title: ERA22LA071 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104288/pdf description:
Unique identifier
104288
NTSB case number
ERA22LA071
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-21T10:26:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2021-11-23T18:49:06.03Z
Event type
Accident
Location
Brent, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On November 21, 2021, at 0826 central standard time, a Cessna 210 airplane, N5779J, was substantially damaged when it was involved in an accident near Brent, Alabama. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. While on an instrument flight rules flight plan, and during cruise flight about 14 minutes after takeoff from Tuscaloosa Regional Airport (TCL), Tuscaloosa, Alabama, the airplane’s flight system monitor annunciated “check oil pressure.” The pilot checked his instruments and noted that the oil pressure indicated 0 psi. The pilot declared an emergency and established best glide speed, then navigated toward the closest airport. The pilot was cleared to descend and air traffic control inquired whether the plot would be able to reach the diversion airport. Given the circumstances, the pilot decided it was prudent to land immediately. During the descent the pilot descended out of the cloud cover and selected a road for a forced landing site. After touchdown, the airplane’s right wing collided with several road signs before the airplane impacted a ditch and several trees, coming to rest upright in a nose-down attitude. Postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the fuselage, firewall, and both wings sustained substantial damage and the tail cone exhibited compression wrinkling forward of the vertical stabilizer. The front windscreen was broken. The left-wing fuel tank was breached with no fuel remaining. The right-wing fuel tank remained intact and contained fuel. Data downloaded from the JPI EDM-830 engine data monitoring device revealed normal engine operation until 0818 when the oil pressure began to drop. Shortly thereafter the manifold pressure decreased and there was a corresponding reduction in recorded values for most other engine parameters. Around this time, recorded GPS data showed the aircraft began to descend from 7,000 ft mean sea level. The data ended at 0826. Examination of the engine revealed that it was equipped with an F&M screw-on oil filter adapter. Oil was observed on the lower area of the oil adapter fiber gasket seal (see figure 1), in the engine compartment and on the underside of the fuselage. The oil filter adapter installation was tested using a digital torque wrench. The tightening torque was measured at 38.5 ft-lbs. The loosening torque (breakaway torque) measured was 34.0 ft-lbs. Per the Stratus Tools Technologies mandatory service bulletin (SB) SB-001Rev B, revised June 17, 2021(originally issued October 25, 2019), the oil adapter transfer cylinder was to be tightened to 65 ft-lbs during installation. Upon removal of the oil filter adapter, examination revealed a fiber gasket between the airplane’s engine oil pump assembly and the oil filter adapter was torn and indented (see figure 2). Figure 1: Oil around oil adapter fiber gasket seal. Figure 2: Torn, indented fiber gasket. The revised SB also required the removal of the fiber gasket (if installed) and replacement with a copper gasket, as well as inspection of the adapter for security, leaks, seepage, or gasket damage “within the next 10 flight hours, annual inspection, or 100-hour inspection, whichever occurs first.” The SB further stated that the use of fiber gaskets had been discontinued and that “only copper gaskets are approved for initial installation or reinstallation of F&M or Stratus Tool Technologies oil filter adapters.” A review of the airplane’s maintenance records found no entries that specifically addressed the SB. The most recent entry related to the adapter was in May 2015 when the adapter was removed, and the “gasket and crush washer” were replaced. During a postaccident interview, the pilot stated that he had not experienced any anomalies or malfunctions of the airplane prior to the loss of oil pressure. He also stated that he had read about the issue with the oil filter adapter a few weeks before the accident. Given that, “it had lasted this long,” he did not believe his installation was at issue. -
Analysis
During cruise flight, the pilot noticed a drop in engine oil pressure and turned toward the closest airport. The pilot subsequently elected to perform a precautionary off-airport landing during which the airplane sustained substantial damage. A postaccident examination of the engine revealed that it was equipped with a screw-on oil filter adapter. Oil seepage was found on the area surrounding the oil filter adapter attachment point, in the engine compartment, and on the underside of the fuselage. Examination of the adapter found its tightening torque to be 38.5 ft-lbs, which was below the prescribed installation torque of 65 ft-lbs. Additionally, the adapter was found installed with the originally specified fiber gasket, which the manufacturer had subsequently advised to remove and replace with a copper gasket in a mandatory service bulletin. The fiber gasket was found torn and indented. It is likely that the loose adapter and the torn fiber gasket allowed the engine oil to be pumped overboard. This ultimately resulted in the loss of oil pressure and the pilot’s decision to perform the precautionary off-airport landing. It is likely that had the mandatory service bulletin been complied with, the loss of oil pressure would not have occurred.
Probable cause
The inadequate maintenance of the oil filter adapter, which resulted in in an engine oil leak and subsequent loss engine oil pressure, and the subsequent off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210
Amateur built
false
Engines
1 Reciprocating
Registration number
N5779J
Operator
BEAVERS AIR LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21059479
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-23T18:49:06Z guid: 104288 uri: 104288 title: CEN22FA042 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104284/pdf description:
Unique identifier
104284
NTSB case number
CEN22FA042
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-21T21:20:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2021-11-29T18:44:06.908Z
Event type
Accident
Location
Chadron, Nebraska
Airport
Chadron Municipal (CDR)
Weather conditions
Visual Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
On November 21, 2021, about 1920 mountain standard time, a Cessna T310R, N310JA, was destroyed when it was involved in an accident near Chadron, Nebraska. The pilot and two passengers sustained fatal injuries. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The airplane landed at the Chadron Municipal Airport (CDR), Chadron, Nebraska, dropped off a passenger, and refueled. About 40 minutes later, the airplane departed from runway 30 at CDR in dark night visual meteorological conditions. Airport security video showed the airplane takeoff roll and liftoff. Automatic dependent surveillance – broadcast (ADS-B) data showed the airplane climbed to about 200 ft, turned to the right, and descended into rising terrain (Figure 1). According to a Federal Aviation Administration (FAA) inspector, the pilot had flown two legs the day before the accident flight. On November 20, 2021, the pilot departed his home airport about 1134 and returned to his home airport about 0023. The pilot departed about 6 hours later and arrived at CDR about 0630 on November 21, 2021, then proceeded to Flying Cloud Municipal Airport (FCM), Eden Prairie, Minnesota. The pilot departed FCM about 1704 central standard time and arrived at CDR about 1843. About 1920, the pilot departed CDR on the accident flight. Figure 1 – ADS-B flight path. - An autopsy of the pilot was performed by Western Pathology Consultants. According to the autopsy report, the cause of death was blunt force injuries due to acute coronary thrombosis and the manner of death was accident. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the pilot. Chlorpheniramine was detected. Chlorpheniramine is an antihistamine used to treat allergies and can cause drowsiness. Chlorpheniramine is acceptable for flying if it is used no more than 1-2 times per week and 5 days have elapsed before flying. Dextromethorphan and its metabolite dextrorphan were detected. This medication is used as a cough suppressant and can cause drowsiness and nausea. Dextromethorphan is disqualifying for flying and requires at least 48 hours before performing pilot duties. Loratadine and the metabolite desloratadine was detected. Loratadine (Claritin) is a nonprescription nonsedating antihistamine used to treat allergies. It is acceptable for FAA medical certification. Losartan was detected. Losartan (Cozaar) is an ACE-II inhibitor-type antihypertensive used to treat high blood pressure and is acceptable for FAA medical certification. This medication was reported on the most recent medical exam. - Local airport personnel stated that the night was dark with no visible horizon at the departure end of the runway. - The pilot held a private pilot certificate with a rating for airplane multi-engine land and airplane single-engine land. The pilot’s most recent FAA medical examination was on July 27, 2020. At that time, the pilot reported civil flight experience of 445 total hours. He had reported hay fever and high blood pressure to the FAA and used losartan to treat his blood pressure. No significant abnormalities were identified during the exam, and he was issued a third-class medical certificate limited by a requirement to wear corrective lenses. A review of the pilot’s logbook revealed that the pilot had accumulated 502.3 total hours of flight experience as of November 20, 2021, the day before the accident. He had about 83 hours of flight experience in the accident airplane make and model. In the 30 days before the accident, he had accumulated about 10 hours, with about 7 hours in the 24 hours before the accident. - The initial ground impact was about 3,347 ft above mean sea level (msl), on an approximate heading of 350°. The wreckage debris was dispersed over 600 ft past the initial ground impact point. See Figure 2. Figure 2. Wreckage Distribution. A postcrash fire consumed most of the airplane. The distribution of the debris was consistent with a nearly-wings-level, slightly nose-down, high-speed impact. Ground scars from the propeller blades of both engines were present and consistent with rotation at the time of impact. Although most of the airplane wreckage was consumed by fire, examinations of the flight controls did not reveal any preimpact anomalies. Both engines were examined and did not reveal any preimpact anomalies. Fuel was present in each engine’s fuel distribution system. The damage to the propeller blade assemblies from both left and right engines were symmetrical, consistent with the engines producing similar power at the time of impact. -
Analysis
The pilot departed on a personal flight in dark night visual meteorological conditions. The airplane impacted terrain northwest of the airport about 30 seconds after departure. The distribution of the debris was consistent with a wings-level, slightly nose-down impact. The airplane was destroyed by impact forces and a postimpact fire. Postaccident examination of the airframe and engines revealed no mechanical anomalies that would have precluded normal operation. Although toxicology results revealed that the pilot was taking at least two medications (chlorpheniramine and dextromethorphan) that may have impaired his performance, the fact that the medication levels were unquantifiable indicated that their levels were too low for them to have had significantly impairing effects at the time of the accident. According to the autopsy findings, the pilot was actively having a heart attack in the hours before the accident. This placed him at severely increased risk for acute impairment/incapacitation from chest pain, shortness of breath, feeling faint, or becoming unconscious. Any of these symptoms would have likely led to the low altitude loss of control identified in this crash. Therefore, the pilot’s ongoing myocardial infarction (heart attack) is the most likely cause of this accident.
Probable cause
The incapacitating effects of a myocardial infarction (heart attack), which resulted in the pilot's loss of airplane control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T310R
Amateur built
false
Engines
2 Reciprocating
Registration number
N310JA
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310R-1319
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-29T18:44:06Z guid: 104284 uri: 104284 title: WPR22LA046 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104301/pdf description:
Unique identifier
104301
NTSB case number
WPR22LA046
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-22T13:40:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-12-03T03:17:01.41Z
Event type
Accident
Location
Hurricane, Utah
Airport
GRASSY MEADOWS/SKY RANCH LANDOWNERS ASSN (UT47)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On November 22, 2021, about 1140 mountain standard time, an experimental amateur-built Vans RV-10 airplane, N54CT, was substantially damaged when it was involved in an accident near the Grassy Meadows/Sky Ranch Airport, Hurricane, Utah. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that prior to takeoff, he conducted an uneventful engine runup with the fuel selector set to the left fuel tank. Following completion of the engine runup, he switched to the right fuel tank and back taxied on runway 17 for takeoff. The pilot departed runway 17 with the intention of conducting a downwind departure to the north. While on the downwind leg, he reduced power and decreased his rate of climb due to rising engine operating temperatures. Shortly after, the engine had a complete loss of engine power. He advanced the propeller control to full rpm, switched the fuel selector valve to the left fuel tank, and turned on the fuel boost pump. Unable to restore engine power, he conducted a 360° turn to lose altitude prior to landing. However, after turning onto final approach for runway 17, he realized he did not have enough altitude to make it to the runway and initiated a forced landing to an open field. Subsequently, the airplane landed hard and impacted terrain before it came to rest in a nose low attitude. Postaccident examination of the airplane by the pilot revealed that the fuselage and left wing were substantially damaged. The wreckage was recovered to a secure location for further examination. Downloaded data from the airplane’s avionics recorded various engine parameters. The data showed that 1140:27-unit time, power was advanced for takeoff, with a fuel flow increasing to 22 gallons per hour (gph). About 51 seconds later, fuel flow started to decrease, however, fuel pressure remained around 26 psi. The data showed that when fuel flow decayed below 9.7 gph, engine rpm began to decrease from about 2,500 rpm. Examination of the recovered airframe and engine revealed that the fuel line from the fuel servo outlet port to the fuel flow transducer inlet port was loose at the fuel servo fitting. An external fuel source was attached to the left-wing fuel inlet line, and the No. 1 cylinder fuel injector line was removed from the fuel injector for testing. When power was applied to the airframe and the airframe boost pump was turned on with the throttle and mixture levers in the full forward position, fuel was observed expelling from the loose fuel line fitting, and no fuel was observed flowing from the fuel injector line. Additionally, damage sustained to the firewall appeared to restrict fuel flow from left- and right-wing fuel inlet lines. An external electric fuel boost pump was attached inline from an external fuel source to the fuel inlet line of the engine-driven fuel pump, and the loose fuel fitting at the fuel servo was tightened about 3.5 turns. The fuel boost pump was turned on with the throttle and mixture levers in the full forward position. Fuel was observed expelling from the cylinder no. 1 fuel injector line. Then the fuel outlet line at the fuel servo was loosened about 3.5 turns, fuel began to leak from the fitting, with no fuel expelling from the no. 1 fuel injector line. -
Analysis
The pilot reported that after takeoff, on the downwind leg of the airport traffic pattern, he reduced power and decreased his rate of climb due to rising engine operating temperatures. Shortly after, the engine experienced a complete loss of power. Despite attempts to troubleshoot, the pilot was unable to restore engine power and conducted a 360° turn to lose altitude prior to landing. However, after turning onto final approach for the runway, he realized he did not have enough altitude to make it to the runway and initiated a forced landing to an open field. The airplane landed hard and impacted terrain before it came to rest in a nose-low attitude, resulting in substantial damage to the fuselage and left wing. Postaccident examination of the recovered airframe and engine revealed that the fuel line from the fuel servo outlet port to the fuel flow transducer inlet port was loose at the fuel servo fitting. The loose fuel line would not allow for enough fuel pressure to reach the fuel flow divider and fuel injection nozzles, thus resulting in a loss of engine power. Recorded engine data revealed that fuel flow had decreased, while fuel pressure had remained steady, which would be consistent with a loose fuel line. The airplane’s last condition inspection was performed about 19 flight hours before the accident.
Probable cause
The total loss of engine power due to a loose fuel line at the fuel servo outlet port.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV10
Amateur built
true
Engines
1 Reciprocating
Registration number
N54CT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
40212
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-03T03:17:01Z guid: 104301 uri: 104301 title: WPR22LA047 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104302/pdf description:
Unique identifier
104302
NTSB case number
WPR22LA047
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-22T15:49:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-11-24T00:14:47.769Z
Event type
Accident
Location
Puyallup, Washington
Airport
PIERCE COUNTY - THUN FLD (PLU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 22, 2021, about 1349 Pacific standard time, a Cessna R182, N7592Y, was substantially damaged when it was involved in an accident near Puyallup, Washington. The flight instructor and private pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The instructor reported that the intent of the flight was to conduct a stage check for the pilot receiving instruction, who was preparing for an upcoming practical test. They completed several maneuvers in the practice area and were returning to the airport when the instructor requested that the pilot perform a simulated emergency landing gear extension. The pilot noticed that the left main landing gear did not extend. Despite multiple attempts to cycle the landing gear, which included utilizing the emergency landing gear extension procedures, they were unable to extend the left main landing gear. The instructor took control of the airplane and chose to land the airplane with the landing gear retracted. Postaccident examination of the airplane revealed that the fuselage was substantially damaged. A subsequent examination of the airplane revealed the left main landing gear pivot assembly shaft had fracture-separated near the pivot housing, which prevented the left main landing gear from extending or retracting. The left landing gear pivot assembly was sent to National Transportation Safety Board Materials Laboratory, Washington, DC, for examination, which revealed characteristics consistent with a shear overstress fracture in clockwise torsion. A review of the airplane’s maintenance records could not determine the age of the component, or if any maintenance had been performed on the assembly. The operator reported that the accident airplane had always been flown with a flight instructor or examiner on board and no hard landings were reported or documented before the accident flight. -
Analysis
During an instructional flight, the pilot receiving instruction performed an emergency landing gear extension; however, the left main gear did not extend despite multiple attempts, and the instructor chose to land with the gear retracted, resulting in substantial damage to the fuselage. Examination revealed that the left main landing gear pivot assembly shaft had fracture-separated near the pivot housing. Metallurgical examination of the fracture surfaces revealed signatures of overstress. The overstress fracture of the pivot assembly resulted in the failure of the left landing gear to fully extend.
Probable cause
An overstress fracture of the left main landing gear pivot assembly, which resulted in the failure of the left main landing gear to fully extend and lock into place.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
R182
Amateur built
false
Engines
1 Reciprocating
Registration number
N7592Y
Operator
CLOVER PARK TECHNICAL COLLEGE
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
R18200141
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-11-24T00:14:47Z guid: 104302 uri: 104302 title: WPR22FA048 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104310/pdf description:
Unique identifier
104310
NTSB case number
WPR22FA048
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-23T12:33:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-02T06:20:06.624Z
Event type
Accident
Location
Temecula, California
Airport
FRENCH VALLEY (F70)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Construction of the airplane was completed by the owner in 2007, and its special airworthiness certificate was issued in November of that year. The airplane was then involved in a hard landing event, which necessitated replacement of both wings and repairs to the fuselage, along with replacement of the canopy. The airplane was taken out of service in 2014 for an engine rebuild after 45 total flight hours. The rebuild was completed on September 1, 2020, along with a condition inspection. The logbooks indicated that the owner then performed a series of flights in accordance with “Phase I” flight testing, and on December 20, 2020, he documented that the airplane had accrued 54 total flight hours and was authorized for “Phase II” flight. The accident pilot then flew the airplane six more times through January 10, 2021. The Zodiac CH 601 series was the subject of an FAA Special Airworthiness Information Bulletin (SAIB) CE-10-08, dated November 7, 2009, that identified a concern with the airplane’s wing structure following a series of in-flight structural failures. To address the SAIB, the kit manufacturer provided a wing upgrade modification package. The airplane’s maintenance logbooks indicated that the modifications were accomplished in June 2012, along with the addition of aileron balance weights. Although the airplane was equipped with an autopilot, it had been disabled by the owner and had never been used. - On November 23, 2021, about 1033 Pacific standard time, an experimental, amateur-built Zenith Zodiac 601XL, N601KS, was destroyed when it was involved in an accident in Temecula, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Data from an onboard Appareo Stratus GPS/ADS-B receiver showed that the airplane departed from runway 18 at French Valley Airport (F70) at 1020 and began a climbing left turn to the southeast, reaching an altitude of about 3,600 ft mean sea level (msl) about 7 minutes later. After reaching the shores of Vail Lake, 10 miles southeast, it began a 180° descending right turn to a heading of about 320° back in the direction of F70. Over the next three minutes, the airplane gradually descended from 2,800 to 2,400 ft msl, while maintaining an airspeed of about 100 knots (kts). The airplane then pitched about 60° nose-down while rolling about 90° right as it began descending at a rate that reached 9,600 ft per minute before the data ended. About that time, a witness, who was in the front yard of a residence about 3 miles southeast of F70, reported hearing a loud bang, then looked overhead to see an airplane flying to the northwest. The airplane rolled inverted while diving diagonally into the ground. After impact, debris started falling from the sky almost directly above her. Multiple other witnesses within the area of the housing development recounted similar observations of hearing a loud booming sound followed by observing an airplane dive toward the ground while debris fell from it. The FAA does not record the common traffic advisory frequency (CTAF) transmissions at F70 airport; however, CTAF audio was being recorded by a public audio streaming service at the time of the accident. The recording indicated that, shortly before 1033, a sound consistent with buffeting wind noise was captured, along with a person in distress, possibly shouting, “help.” Family members later confirmed that the recording sounded like the pilot. - The last entry in the pilot’s logbook was for a flight review six days before the accident, which was conducted in a Piper PA23-250. At that time, his total flight experience was 855.1 hours. Most of his recent flight experience was in the multi-engine Beech D95A airplane, and he attained his helicopter rating on September 9, 2021. His total flight experience in the accident airplane was 10.3 hours, which took place during 12 flights between December 12, 2020, and January 10, 2021. The pilot had an arrangement with the owner that he could fly the airplane at any time. The owner was not aware that he was going to fly the airplane on the day of the accident, and the reason for the flight could not be determined. - There was no evidence of bird strike to any of the airframe structure. Samples recovered from windshield fragments, both propeller blades, and the vertical and horizontal stabilizer were examined by specialists from the Smithsonian Institution’s Feather Identification Lab using DNA and microscopic analysis. None of the samples contained bird material. Canopy The airplane was equipped with a forward hinging, tip-up canopy that comprised an aluminum and steel frame structure and an acrylic bubble with a thickness ranging between 1/16 and 1/8 inch. Gas struts supported the canopy when open, and the original design used an automotive-style latch within the frame that locked into a striker-pin on either side of the cabin sidewall canopy sill. The airplane’s pre-flight inspection section of the Pilot Operating Handbook (POH), dated March 2010 (revision) 2, stated: Check that your canopy closes and latches properly on both sides. If in doubt, add a secondary latching system as recommended by the Australian CAA. Zenair Ltd, published the “MANDATORY ACTION – SAFETY ALERT” document on December 6, 2021, about two weeks after the accident. The alert documented a series of events where canopies had opened in flight and recommended the installation of a secondary canopy latch. The alert referenced the “Recreational Aircraft Airworthiness Notice AN 070109-Issue 1” issued by Recreational Aviation Australia in January 2009. This notice documented the compulsory fitment of a secondary canopy locking device on Zodiac/Zenair/Zenith aircraft models fitted with a forward hinging canopy. AN 070109-1 stated that the canopy was of relatively light construction, and was prone to distortion during flight, which can cause the latches to release. It also revealed that the locking mechanism can be latched without adequately locking the canopy. It cited reports where the canopy had opened in flight, and while those airplanes remained capable of flight, a speed or power reduction resulted in increased turbulent airflow over the elevators and a sudden nose-down attitude. FAA regulations do not mandate compliance with safety alerts, nor are there provisions for issuing airworthiness directives to experimental airplanes. The NTSB has investigated seven accidents that occurred after the canopies of Zenith 600 series airplanes opened in flight. Review of international accident reports, along with various Zenith internet forums, also revealed that multiple pilots had encountered similar events. The openings all resulted in control difficulties in flight, often leading to high negative G-forces, aggressive nose-down pitch movements, and cabin contents being sucked out of the airplane. The owner of the accident airplane stated that the canopy had once opened during takeoff. It was accompanied by a very loud bang sound, and then loud wind noise as the flight progressed. The canopy opened to about 6 inches, and he was able to maintain aircraft control and return to the airport to land. He stated that, following that event, he disabled the airplane’s standard lock by removing the striker-pins mounted on the canopy sill. He then installed a lock that consisted of two 2 ½-inch-long, over-center latches mounted to the rear of the canopy frame. He did not install a secondary latch. The canopy over-center latches installed by the owner were held in place with two 1/8 inch aluminum blind rivets per side. Both latches had separated from the airframe and were found with the main wreckage. The canopy latch hooks remained attached to the sides of the rear canopy structure. For one latch, the 7/32 inch head of the blind rivet was still in place and appeared to have sheared from the rivet shank, which was not located. The other rivet was missing. The inboard side of the over-centering arm and the corresponding threaded portion of the hook exhibited scratches and paint transfer marks. The mating side of the mounting plate exhibited scratches and grooves in the vertical plane (canopy tilt direction), that were not present on latch the second latch. Both rivets were missing from second latch. Its over-centering arm had deformed inward, and its mounting plate was twisted. The owner stated that, because of his height, he moved the seat 4 inches forward and raised it by 2 inches to enhance forward visibility, and that during turbulence, his headset often touched the canopy. He surmised that the pilot, who was 8 inches taller, would have needed to lean inboard to avoid touching the canopy. He further stated that turbulence was not uncommon in the accident area. The POH contained a section entitled “Canopy Opening in Flight,” which stated: -Concentrate on flying the airplane. -REDUCE SPEED TO 60 KNOTS -RAISE FLAPS -Ignore the canopy and wind noise -Fly a normal approach and landing without flaps, including completing the landing checklist. -The canopy will remain raised in an open position about 1 foot -If the canopy opens after lift-off, do not rush to land. Climb to normal traffic pattern altitude, fly a normal traffic pattern, and make a normal landing. -Do not release the seat belt and shoulder harness in an attempt to reach the canopy. Leave the canopy alone. Land as soon as practicable and close the canopy once safely on the ground. -Do not panic. Try to ignore the unfamiliar wind. Also, do not rush. Attempting to get the airplane on the ground as quickly as possible may result in steep turns at low airspeeds and altitude. -Complete all items on the landing checklist. -Remember that accidents are almost never caused by an open canopy. Rather, an open canopy accident is caused by the pilot's distraction or failure to maintain control of the airplane. - The airplane came to rest inverted and nose down in a field. The airframe was compressed aft, such that the engine and firewall were in line with the trailing edge of the wings. Both wings sustained crush damage through to the aft spar, both fuel tanks were breached, and the smell of fuel was present in the soil surrounding the site. A 70-ft-long debris field consisting of aluminum fragments, flight instruments, and significant quantities of clear canopy acrylic shards emanated west from the main wreckage. The pilot’s flight bag, an iPad, seat cushion, sun visor, and a fuel sump jar were located about 400 ft east of the main wreckage, dispersed in the general area below the descending segment of the flight track. The flight controls and corresponding control surfaces sustained impact damage and were severely deformed and separated in multiple locations. Examination did not reveal any preimpact failures. Similarly, the fuel system sustained multiple breaches, but all fittings were tight, and the fuel selector valve appeared to be in the right tank position. A significant quantity of canopy fragments were dispersed west of the initial impact point. Remnants of the canopy frame were comingled with the main wreckage. The canopy sides remained attached to the rear bow, and the forward bow had broken away from the left side structure. The engine sustained extensive impact damage, detaching sections of the intake manifold and most accessories. The firewall had formed around the rear of the engine. There was no evidence catastrophic internal engine failure or oil leak. The propeller hub remained attached to the crankshaft, and both composite propeller blades had detached at their roots. One blade exhibited leading edge knicks, dents, and chordwise scratches consistent with rotation at impact. The other blade was bent about 6 inches from the root, but otherwise intact. Both a ground and overhead drone search of the area below the flight track leading up to the initial upset did not reveal any other cabin contents, airplane parts, or canopy material. -
Analysis
About seven minutes after departure, following what appeared to be an uneventful takeoff and initial climb, the airplane began a 180° turn toward the departure airport. A few minutes later, witnesses heard a loud bang, and the airplane pitched down aggressively, rolled inverted, and impacted the ground in a steep, nose-down attitude. During the descent, the pilot’s flight bag and other cabin contents fell out of the airplane, and the sound of buffeting wind noise and the pilot struggling were heard on the airport’s common traffic advisory frequency. Examination did not reveal any anomalies with the flight controls or engine that would have precluded normal operation, and all components from the airplane were found in the immediate vicinity of the impact site. There was no evidence of bird strike. The owner/builder of the airplane stated that he had once experienced the canopy opening on takeoff but was able to land safely. As a result of this event, he disabled the standard lock and installed a set of two small over-center latches, each mounted to the rear sides of the canopy frame with two soft aluminum rivets. Examination of the canopy system revealed damage signatures that appeared to indicate that the rivets of one latch had separated in shear, and the other latch had twisted away from the airframe. It is likely that the accident was initiated by the failure of the mounting rivets in one latch, which caused the canopy to partially open on one side, then twist the latch away from the other side, resulting in an open and possibly deformed canopy. The reason for the initial failure could not be determined; however, the owner of the airplane was shorter than the pilot and had raised the seat and moved it forward during construction. The modification would have resulted in the accident pilot having to lean inboard, or sit with his head tilted, to avoid touching the canopy. It is possible that the airplane encountered turbulence that caused the pilot to hit the canopy, resulting in the failure of one of the latches. Multiple instances of canopies opening in flight were reported for this airplane model. Because an open canopy disturbs airflow over the horizontal stabilizer, flight control difficulties can result in a loss of control nose-down pitching motion, often accompanied by a loud banging sound and cabin contents being sucked out, all which were observed in this accident. Although the Pilot Operating Handbook (POH) provides instructions for continued flight with an open canopy, evidence from both this and previous accidents suggests that both the nose-down motion and associated negative G-forces can be hard for pilots to maintain airplane control. The airplane’s POH suggested the installation of a secondary backup latch system, and 2 weeks following the accident, the manufacturer issued a safety alert recommending such. The accident airplane was not equipped with a secondary latch.
Probable cause
The failure of the airplane’s canopy latch system, which resulted in the canopy opening in flight and a loss of airplane control. Contributing to the accident was the lack of a secondary canopy latch as recommended by the kit manufacturer.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
Zodiac CH601XL
Amateur built
true
Engines
1 Reciprocating
Registration number
N601KS
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
6-5930
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-02T06:20:06Z guid: 104310 uri: 104310 title: WPR22LA049 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104325/pdf description:
Unique identifier
104325
NTSB case number
WPR22LA049
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-24T12:20:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2021-12-27T23:58:14.373Z
Event type
Accident
Location
New Cuyama, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that the airplane’s engine lost power during cruise flight over mountainous terrain. He stated that after determining that there were no available emergency landing spots, he decided to bail out. The airplane was destroyed during the impact sequence, and the pilot sustained minor injuries as a result of the parachute jump. Shortly after the accident, the pilot provided a statement regarding the circumstances to the NTSB and FAA, and in a series of correspondences later stated that he had not been able to locate the airplane wreckage. However, evidence gathered by the NTSB and FAA indicated that the pilot had recovered the airplane from the accident site, destroyed it, and then disposed of the remains. The case was referred to the U.S. Department of Transportation Office of Inspector General, and in May 2023, the pilot admitted to the US Attorney’s Office that he both intentionally crashed the airplane, and destroyed the evidence. He plead guilty to a felony charge for obstructing a federal investigation by deliberately destroying the airplane wreckage.
Probable cause
The pilot’s decision to intentionally crash the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TAYLORCRAFT
Model
BL-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N29508
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2351
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-27T23:58:14Z guid: 104325 uri: 104325 title: WPR22LA064 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104397/pdf description:
Unique identifier
104397
NTSB case number
WPR22LA064
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-24T14:40:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-12-16T23:55:29.226Z
Event type
Accident
Location
Tooele, Utah
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 24, 2021, about 1240 mountain standard time, a Beech A36, N4370W, was substantially damaged when it was involved in an accident near Tooele Valley Airport (TVY), Tooele, Utah. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane departed from Safford, Arizona, with 80 gallons of fuel aboard. The pilot reported that, during cruise flight at 12,500 ft mean sea level (msl), he used a 65% power setting, consistent with the power setting in the Pilot Operating Handbook (POH) for that phase of flight. As the airplane neared Gunnison, Utah, which was about 85 miles south of TVY, he switched from the right fuel tank to the left fuel tank. Shortly afterward, the pilot initiated descents to 10,500 ft msl and then 8,500 ft msl while west of Provo, Utah. The pilot stated that he maintained a mixture setting of 50° rich of peak throughout the descent. As the airplane neared the Tooele Valley, he descended the airplane to 6,500 ft msl and maneuvered around a ridgeline. While descending to pattern altitude at the destination airport, the pilot reduced the propeller speed to 2,200 rpm, at which time a “slapping' sort of knock began, as well as a shimmy in the plane.” The pilot arrested the descent and observed that the oil temperature and oil pressure were normal. He then looked outside the airplane and verified that no control surface issues were occurring. Afterward, the pilot focused his attention on engine performance. The pilot stated that the airspeed had decreased to 130 miles per hour and that the controls became “heavy and very mushy.” The pilot initiated a forced landing to a nearby road, but he observed a vehicle that was traveling on the opposite direction of the road and decided not to land there. The pilot then advanced the propeller and throttle levers full forward but received no response from the engine. The pilot also noticed that the cylinder head temperature gauge had “dropped completely to the left of the gauge.” The pilot stated that he pitched the airplane upward to avoid power lines and landed in an open desert area. During the landing, the airplane struck multiple juniper trees before it impacted terrain and came to rest nose low, which resulted in substantial damage to the left wing. The airplane was equipped with two 40-gallon fuel tanks, of which, 74 gallons of fuel is usable. The POH indicated that at a 65% cruise power setting, fuel burn is between 10.0 and 13.3 gallons per hour. Postaccident examination of the airframe and engine revealed no evidence of any pre-existing mechanical malfunction that would have precluded normal operation of the engine. -
Analysis
The pilot stated that he began a descent to pattern altitude at the destination airport. When he reduced the propeller speed to 2,200 rpm, a “slapping sort of knock began as well as a shimmy in the plane.” The pilot arrested the descent, observed that the oil temperature and oil pressure were normal, and looked outside the airplane to verify that the flight control surfaces had no issues. The pilot then noticed that the airspeed had decreased to 130 miles per hour and that the controls became “heavy and very mushy.” The pilot initiated a forced landing to a nearby road but abandoned that plan when he observed a vehicle traveling on the road. The pilot advanced the propeller and throttle levers full forward but received no response from the engine, and he noticed that the cylinder head temperature gauge had “dropped completely to the left.” The pilot maneuvered the airplane to avoid power lines and landed in an open desert area. During the landing, the airplane struck trees, impacted terrain, and came to rest at a nose-low attitude. Postaccident examination of the airframe and engine revealed no evidence of any pre-existing mechanical malfunction that would have precluded normal operation. Utilizing the reported fuel quantity at the time of departure and fuel burn rate for the reported power setting, it was determined that the pilot had an adequate amount of fuel for the intended flight. As a result, the reason for the total loss of engine power could not be determined.
Probable cause
The total loss of engine power for reasons that could not be determined based on available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N4370W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-559
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-16T23:55:29Z guid: 104397 uri: 104397 title: ERA22FA076 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104318/pdf description:
Unique identifier
104318
NTSB case number
ERA22FA076
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-24T19:46:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-11-29T21:43:09.115Z
Event type
Accident
Location
Grove City, Pennsylvania
Airport
GROVE CITY (29D)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On November 24, 2021, at 1746 eastern standard time, a Cessna T210R, N6209U, was destroyed when it was involved in an accident near Grove City, Pennsylvania. The private pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated from Westchester County Airport (HPN), White Plains, New York, and was enroute to Akron Fulton Airport (AKR), Akron, Ohio; a distance of about 350 nautical miles. About two hours into the flight, the pilot, who was also the owner of the airplane, diverted to Clarion County Airport (AXQ), Clarion, Pennsylvania, for a reported oil pressure issue. Witnesses at AXQ stated that, after landing, the pilot requested 6 quarts of oil; he also stated that he thought the oil pressure issue was due to the oil filler cap not being properly secured, which resulted in a loss of oil through the dipstick tube. One witness stated that the airplane was “covered in oil,” with oil present on the empennage, lower fuselage, and engine cowl. The pilot and passenger, who was also an aircraft mechanic, cleaned the airplane with rags, serviced the engine with 6 quarts of the new oil, and elected to resume their flight. During the subsequent engine start, one of the witnesses, who was a helicopter mechanic, heard the airplane’s engine making “abnormal cracking and popping” noises. The pilot taxied to the end of the runway and departed without performing an engine run-up. After departure, the pilot contacted air traffic control, climbed to 4,500 ft mean sea level (msl) and requested visual flight rules flight following to AKR, which was about 95 nautical miles west. About 15 minutes after takeoff, at 1739, the pilot reported a loss of engine power, and he requested assistance. The controller provided instructions to land at Grove City Airport (29D), Grove City, Pennsylvania, at the airplane’s 12 o’clock position and 8 miles away, then several minutes later offered an alternative landing site at a nearby outlet mall if he could not make the airport. Shortly after the pilot reported the airport in sight, at 1744, he stated that he did not think the would be able to reach the airport. Communications and radar contact were subsequently lost at 1746. A security video at the airport showed the landing light of the airplane during the approach. The landing light descended rapidly and disappeared behind terrain followed by an explosion. The airplane impacted trees and steep terrain at an elevation of about 1,200 ft msl, about 1.5 miles from the approach end of runway 28 at 29D. The initial tree impact was about 250 ft from the main wreckage, which came to rest on a 35° incline against several trees. A 24-inch section of the left wingtip was located near the initial tree impact and several broken branches were observed on top of an approximately 75-ft-tall pine tree. A post-impact fire consumed the fuselage and cockpit area. The instrument panel and all associated instrumentation, gauges, and electronic devices were destroyed by fire. The empennage separated during impact; the vertical and horizonal stabilizers, rudder, and elevators remained attached. There was oil residue observed on the underside of the empennage, left stabilizer, and elevator. The flight control cables exhibited breaks consistent with overload. Several portions of the left wing were located along the wreckage path and near the main wreckage. The right wing was damaged by impact forces and fire. The aileron control cables were traced to the cockpit through breaks in the cables that were consistent with overload. There was no indication of any airframe anomaly or condition that would have precluded normal operation. The factory-remanufactured engine was installed on the airplane on May 16, 2012, and had accumulated about 350 hours total time since installation. The engine was partially separated from the main wreckage but remained attached to the engine mounts and firewall. The three-blade propeller and spinner remained attached to the crankshaft flange. Two of the three propeller blades were bent aft in a relatively uniform manner. The third blade was bent aft and exhibited severe gouges and scrapes on the upper surface and leading edge of the blade tip, but little chordwise scraping was observed on all three blades. The propeller spinner was crushed uniformly from the front to aft and exhibited no evidence of rotational damage. The engine showed evidence of significant heat exposure but was relatively intact. The turbocharger was examined and static impact impressions consistent with contact from the compressor wheel were observed. There was no rotational damage to the blades or housing. The top spark plugs were removed; the No. 5 spark plug electrode was damaged and covered with oil. The Nos. 3 and 2 spark plugs were covered with oil. The remaining spark plugs remained intact and exhibited minimal wear when compared to the Champion Check-A-Plug chart. Two holes were observed on the top of the engine crankcase. One hole was located forward of the No. 5 cylinder and was about 2 inches in diameter. The second hole was located adjacent to the No. 4 cylinder and was about 3 inches in diameter. The No. 4 cylinder connecting rod was separated from the crankshaft. The No. 5 cylinder piston was fragmented into small pieces with the piston pin still installed in the connecting rod. The oil filler cap was securely installed. The two through-bolts that connected cylinders Nos. 4 and 5 were missing nuts on the right side of the engine and the bolt threads exhibited thermal damage. The two through-bolts that connected cylinders Nos. 2 and 3 were missing nuts on the left side of the engine and the bolts showed signs of thermal damage. Half of a nut was discovered in debris under the No. 3 cylinder and showed signs of thermal damage and was brittle when handled. Disassembly and examination of the crankshaft revealed that the main journal bearings showed evidence of polishing and metal-to-metal contact. -
Analysis
During the visual flight rules cross-country flight, the pilot and pilot-rated passenger, who was also an aircraft mechanic, diverted due to an oil pressure issue. Witnesses at the diversion airport stated that, after landing, the pilot requested 6 quarts of oil and rags to clean his airplane. The airplane was “covered” with oil on the fuselage, wings, and engine cowling. The pilot stated that the oil loss was the result of an unsecured oil filler cap. After servicing the airplane with all 6 quarts of oil and cleaning the residual oil off the airplane, the pilots departed. A witness reported that the airplane’s engine made “abnormal cracking and popping” noises during engine start and taxi, and that the pilots departed without performing an engine run-up. About 15 minutes after departure, while cruising at 4,500 ft mean sea level (msl), the pilot reported a loss of engine power to air traffic control and was given vectors to a nearby airport; however, he was unable to glide to the airport and the airplane impacted trees and steep terrain. A significant post-impact fire ensued. Postaccident examination of the wreckage revealed that the engine exhibited features consistent with a loss of oil lubrication. Although several of the crankcase through-bolts were missing their respective nuts, this was likely the result of postimpact thermal damage rather than improperly secured nuts. Based on the available information, it is likely that the internal components of the engine sustained damage due to oil starvation after the pilot failed to secure the oil filler cap. This damage was sufficient to result in catastrophic engine failure when the engine continued to be operated, even after adding oil. The pilots’ decision to depart on the accident flight without further examining the engine for signs of damage or conducting an engine run-up contributed to the accident.
Probable cause
A catastrophic engine failure due to oil starvation after the pilot’s failure to secure the oil filler cap before flight. Contributing to the accident was the pilots’ decision to continue the flight following the oil loss event and precautionary landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210R
Amateur built
false
Engines
1 Reciprocating
Registration number
N6209U
Operator
CENTURION 85 LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21064922
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-29T21:43:09Z guid: 104318 uri: 104318 title: CEN22FA053 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104326/pdf description:
Unique identifier
104326
NTSB case number
CEN22FA053
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-28T18:58:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-11-30T08:51:17.041Z
Event type
Accident
Location
Perry, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
Flight Controls The task instructions to install and remove the copilot’s flight controls is in the Bell 206 series FAA-approved maintenance manual. Bell released Operations Safety Notice 206-84-12 for the Bell 206 and the TH-57 series helicopters on July 17, 1984. This document discusses the dual control-quick disconnect kit and states in part: Investigation of a recent model 206 helicopter accident, which resulted in a fatality, revealed that lateral cyclic control was lost as a result of an improperly installed copilot’s quick-disconnect cyclic stick. Flight crews are cautioned to assure quick removal flight controls are properly installed prior to operating the helicopter. The Bell Operations Safety Notice was released shortly after an accident (NTSB accident number DEN84FA207) that occurred on July 2, 1984. The accident report, involving a Bell 206B helicopter, stated in part: Witnesses stated the helicopter entered a “hard left turn” in a near inverted position before “it went down hard and fast.” Inspection disclosed the metal connection for the left cyclic stick was broken in half. The pilot was flying from the left seat. Examination of the cyclic stick quick disconnect locking nut revealed it was held in place on the connector by one thread. Properly installed, the locking nut tightens down over six threads on the connector. When backed out to one thread, movement of the cyclic will not produce a corresponding change in the lateral control hydraulic servos. Bell subsequently released Alert Service Bulletin (ASB) 206-85-27 for the Bell 206 and the TH-57 series helicopters on March 15, 1985. This document discusses design changes made to the dual control-quick disconnect kit to help ensure proper installation. Compliance with manufacturer service bulletins for aircraft operated under 14 CFR Part 91 and 14 CFR Part 137 is not mandated by the FAA. Since the airframe maintenance records for the helicopter were not available for review, it was undetermined if ASB 206-85-27 was complied with. At the time of the accident, there was no clear guidance published about the topic of flight control installation and removal (such as who is allowed to perform the task, inspection requirements, weight and balance documentation requirements, and maintenance record entry requirements) for owners, operators, pilots, and maintenance personnel operating helicopters under 14 CFR Part 91 and 14 CFR Part 137. Bell was asked by the NTSB investigator-in-charge (IIC) if they would publish guidance on this task for operations in the United States (as the type certificate for the helicopter is held in Canada and is managed by Transport Canada) and Bell declined. Rotorcraft Flight Manual A review of the FAA-approved Bell 206B rotorcraft flight manual found no guidance for pilots listed if a flight control malfunction occurs. This includes a failure of components with the flight control system transmitted through feedback, binding, resistance, or sloppiness and not mistaking these conditions for a failure of hydraulic power. Bell was asked by the NTSB IIC if they would publish guidance for pilots on this emergency procedure topic and Bell declined. Startle Response The FAA has published a Fly Safe Fact Sheet that defines what startle response is and states in part: Humans are subject to a “startle response” when they are faced with unexpected emergency situations and may delay or initiate inappropriate action in response to the emergency. Training and preparation can reduce startle response time and promote more effective and timely responses to emergencies. - The helicopter was certificated by the FAA in both the standard and restricted airworthiness categories. According to FAA records, the pilot purchased the helicopter in November 2013. According to the pilot’s girlfriend, she flew with the pilot in the helicopter about 1.5 weeks prior to the accident. The pilot took her on an aerial application flight in the local area to spray several crop fields and nothing abnormal was noticed with the helicopter. The girlfriend reported that the pilot was the only one who would install and remove the copilot cyclic control in the helicopter. The pilot would install the copilot cyclic if he was going to fly with his son and then the pilot would later remove it. The helicopter was modified with a Simplex 4900 aerial application spray system per a FAA-approved supplemental type certificate. At the time of the accident, the helicopter did not have the spray booms installed. Per FAA records, the helicopter was equipped with a Satloc unit (unknown model) and a Shadin Fuel Flow Indicator unit (unknown model); however, the Satloc was destroyed and the Shadin Fuel Flow Indicator unit was not identified in the wreckage. The helicopter was not equipped with a crash-resistant fuel system, nor was it required to be. An emergency locator transmitter was not identified in the wreckage and the passenger reported he was unsure if one was installed in the helicopter. The airframe and engine maintenance records for the helicopter were not available for review. - The helicopter was not equipped with a crashworthy flight data recorder or a cockpit voice recorder, nor was it required to be. - On November 28, 2021, about 1658 central standard time, a Bell 206B helicopter, N59600, was destroyed when it was involved in an accident near Perry, Oklahoma. The commercial pilot sustained fatal injuries and the passenger, who held a student pilot certificate, sustained serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to the passenger, who is the pilot’s son, the pilot preflighted the helicopter at 1530. The helicopter was kept on the pilot’s property in a barn. Nothing abnormal was noticed during the preflight. During the preflight, the pilot installed the flight controls for the left seat position. For the flight, both front doors were installed and neither occupant did any filming during the flight. The pilot, in the left seat, had on a surplus US Army (Gentex) SPH-4 helicopter flight helmet, but the flight helmet did not have a tinted visor and he did not have on sunglasses. The passenger, in the right seat, had on a headset, and he did not have on sunglasses. The helicopter departed from the pilot’s property about 1600 with about 50 gallons of fuel onboard, and when the accident occurred there was about 25 gallons of fuel onboard. After departing from the property, the helicopter flew to the Perry Municipal Airport (F22), Perry, Oklahoma. The pilot flew three traffic pattern flights. After the three traffic pattern circuits, the helicopter departed the airport and flew to the west of I-35. According to the passenger, everything appeared normal with the helicopter up to this point. The pilot flew to the west of I-35 over ranch property to demonstrate how he performed his 14 CFR 137 low-level aerial application flights in the helicopter. The passenger reported that the setting sun was in both of their eyes during this timeframe. The pilot performed several low-level east to west maneuvers and he was demonstrating the use of the Satloc aerial application navigation system to the passenger. During these maneuvers, the helicopter was about 15 ft above ground level (agl) and was traveling about 60 kts airspeed. During a pass to the east, the two occupants both observed a coyote in a large field. The coyote was in tall grass, just to the south of a barbed wire fence near where the helicopter came to rest. The pilot performed a right pedal turn to get a better look at the coyote. The pilot maneuvered the helicopter to an out-of-ground effect hover over the tall grass, facing to the south, about 40 ft agl. Both the pilot and passenger were looking at the coyote when the helicopter began an uncommanded left roll. The passenger couldn’t tell what the cyclic positions were (such as if they both went to the left or if just one went to the left) during the uncommanded left roll. The passenger reported the accident sequence happened “very fast,” the pilot was on the flight controls for the entire flight, and that the passenger was not operating the flight controls during the accident sequence. The pilot did not announce anything during this time regarding what he thought was going on with the helicopter. The helicopter did not spin, and the passenger did not recall the main rotor blade striking the ground before the helicopter impacted the terrain. There were no vibrations emitted from the helicopter and no alarms or warning lights came on during this period. The helicopter impacted a grass field just south of a barbed wire fence. The grass around the helicopter instantly caught on fire after the impact. The passenger was able to extract himself and the deceased pilot away from the wreckage. About 5 minutes later, the wreckage caught on fire and was destroyed. The passenger then contacted first responders from his cellular phone who then arrived shortly after. There were no known witnesses who observed the accident sequence. - Pilot At his most recent FAA medical examination, he reported no medications or medical conditions. According to the autopsy report from the Office of the Medical Examiner, Oklahoma City, Oklahoma, the cause of death of the pilot was multiple blunt force injuries and the manner of death was accident. The medical examiner reported the pilot had 90% stenosis of his left anterior descending and right coronary arteries. Toxicological testing performed by the FAA’s Forensic Sciences Laboratory identified the non-sedating pain reliever acetaminophen (commonly marketed as Tylenol) in the pilot’s femoral blood and urine. Passenger At his most recent FAA medical examination, he reported no medications or medical conditions. Toxicology testing performed by the FAA Forensic Sciences laboratory detected the primary psychoactive compound of cannabis, THC, in the passenger’s urine at 1.7 nanograms per milliliter (ng/mL); THC was not detected in his blood. THC’s psychoactive metabolite 11-OH-THC was detected but not quantified in his urine but was not detected in his blood. THC’s inactive metabolite THC-COOH was detected in the passenger’s hospital admission blood at 23.4 ng/mL and in his urine at 84.1 ng/mL. - The passenger reported the local weather conditions for the flight were no wind, no turbulence, and clear visibility. A review of meteorological data indicated a light southerly wind below 2,000 ft agl, no indication of turbulence or low-level wind shear, or any other outflows or wind shifts. A pilot report indicated flight visibility of 10 miles. There were no inflight weather advisories over the region during the flight. Astronomical conditions indicated the accident occurred before sunset with a low sun elevation present. A review of the meteorological data surrounding the time and location of the accident did not reveal any meteorological areas of concern. The estimated density altitude for the accident site was 931 ft above msl. - Pilot The pilot, who owned the accident helicopter, worked full time as a helicopter air ambulance pilot. The pilot also worked part time as a 14 CFR Part 137 aerial application pilot (as the sole pilot in the business he owned) and as a rancher. The pilot’s helicopter air ambulance company records were available for review; however, the pilot’s personal logbook was not available for review. According to Federal Aviation Administration (FAA) records, the pilot did not hold a mechanic certificate. Passenger/Student Pilot The passenger was enrolled in a university aviation program and was learning to fly helicopters. - The accident site, at an elevation of 1,056 ft above msl, consisted of private property that is used as a cattle pasture. The barbed wire fence that the helicopter came to rest just prior to, was found intact with no sign of impact. The barbed wire fence was later cut by the investigative team to facilitate access to the wreckage. All major structural parts of the helicopter were accounted for at the accident site. Most of the forward and intermediate fuselage was consumed in the fire. The tailboom detached from the intermediate fuselage and was found near the main wreckage. The main rotor hub and blade assembly remained attached to the mast which fractured just below the hub. Both main rotor blades suffered various degrees of fracturing and bending. All remnants of the main rotor blades were accounted for. The transmission case was partially consumed in the post-crash fire. Due to the thermal and impact damage, main rotor drive continuity could not be established. The tail rotor drive system was continuous within the tail boom section found adjacent to the wreckage. During the impact sequence, the tail rotor gearbox separated from the tail boom. The complete tail rotor assembly separated from the tail rotor gearbox output shaft. The tail rotor gearbox was able to be rotated by hand in both directions with no binding or abnormal sounds coming from the tail rotor gearbox. The components of the fuel system, including the fuel bladder, two electric boost pumps, lower and upper tank indicating units, fuel/vent lines, fuel shutoff valve, airframe fuel filter, and an electric sump drain valve were destroyed by the fire. The components of the hydraulic system, including the hydraulic pump and regulator assembly, three servo actuators, solenoid valve, tube assemblies, hose assemblies, and hydraulic filter were destroyed by the fire. The hydraulic servo actuator support suffered significant thermal damage. However, the left/right (cyclic) and collective (center) servo actuators were located and retained for further examination. The components of the flight controls, including collective pitch controls, cyclic controls, and tail rotor controls were destroyed by the fire. One collective stick was present in the wreckage along with one pedal assembly. However, the cyclic control were not located in the wreckage. Due to the extensive damage to the flight controls from the fire, flight control continuity could not be established. The hopper was destroyed and there was no evidence of chemical being carried in the helicopter at the time of the accident. The cockpit structure, dash panel, and two cockpit seats and restraints were destroyed. All the cockpit gauges were destroyed by the impact sequence and postimpact fire and no readings were obtained. Fuel samples from the airframe and engine were not available. The turboshaft engine was found securely mounted to the remnants of the airframe. The engine sections (intake, compression, combustion, and exhaust) all sustained fire damage. Damaged sustained to the cockpit and fuselage prevented engine control continuity checks to the fuel control unit and the power turbine governor. The power turbine support was removed from the exhaust collector to inspect the remainder of the turbine stages. The second, third, and fourth stage turbine wheels were undamaged with no missing blades or nozzle airfoils. The turbine to compressor coupling (N1 shaft) was intact and dark in appearance. A silver powder-like substance was observed on the first stage nozzle shield, third stage nozzle, and third stage turbine wheel. This substance is consistent with the compressor front diffuser coating and was likely liberated during the impact sequence, supporting engine operation at impact. Postaccident Fourier Transform Infrared Spectroscopy and mass spectroscopy analysis of fluid samples extracted from the servo actuators revealed that the fluid did not match either MIL-H-5606 or MIL-H-6803 hydraulic oils that were listed in the engineering drawing. The actual identity of the fluid could not be determined, but the results of the analysis indicated that it was a mixture of a petroleum based and synthetic based hydraulic fluid, combined with a third unknown component. The passenger reported he did not know if any hydraulic fluid was added before the accident flight. Postaccident scanning and examination of the three servo actuators did not reveal any mechanical malfunctions or failures that could result in a cyclic hard over sequence. -
Analysis
Prior to the flight, the pilot, who is not a mechanic, installed the flight controls at the helicopter’s left seat position. The pilot and passenger, who was in the right seat and held a student pilot certificate, departed from the pilot’s property for a local area flight. The pilot was demonstrating how he performed low-level aerial application maneuvers to the passenger. During a pass to the east, the two occupants both observed a coyote in a large field. The pilot performed a right pedal turn to get a better look at the coyote. The pilot maneuvered the helicopter to an out-of-ground effect hover over the tall grass, facing to the south, about 40 ft agl, and the two occupants were looking at the coyote. The helicopter then immediately began an uncommanded left roll. The passenger couldn’t tell what the cyclic positions were (such as if they both went to the left or if just one went to the left) during the uncommanded left roll. The passenger reported the accident sequence happened “very fast” and that the pilot was on the flight controls for the entire flight. The helicopter did not spin, there were no vibrations emitted from the helicopter, and no alarms or warning lights came on during this period. The helicopter impacted a grass field just prior to a barbed wire fence and a postimpact fire ensued. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation; however, the helicopter was destroyed by the postimpact fire. Detailed examination of the flight control system, including determining flight control continuity, could not be established due to the impact and thermal damage. Postaccident scanning and examination of the three hydraulic servo actuators did not reveal any mechanical malfunctions or failures that would result in a cyclic hard over sequence. Based on autopsy findings, the pilot had severe stenosis of two coronary arteries. However, there was no evidence of sudden incapacitation, and the passenger reported that the pilot was acting fine the entire flight. Thus, the pilot’s cardiovascular medical condition was not a factor in this accident. The drug identified on the pilot’s toxicology results was the non-impairing pain reliever acetaminophen, thus the pilot’s medication use was not a factor in this accident. The passenger had reported no medical conditions that would be a factor in this accident. Toxicology testing detected no psychoactive compounds from cannabis in his blood but detected tetrahydrocannabinol (THC) and its psychoactive metabolite 11hydroxy-delta-9-THC (11-OH-THC) in his urine. THC’s inactive metabolite, carboxy-delta-9- tetrahydrocannabinol (THC-COOH), was detected in his blood and urine, but this compound can be found long after using cannabis. Thus, it is unlikely that the passenger’s use of cannabis contributed to the accident. At the time of the loss of lateral control, the pilot and passenger were visually focused outside of the helicopter. With the unexpected and rapid onset of the uncommanded left roll as described by the passenger, there would have been minimal time for the flying pilot to assess and initiate corrective actions. Based on the available evidence, the reason for the loss of lateral control during a hover could not be determined.
Probable cause
A loss of lateral control during a hover that resulted in an impact with terrain. Based on the available evidence, the reason for the loss of lateral control could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206
Amateur built
false
Engines
1 Turbo shaft
Registration number
N59600
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1420
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-11-30T08:51:17Z guid: 104326 uri: 104326 title: ERA22LA079 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104333/pdf description:
Unique identifier
104333
NTSB case number
ERA22LA079
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-11-29T16:47:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2021-12-13T23:09:28.044Z
Event type
Accident
Location
Cornelia, Georgia
Airport
Habersham County Airport (AJR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On November 29, 2021, about 1447 eastern standard time, a Piper PA-46-500TP, N172MA, was substantially damaged when it was involved in an accident near Cornelia, Georgia. The airline transport pilot and two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he performed a straight-in visual approach to runway 6, a 5,500 ft-long, 100 ft-wide, asphalt runway at Habersham County Airport (AJR), Cornelia, Georgia. He added that the airplane was on a correct glidepath and correct airspeed of 120 knots on short final approach. The main landing gear touched down first, followed by the nose landing gear. As soon as the nosewheel touched down, the airplane pulled to the left. The pilot initially corrected with right rudder input, but the airplane pulled again to the left and the pilot again put in right rudder deflection. The pilot relaxed right rudder pressure a second time and then the airplane pulled very aggressively to the left. He set the throttle to beta, applied both brakes, and right rudder, but the airplane departed the left side of the runway about halfway down the runway. The airplane traveled into a ditch and came to rest upright in a grass area next to the runway. Although runway 6 was 5,500 ft long, it had a displaced threshold of 1,392 ft. Review of skid marks revealed that the airplane touched down about halfway down the remaining 4,108-ft runway. The skid marks consisted of nose gear tire and right main gear tire, but no left main gear tire, consistent with touchdown in a left crab angle. As the skid marks neared the left edge of the runway, the left skid mark became visible, and all three tire marks were visible in the grass off the left side of the runway. Examination of the wreckage by a Federal Aviation Administration inspector and a representative from the airframe manufacturer revealed that the left wing had separated from the airframe during impact with the ditch. Steering control continuity was confirmed from the rudder pedals to the steering horn. A primary flight display (PFD), multifunction display, and a fractured section of the lower nose landing gear trunnion were retained and forwarded to National Transportation Safety Board laboratories for further examination. Metallurgical examination of the nose landing gear lower trunnion revealed fracture features consistent with overstress, and no evidence of fatigue. Review of PFD data revealed that the airplane was flying about 110 knots for 25 seconds on final approach. It crossed the displaced runway threshold about 100 knots, the 1,000-ft marker at 85 knots, and the midpoint of the available runway about 73 knots. Review of a pilot’s operating handbook for the make and model airplane revealed a published landing speed of 85 knots indicated airspeed (and 70 knots stall speed in the landing configuration). The wind was recorded as calm at AJR about the time of the accident. -
Analysis
The pilot of the single-engine turboprop airplane stated that he flew a straight-in visual approach to the 5,500 ft-long asphalt runway. He added that the airplane was on a correct glidepath and correct airspeed of 120 knots on short final approach. The main landing gear touched down first during the landing, followed by the nose landing gear. As soon as the nosewheel touched down, the airplane pulled to the left. The pilot corrected with right rudder input, but the airplane pulled again to the left and the pilot again applied right rudder. The pilot relaxed right rudder pressure a second time and the airplane again pulled aggressively to the left. He set the throttle to beta, applied both brakes, and right rudder, but the airplane departed the left side of the runway about halfway down the runway. The wind was recorded as calm at the time of the accident. The runway had a displaced threshold of 1,392 ft; skid marks on the runway (consisting of the nose gear tire and right main gear tire) indicated that the airplane touched down about halfway down the remaining 4,108 ft of the runway. The lack of skid marks for the left main landing gear tire was consistent with the airplane touching down in a left crab angle. As the skid marks neared the left edge of the runway, a skid mark corresponding to the left main landing gear tire became visible, and all three tire marks were visible in the grass off the left side of the runway. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. Given all available information, it is likely that the airplane was in a crab to the left when it touched down, which resulted in the subsequent loss of directional control and runway excursion.
Probable cause
The pilot’s failure to maintain directional control during the landing, which resulted in a runway excursion and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA46
Amateur built
false
Engines
1 Turbo prop
Registration number
N172MA
Operator
N172MA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4697263
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-13T23:09:28Z guid: 104333 uri: 104333 title: WPR22FA053 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104342/pdf description:
Unique identifier
104342
NTSB case number
WPR22FA053
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-02T13:15:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2021-12-07T22:25:02.445Z
Event type
Accident
Location
Lakeport, California
Airport
LAMPSON FLD (1O2)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On December 2, 2021, about 1115 Pacific standard time, an experimental amateur-built, Sport Copter Vortex gyroplane, N425RD, was substantially damaged when it was involved in an accident near Lakeport, California. The pilot was fatally injured. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Witnesses located about 2 miles west of the accident site observed the gyroplane in level flight, about the same height as a set of telephone poles, and then saw it tumble tail over nose three times before they lost sight of it behind a tree line. The gyroplane was not equipped with an automatic dependent surveillance – broadcast transponder and it was flying too low for radar coverage. PILOT INFORMATION The pilot had been involved in another accident in the same area while flying a gyroplane in August 2020. The National Transportation Safety Board (NTSB) determined the probable cause of that accident to be: “The pilot’s distraction and failure to maintain adequate airspeed during a low altitude maneuver, which resulted in a loss of aircraft control and collision with terrain.” See NTSB accident report WPR20CA253. Flight logbook records were not recovered for the pilot; however, at the time of the last accident, he reported to the NTSB that he had accrued 853.8 total hours of flight time in single-engine airplanes and 71.3 total hours in rotorcraft. WRECKAGE AND IMPACT INFORMATION The entire gyroplane came to rest generally intact on its left side on flat open terrain covered with tall heavily vegetated brush near the shoreline of a lake. The fuselage sustained crush and bending damage, consistent with the impact, and there was no evidence to indicate an inflight structural failure. The smell of fuel was present at the accident site and there was no evidence of a wire or bird strike. There were no reports of damaged power lines or power outages in the accident area. The rotor head and mast were intact and remained attached to the airframe. The main rotor blade hub could be rotated freely. The main rotor blades remained attached to the hub bar and straps and both showed a 20° downward bow outboard of the strap fittings. Both blades exhibited similar tear marks to their trailing edge skins, just outboard of the straps. One blade exhibited a black streak on its lower surface next to the strap consistent with engine propeller blade contact. Flight control continuity was established from the foot pedals through to the rudder surface, and from the cyclic control stick through to the rotor mast. There was no evidence of a catastrophic engine failure, and the engine crankshaft could be rotated via the propeller reduction drive hub. One propeller blade remained attached at the hub. The second propeller blade had detached at the root, and the third propeller blade had similarly detached but its tip was not located in the surrounding heavy vegetation. Further examination of the gyroplane revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed by Bennet Omalu Pathology, Stockton, California. The autopsy report was reviewed by the NTSB Investigator-In-Charge. According to the autopsy report, the cause of death was blunt force trauma. Toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. ADDITIONAL INFORMATION According to the FAA Rotorcraft Flying Handbook (FAA-H-8083-21), Chapter 21, Gyroplane Emergencies, if the rotor force is rapidly removed, some gyroplanes may tend to pitch forward abruptly, often referred to as a power pushover, forward tumble, or buntover. “A power pushover can occur on some gyroplanes that have the propeller thrust line above the center of gravity and do not have an adequate horizontal stabilizer.” Removing the rotor force is often referred to as unloading the rotor and can occur if pilot-induced oscillations become excessive, in extremely turbulent conditions are encountered, or the nose of the gyroplane is pushed forward rapidly after a steep climb. If a correction is not made, the nose pitching action can become “self-sustaining and irreversible.” Additionally, the FAA handbook states that “an adequate horizontal stabilizer slows the pitching rate and allows time for recovery.” According to the Pilot’s Operating Handbook, Section 3.10, Emergency Procedures, Flight Control Malfunction: “an immediate reduction of power, respectively speed [sic] may be necessary to avoid pitch oscillations or other effects affecting dynamic or static stability.” -
Analysis
A witness reported seeing the gyroplane flying straight and level about two miles from the departure airport. The witness reported the gyroplane then tumbled tail over nose three times before he lost sight of it below the tree line. The gyroplane sustained substantial damage when it impacted the heavily vegetated terrain. The smell of fuel was present at the accident site and there was no evidence of a wire or bird strike. Additionally, there were no reports of downed power lines or power outages in the accident area. Examination of the gyroplane revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. The gyroplane was equipped with a horizontal stabilizer that remained intact. The engine was likely producing power at the time of the accident, because two of its propeller blades contacted the main rotor blades during the accident sequence. The main rotor blades sustained minimal damage, consistent with the gyroplane entering a low-rotor-rpm state for undetermined reasons before ground impact. According to the Federal Aviation Administration (FAA), FAA-H-8083-21, Chapter 21, Gyroplane Emergencies, if rotor force is rapidly removed, some gyroplanes may pitch forward abruptly into a power pushover event and if not corrected can continue to tumble and become irreversible.
Probable cause
The pilot’s loss of control for reasons that could not be determined and the delayed remedial action to recover from the power pushover event.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
RUSSELL W DYER
Model
VORTEX
Amateur built
true
Engines
1 Reciprocating
Registration number
N425RD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
011
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-07T22:25:02Z guid: 104342 uri: 104342 title: CEN22LA059 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104356/pdf description:
Unique identifier
104356
NTSB case number
CEN22LA059
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-02T16:15:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2021-12-16T22:38:16.296Z
Event type
Accident
Location
Cleveland, Texas
Airport
CLEVELAND MUNI (6R3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On December 2, 2021, about 1415 central standard time, a Beech A36, N8038Z, was substantially damaged when it was involved in an accident near Cleveland, Texas. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while en route at 6,000 ft on an instrument flight rules flight plan the airplane engine suddenly lost power. He reported that he was not in the process of changing or manipulating any controls at the time of the power loss. The pilot elected to fly toward a nearby airport depicted on his GPS receiver. While gliding toward the airport, he attempted to restart the engine several times, but he could not get fuel flow back even with the fuel pump on. He attempted switching fuel tanks during this time and the airplane engine monitor showed no fuel flow despite restart attempts. During the descent, the airplane broke out of the clouds about 3,000 ft. The pilot realized that he would not be able to reach the airport he had selected and redirected the airplane toward a nearby highway. During the landing flare on the highway, the right-wing tip struck a road sign. The airplane exited the highway and came to rest nose down in a ditch. The fuselage sustained substantial damage. The pilot reported that he was utilizing the fuel flow indicator during the flight to aid in balancing fuel during the flight. He noted that he would switch tanks after about every 10 gallons burned. When the airplane was recovered from the accident site, recovery personnel drained 22 gallons from the right-wing fuel tanks and 26 gallons from the left-wing fuel tanks. A postaccident engine test run was conducted. The airplane’s wings had been removed and a temporary fuel can plumbed into the left wing fuel line for the test run. The propeller was bent and was replaced with a surrogate propeller for the test run. The engine started on the first attempt and ran without any problems or malfunctions. The J.P. Instruments, Inc., EDM-900 engine monitor was removed from the airplane for subsequent download of stored data. The data supported the pilot’s description that the fuel flow dropped and the engine lost power with a corresponding loss of exhaust gas temperatures and cylinder head temperatures. The reason for the interruption of fuel flow could not be determined during the postaccident airplane examination. -
Analysis
The pilot reported that while in cruise flight, the airplane’s engine lost power suddenly. He noted that he was not in the process of changing or manipulating any controls when the power loss occurred. The pilot reported that the fuel flow to the engine dropped and the engine lost power, which is supported by engine monitor data. The pilot’s attempts to restore fuel flow and restart the engine were unsuccessful. The pilot realized that he would not be able to reach the airport he had selected and redirected the airplane toward a nearby highway. During the landing flare on the highway, the right-wing tip struck a road sign. The airplane exited the highway and came to rest nose down in a ditch which resulted in substantial damage to the fuselage. During recovery of the airplane, 22 gallons of fuel were recovered from the right-wing fuel tanks, and 26 gallons were recovered from the left-wing fuel tanks. Postaccident examination of the airplane and an engine test run were performed. The engine ran normally and no reason for the interruption of fuel flow was discovered. Based on the available information, the airplane’s engine lost power due to a fuel flow interruption for reasons that could not be determined.
Probable cause
A total loss of engine power due to fuel starvation, the reason for which could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N8038Z
Operator
KJK ENTERPRISES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-2568
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-16T22:38:16Z guid: 104356 uri: 104356 title: CEN22LA071 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104390/pdf description:
Unique identifier
104390
NTSB case number
CEN22LA071
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-04T18:30:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-05-11T00:11:36.873Z
Event type
Accident
Location
Wichita Falls, Texas
Airport
Wichita Valley Airport (F14)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On December 4, 2021, at 1630 central standard time, a Vans RV8, N421RT, sustained substantial damage when it was involved in an accident near Wichita Falls, Texas. The pilot and passenger received serious injuries. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot-rated passenger, who was the airplane owner/builder, stated that while the airplane was returning to the departure airport for landing, there was a total loss of engine power on final approach. The pilot performed a forced landing along the final approach path and the airplane sustained substantial damage to both wings. \ Postaccident examination of the airplane revealed there was useable fuel in the left fuel tank, and there was no useable fuel in the right fuel tank. A witness who responded to the accident, turned the fuel selector from the right fuel tank to the off position. There were no preaccident mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. -
Analysis
The pilot-rated passenger, who was the airplane owner/builder, stated while the airplane was returning to the departure airport for landing, there was a total loss of engine power on final approach. The pilot performed a forced landing and the airplane sustained substantial damage to both wings. Postaccident examination of the airplane revealed there was useable fuel in the left fuel tank, and there was no useable fuel in the right fuel tank. There were no preaccident mechanical malfunctions or failures with the airplane or engine that would have precluded normal operation. The loss of engine power was consistent with fuel starvation.
Probable cause
The pilot’s improper fuel management that resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV8
Amateur built
true
Engines
1 Reciprocating
Registration number
N421RT
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
82522
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-11T00:11:36Z guid: 104390 uri: 104390 title: WPR22FA054 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104345/pdf description:
Unique identifier
104345
NTSB case number
WPR22FA054
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-04T20:40:00Z
Publication date
2023-04-26T04:00:00Z
Report type
Final
Last updated
2021-12-08T23:27:41.174Z
Event type
Accident
Location
Visalia, California
Airport
VISALIA MUNI (VIS)
Weather conditions
Instrument Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude.    The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following:   The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - On December 4, 2021, about 1840 Pacific standard time (PST), a Beech V35 N7933M, was substantially damaged when it was involved in an accident near Visalia, California. The pilot and three passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Recorded ADS-B data provided by the Federal Aviation Administration (FAA) showed that the airplane departed runway 30 at 1837:01 and climbed to 495 ft msl before entering a left turn. The data showed that at 1837:26, the airplane continued to climb in a left turn and reached an altitude of 620 ft msl before entering a descent. The data showed that the airplane continued descending in a left turn until ADS-B contact was lost at 1837:37, at an altitude of 395 ft, about 660 ft northwest of the accident site as seen in figure 1. The departing airport elevation was 295 ft msl. A witness located near the accident location reported that, while in her residence, she heard an airplane flying very low, followed by the sound of the airplane impacting terrain. While the airplane was flying overhead, the engine noise was constant and did not sound like it was malfunctioning. Concerned, she then notified first responders. Figure 1: View of airplane ADS-B track - The Tulare County Coroner's Office, Tulare, California, performed an autopsy of the pilot. The pilot's cause of death was blunt trauma. Toxicology testing performed at the FAA Forensic Sciences Laboratory detected ethanol in the pilot’s liver (0.402 grams per hectogram [gm/hg]), kidney (0.045 gm/hg), and muscle tissue (0.035 gm/hg); no ethanol was detected in the pilot’s muscle tissue by another laboratory. Isopropanol was detected in his liver tissue at 0.009 gm/hg. The non-impairing cholesterol lowering medication atorvastatin was detected in the pilot’s liver and muscle tissue. - At 1830, the Visalia Municipal Airport (VIS) automated weather observation station reported wind from 280° at 5 knots, visibility of 2 ½ miles, mist, broken ceiling at 300 ft above ground level (agl), temperature 8°Cand dew point temperature 8°C, altimeter 30.24 inches of mercury. An AIRMET SIERRA advisory for instrument flight rules conditions was issued at 1245 and was valid at the time of the accident. The advisory identified ceilings below 1,000 ft, visibility below 3 statute miles, mist, and fog. No air traffic control services were provided to the pilot during the accident flight. - A review of the pilot’s logbook showed that he completed an instrument proficiency check on March 24, 2021. In the 12 months preceding the accident flight, he accumulated about 4 hours of simulated instrument flight, 0.4 hours of actual instrument flight and about 1 hour of night flight. - The airplane impacted a flat, open wheat field about 1 mile southwest of the departure end of runway 30. It came to rest on its left side, on a heading of about 265° magnetic, at an altitude of 290 ft mean sea level. The first identified point of contact with terrain was a ground scar/impression about 14 ft long, 22 inches wide, and 3 inches deep. The debris field extended about 345 ft to the main wreckage on a magnetic heading of 105°and was 200 ft wide. The propeller and propeller hub were located about 15 ft from the initial impact point. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system consistent with signatures consistent with overload separation or due to recovery personnel during the recovery process. There were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. -
Analysis
The instrument-rated pilot and three passengers departed on a night cross-country flight into instrument meteorological conditions (IMC). Automatic dependent surveillance-broadcast (ADS-B) flight track information indicated that the pilot departed and climbed the airplane to 495 ft mean sea level (msl), about 200 ft above ground level, before initiating a left turn. The airplane reached an altitude of 620 ft msl, then began a descent as the left turn continued. ADS-B data ended at an altitude of 395 ft about 660 ft northwest of the accident site. The airplane impacted flat, open terrain about 1 mile southwest of the departure end of the runway. The wreckage was fragmented and distributed in a manner consistent with a high-energy impact with terrain. All major structural components of the airplane were located at the accident site. Examination of the airframe and engine revealed no evidence of any preexisting anomalies that would have precluded normal operation. Review of weather information at the time of the accident indicated low cloud ceilings and restricted visibility due to mist, with ceilings near 300 ft above ground level and tops near 2,000 ft msl. The pilot obtained a weather briefing before departure. The night IMC present at the time of the accident were conducive to the development of spatial disorientation and would have made control of the airplane by visual references difficult, especially if the pilot encountered restrictions to visibility, such as clouds, during the transitional phase of flight after takeoff and initial climb. The left turn initiated at low altitude, the pilot’s failure to maintain the climb, the tightening, descending turn, and the subsequent high-energy impact are all consistent with the known effects of spatial disorientation. Therefore, it is likely that the pilot was experiencing the effects of spatial disorientation when the accident occurred. Postaccident toxicology testing revealed varying levels of ethanol in the pilot’s liver, kidney, and muscle tissue; a second lab did not report any ethanol in his muscle tissue. The ethanol concentration found in liver tissue was higher than the detected ethanol concentrations in kidney and muscle tissue. Isopropanol was also detected in liver tissue. Given the differing ethanol tissue concentrations, the state the body was recovered, and the presence of isopropanol in liver tissue, it is likely that the identified ethanol was from sources other than ingestion and did not contribute to this accident.
Probable cause
The pilot’s loss of control due to spatial disorientation shortly after takeoff. Contributing to the accident was the pilot’s decision to depart into night instrument meteorological conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
V35
Amateur built
false
Engines
1 Reciprocating
Registration number
N7933M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-8265
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-08T23:27:41Z guid: 104345 uri: 104345 title: WPR22FA055 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104346/pdf description:
Unique identifier
104346
NTSB case number
WPR22FA055
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-05T18:52:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-01-07T02:32:09.854Z
Event type
Accident
Location
Medford, Oregon
Airport
ROGUE VALLEY INTL - MEDFORD (MFR)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
According to a publication from the Flight Safety Foundation: “Flicker vertigo is an imbalance in brain-cell activity caused by exposure to the low-frequency flickering (or flashing) of a relatively bright light (such as a rotating beacon; a strobe light; or sunlight seen through a windmilling propeller). Flicker vertigo can result in nausea, dizziness, headache, panic, confusion, and — in rare cases — seizures and loss of consciousness, which could result in a pilot's loss of control of an aircraft” … and “Flicker vertigo also can develop in someone viewing strobe lights or rotating beacons — or their reflections off clouds or water.” - The Piper PA-31-350 Navajo Chieftain (Panther conversion), airplane was manufactured in 1977 and was powered by two Lycoming TIO-540-J2B series engines driving two, four-bladed Q-Tip propellers. The airplane was equipped with a Garmin GNS 530W and an autopilot.    The last examination was recorded as being completed on December 04, 2021, at a tachometer time of 1,754.4 hours. The invoice stated that an auxiliary hose assembly was replaced the day before the accident following a leak. The mechanic that replaced the fuel line could not recall the position that he left the fuel selector after completing the maintenance. The airplane’s Pilot Operating Handbook stated, “Anti-collision lights should not be operating when flying through cloud, fog or haze, since the reflected light can produce spatial disorientation.” - Investigators compiled a comparison of ADS-B data from two airplanes that departed before the accident airplane (at 1507 and 1556) and two that departed after (1734 and 1813). A comparison of flight tracks from the three airplanes that departed runway 14 revealed that the accident airplane had started its right turn earlier than the other three airplanes, and the radius of its turn was tighter than the other three airplanes. ( Figure 4 below). Figure 4: Other Departures Flight Paths Before and After the Accident Flight - On December 05, 2021, at 1652, a Piper PA-31-350 Navajo Chieftain airplane, N64BR, was substantially damaged when it was involved in an accident in Medford, Oregon. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot and passenger made a flight on November 24 from the airplane’s home airport in Fallon, Nevada, to Medford. After landing, the pilot noticed the airplane was leaking a large amount of fuel from the right wing root. The pilot arranged to make the necessary repairs with a fixed based operator (FBO) at the airport and drove a rental car back home to Nevada. On December 4, a mechanic at the FBO notified the pilot that the maintenance to the airplane was completed. The pilot responded that he would plan to get to the airport about 1430 the following day (on the day of the accident). The pilot and passenger drove to Medford arriving about 1600.   The exact radio communication times could not be confirmed for the accident flight. The pilot received an instrument flight rules (IFR) clearance and was issued the BRUTE7 departure procedure with the LANKS transition. The published BRUTE SEVEN Standard Instrument Departure (SID) with a takeoff from runway 14 consisted of a “climbing right turn direct MEF [Medford] NDB [nondirectional beacon],” and continue to the BRUTE intersection on a bearing of 066°.   After receiving the clearance, the controller informed the pilot the overcast layer base was at 200 ft above ground level (agl) the tops of the layer was at 2,500 ft. After the airplane departed the pilot made a radio communication to the controller asking “will you be calling my turn for the BRUTE7?” The controller replied that he would not be calling his turn and that the pilot should fly the departure as published making a climbing right turn to overfly the approach end of runway 14 before proceeding to the BRUTE intersection (Figure 1 below). The pilot acknowledged the communication, which was his last transmission. Several seconds later, the controller stated that he was receiving a low-altitude alert that the airplane’s altitude was showing 1,700 ft. He made several attempts to reach the pilot with no response.   Figure 1: The Airplane’s Flight Track Overlayed a Visual Depiction of the BRUTE7 Departure The radar and automatic dependent surveillance-broadcast (ADS-B) information indicated that the airplane arrived in the run-up area for runway 14 about 1643 and then continued onto the runway about 6 minutes thereafter. The airplane departed about 1649:30 and, after crossing over the south end of the runway, it climbed to about 1,550 ft mean sea level, equivalent to 200 ft agl (Figure 2 below). The airplane then began a gradual right turn and climbed to 1,950 ft, maintaining an airspeed between 120-130 kts. As the airplane turn continued to the north, the altitude momentarily decreased to 1,650 ft (about 350 ft agl) with the airspeed increasing to 160 kts. Thereafter, the airplane then increased the bank angle and made a 360-degree turn, initially climbing to 2,050 ft. At the completion of the turn, the airplane descended to 1,350 ft, consistent with it maneuvering below the cloud layer. The airspeed increased to about 160 kts and several seconds later, the airplane climbed to 2,250 ft with the derived airspeed showing below 15 kts. Six seconds later was the last radar return, located about 990 ft north-northwest of the accident site. Figure 2: The Airplane’s ADS-B Flight Track Video footage was obtained from several fixed security cameras on buildings around the accident site. A review of the footage revealed that the airplane descended below the cloud layer and then climbed back up. About 16 seconds thereafter, the airplane is seen descending in a near-vertical attitude (Figure 3 below). The airplane’s position and strobe light appeared to be illuminated throughout the video. Figure 3: Excerpts of Security Camera Footage - Video footage revealed that the airplane disappeared into a cloud layer and then reappeared immediately before the accident. Automated 5-minute observations were generated by an Automated Surface Observation System (ASOS) at the Medford Airport. The 5-minute observation generated at 1650 included wind calm; visibility of 3 statute miles; mist; an overcast cloud layer at 200 feet. It recorded the temperature at 39 degrees Fahrenheit; dew point 39 degrees Fahrenheit and an altimeter setting of 30.39 inHg. High-Resolution Rapid Refresh (HRRR) model sounding for near the accident site at 1700 indicated cloud tops for the cloud layer nearest the surface around MFR was about 2,200 to 2,500 feet above mean sea level. - The pilot had previously owned a PA-31-350 and purchased the accident airplane in 2013. According to his electronic logbooks he had amassed about 1,520 hours in a PA-31-350 of which 273 hours was in actual instrument meteorological conditions. The logbooks indicated that the pilot had departed from Medford in August 2018 and 2019 by way of the JACKSON1 and EAGLE6 departure procedures, respectively. In early November 2021 the pilot went to recurrent SIMCOM training. The training consisted of 4 flight hours; 2 hours of simulated IMC, both of which is in the same make and model. During the exchange of the clearance instructions on the accident flight, the pilot requested the controller read back the departure procedure and transition phonetically. The pilot’s family and a business associate stated this was very normal for the pilot and he would often have people clarify names and instructions. - The National Transportation Safety Board’s Performance Division reviewed the audio from recorded videos. A performance engineer stated that the engine speeds were estimated retrospectively through spectral analysis of sound recorded by a camera on a nearby commercial building. This analysis revealed that the estimated engine speed remained consistent within the range of 2,500±100 rpm throughout the time before the accident, consistent with normal operation. From the sound analysis alone, it was not possible to ascertain whether the recorded sound originated from both engines operating at the same speed or from a single engine. - The accident site was adjacent to the garage bays of an automobile dealership located about 2,800 ft west-southwest from the departure end of runway 14. A majority of the wreckage had been consumed by fire and sustained major crush deformation. Various items in the cockpit were not burned, including numerous paper sectionals and IFR charts, of which there were several current departure procedure plates for the Medford Airport.  Investigators could not completely confirm control continuity because of the impact and thermal damage. All the propeller blades on both engines exhibited chordwise scoring, leading edge chips, and were twisted and bent. The signatures on both propellers were consistent with one another and consistent with the engines operating at a similar rpm. The fuel caps were found secure in the wings. In the wing root area of the right wing, the fuel system components had sustained damage from both impact and thermal effects. The fuel selector valve was found positioned to the outboard tank, and the firewall shutoff valve was found in the open position. Within the wing root area of the left wing, the fuel system components had suffered damage from both impact and thermal effects. The fuel selector valve was located near the outboard tank; the firewall shutoff valve was found in the closed position, and the cross-feed valve was open. The fuel selector in the cockpit was thermally damaged and the positions could not be determined. It is unknown if the positions of the fuel selector valves were positioned in that way prior to impact or why the pilot would have configured the selectors in that manner. A postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures. -
Analysis
The airplane was departing into instrument meteorological conditions using a standard instrument departure. The takeoff instructions consisted of making a climbing right turn direct to a nondirectional beacon. After departing, the pilot made a radio communication to an air traffic controller asking if he will tell him when to turn. The controller replied that he would not be calling his turn and that the pilot should fly the departure as published making a climbing right turn to overfly the approach end of the runway. The pilot acknowledged the communication, which was his last transmission. The airplane made a 360° turn and descended below the cloud layer. The airplane then climbed back into the cloud layer and made an inverted loop, descending into the ground in a near-vertical attitude. A postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures. Recorded audio of the airplane before the accident was consistent with the engines operating. The signatures on both propellers were consistent with one another and consistent with the engines operating at a similar rpm. The pilot was qualified and recently underwent recurrent training. The reasons the pilot became spatially disoriented could not definitely determined. The pilot left the anti-collision lights on while in the clouds, which may have resulted in him having flicker vertigo.
Probable cause
The pilot’s failure to maintain aircraft control during the initial climb into clouds due to spatial disorientation, which resulted in an uncontrolled descent and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-31-350
Amateur built
false
Engines
2 Reciprocating
Registration number
N64BR
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
31-7752124
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-07T02:32:09Z guid: 104346 uri: 104346 title: ERA22LA082 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104358/pdf description:
Unique identifier
104358
NTSB case number
ERA22LA082
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-07T09:57:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2021-12-07T20:36:50.895Z
Event type
Accident
Location
Tallahassee, Florida
Airport
TALLAHASSEE INTL (TLH)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On December 7, 2021, about 0757 eastern standard time, a Beech BE-35, N80YD, was substantially damaged when it was involved in an accident near Tallahassee, Florida. The pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, during his preflight inspection he noted that the oil quantity on the dipstick indicated 11.5 quarts and that the oil filler cap was tight. The pilot also described that he did not observe any abnormalities during the engine runup. The pilot then departed for Columbus Airport (CSG), Columbus Georgia, on an instrument flight rules flight plan. During cruise flight, at 6,000 ft, the pilot reported a faint smell of smoke and observed that the engine instruments were nominal. He was concerned and contacted air traffic control to inquire about the weather conditions at nearby airports and reported that there was dense fog all around. The smoke smell then became more prominent, with the pilot describing it as having a distinct smell of oil burning but without visible smoke. The engine oil pressure then began to decrease, after which the pilot declared an emergency with air traffic control. The engine continued to run smoothly for another two minutes before the oil pressure decreased to zero. Shortly thereafter the engine began to run roughly, and smoke began to enter the cabin. Air traffic control subsequently provided the pilot with radar vectors for an instrument approach to Tallahassee International Airport (TLH), Tallahassee, Florida. The engine eventually lost power completely and the pilot knew that he would not be able to reach TLH. The pilot began to look through breaks in the fog to locate where he could perform a forced landing. The pilot eventually saw a dirt road and as he broke through a final layer of fog, he realized he would not be able to clear a tree line. As the airplane approached the trees, the pilot pulled the control yoke back in attempt to rapidly slow the airplane before it struck the trees with its underside. Following the impact with the trees, the pilot egressed the airplane. The airplane’s fuselage, both wings, and the left ruddervator were substantially damaged during the accident. Postaccident examination of the engine (about 1 month after the accident) revealed that the cylinder Nos. 5 and 6 connecting rods had fractured and breached the engine case. The engine was bearing races were corroded from being exposed to the elements following the accident. The connecting rods were heat damaged consistent with a lack of lubrication. A lighted borescope was used to examine the remaining connecting rods. The No. 4 connecting rod was fractured. The Nos. 1, 2 and 3 connecting rods were intact. All of the rocker covers were removed and no anomalies noted with the rocker arms, springs, or push rods. The oil drain plug was fractured off and no oil remained in the engine. The oil pump was fractured off the engine, impact damaged, and the pressure adjustment screw was missing. The oil pump rotated smoothly. The spark plugs were removed and displayed a worn out-severe appearance. According to the maintenance logbooks, the airplane had an annual inspection completed on June 8, 2021. At that time, the engine had accumulated 4,363 hours of total time and 942 hours since major overhaul. No anomalies were noted. -
Analysis
The pilot reported that, during a cross-country flight under instrument flight rules, he smelled burning oil. The engine oil pressure decreased to zero and the pilot declared an emergency with air traffic control. While diverting to a nearby airport, smoke began to enter the cabin before the engine lost all power. The airplane descended through the clouds and the pilot attempted to perform a forced landing to a dirt road, but impacted trees during the landing, which resulted in substantial damage to both wings and the left ruddervator. Postaccident examination of the engine revealed evidence of lubrication distress that ultimately resulted in the failure of three of the engine’s six connecting rods. Based on this evidence and the pilot’s description that a burning oil smell and loss of oil pressure preceded the loss of engine power, it is likely that the engine began to leak oil at some point during the flight; however, the reason for or source of the oil leak was not determined.
Probable cause
A total loss of engine power due to a lack of oil lubrication.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
S35
Amateur built
false
Engines
1 Reciprocating
Registration number
N80YD
Operator
James Hunt / AeroMed Transport Co
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-7394
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-07T20:36:50Z guid: 104358 uri: 104358 title: ERA22FA083 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104367/pdf description:
Unique identifier
104367
NTSB case number
ERA22FA083
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-07T23:24:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-13T18:07:40.351Z
Event type
Accident
Location
Statesboro, Georgia
Airport
STATESBORO-BULLOCH COUNTY (TBR)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA Civil Aerospace Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a loss of proper bearings or a state of mental confusion as to position, location, or movement relative to the position of the earth. Factors contributing to spatial disorientation include changes in acceleration, flight in instrument meteorological conditions (IMC), frequent transfer between visual meteorological conditions (VMC) and IMC, and unperceived changes in aircraft attitude. The FAA's Airplane Flying Handbook (FAA-H-8083-3A) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - On December 7, 2021, at 2124 eastern standard time, a Cessna 182 airplane, N5776B, was destroyed when it was involved in an accident near Statesboro, Georgia. The pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a family member, the pilot had flown the airplane from her home airport, Zephyrhills Municipal Airport (ZPH), Zephyrhills , FL (ZPH)Florida, to the Statesboro-Bulloch County Airport (TBR), Statesboro, Georgia, for a meeting and planned to return that night. The pilot owned a sky diving business that had operated out of TBR and was familiar with the area. The family member reported that during a telephone conversation that occurred about 2030, the pilot told him that the clouds were low and that she would not be flying under an instrument flight rules (IFR) flight plan. She planned to stay at a low altitude for 10 to 15 miles after takeoff during the return trip to ZPH. Review of automatic dependent surveillance-broadcast (ADS-B) data found that the airplane departed runway 14 at 2121. Shortly after takeoff, the flight track turned south, climbed to about 1,000 ft msl, which was about 800 ft agl, and then about 1.8 nautical miles south of TBR, the airplane entered a left turn. The airplane continued in a left 360° tightening turn where a maximum altitude of about 1,800 ft msl was reached, which was subsequently followed by a rapid descent. The final position recorded at 2124:32 was about 0.1-miles from the accident site and showed the airplane headed east at an altitude of 575 ft msl (about 375 ft agl). Figure 1 displays the ADS-B flight track, main wreckage area, and witness locations. Figure 1: Overview of the flight track, wreckage, and witness locations. Multiple witnesses reported observing and/or hearing the airplane in-flight. A witness located at the TBR airport parking lot saw the takeoff. The airplane’s lights were on; and it sounded as if the airplane was climbing “steeply;” and the engine noise was loud. Two additional witnesses, who were located together near the accident site, reported seeing the airplane while outside in a driveway. One witness reported that she heard a low flying airplane that sounded like a “crop duster” and “got louder.” She then saw the right side of the airplane, and it appeared to be flying in a “curved” descent that continued into a “rapid descent.” When the airplane first came into view, she could not recall observing lights or a glow from the airplane; however, as it flew away from her position, she saw a “sparkler glow” before it impacted the ground. The other witness also reported observing the airplane in a descent that continued into a rapid descent into a field just beyond his view. He added that when the airplane flew by, he could see “lights on the bottom” of the airplane. When asked specifically if he recalled seeing the airplane on fire in the air, he stated that it was not on fire. Two additional witnesses heard the airplane while in their houses. One of these witnesses was a private pilot and reported that due to the proximity of his house to the airport, he was accustomed to hearing airplanes, but this airplane was “unusually low.” He added that the sound dissipated, but a few minutes later, he heard the airplane again, and it sounded like “the engine was screaming” as if the “throttle was through the panel.” The other witness reported that she heard engine noise until a “thud” was heard. - According to the autopsy report issued by the Georgia State Bureau of Investigation, Division of Forensic Sciences, the pilot’s cause of death was multiple blunt force injuries, and the manner of death was an accident. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified ethanol in muscle tissue at 0.025 gm/dl but none in liver tissue, and testing in brain tissue was inconclusive. In addition, quetiapine was identified in liver tissue at 17 ng/gm. Quetiapine, commonly marketed with the name Seroquel, is an atypical antipsychotic approved for the treatment of schizophrenia and bipolar disease. Off label, in much smaller doses, it may often be used to treat insomnia. - Review of weather information revealed that instrument meteorological conditions (IMC) in the form of low clouds prevailed at TBR. The IMC conditions were first recorded at 2035, about 45 minutes before the pilot’s takeoff. Multiple witnesses confirmed that a low cloud layer persisted throughout the evening. At 2115, the reported ceiling at TBR was 600 ft agl. Based on this weather observation, the airplane likely entered the low cloud layer about 800 ft msl and did not climb above the top of the cloud layer, which was near 8,000 to 9,000 ft msl. Dark night conditions prevailed. The end of civil twilight was at 1748, and the moon set was at 2105, about 20 minutes before the accident. According to Leidos, the Federal Aviation Administration (FAA) contract Flight Service Station provider, and ForeFlight LLC, there was no record that the pilot filed a flight plan or requested a weather briefing via telephone or online. There was also no record of the pilot contacting FAA air traffic control before or during the flight. - The pilot’s logbook was not recovered during the investigation. The pilot’s most recent flight review, instrument currency, and night currency could not be determined. - The wreckage was highly fragmented and was oriented on a debris path of about 110° magnetic. The initial impact ground scar was located about 220 ft from the main wreckage final resting location, and the elevation was about 175 ft msl. Figure 2 provides an overview of the major components of the airplane located at the accident site. Figure 2: Overview of the major airplane components as located in the debris path. All major components of the airplane were located in the debris path. The left-wing tip and additional left-wing fragments were located in the initial impact scar, which was consistent with the airplane impacting terrain in a descending left bank. There was no evidence of an in-flight fire; however, the wreckage was thermally damaged during a postcrash fire. The examination of the wreckage found no evidence of preimpact mechanical malfunctions or failures with the airplane. The altimeter setting corresponded to the correct altimeter setting based on the 2115 TBR weather observation. There was no evidence of a vacuum pump failure. -
Analysis
The instrument-rated commercial pilot had conducted a cross-country flight to the airport arriving in the afternoon and, after attending a meeting, was returning to her home airport on a night visual flight rules (VFR) cross-country flight. Before the return flight, the pilot discussed with a family member her knowledge of a low cloud layer and her intention to stay low for the first 10 to 15 miles of the flight. At the time of departure, dark night conditions prevailed, and the airport was reporting an overcast cloud ceiling at 600 ft above ground level (agl). Review of automatic dependent surveillance-broadcast (ADS-B) data found that the airplane became airborne before the midpoint of the runway and turned right toward the destination airport. It then climbed to about 1,000 ft mean sea level (msl), which was about 800 ft agl, before entering a left turn about 2 miles south of the airport. The airplane continued in a left 360° tightening turn where a maximum altitude of about 1,800 ft msl was reached, which was subsequently followed by a rapid descent. Before the left 360° turn, the airplane likely entered the low cloud layer and never exited the clouds until a few seconds before it impacted with terrain. Multiple witnesses reported that the airplane’s engine noise was loud and continuous until impact. Examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures with the airplane. Evaluation of the wreckage indicated that the airplane impacted terrain in a left turning descent at high speed. Based upon ADS-B, meteorological, and astronomical data, the pilot initiated a VFR flight into known dark night instrument meteorological conditions, which would have prevented reliable control of the airplane using external visual cues. The circling and rapidly ascending and descending flight track was consistent with a pilot who was experiencing spatial disorientation, which resulted in a loss of control in flight and a high speed impact with terrain. The pilot’s instrument and night currency could not be determined. The pilot’s toxicology report was positive for ethanol and quetiapine. Given that the ethanol was identified at a low level in muscle and that none was found in liver tissue, it is likely that the identified ethanol is from sources other than ingestion and unlikely that any effects from it contributed to the circumstances of the crash. Attempts were made to identify the underlying reason for the pilot’s use of quetiapine; however, the investigation was unable to do so. While the drug itself may cause neuropsychiatric effects, at the low levels likely present at the time of the event, it was unlikely to impair judgment. However, whether an underlying medical condition might have influenced the pilot’s decision-making could not be determined from the available information.
Probable cause
The pilot’s decision to initiate a visual flight rules flight into dark night instrument meteorological conditions, which resulted in spatial disorientation and subsequent loss of control shortly after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N5776B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
33776
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-13T18:07:40Z guid: 104367 uri: 104367 title: RRD22LR003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104373/pdf description:
Unique identifier
104373
NTSB case number
RRD22LR003
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-08T13:20:00Z
Publication date
2023-12-11T05:00:00Z
Report type
Final
Last updated
2023-11-14T05:00:00Z
Event type
Accident
Location
Reed, Pennsylvania
Injuries
1 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Reed, Pennsylvania, accident was the inability of the spiker operator to see the contract worker behind the spiker and the contract worker not being alerted by the spiker’s nonfunctional horn and change-of-direction alarms. Contributing to the accident was (1) Norfolk Southern Railway’s preshift inspection that did not check the audibility of the spiker’s alerts above ambient noise; (2) Nordco Inc. allowing the spikers to leave the factory without assuring the change-of-direction alarm was working; and (3) insufficient standoff distance chosen by Norfolk Southern Railwaythat did not provide adequate visibility behind the spiker.
Has safety recommendations
true

Vehicle 1

Railroad name
Norfolk Southern
Equipment type
Special maintenance-of-way equipment
Train name
Norfolk Southern
Train number
GS 15022
Train type
FRA regulated freight
Findings
creator: NTSB last-modified: 2023-11-14T05:00:00Z guid: 104373 uri: 104373 title: RRD22LR004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104377/pdf description:
Unique identifier
104377
NTSB case number
RRD22LR004
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-09T10:25:00Z
Publication date
2023-09-18T04:00:00Z
Report type
Final
Last updated
2023-09-11T04:00:00Z
Event type
Accident
Location
Darby, Pennsylvania
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the December 9, 2021, collision between a Southeastern Pennsylvania Transportation Authority trolley and a CSX Transportation freight train was the trolley operator stopping the trolley within the foul of the CSX track using the emergency brake.
Has safety recommendations
false

Vehicle 1

Railroad name
SEPTA
Train name
8104
Train number
9070
Train type
FTA regulated transit
Total cars
1
Total locomotive units
1
Findings

Vehicle 2

Railroad name
CSX Transportation
Equipment type
Freight train
Train name
I03309
Train number
3008
Train type
FRA regulated freight
Total cars
48
Total locomotive units
2
Trailing tons
5555
Findings
creator: NTSB last-modified: 2023-09-11T04:00:00Z guid: 104377 uri: 104377 title: CEN22LA076 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104413/pdf description:
Unique identifier
104413
NTSB case number
CEN22LA076
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-09T18:52:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2021-12-24T01:44:06.526Z
Event type
Accident
Location
St. Jo, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On December 9, 2021, about 1652 central daylight time, an Aviat Aircraft A-1A, N111XJ, was substantially damaged when it was involved in an accident near St. Jo, Texas. The pilot sustained minor injuries, and the passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, while the airplane was in cruise flight at 2,500 ft above ground level, the engine lost total power. The pilot executed a forced landing to a field, and the airplane nosed over while the pilot applied braking to avoid trees and a deep ravine. The airplane sustained substantial damage to the rudder and vertical stabilizer. In a postaccident statement, the pilot asserted that the loss of engine power was due to an in-flight oil loss. Postaccident examination noted that the bottom of the fuselage was covered with oil. The engine was found to contain 6 quarts of oil when checked using a dip stick, and no metal was found in the oil. The gasolator contained fuel, and the engine could be rotated by hand. No major oil leaks were observed within the cowling. A fuel supply from a temporary fuel tank was plumbed to the carburetor using gravity feed. Examination found that the throttle plate would not fully open at a high rpm. The propeller of the airplane had broken during the accident sequence, and a surrogate propeller was installed for an engine test run. The engine started within two revolutions. Afterward, a magneto check and propeller cycle check were performed; the results were normal. A full throttle rpm check was also performed, and a static rpm of 2,510 was achieved. No anomalies were detected during the test run, and all pressures and temperatures were normal. No oil leaks were detected except for a small amount of oil exiting the exhaust at engine start, which cleared after the engine was running. The airplane maintenance records indicated that an annual inspection was completed on October 19, 2021. During that inspection, the engine oil was changed, and a subsequent leak check performed with no leaks detected. According to the carburetor icing probability chart contained in Federal Aviation Administration (FAA), Special Airworthiness Information Bulletin CE-09-35, titled “Carburetor Icing Prevention,” the recorded temperature and dew point near the accident site about the time of the accident (26°C and 12°C, respectively) were in the range for serious icing at glide power settings. According to a similar carburetor icing probability chart, distributed by the Civil Aviation Safety Authority of Australia, the temperature and dew point were in the range for moderate icing at cruise power settings and serious icing at descent power settings. -
Analysis
The pilot reported that the airplane’s engine lost power during cruise flight. He executed a forced landing to a field, and the airplane nosed over when the pilot applied braking to avoid trees and a deep ravine. The airplane sustained substantial damage to the rudder and vertical stabilizer. The pilot attributed the loss of engine power to engine oil loss during flight. However, postaccident testing and inspection of the engine revealed that 6 quarts of oil remained in the engine. A test run of the engine was performed with no anomalies noted that would have precluded normal operations. Although there was oil staining and streaking on the exterior of the airplane, indicating a possible oil leak, there was still sufficient oil within the engine, oil pressure was normal during the postaccident test run, and no leaks were detected during the test run, leading to the conclusion that the loss of engine power was not due to an oil system issue. The temperature and dew point near the accident location at the time of the accident were conducive for serious carburetor icing at glide power. Thus, given the available information for this accident investigation, the loss of engine power was likely the result of carburetor icing.
Probable cause
The total loss of engine power due to carburetor icing during cruise flight, which resulted in a forced landing and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1A
Amateur built
false
Engines
1 Reciprocating
Registration number
N111XJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1429
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-24T01:44:06Z guid: 104413 uri: 104413 title: ERA22FA085 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104384/pdf description:
Unique identifier
104384
NTSB case number
ERA22FA085
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-10T18:51:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2021-12-30T01:29:37.685Z
Event type
Accident
Location
Crab Orchard, Kentucky
Airport
STUART POWELL FLD (DVK)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airframe and engine logbooks were not located after the accident. Documentation of the latest annual inspection was obtained from the mechanic who provided the services. According to the pilot’s family, the pilot kept the maintenance logbooks in his hangar where he stored the airplane. The hangar was destroyed by a tornado that came through the area during the early morning hours after the accident. The maintenance records pertaining to the engine-driven vacuum pump were not located. The maintenance history of the pump was not determined. The manufacturer of the pump reported that the pump style installed on the aircraft had not been manufactured by them in over 20 years. A sticker on the pump stated, “FAA Approved Overhaul” but did not list an overhaul facility. The rotor hub had “FAA-PMA” etched on it. - On December 10, 2021, about 1651 eastern standard time, a Beech V35, N5704V, was substantially damaged when it was involved in an accident near Crab Orchard, Kentucky. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The visual flight rules cross-country flight originated at Okeechobee County Airport (OBE), Okeechobee, Florida, on the morning of the accident with intermediate stops at Flagler Executive Airport (FIN), Palm Coast, Florida, and Baxley Municipal Airport (BHC), Baxley, Georgia. The pilot purchased 46 gallons of 100LL aviation fuel at OBE, and the passenger purchased 25 gallons of fuel at BHC. Both fuel purchases were from self-service pumps, and no other services were requested. The accident flight departed BHC about 1426, destined for Stuart Powell Field Airport (DVK), Danville, Kentucky, the pilot’s home airport.   According to ADS-B data, after the airplane departed BHC, in climbed to about 9,500 ft pressure altitude, leveled off, then climbed to about 10,500 ft, arriving at that altitude about 1453. The airplane remained near 10,500 ft until about 1532, when it descended briefly to about 8,500 ft, then climbed back to 10,500 ft. About 1603, the airplane descended out of 10,500 ft and continued its descent to about 2,000 ft. At 1639:32, there was a loss of ADS-B data lasting about 6 minutes 46 seconds as the airplane was tracking northbound. After ADS-B targets resumed, they showed that the flight approached the area about 14 nautical miles southeast of DVK at an altitude of 300 to 400 ft above ground level. The airplane then proceeded north for about 1 mile and began a left 270° turn to the east, which was followed by a right turn until the airplane was heading north. The airplane then pitched up, gaining about 500 ft of altitude, as it approached rapidly rising terrain. The last two data points indicated a descent, and the last data point was located about 275 ft south of the accident site. A witness, who owned the property where the accident site was located, reported that he heard the airplane coming down, and the engine was “very loud, getting louder, and running at high speed” with no interruption until he heard the “boom” from the ground impact. He never saw the airplane in flight. - According to the Office of the State Medical Examiner, Frankfort, Kentucky, autopsy report, the cause of death of the pilot was extensive blunt force injuries, and the manner of death was accident. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected dextromethorphan in the liver and its metabolite dextrorphan in the liver and muscle. Dextromethorphan is a non-sedating, over-the-counter cough suppressant. - At the time of the accident, there was a low-pressure system over North Carolina with a warm front extending through several states, including Kentucky, positioned immediately west of the accident site. Several stations in Kentucky, east of the warm front, reported visibility restrictions in fog, mist, and light rain. The weather conditions at DVK included low instrument flight rules (LIFR) conditions about 16 minutes before the accident and instrument flight rules (IFR) conditions about 4 minutes after the accident. During this time, the ceiling varied between 300 and 500 ft overcast. According to Leidos, Leidos Flight Services (LFS) and third-party vendors utilizing the LFS system had no contact with the airplane on the day of the accident. The pilot had an account with ForeFlight; however, he did not file a flight plan for the day of the accidents, and no weather imagery was accessed through ForeFlight before the accident flight. - The pilot did not possess an instrument rating. In his pilot logbook, he logged two flights in April 2021, where he noted “Practice – Instruments.” These flights did not include logged instrument approaches or simulated instrument time, and there was no documentation that a flight instructor was on board. - The accident site was in heavily-wooded terrain that was rising in the direction of the destination. The elevation of the accident site was about 1,154 ft. There was a peak elevation of about 1,302 ft, about 975 ft west-northwest of the accident site.   Initial examination of the accident site and wreckage revealed that all major structural components of the airplane were accounted for at the scene. The damage to the airplane and the wreckage distribution were consistent with the airplane striking the top of a 50-ft-tall oak tree before colliding with terrain. The measured descent angle from the tree breaks to the initial impact crater was about 75° nose down. There was no fire. The fuselage, aft of the entry door, was intact and exhibited buckling signatures in several areas. The cabin, at and forward of the entry door, was opened and exposed by impact forces.   Both wings were intact and exhibited forward-to-aft crushing signatures throughout their lengths. Both ailerons remained attached to the wings, and continuity was confirmed from the control surface attachment points to the main spar in the cockpit. The flaps remained attached to the wings, and the actuators were found extended about 2 inches, which equated to a flap setting between 0° and 5°. The v-tail assembly remained intact and exhibited light impact damage. Control continuity was confirmed from the ruddervators to the cockpit. The ruddervator trim actuator was found extended about 1 inch, which equated to 5° tab up. Both fuel tanks were compromised by impact forces, and only residual fuel remained. The fuel strainer screen and bowl were both clear and free of obstructions. There was residual fuel in the bowl. The fuel selector handle and valve were both in the “RIGHT” tank positions. The fuel boost pump was in the “OFF” position. All landing gear were found in the retracted positions. The landing gear selector was in the “UP” position, and the emergency landing gear handle was stowed. The throttle, mixture, and propeller controls were in the full forward positions. The engine mount was fractured in several places, and the engine remained partially attached to the airframe. The propeller remained attached to the engine. The engine crankshaft was turned manually using the propeller. Compression and suction were observed on all six cylinders, and continuity was confirmed to the aft accessory section. Valve movement was correct on all cylinders. The engine-driven fuel pump was removed for examination. The pump drive shaft was intact. The fuel control inlet screen was clean and unblocked. A small amount of residual fuel was observed. All six fuel injectors were unobstructed. The fuel distribution valve screen was clean, and the diaphragm was supple and undamaged. Both magnetos were rotated using a power drill and produced spark at all leads. All six top spark plugs were examined; the electrodes were normal in color and wear when compared to a Champion inspection chart. The engine-driven vacuum pump was removed and opened for examination. The pump’s drive coupling was found fractured, and the pump was forwarded to the National Transportation Safety Board Materials Laboratory for further examination. The subsequent examination at the lab revealed the drive coupling fractured along the shaft’s transverse plane in a reduced diameter section. Examination of the fracture surfaces revealed circular marks and a molten/resolidified polymeric appearance that was consistent with a torsion overstress fracture (see figure). Figure – Fractured Vacuum Pump Drive Coupling Further examination of the pump revealed that one of the two screws that attached the inlet cover plate to the stator housing was missing, and the stator housing and inlet cover plate were visibly offset relative to one another in the lateral direction. The airplane was equipped with a Precise Flight, Inc. standby vacuum system (SVS). The SVS operated on a differential between manifold pressure and ambient atmospheric pressure and was directed through a shuttle valve system to drive flight instruments. The SVS control knob was found in the OFF position. Due to the extensive impact damage to the area on and around the exhaust manifold, the position of the SVS components could not be determined. Due to the general destruction of the instrument panel, the vacuum pump inoperative light was not located. The attitude gyro was located and disassembled; there were no rotational scoring signatures observed inside the rotor housing or on the rotor. All three propeller blades were bent aft. Two of the three blades exhibited “s” bending signatures. -
Analysis
The noninstrument-rated pilot was nearing his home airport at the end of a cross-country flight. Automatic Dependent surveillance-broadcast (ADS-B) and weather data indicated that the flight encountered instrument meteorological conditions (IMC) while enroute to the destination airport. These conditions included low ceilings, fog, mist, and light rain. The pilot was not communicating with air traffic control at the time of the accident, and there was no evidence that he obtained a weather briefing before the flight. The ADS-B data showed that the airplane began a left 270° turn to the east, followed by a right turn until the airplane was heading north. The airplane then pitched up, gaining about 500 ft as it approached rapidly rising terrain. The last two data points indicated a descent, and the last data point was located very close to the accident site. The owner of the land where the airplane crashed did not see the accident; however, he heard the airplane descending and described the engine sound as “very loud” and continuing with no interruption until he heard the noise of the ground impact. The airplane impacted rising terrain about 13 miles southeast of the destination airport. The path through the trees and the general destruction of the wreckage were indicative of an inflight loss of control and a collision with terrain at high speed and at a high descent angle. Based upon ADS-B and meteorological data, the pilot continued a visual flight rules flight into instrument meteorological conditions, which would have prevented reliable control of the airplane using external visual cues. The turns and rapid ascents and descents at the end of the flight track were consistent with a pilot who was experiencing spatial disorientation, which resulted in a loss of control in flight and a high-speed impact with terrain. Examination of the wreckage revealed that the engine-driven vacuum pump drive coupling was fractured; no evidence of any other preaccident malfunctions or failures of the airframe or engine was found. Disassembly of the attitude gyro revealed no rotational scoring signatures inside the rotor housing or on the rotor; this finding suggested that the vacuum pump was not operating before ground impact. Further examination revealed that one of the fasteners that secured the pump’s inlet cover plate to the stator housing was missing, and the stator housing and inlet cover plate were visibly offset relative to one another in the lateral direction; this condition likely led to the eventual seizure of the pump and the failure of the drive coupling. The airplane’s maintenance records were lost in a tornado the morning after the accident; therefore, the history of the pump was not determined. Although the exact time of pump failure could not be determined, it is unlikely that the pump failed at the same time the flight entered IMC; rather, it is likely the pump failed at some earlier time. The airplane was equipped with a standby vacuum system operated by the differential between engine intake manifold pressure and ambient atmospheric pressure; this system would operate only when engaged by the pilot. While impact damage to the system components made it impossible to determine if the standby system was in operation at the time of the accident, the lack of rotational signatures on the attitude gyro supports that it was not operating/activated. Therefore, it is likely that the airplane’s vacuum-powered flight instruments, including the attitude indicator, were inoperative, increasing the probability of a spatial disorientation event.
Probable cause
The noninstrument-rated pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions, which resulted in spatial disorientation and a loss of airplane control and collision with terrain. Contributing to the accident was the inoperative engine-driven vacuum pump.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
V35
Amateur built
false
Engines
1 Reciprocating
Registration number
N5704V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-8082
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-30T01:29:37Z guid: 104384 uri: 104384 title: CEN22FA069 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104385/pdf description:
Unique identifier
104385
NTSB case number
CEN22FA069
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-10T20:09:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-13T20:48:00.766Z
Event type
Accident
Location
Steamboat Springs, Colorado
Airport
STEAMBOAT SPRINGS/BOB ADAMS FLD (SBS)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Data recovered from the Garmin GPS revealed that the airspeed varied between 89 and 110 knots during the instrument approach. 14 CFR 97.3 states that approach category is determined by either the reference landing speed (VREF), if specified, or if VREF is not specified, 1.3 VSO at the maximum certificated landing weight. The Piper PA46-500TP Pilot’s Operating Handbook did not specify a VREF but did state that VSO at maximum certificated landing weight was 69 knots. When multiplied by a factor of 1.3, the resultant value was 89.7. 14 CFR 97.3 further stated that if the speed was less than 91 knots, the airplane would fall into a Category A approach category and if it was between 91 knots, but less than 121 knots, it would fall into a Category B approach category. The instrument approach procedure for a Category A aircraft required 1¼ sm flight visibility for landing and a Category B aircraft required 1 ½ sm flight visibility for landing. It could not be determined if the pilot decided his approach category based upon 1.3 VSO or the actual approach speed flown. - On December 10, 2021, about 1809 mountain standard time, a Piper PA46-500TP, N744Z, was substantially damaged when it was involved in an accident near Steamboat Springs, Colorado. The pilot and sole occupant was fatally injured. The airplane was operated under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. A review of archived Federal Aviation Administration (FAA) automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed Cody, Wyoming (COD), about 1705 and was en route to Steamboat Springs/Bob Adams Field (SBS). FAA air traffic control data showed that the pilot was operating on an instrument flight rules flight plan and at 1757 was cleared by an air traffic controller to conduct the RNAV (GPS)-E instrument approach procedure at SBS (see figure 1). Figure 1: Published Instrument Approach Procedure For terrain clearance, the procedure required the airplane to cross the final approach fix PEXSA at or above 9,700 ft mean sea level (msl) and WAKOR, the next waypoint located 2.2 nm from runway 32 threshold, at or above 8,740 ft msl. The ADS-B data showed that the accident airplane crossed PEXSA about 9,100 ft msl and WAKOR about 8,200 ft msl respectively. The procedure allowed for a descent to the minimum descent altitude of 8,140 ft msl or 1,258 ft above ground level after passing WAKOR. The missed approach point for the procedure was the runway 32 approach end, and then required a climbing left turn to 11,300 ft msl and indicated the pilot should proceed direct to the HABRO waypoint to enter a holding pattern. Immediately after passing WAKOR, the airplane made a left turn as shown in figure 2 and descended to an altitude of about 7,850 ft msl. The airplane subsequently began to climb, and the last ADS-B data point recorded at 1808:49 indicated an altitude of about 8,125 ft msl and was located about 3.5 miles north of the accident site. Figure 2: A Google Earth plot showing the accident aiplane’s ground track in the vicinity of the KSBS terminal area. An FAA published approach plate for the RNAV (GPS)-E approach has been overlaid with a 50% opacity. A yellow pin has been added indicating the position of the wreckage. - A search of the FAA contract automated flight service station Leidos indicated that they had no contact with the pilot nor did any third-party vendors utilizing the Leidos Flight Service system on December 10 or 11, 2021. A search of ForeFlight indicated that they had an account with the pilot who filed an IFR flight plan through their system for the flight between COD to SBS. Before the accident flight the pilot did not view any weather imagery but did enter the flight route into the system, which generated a general route briefing. As a part of that briefing, the pilot was provided the current METAR for SBS, which indicated a broken cloud ceiling of 4,500 ft and 7 sm visibility. - The airplane first impacted Emerald Mountain about 8,172 ft msl on a heading of about 164° as evidenced by broken and cut tree branches. After the initial impact, the airplane bounced and came to rest about 8,216 ft msl, and sustained substantial damage to the fuselage, tail and both wings. A postaccident examination of the airframe, engine, and propeller revealed no pre-accident mechanical malfunctions or anomalies that would have precluded normal operation. The positions of the landing gear and flap actuator were consistent with both being in transit at the time of impact. -
Analysis
The pilot was conducting a solo night cross-country flight in low visibility through mountainous terrain. The pilot was then cleared by an air traffic controller to conduct a RNAV (GPS)-E instrument approach into the destination airport. After passing the final approach fix and before the missed approach point, the pilot, for an unknown reason, executed a left turn, consistent with the missed approach procedure. During the turn toward the holding waypoint, the airplane did not climb. Shortly thereafter, the airplane impacted steep rising terrain The local weather at the time of the accident indicated a cloud ceiling of 1,200 ft above ground level and 1 statute mile visibility, which was below the weather minimums for the approach. Data retrieved from the onboard avionics revealed that although the pilot flew the published route in accordance with the instrument approach procedure, the minimum required altitudes were not adhered to. A review of the ForeFlight weather briefing data indicated that a route weather briefing had been generated by the pilot with the filing of the instrument flight rules (IFR) flight plan. While no weather imagery was reviewed during the period, the pilot had checked METARs for the destination and another nearby airport before departure and viewed the RNAV (GPS)-E approach procedure at the destination airport. A review of the data that was presented to the pilot indicated that visual flight rules conditions prevailed at the destination with light snow in the vicinity at the time it was generated. Based on the preflight weather briefing the pilot obtained, he was likely unaware of the IFR conditions and below minimum weather conditions at the destination until he descended into the area and obtained the current local weather during the flight. It is probable that, based upon the weather and flight track information, as the pilot was on the instrument approach, he became aware of the below minimum weather conditions and elected to initiate the missed approach, as evident by the turn away from the airport similar to the missed approach procedure and the flaps and landing gear being in transition. This investigation was unable to determine why the missed approach procedure was prematurely initiated and why the airplane failed to climb. Additionally, there were no preimpact mechanical malfunctions or anomalies found during a postaccident examination that would have precluded normal operation.
Probable cause
The pilot’s failure to adhere to the published instrument approach procedure, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA46-500TP
Amateur built
false
Engines
1 Turbo prop
Registration number
N744Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4697134
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-13T20:48:00Z guid: 104385 uri: 104385 title: ERA22FA086 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104386/pdf description:
Unique identifier
104386
NTSB case number
ERA22FA086
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-11T01:30:00Z
Publication date
2023-12-06T05:00:00Z
Report type
Final
Last updated
2021-12-15T23:19:45.652Z
Event type
Accident
Location
Bedford, New Hampshire
Airport
MANCHESTER BOSTON RGNL (MHT)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Review of a pilot operating handbook for the make and model airplane revealed: “…WARNING IN THE EVENT OF AN ENGINE FAILURE OR POWER LOSS, THE ENGINE NEGATIVE TORQUE SYSTEM (NTS) ONLY ROVIDES PARTIAL DRAG REDUCTION BUT NOT TO THE EXTENT OF A FULLY FEATHERED PROPELLER. PILOT MUST TAKE ACTOIN TO FULLY FEATHER THE PROPELLER (ON THE AFFECTED ENGINE) TO REDUCE PROPELLER DRAG. 1. ENGINE STOP AND FEATHER CONTROL (failed engine)........................ PULL…” - Review of maintenance information provided by the operator revealed that the most recent maintenance inspection performed on the airplane was a 100/150, 200, and 450-hr inspection, completed 10 days before the accident, on November 30, 2021. At the time of the accident, the left engine had accrued 15,419 total hours of operation, of which 3,339 hours were since major overhaul. The right engine had accrued 12,155.5 total hours of operation, of which 2,871 were since major overhaul (time between overhaul was 5,400 hours). The published minimum controllable airspeed (Vmc) on the airplane’s airspeed indicator was 92 kts. - On December 10, 2021, about 2330 eastern standard time, a Swearingen SA-226AT, N54GP, was destroyed when it was involved in an accident near Bedford, New Hampshire. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on-demand cargo flight. According to information provided by the Federal Aviation Administration, the airplane was on the instrument landing system approach to runway 6 at Manchester Boston Regional Airport (MHT), Manchester, New Hampshire. During the approach, the pilot reported an engine failure at 2330:42 but did not specify which engine. Radio and radar contact were lost at 2330:51, when the airplane was about 1/4 mile from the runway. Review of ADS-B data revealed that during that last 9-second period, the airplane’s groundspeed slowed from 99 kts to 88 kts, as it descended about 400 ft in a slight left turn to impact. Video from a residential security camera recorded a portion of the airplane’s approach, but only the airplane’s navigation lights could be seen in the distance on a portion of a video; however, a sound spectrum study was performed on recorded engine noise. The sound spectrum study revealed that the engine noise was constant at about 2,000 rpm. As the airplane increased its distance from the camera, the audio data became unreliable for the study. The last reliable data was recorded at 2330:28, 14 seconds before the pilot reported an engine failure. - Review of information provided by the operator revealed that the pilot had a total flight experience of 2,257 hours, of which 496 hours were in multi-engine airplanes. Of the 496 hours in multi-engine airplanes, 118 hours were in the accident make and model airplane. Review of the operator’s pilot flight and duty report revealed that the pilot had 14.8 hours of off-duty rest before reporting for work at 1930. - The wreckage was located on a river sand jetty, oriented north, and a postcrash fire consumed the cockpit, cabin, and both wings. No debris path was observed. A crater about 6 ft long, 3 ft wide, and 2 ft deep was observed at the beginning of the sand jetty. The left aileron was recovered in the water near the crater. The empennage was located just beyond the crater. The empennage remained intact, with the elevator and rudder attached and undamaged except for the right elevator tip. The right wingtip was located near the empennage and an outboard left-wing section was located 60 ft left of the main wreckage. Three landing gear were located near the main wreckage and the radome was located at the end of the sand jetty, in water. Elevator control continuity was confirmed from the elevator to the cockpit area. Rudder control continuity was confirmed from the rudder to the cabin area. No aileron cables were identified. The left engine was located in the main wreckage. The left propeller had separated and was partially embedded in mud to the left of the left engine. All three blades remained attached to the hub. The right engine was located forward and left of the main wreckage. The right propeller remained attached to the right engine and all three propeller blade roots remained attached to the hub and were charred. Both engines and propellers were retained for further examination. Teardown examination of the left engine revealed that a 1st stage turbine blade separated mid-span. The fracture surface of the blade exhibited varying levels of oxidation, and the investigation could not determine if the blade separated during the accident flight or a prior flight. Microscopic examination of the blades revealed that the 1st stage was operating at a temperature near 1,700° F, and the 2nd stage was operating at a temperature near 2,200° F, for a period of 10 to 100 hours. The 2nd stage operating at temperatures higher than the 1st stage was consistent with engine degradation over a period of time. The 2nd stage turbine stator assembly was missing vane material from the 6 to 12 o’clock positions, consistent with thermal damage over a period of time. Rotational scoring was documented throughout the engine, including the propeller shaft, compressor impellers and shrouds, and turbine rotor blade tips. Sand debris was observed throughout the gas path. Teardown examination of the right engine did not reveal any anomalies that would have precluded normal operation. Rotational scoring was documented at multiple locations in the engine, including the propeller shaft, compressor impellers/shrouds, and turbine stages. Sand debris was observed throughout the gas path and was accumulated in the combustor and outer transition liner. Teardown examination of both propellers revealed no anomalies that would have precluded normal operation. All blade angles were mid-range (not feathered) and exhibited evidence of little to no powered rotation. For more information see Powerplants Group Chair’s Factual Report and Propellers Examination Report in the public docket for this investigation. -
Analysis
During an instrument approach at night in a twin-engine turboprop airplane, the pilot reported an engine failure, but did not specify which engine. About 9 seconds later, the airplane impacted terrain about ¼-mile short of the runway and a postcrash fire consumed a majority of the wreckage. During that last 9-second period of the flight, the airplane’s groundspeed slowed from 99 kts to 88 kts, as it descended about 400 ft in a slight left turn to impact (the airplane’s minimum controllable airspeed was 92 kts). The slowing left turn, in conjunction with left wing low impact signatures observed at the accident site were consistent with a loss of control just prior to impact. Postaccident teardown examination of the left engine revealed that the 1st stage turbine rotor had one blade separated at the midspan. The blade fracture surface had varying levels of oxidation and the investigation could not determine if the 1st stage turbine blade separation occurred during the accident flight or a prior flight. The 2nd stage turbine was operating at temperatures higher than the 1st stage turbine, which was consistent with engine degradation over a period of time. Additionally, the 2nd stage turbine stator assembly was missing vane material from the 6 to 12 o’clock positions, consistent with thermal damage. All of these findings would have resulted in reduced performance of the left engine, but not a total loss of left engine power. The teardown examination of the right engine did not reveal evidence of any preimact anomalies that would have precluded normal operation. Examination of both propellers revealed that all blade angles were mid-range and exhibited evidence of little to no powered rotation. Neither propeller was in a feathered position, as instructed by the pilot operating handbook for an engine failure. If the pilot had perceived that the left engine had failed, and had he secured the engine and feathered its propeller (both being accomplished by pulling the red Engine Stop and Feather Control handle) and increased power on the right engine, the airplane’s performance should have been sufficient for the pilot to complete the landing on the runway.
Probable cause
The pilot’s failure to secure and feather the left engine and increase power on the right engine after a perceived loss of engine power in the left engine, which resulted in a loss of control and impact with terrain just short of the runway. Contributing to the accident was a reduction in engine power from the left engine due to a 1st stage turbine blade midspan separation and material loss in the 2nd stage stator that were the result of engine operation at high temperatures for an extended period of time.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SWEARINGEN
Model
SA226
Amateur built
false
Engines
2 Turbo prop
Registration number
N54GP
Operator
CASTLE AVIATION INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
AT034
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-15T23:19:45Z guid: 104386 uri: 104386 title: WPR22LA061 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104387/pdf description:
Unique identifier
104387
NTSB case number
WPR22LA061
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-11T14:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-21T02:17:21.731Z
Event type
Accident
Location
Bermuda Dunes, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On December 11, 2021, about 1230 Pacific standard time, an experimental, amateur-built RV-3 airplane, N9YY, was substantially damaged when it was involved in an accident near Bermuda Dunes, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a friend who had spoken to the pilot’s wife after the accident, the pilot planned a local flight, with the intention to overfly his home, located about 2.7 miles southwest of Bermuda Dunes Airport (UDD), Palm Springs, California. A security camera located at UDD, captured the airplane as it lifted off at 1226:17 and flew out of view. Automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) revealed that, at 1226:55 the airplane was about .6 miles southwest of UDD at an altitude of 517 ft above ground level (agl), and on a heading consistent with a track toward the pilot’s residence. The airplane overflew a portion of the city of Bermuda Dunes, California. The airplane maintained the southeast heading for about 1.3 miles. At 1227:22, the airplane overflew a 300-ft-by-900 ft vacant lot. About 10 seconds later, the airplane had reached a maximum altitude of 712 ft agl. Nine seconds later, it had descended to 672 ft agl and began a right turn. The airplane continued the descending right turn until the end of the track data, at 1228:22. At that time, the airplane was on a heading of 124° at a low altitude, about 525 ft north of the accident site, as shown in figure 1. The accident site was immediately north of the vacant lot the airplane had previously overflown. Multiple witnesses saw the airplane in flight. One witness, located about .7 miles west of the accident site, reported that she first heard a loud airplane, then saw it in a descending right turn. She could see the individual propeller blades spinning but not as fast as she thought they should be. Another witness, located about 1,500 ft north of the accident site, reported that he saw the airplane in a normal attitude travelling from north to south at a very low altitude. He could not hear the engine. Another witness, located about 1,000 ft north of the accident site, captured a 10-second video of the airplane just before the accident. The video revealed the airplane in a near-level pitch attitude and traveling to the southeast. No engine noise from the airplane was heard. The airplane’s pitch attitude increased, and the airplane entered a right bank. The last moments of the video revealed the airplane in a right bank angle exceeding 90° as the nose dropped. Figure 1. Overhead view of the ADS-B flight track. A vacant lot is identified by a yellow border. The airplane came to rest upright on a residential driveway about 1.3 miles southwest of UDD. The first point of impact was a palm tree about 35 ft in height located about 50 ft north of the wreckage. The top portion of the palm tree lay adjacent to the airplane and one of the airplane’s wooden propeller blades was located at the base of the tree. All major structural components remained attached to the airplane and flight control continuity was established to all flight control surfaces. The forward engine cowling area exhibited crush damage with embedded palm fronds. There was crush damage of the fuselage, aft of the firewall, that extended to the cockpit area. The right wing exhibited substantial damage to the leading edge. The left wing exhibited substantial damage to the leading edge near the root. The empennage exhibited only minor damage. Postaccident examination revealed a fuel shutoff valve mounted to the underside of the breached fuel tank. The fuel shutoff valve handle had no markings to identify an open or closed position, and it was positioned 90° to the fuel line. (see figure 2). The valve was disassembled and examined. When viewed through the fuel passage, and the valve handle was set at 90° to the fuel line; the fuel passage was open about 50%. When the handle was moved aft to the 135° position; the fuel flow was shut off. When the handle was pushed forward to the 45° position, the fuel passage was open 100%. According to a first responder, he did not see anyone manipulate the fuel shutoff valve following the accident. He reported that, by the time they arrived, all the fuel had drained from the fuel tank, and no one was worried about closing a fuel shutoff valve. According to recovery personnel, about 8 gallons of fuel drained out of the tank after the accident. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. Figure 2. Image of the fuel shutoff valve as found at the accident site. -
Analysis
The pilot departed on a local flight in the experimental, amateur-built airplane. Flight track information indicated that the airplane departed and climbed to a maximum altitude of about 712 ft above ground level. One witness saw the airplane and described the engine noise as loud. As the airplane turned toward her location, she saw that the propeller blades were spinning slower than she thought they should. Another witness, who was closer to the accident site, saw the airplane at low altitude but could not hear the engine noise. A third witness captured video showing the airplane first in level flight, then its pitch attitude increased, and the airplane entered a right bank. The right bank continued past 90° as the airplane entered a nose-low descent. The airplane impacted a palm tree about 35 ft agl about 3 minutes after takeoff and came to rest upright in the driveway of a private residence. Examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation; however, the fuel shutoff valve was found in an intermediate position that restricted fuel flow about 50%. Based on the available information, it is likely that the pilot’s improper positioning of the fuel shutoff valve resulted in fuel starvation and a total loss of engine power during the takeoff climb as evidenced by the absence of engine noise in the witness video. The pilot subsequently exceeded the airplane’s critical angle of attack, resulting in an aerodynamic stall/spin and loss of control.
Probable cause
The pilot’s improper positioning of the fuel shutoff valve, which resulted in a loss of engine power, and the pilot’s subsequent exceedance of the airplane’s critical angle of attack, resulting in an aerodynamic stall and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOUL WILLIS
Model
RV-3
Amateur built
true
Engines
1 Reciprocating
Registration number
N9YY
Operator
WALLACE JAMES A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11267
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-21T02:17:21Z guid: 104387 uri: 104387 title: WPR22LA062 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104388/pdf description:
Unique identifier
104388
NTSB case number
WPR22LA062
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-11T16:55:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-21T08:11:12.593Z
Event type
Accident
Location
Temecula, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On December 11, 2021, about 1455 Pacific standard time, a Beech K35 airplane, N654HR, was substantially damaged when it was involved in an accident near Temecula, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that about 8 minutes after takeoff, while at a cruise altitude of about 3,100 ft mean sea level, the engine started to run rough and lose power. He activated the fuel pump and switched from the left fuel tank to the right fuel tank but that did not resolve the issue. The engine continued to lose power until it was not producing any power. The pilot maneuvered the airplane to land on a golf course fairway but had to abort the approach due to individuals on the fairway. Subsequently, the pilot elected to make a forced landing in a nearby grape vineyard. He intentionally kept the landing gear retracted to minimize any entanglement with the wire that was used to support growing the grape vines. During the landing sequence, the airplane sustained substantial damage to the fuselage and wings when it struck posts that supported the wire. Before an airframe and engine examination could be accomplished, the airplane wreckage was inadvertently sold. Therefore, the reason for the loss of engine power was undetermined. -
Analysis
The pilot reported that about 8 minutes after takeoff, the airplane’s engine began running rough and lost power. The pilot initiated an emergency landing in a vineyard, and during the landing, the airplane sustained substantial damage when it struck posts. The airplane wreckage was inadvertently sold before an examination could be accomplished; therefore, the reason for the loss of engine power could not be determined.
Probable cause
The total loss of engine power for reasons that could not be determined from the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
K35
Amateur built
false
Engines
1 Reciprocating
Registration number
N654HR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-5840
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-21T08:11:12Z guid: 104388 uri: 104388 title: CEN22FA070 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104389/pdf description:
Unique identifier
104389
NTSB case number
CEN22FA070
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-12T11:31:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2021-12-15T03:08:52.322Z
Event type
Accident
Location
Inola, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
According to a work order from the maintenance company that began the annual inspection in March 2021, one of the discrepancies listed was “Left hand Prop control will not feather.” In addition, the work order stated, “Inspection stopped. Aircraft unairworthy. Aircraft put back together for customer.” - Following the accident, a review of the air traffic control communications and procedures was conducted by the National Transportation Safety Board, Federal Aviation Administration (FAA), and the National Air Traffic Controllers Association. The group reviewed certified audio as provided by TUL and reviewed the Standard Terminal Automation Replacement System (STARS) replay of the accident as depicted on the radar display available to the air traffic controller working the accident flight. A review of the TUL STARS replay on the controller display revealed what keystrokes were made by the radar west (RW) controller and indicated what the airplane target displayed on the controller’s radar display. For the last 30 seconds of the flight, the airplane’s altitude decreased from 6,100 ft msl to 4,700 ft msl, followed by the code XXX, which indicated rapidly changing data. At 0931:21, the track was indicated as in a “coast” status, which occurs when the airplane is no longer giving a radar return. About 30 seconds later, the track was no longer active (ZZ status), and the STARS system would no longer predict the location of the target. At 0932:36, the RW controller informed the pilot that radar services were terminated and a frequency change was approved. The pilot did not respond and about 7 seconds later, the controller again called the accident pilot, and there was no response. The STARS replay also showed a VFR airplane conducting multiple passes at Claremore Regional Airport (GCM) about 5 nautical miles north of the final ADS-B target for the accident airplane. The STARS replay indicated that after the accident airplane went into ZZ status, the RW controller activated a quick look function (“beacon all” button) that pulled up the ADS-B unique Mode S assigned code and call sign for all airplanes on the display. The VFR airplane at GCM was determined not to be the accident airplane, and there were no other displayed aircraft near the accident airplane’s last location. The STARS replay noted that the RW controller had pushed the “beacon all” button ten times. No alert notice (ALNOT) was issued for the accident airplane. During an interview, the RW controller reported that he saw the accident airplane turning towards the northeast toward GCM, which was not uncommon in that area, and never observed the airplane in a descent. When he looked back, the track was in coast status, but he observed a primary target over GCM that he assumed was the accident airplane. - On December 12, 2021, about 0931 central standard time, a Cessna 310J airplane, N3187L, was destroyed when it was involved in an accident near Inola, Oklahoma. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. According to the airplane owner, he purchased the airplane in March 2020 and then became ill, which precluded him from flying the airplane. In March 2021, the owner requested a maintenance company at Tulsa International Airport (TUL) where the airplane was located to complete a required annual inspection, and the maintenance company performed a short maintenance test flight, which was the first flight since March 2020. Due to several discrepancies found during the initial inspection, which included airframe corrosion and a recommendation for both engines to be overhauled, the maintenance company would not complete the annual inspection without the discrepancies being corrected. Several months later, the owner then elected to hire the accident pilot, who was also a mechanic that had previously worked on the airplane, to ferry the airplane to North Carolina to complete the overdue annual inspection. Before the ferry flight, the airplane fuel tanks were topped off with fuel, and the pilot completed a preflight inspection that the owner estimated took about 1 hour. The pilot then started the engines and taxied the airplane for departure. A few minutes later, the owner, who was listening to air traffic control (ATC) communications on a handheld radio, heard the pilot inform ATC that he needed to return to the ramp/parking area due to an engine issue. The pilot called the owner via cellular phone and advised him of the situation. The owner observed the pilot complete an extensive engine run-up, and about 20 minutes later, the pilot taxied back for departure. The owner had no further communication with the pilot. A review of TUL ATC ground and tower communications revealed that at 0838, the pilot requested a visual flight rules (VFR) clearance for departure. At 0855, the pilot stated he needed to taxi back to parking due to “a miss on the right engine there pretty bad.” About 20 minutes later, the pilot contacted ground control and stated, “ready to go and try it again sir…we’ve got it cleared up enough.” TUL ground control cleared the pilot to taxi for departure. At 0921, the pilot was cleared for takeoff and told to execute a left turn to a 090° heading. At 0925, the pilot was cleared to an altitude of his discretion, and the pilot acknowledged a climb to 9,500 ft mean sea level (msl). At 0932:36, the TUL tower radar west controller terminated radar services and approved a frequency change for the flight. The pilot did not respond, and at 0932:43, the TUL controller again radioed the pilot and received no response. There were no further transmissions with the airplane. Automatic dependent surveillance-broadcast (ADS-B) data for the airplane began at 0922 and ended at 0931:11, about 21 miles east of TUL. The data showed the airplane climbed to 5,800 ft msl, and about 1 minute before the accident, the airplane made a left turn to the north and began a rapid descent (see figure 1). During the last 23 seconds of the flight, the descent rate increased from about 1,000 to 30,000 ft per minute; the ground speed varied between 151 and 198 knots; and the heading varied between 027° and 007°. Figure 1. Accident flight track About 1100, the airplane wreckage was located on a private ranch by personnel who were tending to cattle. There were no witnesses to the accident. - Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified gabapentin in urine and liver tissue. Gabapentin is an antiseizure medication also commonly used to treat painful nerve conditions. The medication carries a warning about driving, sleepiness, and dizziness. According to the FAA, gabapentin is disqualifying for a medical certificate. - The pilot’s logbook was not located during the investigation, and his recent flight review and total flight time in the accident airplane make/model could not be determined. - Postaccident examination of the accident site revealed the airplane impacted terrain on a measured magnetic heading of about 060°, and the wreckage distribution field measured about 900 ft in length (see figure 2). Fragmented sections of the outboard wings, horizontal and vertical stabilizers, rudder, and elevators were the first components identified in the debris field. A large impact crater, consistent with the left engine and propeller assembly, was located about 300 ft from the fragmented empennage components. The left engine came to rest adjacent to the crater. Another large impact crater, consistent with the right engine and propeller assembly, was located about 300 ft from the left engine crater. The right engine came to rest adjacent to the crater. The main wreckage, which consisted of the inboard left and right wings, left and right engine nacelles, fuselage, and cockpit, was located about 300 ft from the right engine crater. Figure 2. Accident site Examination of the airplane revealed the main landing gear assemblies were retracted in the wing wheel wells. The cockpit flight and engine instruments were fragmented and destroyed. The cockpit throttle quadrant control levers were found in the following positions: Left and Right throttles – full forward, Left propeller – feather, Right propeller – full forward, and Left and Right mixtures – full forward. The empennage separated from the aft fuselage near the aft bulkhead location. The vertical stabilizer and a majority of the rudder remained attached to the empennage. The horizontal stabilizer and elevators separated from the empennage and fractured into multiple pieces. The horizontal rear spar was mostly intact; the structure forward of the left rear spar was deformed downward about 90°; and the outboard portion of the rear spar was twisted. The outboard left rear spar lower cap was rotated about 90° forward and up. The right rear spar was deformed forward and downward more than 90° from the centerline to the outboard section. The right and left wings outboard of the engines were highly fragmented. There was no obvious evidence of failure direction on any of the front spar segments, and no evidence of significant corrosion or pre-existing cracking was noted on any of the components. The extensive impact damage to the airframe precluded a functional examination of the flight controls. Due to extensive damage, both engines could not be functionally tested and were disassembled. The left engine would not rotate. Some metallic deposits were noted within the oil screen, pump drive gears, and oil bypass valve cap. All mechanical components within the engine displayed normal wear signatures. The origin of the deposits could not be determined. The right engine rotated by input through starter adapter. Mechanical continuity was noted throughout the right engine to all pistons, valves, and accessory gears. The magnetos for both engines were separated and could not be functionally tested due to damage. Examination of both propeller assemblies revealed no indications of any type of propeller failure or malfunction before impact. Both propellers displayed indications consistent with low power; however, exact engine power levels could not be determined. In addition, both propellers had impact signature markings indicating blade positions at or near feather blade angles during the impact sequence. -
Analysis
The airplane’s most recent flight was about 9 months before the accident, and the pilot was flying the airplane on a ferry permit to another location to complete an overdue annual inspection. Before the accident flight, the airplane’s fuel tanks were topped off, and the pilot completed a preflight inspection that took about 1 hour. After taxiing to the runway area, the pilot returned to the ramp due to an unknown right engine issue. Following an extended engine run-up, the pilot taxied back to the runway and departed. Flight data showed that the airplane climbed to 5,800 ft mean sea level on an easterly heading, and about 1 minute before the accident, the airplane made a left turn to the north and began a rapid descent. For the last 23 seconds of the flight, the descent rate increased from about 1,000 to 30,000 ft per minute, and the ground speed varied between 151 and 198 knots. During the rapid descent and just before impact, the empennage and outboard wing sections separated. There were no emergency communications from the pilot and no witnesses to the accident. Distribution of the wreckage and damage signatures observed during postaccident examination were indicative of an in-flight breakup at low altitude due to the exceedance of structure design limitations. The left cockpit propeller control lever was found in the feathered position. Both propellers displayed indications consistent with low power; however, exact engine power levels could not be determined. In addition, both propellers had impact signature markings indicating blade positions at or near feather blade angles during the impact sequence. Although the airframe and engine examinations revealed no evidence of mechanical malfunctions or failures, the extensive impact damage precluded a functional examination of the flight controls. Investigators were unable to determine the reason for the loss of control and rapid descent based on the available evidence. The airframe and engine examinations revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Although the pilot tested positive for gabapentin, which is potentially sedating, tolerance to the sedating effects build quickly, and the pilot had likely been using the medication for some time. Thus, it is unlikely that any effects from the pilot’s use of gabapentin contributed to the circumstances of the accident.
Probable cause
The loss of airplane control for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310J
Amateur built
false
Engines
2 Reciprocating
Registration number
N3187L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
310J0187
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-15T03:08:52Z guid: 104389 uri: 104389 title: CEN22FA073 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104406/pdf description:
Unique identifier
104406
NTSB case number
CEN22FA073
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-14T14:36:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2021-12-17T21:04:25.767Z
Event type
Accident
Location
LaPlace, Louisiana
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On December 14, 2021, about 1236 central standard time, a Bell 407 helicopter, N150AS, was destroyed when it was involved in an accident near LaPlace, Louisiana. The pilot was fatally injured. The helicopter was operating as a Title 14 Code of Federal Regulations Part 91 personal flight. The helicopter departed from the Gonzales, Louisiana, area and was en route to New Orleans Lakefront Airport (NEW), New Orleans, Louisiana. Automatic dependent surveillance-broadcast (ADS-B) data tracked the helicopter’s flightpath as it flew toward NEW. The helicopter’s altitude varied between 75 and 175 ft above ground level (agl). About 0.88 miles from the accident site, the helicopter descended to 50 ft agl. The last ADS-B data point, at 1236:26, indicated that the helicopter was near the intersection of transmission lines over Interstate 10. At that time, the helicopter was traveling at a groundspeed of about 104 knots and an altitude of 75 ft agl. The helicopter subsequently collided with a western guy wire suspended between two transmission line trusses. The guy wire was estimated to be about 130 ft above a trestle bridge on the highway. Several commercial vehicle video cameras captured the helicopter’s descent and impact with the highway. A postimpact fire ensued and destroyed the helicopter. - A review of meteorological information revealed that no frontal boundaries were near the accident site. The closest official aviation weather observation station reported 4 miles visibility, mist, in addition to a broken ceiling at 400 ft, and an overcast ceiling at 1,000 ft. An upper air sounding displayed the potential for cloud formation between 600 to 3,250 ft. Weather satellite imagery of the accident site showed cloud cover above the accident site and to the north and west. At the time of the accident, the clouds were moving south to north. AIRMET Sierra, issued at 0845, forecast instrument meteorological conditions with mist and fog through 1500 near the accident site. The pilot did not receive a weather briefing from Leidos Flight Service or ForeFlight. After the accident, a US Coast Guard (USCG) helicopter was launched to the scene to provide search and rescue support. The USCG pilot reported that the weather was visual flight rules (VFR) at Louis Armstrong International Airport (MSY), New Orleans, Louisiana, but deteriorated to marginal VFR and instrument flight rules to the west. Because of low-level fog, the stanchions of the power lines were “barely visible” from the east; from the west, the fog layer was above the power lines with high cloud layers that reached about 1,200 ft. The USCG pilot also reported that, from a topdown view, “there was very dense fog from all areas with a tall column of clouds to the west of the power line intersection” where the accident occurred. The USCG pilot stated that the helicopter orbited with good visibility at 500 ft over the shoreline but that, on land to the west, a “wall of clouds” to 1,200 ft was present. - A review of the pilot’s logbook revealed that he had 12 hours of instrument flight experience, all of which were logged in fixed-wing aircraft. The pilot’s most recent instrument flight was on May 21, 2019. - The helicopter impacted the highway on a trestle bridge in a steep nose-low attitude. The main rotor blades, mast, and transmission separated from the fuselage and fell into Lake Pontchartrain. The postimpact fire consumed most of the fuselage. Postaccident examination of the wreckage revealed markings on two main rotor blades that were consistent with contact with a braided metal wire. No anomalies were found with the airframe or engine that would have precluded normal operation of the helicopter. -
Analysis
The pilot was operating the helicopter in an area of low cloud ceilings, fog, and mist. Flight data showed that the helicopter’s altitude varied and that the maximum altitude reached was 175 ft above ground level. The last recorded altitude was 75 ft. The helicopter subsequently collided with a guy wire suspended between two transmission line trusses and impacted the highway below. A postimpact fire ensued and destroyed the helicopter. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation of the helicopter. The pilot did not receive an official weather briefing before the flight. After the accident, a US Coast Guard pilot was deployed to the accident area. The Coast Guard pilot stated that a “wall of clouds” extended from the power lines westward to the accident area. Thus, the accident pilot likely could not see the power lines due to the reduced visibilities in mist and clouds at the accident time.
Probable cause
The pilot’s failure to maintain clearance from power lines. Contributing to the accident was the pilot’s decision to fly in instrument conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N150AS
Operator
RC SMITH AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
54658
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-17T21:04:25Z guid: 104406 uri: 104406 title: ANC22LA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104477/pdf description:
Unique identifier
104477
NTSB case number
ANC22LA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-15T11:20:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-01-04T01:20:11.445Z
Event type
Accident
Location
Haines, Alaska
Airport
AIRKAT AIRPARK (9AA9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On December 15, 2021, about 0920 Alaska Standard Time, an experimental amateurbuilt LB-1, N555LB, was substantially damaged when it was involved in an accident near Haines, Alaska. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after preheating the airplane, performing a preflight, and doing a successful run-up of the engine, which included checking the carburetor heat, he initiated a takeoff. During the initial climb he “went to one notch of flaps and immediately the engine faltered.” He “pushed the nose over and re-set to two notches of flaps.” He confirmed the throttle was in the full power position, but the airplane continued to descend. The pilot made a precautionary landing in the snow between tree stump piles. During the landing, the airplane touched down and bounced; on the second touchdown, the tires sunk into the snow, and the airplane nosed over, coming to rest inverted. The pilot and passenger were able to egress without further incident. The airplane sustained substantial damage to the wings, fuselage, and empennage. The pilot reported that he cut the fuel lines while removing the wings from the airplane for postaccident recovery. He reported the fuel color was blue with no contamination or abnormalities. According to the pilot, there were 30 gallons of 100LL fuel onboard the airplane before he took off. He also reported that he did not believe there was any type of internal engine failure. A postaccident examination and engine run revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. A Global Data Assimilation System (GDAS) model sounding was created for 0900 for the accident location and had a modeled surface elevation at 3,143 ft mean sea level (msl). At an elevation of 3,143 ft msl, the GDAS sounding indicated the wind was from 023° at 6 kts, the temperature was 2.3° F, and the dewpoint was -2.2° F, with a relative humidity of 81 percent. According to Federal Aviation Special Airworthiness Information Bulletin CE-09-35, the temperature and dewpoint were not conducive for carburetor ice. Additional data indicated light rime icing. The pilot reported that the weather observation facility at the Haines Airport (PAHN) from 0700 local up to the time of the flight reported a temperature of 0° F. -
Analysis
After performing a preflight inspection and a successful run-up of the engine, the pilot initiated a takeoff. After becoming airborne, the engine “faltered.” The pilot lowered the nose, decreased the flaps, and confirmed that the throttle was set at the full power position, but the airplane continued to descend. During a precautionary landing, the airplane bounced; on the second touchdown the tires sunk into the snow and the airplane nosed over, coming to rest inverted. The pilot reported that he did not believe there was any type of internal engine failure. A postaccident engine run revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation. A review of the weather conditions found that they were not conducive to carburetor ice. A reason for the partial loss of engine power could not be determined based on the available information.
Probable cause
A partial loss of engine power for reasons that could not be determined based on available information, which resulted in a precautionary landing and impact with snow.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Larry Bingham
Model
LB-1
Amateur built
true
Engines
1 Reciprocating
Registration number
N555LB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
01
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-04T01:20:11Z guid: 104477 uri: 104477 title: ERA22LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104416/pdf description:
Unique identifier
104416
NTSB case number
ERA22LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-16T12:07:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2022-01-03T20:21:04.222Z
Event type
Accident
Location
Knoxville, Tennessee
Airport
MC GHEE TYSON (TYS)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On December 16, 2021, about 1007 central standard time, a Cirrus SR22, N162AM, was destroyed when it was involved in an accident near McGhee Tyson Airport (TYS), Knoxville, Tennessee. The private pilot received serious injuries, and the pilot-rated passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 as a personal flight. According to the first responders, they observed an occupant of the airplane, later identified as the pilot-rated passenger, about 30 ft from the aircraft upon arrival at the accident scene. They reported that the passenger had third-degree burns on his body but was alert, conscious, and responsive to verbal commands. The passenger stated he was returning from a 45-minute flight and that he and the other occupant encountered wake turbulence on short final. He explained that the airplane lost lift, rolled inverted, and the ballistic parachute was activated. He mentioned that the airplane "hit the ground and burst into a fireball.". According to the pilot, he recalled they were on the second takeoff and were instructed by air traffic control (ATC) to make right traffic. The crosswind and downwind segments were uneventful. He stated that he was doing most of the flight control manipulation but was primarily focused on experiencing the heads-up display (HUD) that the passenger was demonstrating. The pilot reported that, approximately abeam the 1,000 ft markers for runway 23L, ATC advised them of an incoming Airbus on final. The pilot stated that they made visual contact with the Airbus, and he advised ATC, upon which they cleared them to land behind the Airbus. The pilot did not recall if they were cautioned about wake turbulence or not. The pilot continued the downwind leg and made the base turn. He recalled the base leg felt a bit further away from the runway than standard, potentially due to spacing from the Airbus. He also felt like they were a bit low for their distance from the runway. The pilot stated that the spacing from the Airbus did not feel unusual or “too close” compared to his experience with other landings behind large traffic. The pilot said that once he was established on final, “they felt a bump of wake turbulence.” The passenger was alarmed and asked, “What was that?” to which the pilot stated, “it was wake turbulence.” Around the same time, they heard the autopilot announce, “five hundred.” Shortly after, the airplane rolled approximately 135° to the left in less than a second. The pilot applied corrective control inputs instinctively and then yelled, “PULL CAPS PULL CAPS PULL CAPS” as the passenger reached for the handle and pulled just as they reached a near-level wing attitude with the nose pitched down. They heard the CAPS deployment rocket ignite and fire. He then felt the deceleration of the parachute for a couple of seconds before they impacted the ground. The pilot said the impact was relatively benign compared to his expectations, and for a moment he felt relief until the airplane caught fire seemingly instantaneously and on both sides of the airplane. He yelled “GET OUT GET OUT” as he quickly unlatched his seat belt and opened his door. He stood up in his seat, climbed onto the top of the airplane fuselage aft of the passenger doors, and jumped off the airplane behind the right wing. After exiting the airplane and running a safe distance away, he turned around and saw the passenger still struggling to get away. The passenger exited the airplane onto the ground just aft of the right wing. According to ATC, the air traffic volume and complexity were described as moderate. At the time of the accident, there were two positions open in the tower. The Local Control (LC) position was standalone, while the Ground Control (GC) position was combined with the Flight Data and the controller-in-charge positions. This configuration was reported as normal for the time of day and volume of traffic. The weather conditions were calm wind, 10 miles visibility, few clouds at 4,300 ft, and a ceiling of 25,000 ft broken. The pilot established communication with the GC controller and requested taxi with ATIS A. The GC controller instructed the pilot to taxi to Runway 23L at taxiway A8 via taxiway A. The pilot then established communication with the LC controller and was cleared for takeoff on Runway 23L and instructed to enter the left traffic pattern. Approximately 5 minutes later, the LC controller cleared the pilot for the option on Runway 23L. The pilot executed the approach on Runway 23L, and the LC controller instructed them to enter right traffic to Runway 23L. The pilot advised the LC controller that this would be their last practice approach. While abeam the airport, the LC controller instructed the pilot to extend their downwind and issued a Traffic Advisory regarding (Allegiant) AAY2615, an Airbus A320 on a 3-mile final. The pilot informed the LC controller that they had the traffic in sight. About 1 minute later, the LC controller instructed the pilot to follow AAY2615 and cleared them to land on Runway 23L; however, a cautionary wake turbulence advisory was not issued. The pilot turned onto the base leg approximately 1.8 miles behind AAY2615. Around 2 minutes later, the pilot was on a 1.5-mile final and was observed at 1,000 ft when the radar target disappeared. About 40 seconds later, the LC controller attempted communication with the pilot again without a response. The LC controller asked an uninvolved aircraft if the smoke ahead of the Cirrus was visible, and the aircraft replied in the affirmative, reporting smoke and flames. A postaccident examination of the wreckage by an FAA inspector revealed that the airplane was destroyed by postcrash fire. A review of the flight data downloaded from a cockpit primary flight display did not reveal any anomalies with the engine before the accident. (see Recorded Flight Data Report) Aircraft Separation Responsibility FAA order JO 7110.65Z, titled "Air Traffic Control," comprehensively details the procedures and responsibilities of air traffic controllers. According to JO 7110.65W Section 2-1-1 (ATC SERVICE), the primary purpose of the ATC system is to prevent aircraft collisions and ensure a safe, orderly, and expeditious flow of traffic. The document highlights that, beyond its primary function, the ATC system can provide additional services within certain limitations. These limitations are influenced by various factors, including traffic volume, frequency congestion, controller workload, and higher-priority duties. In JO 7110.65Z Section 2-1-2 (DUTY PRIORITY), guidance for ATC services in Class C airspace emphasizes giving first priority to separating aircraft and issuing safety alerts as required by the order. Furthermore, JO 7110.65Z specifies that when handling both instrument flight rules (IFR) and visual flight rules (VFR) aircraft simultaneously, the controller may transfer separation responsibilities to the VFR aircraft once the required radar separation minima are met, and visual separation criteria are or can be met. Wake Turbulence Advisories JO 7110.65Z Section 2-1-20 (WAKE TURBULENCE CAUTIONARY ADVISORIES): The guidance applied to arriving VFR aircraft that were not being radar vectored but were behind larger aircraft that require wake turbulence separation. The guidance required controllers to issue wake turbulence cautionary advisories "including the position, altitude if known, and direction of flight" to "VFR arriving aircraft that have previously been radar vectored and the vectoring has been discontinued." The guidance also stated, "Issue cautionary information to any aircraft if in your opinion, wake turbulence may have an adverse effect on it." FAA Advisory Circular 90-23G, Aircraft Wake Turbulence, states the following: “… if a pilot accepts a clearance to visually follow a preceding aircraft, the pilot accepts responsibility for both separation and wake turbulence avoidance. The controllers will also provide a Wake Turbulence Cautionary Advisory to pilots of visual flight rules (VFR) aircraft, with whom they are in communication and on whom, in the controller’s opinion, wake turbulence may have an adverse effect. This advisory includes the position, altitude and direction of flight of larger aircraft followed by the phrase “CAUTION–WAKE TURBULENCE.” After issuing the caution for wake turbulence, the air traffic controllers generally do not provide additional information to the following aircraft.” -
Analysis
According to the pilot, the event occurred on final approach when the airplane encountered wake turbulence from a landing Airbus A320. The pilot reported feeling a sudden bump, leading to an extreme roll of approximately 135°. The pilot instinctively applied corrective control inputs and commanded the pilot-rated passenger to pull the Cirrus Airframe Parachute System (CAPS). The passenger reached for the handle and pulled it just as they reached a near-level wing attitude with the nose pitched down. The pilot felt the deceleration of the parachute for a couple of seconds before they impacted the ground. A postimpact fire ensued and both occupants evacuated the aircraft. The pilot was seriously injured, and the passenger received fatal injuries. A review of Air Traffic Control (ATC) communications revealed that all instructions and advisories were acknowledged by the flight crew of the Airbus and the pilot of the Cirrus as appropriate; however, ATC failed to provide a wake turbulence cautionary advisory to the pilot of the Cirrus as required by Federal Aviation Administration (FAA) order JO 7110.65Z, Air Traffic Control, for simultaneous same runway operations involving a small aircraft landing behind a large aircraft. Although the pilot was aware of the preceding Airbus, the very purpose of this advisory is to remind and emphasize to pilots the potential for dangerous wake encounters.
Probable cause
The pilot’s encounter with a wake vortex from a preceding airplane, which resulted in a roll upset at an altitude too low for recovery. Contributing to the accident was the failure of ATC to issue a wake turbulence cautionary advisory.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N162AM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
2724
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-03T20:21:04Z guid: 104416 uri: 104416 title: HWY22FH002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104427/pdf description:
Unique identifier
104427
NTSB case number
HWY22FH002
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-17T14:10:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-08-23T04:00:00Z
Event type
Accident
Location
Monaville, Texas
Injuries
1 fatal, 0 serious, 4 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Monaville, Texas, crash was the bus driver's failure to keep the vehicle in its travel lane due to being distracted by the vehicle's vent window. Contributing to the severity of the injuries was the lack of seat belt use by several school bus passengers.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2018 IC 43-passenger School Bus
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-08-23T04:00:00Z guid: 104427 uri: 104427 title: ERA22LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104419/pdf description:
Unique identifier
104419
NTSB case number
ERA22LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-17T14:24:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-01-24T19:37:04.447Z
Event type
Accident
Location
Auburndale, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On December 17, 2021, at 1224 eastern standard time, a Lake LA-250 amphibious airplane, N1402C, was destroyed when it was involved in an accident in Auburndale, Florida. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to Federal Aviation Administration (FAA) automatic dependent surveillance - broadcast (ADS-B) tracking data, the airplane departed from Lake Hartridge, Winter Haven, Florida, (near the pilot’s residence) about 1130. The airplane departed to the south, then turned north and flew about 25 miles before heading southwest toward Lake Arietta. The airplane flew over the center of Lake Arietta on a southbound heading, at an altitude of about 825 ft above mean sea level, at a groundspeed of 92-96 knots. The track turned slightly toward the west before the altitude sharply decreased. The last track data showed the airplane at an altitude of 450 ft msl and a groundspeed of 105 knots, descending at a rate of 2,500 to 3,500 ft per minute, near the southern end of the lake about 0.1-mile northeast of the accident site. A witness located on the southwest shore of the lake, about 0.1 mile abeam the accident site, reported that the airplane was flying toward his location, at a “fairly low altitude” as the engine was “making a sputtering noise.” He added that he did not see any smoke, flames, or other signs of distress. As the airplane continued toward his location, it descended at a steep angle and impacted the lake in a nose-down attitude. After impact, the airplane “came apart and there was an immediate, explosive ball of flames and smoke.” Another witness saw the airplane flying low over the lake and reported that the engine sounded as if it was “struggling to develop full power.” He then saw the airplane in a climbing right turn and banking before he lost sight of it below a tree line. During recovery of the wreckage, bird feathers, subsequently identified as those from a turkey vulture, were found wrapped around the fuel filler cap on the inside of the damaged and breached right wing fuel tank. The carcass of a turkey vulture was found floating on the surface of the lake, in the vicinity of the wreckage debris field. Figure 1 - Right Fuel Cap Location Examination of the airframe revealed no pre-impact anomalies that would have precluded normal operation. The fuselage area forward of the wing was significantly fragmented. The entire leading edge of the wing exhibited crush damage, as did the forward edge of both sponsons. Soot was present in several locations near the wing roots and both sides of the empennage. The empennage was separated just aft of the wing trailing edge and was damaged though largely intact. Other than the feathers found on the fuel cap/filler neck, there were no other bird remains found within the wreckage or other obvious indications of strikes or marks from impact with bird(s). However, there were no windscreen (or any side window) panels or sections recovered from the accident site, and no fragments of window were found within the wreckage. Flight control continuity was confirmed from the center section of the airplane to the ailerons, elevator, and rudder (and their trim tabs). All fractures within the flight control system were indicative of overload. Examination of the engine revealed no pre-impact anomalies that would have precluded normal operation. Two of the three propeller blades had leading edge damage/gouging near their tips. One of these blades had chordwise scratch marks from about mid span to the tip, the other blade exhibited a trailing edge “S” bend from about mid span to the tip. The engine’s crankshaft was rotated by hand, and crankshaft and valvetrain continuity were confirmed. The engine-driven fuel pump was impact damaged but produced pressure when operated by hand. No obstructions were found in fuel servo screen, flow divider, or fuel injector nozzles. The ignition leads remained intact. The right magneto produced spark on all towers when rotated and the left magneto was electronic and was not tested. All the spark plug electrodes were undamaged and appeared worn “normal” when compared to a Champion check-a-plug chart. The Office of the Medical Examiner, Winter Haven, Florida, performed an autopsy on the pilot. The autopsy report indicated the cause of death was multiple blunt force traumatic injuries. Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. Carvedilol was detected in liver and blood. Carvedilol is a beta-blocker used to treat high blood pressure and is acceptable for FAA medical certification. Valsartan was detected in liver and blood. Valsartan (Diovan) is an ACE II inhibitor type antihypertensive used to treat high blood pressure and is acceptable for FAA medical certification. -
Analysis
The pilot departed from a lake near his residence, about 5 nautical miles southeast of the accident site, for a local flight. About 53 minutes after departure, the airplane overflew another lake at an altitude of about 825 ft above mean sea level. After a slight right turn, the airplane rapidly descended and impacted the water. First responders recovered floating debris and found the carcass of a turkey vulture in the debris field. During recovery of the airplane, feathers were found wrapped around the fuel cap and filler neck of the right wing fuel tank, suggestive of a bird strike. Examination of the wreckage did not reveal any pre-impact anomalies with the airplane that would have precluded normal operation. Although two witnesses reported observing potential problems with the engine, describing its noise as “struggling to develop full power” and “making a sputtering noise”, the damage to the propeller blades, which included leading edge gouging, chordwise scratch marks, and “S” bending, were consistent with the engine rotating and under power at the time of impact. No additional bird remnants or impact marks were found that would conclusively explain precisely how a bird strike (or strikes) may have led to a loss of control. However, the presence of the bird carcass in the debris field, which was located about 0.1 nautical miles southwest of where the airplane began its rapid descent, suggests that bird likely remained with the airplane after being struck by it. No remnants of the windscreen were recovered with the airplane wreckage, which suggests the possibility that a bird (or birds) may have penetrated the cockpit. Given the bird remnants found on the airplane and at the accident site, along with the wreckage examination that did not identify any pre-impact anomalies with the airplane or engine, it is likely that a bird strike led to the loss of control.
Probable cause
A bird strike, which resulted in a loss of control while flying at low altitude over a lake.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AEROFAB INC
Model
LAKE LA-4-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N1402C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-24T19:37:04Z guid: 104419 uri: 104419 title: CEN22FA080 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104420/pdf description:
Unique identifier
104420
NTSB case number
CEN22FA080
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-17T22:08:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2021-12-20T06:11:18.724Z
Event type
Accident
Location
Bloomington, Indiana
Airport
Monroe County (BMG)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The Pilot’s Operating Handbook recommended a final approach indicated airspeed of 75 knots. - The ILS 35 approach at BMG consisted of a 3° glideslope with a final approach crossing altitude of 2,500 ft msl and a decision altitude of 1,044 ft msl. This was 200 ft above the runway touchdown zone elevation of 844 ft. A missed approach required an initial climb to 2,000 ft msl along the extended runway centerline. The FAA defined a stabilized approach as one that maintains a constant angle glidepath toward a predetermined point on the landing runway. When established on a 3° glideslope, an airplane at 90 knots groundspeed will descend at 450 fpm. At 120 knots, an airplane will descend at 600 fpm to remain on the same glideslope. - On December 17, 2021, at 2008 eastern standard time, a Piper PA-32R-300 airplane, N5677V, was destroyed when it was involved in an accident near the Monroe County Airport (BMG), Bloomington, Indiana. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Automatic dependent surveillance – broadcast (ADS-B) and Federal Aviation Administration (FAA) air traffic data revealed that the pilot initially departed Chicago Executive Airport (PWK) at 1618 central standard time en route to Indianapolis Metro Airport (UMP), arriving at 1844 eastern standard time. He subsequently departed UMP at 1925 eastern standard time with an intended destination of BMG. After departure from UMP, the airplane proceeded on course to the southwest, then to the south, and climbed to an altitude of about 4,000 ft mean sea level (msl). Upon contacting the BMG approach controller, the pilot was instructed to descend to 3,000 ft msl and issued radar vectors for the instrument landing system approach to runway 35. About 2003, the controller issued an intercept heading to the pilot and cleared him for the approach. About 2005, the pilot reported that the flight was established on the approach and the controller instructed the pilot to contact the control tower. The tower controller subsequently cleared the pilot to land; however, the pilot never responded. The airplane tracked inbound along the ILS runway 35 localizer. At 2006:58, the airplane passed the final approach fix (NITTE); the airplane’s altitude was about 2,258 ft msl at that time. After the airplane passed NITTE, the flight path appeared to become more erratic in comparison to the airplane flight path before passing NITTE. At 2008:15, the airplane entered a right turn approximately 2.25 miles from the runway. The final data point was recorded at 2008:29; the airplane’s altitude was about 1,045 ft msl at that time. Airspeed and climb/descent rates derived from ADS-B position and altitude data indicated the airplane was stabilized about 3,000 ft msl and 120 knots until about 1959. The airspeed then decreased and appeared to stabilize about 110 knots with the airplane remaining about 3,000 ft msl. At 2002:20, a momentary altitude deviation was recorded consisting of a 200 ft loss immediately followed by a 300 ft gain. During this time, the airspeed initially increased and then decreased to as low as 90 knots before recovering. From 2003:00 until 2006:40, the airplane entered a general descent with momentary level offs or climbs. Airspeed during this timeframe increased to about 150 knots before decreasing again. Beginning at 2006:40, the airplane entered a continuous descent until the final data point. The average airplane descent rate between the final approach fix and the final ADS-B data point varied from about 400 fpm to over 1,200 fpm. A passenger on the flight from PWK to UMP reported that it was smooth with no issues, and communications with air traffic control seemed routine. They encountered some rime icing near Lafayette, Indiana; the pilot descended out of the icing conditions and the flight proceeded without incident. The pilot seemed to be “very conscientious.” She flew with the pilot from UMP to PWK the preceding day, which was also uneventful. - An autopsy of the pilot was performed by Terre Haute Regional Hospital, Terre Haute, Indiana, which listed the cause of death as “multiple blunt impact injuries.” Toxicology testing performed at the FAA Forensic Sciences Laboratory found no evidence of carboxyhemoglobin, ethanol, or tested for drugs and medications. - An area of clouds and precipitation was present in the vicinity of the accident site. The precipitation and cloud cover continued to increase over the region with a southwesterly wind above 5,000 ft. These conditions resulted in low instrument flight rules conditions with ceilings at 400 ft above ground level (agl), and the possibility of light to moderate low-level wind shear below 2,000 ft agl. No icing potential was indicated below 10,000 ft. A wind model indicated a near surface wind from 109° at 9 knots with the wind remaining easterly through 2,000 ft. Above 2,000 ft the wind veered and became southwesterly to westerly through 14,000 ft. The wind speed was between 10 to 20 knots between the surface and about 1,200 ft agl. The wind speed continued to increase with height to 30 knots by 4,000 ft. - The airplane impacted a wooded hillside absent of ground lighting about 2 miles south of the runway on an easterly heading. The initial tree impact was about 112 ft from the final ADS-B data point. Multiple tree breaks were observed along the impact path. One tree strike consistent with a propeller blade cut was located within the debris path. The fuselage came to rest about 300 ft from the initial tree strike and was partially consumed by a postimpact fire. The propeller hub was fractured consistent with overstress. Both propeller blades were liberated and located at the accident site. The engine was partially separated and located in position forward of the firewall. The wings and empennage were fragmented. All airframe structure, including the flight controls, were located within the debris field. Postaccident airframe and engine examinations did not reveal any anomalies consistent with a preimpact malfunction or failure. The airframe exam was hindered by the extent of the postimpact fire. -
Analysis
After departure, the flight proceeded on course and was issued radar vectors for an instrument landing system (ILS) approach at the intended destination airport. The flight tracked inbound along the ILS localizer; however, after it passed the final approach fix the airplane’s flight path appeared to become unstable. The airplane subsequently entered a right turn about 2.25 miles from the runway and impacted a wooded hillside absent of ground lighting about 2 miles south of the airport. The impact path was oriented nearly perpendicular to the runway extended centerline. Postaccident airframe and engine examinations did not reveal any anomalies consistent with a preimpact malfunction or failure. Airplane airspeed varied from about 90 knots to 155 knots as the flight neared and then intercepted the ILS approach course. Airplane vertical speed during this timeframe ranged from a 1,500 feet-per-minute (fpm) climb to a 1,000-fpm descent. The airplane’s airspeed was about 128 knots as it crossed the final approach fix and during the final 60 seconds of the flight was about 118 knots. The airplane remained in a descent that exceeded 1,000 fpm over the final 30 seconds of the flight. A review of available weather data indicated the pilot was likely in instrument meteorological conditions and precipitation and likely encountered turbulence with moderate or greater low-level wind shear during the approach. The Pilot’s Operating Handbook recommended an indicated airspeed of 75 knots on final approach. When established on a 3° glideslope with a 90-knot groundspeed, an airplane will descend at 450 fpm. The FAA defined a stabilized approach as one that maintains a constant angle glidepath toward a predetermined point on the landing runway. It is likely that an inadvertent encounter with turbulence and low-level wind shear resulted in an unstable approach and subsequent loss of control. The presence of instrument meteorological conditions and dark night lighting conditions when the airplane did emerge from the clouds further hindered the pilot’s efforts to remain on the approach or to execute a missed approach.
Probable cause
The pilot’s failure to follow the instrument landing system (ILS) course guidance, which resulted in the pilot’s loss of airplane control during the instrument approach. Contributing to the accident was the presence of turbulence and low-level wind shear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32R-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N5677V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32R-7780359
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-20T06:11:18Z guid: 104420 uri: 104420 title: CEN22FA081 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104432/pdf description:
Unique identifier
104432
NTSB case number
CEN22FA081
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-21T11:26:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2021-12-27T22:17:10.359Z
Event type
Accident
Location
Fulshear, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The Cessna was operating under Title 14 CFR Part 135 on an instrument flight plan in visual meteorological conditions. The Cessna was equipped with a transponder and an ADS-B OUT transmitter, which made the airplane visible to the air traffic control system. The powered paraglider was operating as an ultralight vehicle under the provisions of Title 14 CFR Part 103. In the United States, ultralight vehicles are not identified as aircraft and, as such, do not require a FAA registration certificate, FAA airworthiness certificate, or a FAA pilot certificate to operate. According to Title 14 CFR Part 91.227 (ADS-B OUT Equipment Performance Requirements) and Advisory Circular No. 20-165B (Airworthiness Approval of ADS-B OUT Systems), in the United States, among other requirements, an aircraft registration number and an International Civil Aviation Organization 24-bit address are required for an ADS-B OUT system to be installed in a civil aircraft. As such, ultralight vehicles, which are not typically registered in the United States, are not authorized to use an ADS-B OUT transmitter. The inflight collision at 5,000 ft msl occurred in Class E airspace. The operation of the powered paraglider in Class E airspace did not require two-way radio communication with air traffic control, the use of a transponder, or an ADS-B OUT transmitter. Neither the Cessna nor the powered paraglider were equipped with ADS-B IN technology, cockpit display of traffic information, or a traffic alerting system. According to Title 14 CFR Part 103.13 (Operation Near Aircraft; Right-of-Way Rules), an ultralight vehicle shall maintain vigilance to see and avoid aircraft and shall yield the right-of-way to all aircraft. Additionally, no person shall operate an ultralight vehicle in a manner that creates a collision hazard with respect to any aircraft. - On December 21, 2021, about 0926 central standard time, a Cessna 208B airplane, N1116N, collided with a powered paraglider while inflight near Fulshear, Texas. The pilot of the Cessna and the non-certificated powered paraglider operator were fatally injured. The Cessna was destroyed and the powered paraglider sustained substantial damage. The Cessna was operated as a Title 14 Code of Federal Regulations (CFR) Part 135 cargo flight, and the powered paraglider was operated as a Title 14 CFR Part 103 personal flight. According to air traffic control data, about 0910, the Cessna departed George Bush Intercontinental Airport (IAH), Houston, Texas, and flew southwest toward Victoria Regional Airport (VCT), Victoria, Texas. At 0917:53, the Cessna pilot was cleared to climb and maintain 5,000 ft mean sea level (msl). At 0924:08, the Cessna pilot asked the air traffic controller, “… confirm you wanted me at five thousand opposite direction traffic.” The controller replied that he wanted the Cessna to remain at 5,000 ft msl, but to expect a higher altitude soon. According to ADS-B track data, between 0925:31 and 0925:34, the Cessna departed level flight at 5,000 ft msl and entered a rapidly increasing descent. At 0925:34, the final recorded ADS-B track data was at 4,725 ft msl and about 0.5 mile northeast of the Cessna’s main wreckage site. As of the final recorded ADS-B track point, the Cessna was descending about 8,960 feet per minute. The powered paraglider was not equipped with a transponder or an ADS-B OUT transmitter and, as such, the powered paraglider’s position was not displayed on the air traffic controller’s display. Postaccident review of available radar data revealed sporadic primary returns near where the Cessna departed level flight and ADS-B data was lost. However, these primary returns were not displayed on the controller’s display and did not have a reported altitude. The powered paraglider operator was using a video camera that captured the final 7 minutes 13 seconds of the flight. The recovered camera footage included a field of view that captured almost the entirety of the paraglider operator, the paraglider rigging, and the paraglider wing. The recovered audio track did not align with the video footage and was subsequently determined not relevant to the investigation. Review of the camera footage revealed no anomalies with the operation of the powered paraglider until the final 8 seconds of the flight. At 7 minutes 6 seconds into the recording, the powered paraglider operator turned his head about 45° to the right in a manner consistent with his attention being quickly drawn to something to the right of the powered paraglider’s northerly flight path. Based on the powered paraglider operator’s head movements, his attention remained to the right of his position during the final 8 seconds of the flight. About 6 seconds before the collision, with his head still turned toward the right, the powered paraglider operator pulled the left control toggle and turned toward a northwest heading. The profile of a high-wing airplane, later discernible as a Cessna 208B, emerged slightly above the horizon and to the right of the powered paraglider. About 3 seconds before the collision, with his head still sharply turned to the right, the powered paraglider operator aggressively pulled down on both control toggles. About 1 second before the collision, with his head still sharply turned to the right, the powered paraglider operator relieved the downward pressure on the left control toggle and sharply pulled down on the right control toggle to enter a right turn. The Cessna remained in level flight with no apparent change in roll or heading. In the final moments of the video, the powered paraglider remained in a steep right turn with the operator’s body slung up and to the left with respect to the paraglider’s wing. The powered paraglider operator’s head position remained sharply to the right as the Cessna converged with the powered paraglider. The final recovered frame of video showed the powered paraglider in a steep right bank, the powered paraglider operator’s head rotated about 45° to the right, and his hands on their respective control toggle. The Cessna’s right-wing leading edge, outboard of the right-wing lift strut attachment point, appeared to be inline with the body of the powered paraglider operator. The flight path of the Cessna appeared to be straight and level with no change in roll or heading. - Cessna Pilot The Cessna pilot’s last aviation medical examination was completed on June 14, 2021. At that time, he reported no medication use. He reported a history of anxiety due to legal issues and family stress, and a 2008 court-martial with dishonorable discharge from the Air Force. He had used the antidepressant/sleep aid medication trazodone for a short time in 2008 and was issued a FAA Letter of Eligibility for medical certification for his anxiety and legal issues in 2011. No significant issues were identified at the Cessna pilot’s last aviation medical examination, and he was issued a first-class medical certificate without limitation. An autopsy of the Cessna pilot was performed by Fort Bend County Medical Examiner Office. The autopsy report was reviewed by a National Transportation Safety Board (NTSB) Medical Officer. According to the autopsy report, the cause of death was multiple blunt force trauma, and the manner of death was accident. The ability of the autopsy examination to evaluate for natural disease was extremely limited by the extent of traumatic injury. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the Cessna pilot. The prescription antipsychotic medication quetiapine was detected in muscle tissue. Ethanol was detected in one muscle specimen at 0.022 g/dL but was not detected in another muscle specimen. No blood was available for FAA testing. Quetiapine, sometimes marketed as Seroquel, is a prescription antipsychotic medication. In the United States, quetiapine is approved by the Food and Drug Administration (FDA) for treating schizophrenia. Quetiapine is also FDA-approved for treating acute episodes of mania and depression in bipolar disorder, and as part of chronic multi-drug treatment of bipolar disorder. Additionally, quetiapine is approved as part of multi-drug treatment of major depressive disorder. Quetiapine is regularly prescribed for off-label (non-FDA-approved) uses, including in low doses for treatment of insomnia without underlying psychiatric illness. Some other possible off-label uses include chronic single-drug treatment of bipolar disorder, as well as treatment of post-traumatic stress disorder and anxiety. Quetiapine commonly causes drowsiness, especially in the initial days after starting a treatment regimen. This is a result of the drug’s sedating antihistamine effects, to which users may develop tolerance over time. Quetiapine also has multiple other potential adverse side effects. The drug typically carries a warning that it has the potential to impair judgment, thinking, and motor skills, and that users should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle or hazardous machinery, until they are reasonably certain that the drug does not affect them adversely. The FAA considers quetiapine to be a “do not issue/do not fly” medication. According to the FAA medical case review for this accident, quetiapine is unacceptable for FAA medical certification because of the underlying conditions it is used to treat. In addition to being used medicinally, quetiapine has emerged as a potential drug of misuse and abuse. Commonly, abuse of quetiapine involves its use in combination with recreational substances such as cocaine, marijuana, alcohol, benzodiazepines, or opioids. Users may seek to enhance those substances’ desired effects or to self medicate for undesired symptoms caused by substance use or withdrawal. Some people may abuse quetiapine seeking effects of hypnosis or euphoria, although the drug’s ability to produce a pleasurable “high” in the absence of other recreational drugs is not clear. People also sometimes misuse or abuse quetiapine seeking relief from anxiety or insomnia. A review of the Cessna pilot’s primary care medical records from a period of 3 years before the crash date did not document any use of quetiapine, the presence of any psychiatric disorder, or any history of substance abuse. Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. However, consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury and can cause an affected toxicological specimen to test positive for ethanol while another specimen from the same person tests negative. Powered Paraglider Operator An autopsy of the powered paraglider operator was performed by Fort Bend County Medical Examiner Office. The autopsy report was reviewed by a NTSB Medical Officer. According to the autopsy report, the powered paraglider operator’s cause of death was blunt force injuries, and his manner of death was accident. The autopsy did not identify any significant natural disease. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the powered paraglider operator, which did not detect any ethanol or tested-for drugs. - Based on the video footage recovered from the powered paraglider, visual meteorological conditions prevailed with no clouds or visibility restrictions. At the time of the accident, the sun’s position relative to the accident site was to the southeast (137° true) and was about 22.3° above the horizon. - Inflight Collision Study Based on the video evidence, the Cessna approached the powered paraglider’s right side at an estimated 90° collision angle. Based on ADS-B data, the Cessna was traveling at 162 knots groundspeed before the collision with the powered paraglider. According to its manufacturer, the powered paraglider’s trim speed range was 21-27 knots. Therefore, the powered paraglider’s speed was estimated to be about 24 knots. Assuming a 90° collision angle, the closing speed between the Cessna and the powered paraglider was about 164 knots. As discussed previously, about 8 seconds before the collision, the powered paraglider operator suddenly turned his head to the right and continued to look in that direction until the collision with the Cessna. About 6 seconds before the collision, the powered paraglider operator began maneuvering the powered paraglider in a manner consistent with an attempt to avoid a collision with the converging Cessna. FAA Advisory Circular 90-48E, Pilot’s Role in Collision Avoidance, identifies the perceptual, cognitive, and psychomotor steps required for collision avoidance and provides a time approximation for each step. This breakdown indicates that about 12.5 seconds can be expected to elapse between the time that a pilot sees a conflicting aircraft and the time an avoidance maneuver begins, as depicted in table 1. Table 1. Time required for a pilot to see an object, recognize the potential for an inflight collision, and maneuver to avoid the inflight collision Under optimal viewing conditions, consisting of a static object exhibiting a high contrast with its background, normal visual acuity can be as small as 1 minute of arc (0.017°) to resolve a detail like a line or space; however, about 5 minutes of arc (0.083°) is required for an individual to recognize a simple shape such as a test letter “E”. From the powered paraglider operator’s view, about 8 seconds before the collision, the subtended visual angle of the Cessna’s 52 ft wingspan was about 1.35°. For comparison, a thumbnail held at arm’s length subtends a visual angle of about 1.5°. Research has demonstrated that visual acuity drops dramatically about 2° away from the center of fixation (an area known as the fovea), and that visual acuity is very poor in the peripheral field. Although the periphery is sensitive to motion, from the powered paraglider operator’s view, the Cessna would have had little apparent motion because the two aircraft were on a collision course. From the Cessna pilot’s field of view, the powered paraglider would have appeared vertically centered and about 8.4° left of center. Based on the video evidence, the airplane’s windscreen center post did not obstruct the pilot’s view of the powered paraglider. Additionally, despite the powered paraglider’s position near the center of his field of view, the Cessna pilot did not attempt to maneuver his airplane to avoid a collision with the powered paraglider. The powered paraglider’s wing was its largest component. The Cessna pilot’s view of the powered paraglider was from the side; therefore, the powered paraglider’s wing chord, measuring about 7 ft, was the widest visible dimension. From the Cessna’s pilot view, about 17.5 seconds before the collision, the subtended angle of the powered paraglider’s wing chord was 0.083°. Similarly, at 12.5 seconds before the collision, the subtended angle of the power paraglider’s wing chord was 0.116°. Based on the video evidence, the powered paraglider was superimposed on a horizon containing terrain features creating a complex background. Research indicates that the minimum subtended angle required for recognizing an uncommon shape in a field of distractor items is 0.20°. Using this criterion, the powered paraglider would have been recognizable about 7.4 seconds before collision. Visual contrast is another consideration for estimating recognition time. The powered paraglider wing was white and blue, with orange wingtips. The wing was likely superimposed on or adjacent to (just below) a bright blue sky. The paraglider operator, who was suspended below the powered paraglider wing, was wearing a dark brown or olive-colored flight suit and was superimposed on or adjacent to the terrain, which was a patchwork of brown and green colors. Research indicates that the minimum subtended angle for recognizing a complex, low-contrast target is about 0.4° to 0.6°. Using this criterion, from the Cessna pilot’s view, the powered paraglider’s wing chord would have been recognizable 2-3 seconds before the collision. Limitations of Visual Scanning As previously discussed, visual acuity is dramatically lower more than 2° away from the center of fixation. To compensate for the small foveal area, the FAA recommends pilots make separate fixations on different portions of their visual field, no less than 10° apart, and devote at least one second to each fixation. However, as highlighted by an Australian Transport Safety Bureau (ATSB) study, a pilot using this strategy would need 54 seconds to systematically scan an area 180° wide and 30° tall. By the time a pilot completed such a scan, the scene could have changed, and they would need to start over, causing the ATSB to conclude that the systematic use of this strategy is impractical. In a separate study that used a mathematical model of optimum scanning techniques, it was determined that there was a 30% likelihood of detecting a 40-foot-wide aircraft with a 200 knot closing speed. Additional research indicates that pilots do not systematically scan their visual field; their visual scans are biased. Moreover, general aviation pilots may only spend 30-50% of their time scanning outside the cockpit. The authors of a study that examined data from actual flights utilizing an intruder aircraft determined an 85% probability that detection would occur with 12 or fewer seconds before a collision, given a closing speed of 120 knots. - An onsite examination revealed that the outboard 10 ft of the Cessna’s right wing separated following the impact with the powered paraglider. The separated section of the right wing was located about 0.6 mile east of the main wreckage site. There was a semicircular impact impression in the leading edge of the right wing outboard section that measured about 5 ft wide and about 36 inches deep. Fabric remnants resembling the powered paraglider operator’s jacket were found within the semicircular impression. The Cessna impacted terrain at high vertical speed in a steep nose-down and inverted attitude on a 332° magnetic heading. The Cessna wreckage was found highly fragmented in the 10-ft-deep impact crater. Flight control continuity could not be established due to fragmentation and soil embedment; however, all flight control cable separations were consistent with tensile overload. The engine and propeller were located at the base of the impact crater. All three propeller blades had separated from the hub and exhibited leading edge gouging and chordwise scoring. Two of the propeller blades exhibited S-shape bending. The powered paraglider operator and the paraglider engine were found about 0.7 mile east-northeast of the Cessna’s main wreckage site. The powered paraglider operator had separated from his seat-style harness. The paraglider wing, harness, and emergency parachute were located about 3.9 miles south of the Cessna’s main wreckage site. The paraglider harness exhibited tearing and impact damage. The static and control lines remained intact and attached to the harness and wing. The paraglider wing remained intact with minor tearing of the lower wing surface. The emergency parachute was found deployed, intact, with no tearing or damage. -
Analysis
A Cessna 208B airplane collided with a powered paraglider during cruise flight at 5,000 feet mean sea level (msl) in Class E airspace. Based on video evidence, the powered paraglider operator impacted the Cessna’s right wing leading edge, outboard of the lift strut attachment point. The outboard 10 ft of the Cessna’s right wing separated during the collision. The Cessna impacted terrain at high vertical speed in a steep nose-down and inverted attitude. The powered paraglider operator was found separated from his seat style harness. The paraglider wing, harness, and emergency parachute were located about 3.9 miles south of the Cessna’s main wreckage site. Based on video evidence and automatic dependent surveillance-broadcast (ADS-B) data, the Cessna and the powered paraglider converged with a 90° collision angle and a closing speed of about 164 knots. About 8 seconds before the collision, the powered paraglider operator suddenly turned his head to the right and about 6 seconds before the collision, the powered paraglider maneuvered in a manner consistent with an attempt to avoid a collision with the converging Cessna. Research indicates that about 12.5 seconds can be expected to elapse between the time that a pilot sees a conflicting aircraft and the time an avoidance maneuver begins. Additionally, research suggests that general aviation pilots may only spend 30-50% of their time scanning outside the cockpit. About 8 seconds before the collision (when the powered paraglider operator’s head suddenly turned to the right), the Cessna would have appeared in the powered paraglider operator’s peripheral view, where research has demonstrated visual acuity is very poor. Additionally, there would have been little apparent motion because the Cessna and the powered paraglider were on a collision course. Under optimal viewing conditions, the powered paraglider may have been recognizable to the Cessna pilot about 17.5 seconds before the collision. However, despite the powered paraglider’s position near the center of his field of view, the Cessna pilot did not attempt to maneuver his airplane to avoid a collision. Further review of the video evidence revealed that the powered paraglider was superimposed on a horizon containing terrain features creating a complex background. Research suggests that the powered paraglider in a complex background may have been recognizable about 7.4 seconds before the collision. However, the limited visual contrast of the powered paraglider and its occupant against the background may have further reduced visual detection to 2-3 seconds before the collision. Thus, after considering all the known variables, it is likely that the Cessna pilot did not see the powered paraglider with sufficient time to avoid the collision. The Cessna was equipped with a transponder and an ADS-B OUT transmitter, which made the airplane visible to the air traffic control system. The operation of the powered paraglider in Class E airspace did not require two-way radio communication with air traffic control, the use of a transponder, or an ADS-B OUT transmitter and therefore was not visible to air traffic control. Neither the Cessna nor the powered paraglider were equipped with ADS-B IN technology, cockpit display of traffic information, or a traffic alerting system. Postmortem toxicological testing detected the prescription antipsychotic medication quetiapine, which is not approved by the Federal Aviation Administration (FAA), in the Cessna pilot’s muscle specimen but the test results did not provide sufficient basis for determining whether he was drowsy or otherwise impaired at the time of the collision (especially in the absence of any supporting details to suggest quetiapine use). Testing also detected ethanol at a low level (0.022 g/dL) in the Cessna pilot’s muscle specimen, but ethanol was not detected (less than 0.01 g/dL) in another muscle specimen. Based on the available results, some, or all of the small amount of detected ethanol may have been from postmortem production, and it is unlikely that ethanol effects contributed to the accident. The Cessna pilot likely did not have sufficient time to see and avoid the powered paraglider (regardless of whether he was impaired by the quetiapine) and, thus, it is unlikely the effects of quetiapine or an associated medical condition contributed to the accident.
Probable cause
The limitations of the see-and-avoid concept as a method for self-separation of aircraft, which resulted in an inflight collision. Contributing to the accident was the absence of collision avoidance technology on both aircraft.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
208
Amateur built
false
Engines
1 Turbo prop
Registration number
N1116N
Operator
Martinaire Aviation LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
208B0417
Damage level
Destroyed
Events
Findings

Vehicle 2

Aircraft category
Ultralight
Make
Dudek Paragliders
Model
Solo 21
Amateur built
false
Engines
1 Reciprocating
Registration number
Unregistered Ultralight
Second pilot present
false
Flight conducted under
Part 103: Ultralight
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
P-231031
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-27T22:17:10Z guid: 104432 uri: 104432 title: WPR22FA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104437/pdf description:
Unique identifier
104437
NTSB case number
WPR22FA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-22T18:39:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2022-01-03T21:29:46.075Z
Event type
Accident
Location
Show Low, Arizona
Airport
SHOW LOW RGNL (SOW)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
According to the FAA Airplane Flying Handbook (FAA-H-8083-3C): At the same gross weight, airplane configuration, CG location, power setting, and environmental conditions, a given airplane consistently stalls at the same indicated airspeed provided the airplane is at +1G (i.e., steady-state unaccelerated flight). However, the airplane can also stall at a higher indicated airspeed when the airplane is subject to an acceleration greater than +1G, such as when turning, pulling up, or other abrupt changes in flightpath. Stalls encountered any time the G-load exceeds +1G are called “accelerated maneuver stalls.” The accelerated stall would most frequently occur inadvertently during improperly executed turns, stall and spin recoveries, pullouts from steep dives, or when overshooting a base to final turn… Stalls that result from abrupt maneuvers tend to be more aggressive than unaccelerated, +1G stalls. Because they occur at higher-than-normal airspeeds or may occur at lower-than-anticipated pitch attitudes, they can surprise an inexperienced pilot…Failure to execute an immediate recovery may result in a spin or other departure from controlled flight. - SOW is a publicly owned, nontower-controlled airport with a reported field elevation of 6,415 ft mean sea level. The airport was equipped with two asphalt runways. Runway 22 was 3,938 ft long, 60 ft wide, and had a left traffic pattern. - On December 22, 2021, about 1639 mountain standard time, an experimental, amateur-built RV-6A airplane, N6000Z, was destroyed when it was involved in an accident near Show Low, Arizona. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. An airport employee reported that he saw two airplanes on final approach for landing; the airplane in front, a Cessna, was at a lower altitude than the accident airplane, which was descending toward the Cessna. The pilot of the Cessna was making radio calls on the airport’s common traffic advisory frequency. He did not hear any radio transmissions from the pilot of the other airplane (the accident airplane). The employee transmitted via radio that the two airplanes were about to collide, and the pilot of the Cessna aborted his landing and turned to the north. Shortly thereafter, the pilot of the accident airplane transmitted via radio that he was on the wrong frequency and aborted his landing to the north. The accident airplane continued its turn at low altitude and appeared to stall, immediately entering a “nosedive” toward the ground. Another witness reported that he also saw the two airplanes close to each other on final approach for landing, with the second airplane descending toward the first airplane. He then saw the first airplane turn north, and about five seconds later, the second airplane turned north. He saw the second airplane’s wing dip, and the airplane entered a nose-low descent toward the ground. The pilot of the Cessna reported that he did not see the accident airplane, and aborted his landing when he heard the transmission that there were two airplanes on final approach. - Based on the environmental conditions on the day of the accident, the density altitude at the accident site was estimated to be about 7,423 ft. - The private pilot held a rating for airplane single-engine land. His most recent Federal Aviation Administration (FAA) second-class airman medical certificate was issued on May 5, 2015, without limitations. The pilot reported on his application that he had accumulated 5 total hours of flight experience, with 5 hours in the previous 6 months since the examination. The pilot’s logbooks were not located during the investigation. - Examination of the accident site revealed that the airplane impacted terrain near the edge of a dry lakebed. The first point of impact displayed marks consistent with the wings and propeller hub in a near-vertical impact attitude. All major components of the airplane and most of the wreckage debris was contained within the main wreckage site. A post-impact fire consumed most of the airplane. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
Witnesses reported that a high-wing airplane and a low-wing airplane were on final approach for landing to the same runway, with the high-wing airplane ahead of and slightly below the low-wing airplane. An airport employee stated that the pilot of the high-wing airplane was making position reports over the airport’s common traffic advisory frequency (CTAF), but the pilot of the low-wing airplane was not. The employee transmitted via the CTAF that there were two airplanes on final approach, at which time the pilot of the high-wing airplane aborted the landing. That pilot reported that he never saw the other airplane. The pilot of the low-wing airplane (accident airplane) subsequently transmitted that he had been using the wrong radio frequency and aborted the landing approach, entering a right turn away from the runway at low altitude. Witnesses reported that, during the turn, the accident airplane entered a nose-low descent that continued until it impacted the ground. The airplane impacted terrain in a near-vertical, nose-down attitude. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on the available information, it is likely that the pilot exceeded the airplane’s critical angle of attack while maneuvering away from the runway during the aborted landing approach, which resulted in an aerodynamic stall and loss of control at an altitude too low for recovery. It is possible that the high-density altitude conditions and the distraction of looking for conflicting traffic may have contributed to the accident.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack following an aborted landing approach, which resulted in an aerodynamic stall and loss of control at an altitude too low for recovery.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
true
Engines
1 Reciprocating
Registration number
N6000Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24142
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-03T21:29:46Z guid: 104437 uri: 104437 title: CEN22LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104465/pdf description:
Unique identifier
104465
NTSB case number
CEN22LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-25T10:25:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-01-04T04:20:18.793Z
Event type
Accident
Location
Iron Mountain, Michigan
Airport
Ford Airport (IMT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On December 25, 2021, about 0825 central standard time, an experimental Lancair IV-TP, N994PT, was substantially damaged when it was involved in an accident near Iron Mountain, Michigan. The pilot and passenger sustained minor injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that he took off at a reduced winter takeoff power setting. Once airborne and established on a climb, he retracted the landing gear and flaps, added climb power in increments and input rate of climb (165 knots) on the autopilot and then noticed a generator control unit (GCU) annunciator display a failure. About the same time the pilot noticed the engine seemed quieter and the airspeed was decreasing. The pilot further increased the throttle lever, confirmed that the No. 1 fuel pump was switched on and the left fuel tank was selected, and then determined that the engine had shut down. The pilot lined up with a clearing in the trees to his left; however, the airplane struck a small tree on approach to the clearing. The contact with the tree separated about half the outboard section of the right wing. The airplane touched down in rough, snow-covered terrain and came to rest with the engine and engine mount separated from the firewall. The pilot and passenger exited the wreckage from the entry door. The pilot stated that due to challenging terrain and poor options for a forced landing site he did not perform any other emergency procedures such as turning the fuel pump off, pulling the condition lever to idle cut-off, or feathering the propeller. Photographs taken by law enforcement following the accident show the condition lever in an unlatched position towards the idle cut off detent. An onboard GPS and avionics unit captured data from the accident flight. Data showed that, at 0824:02 about 12 seconds after liftoff, torque and N1 (gas generator speed) reduced from 86.9% and 93.6% to 72.5% and 89%, respectively, with a simultaneous decrease in fuel flow (FF) from 62.2 gallons per hour (gph) to 53.7 gph and inter-turbine temperature (ITT) from 1114°F to 1011°F. About one second later indicated air speed (IAS) accelerated past 127 knots and the flap system indicated movement to a retracted position. At 0824:07 the autopilot was engaged and over the next 9 seconds heading (HDG) and IAS modes were selected, and IAS set to 165 knots. During this time the torque decreased and stabilized at 41.5% for several seconds with a concurrent decrease in N1 to 84.8%, FF to 40.3 gph and ITT to 900°F. At 0824:21 all parameters are consistent with an engine shutdown. Six seconds later, the GCU FAIL light (governor control unit) illuminated. During the last 22 seconds of the flight, the airplane turned 54° to the left and lost about 490 ft of altitude while slowing from 117 knots (kts) to 96 kts. During this time, the engine torque and N1 were 0% with propeller speed slowing to 1270 rpm. 0824:49 marked the last datapoint with the autopilot engaged, with the fuel pressure at 35.6 PSI and voltage at 24.9 volts. The Garmin G3X data was recovered from records with a resolution of 1 time per second (1 Hz). Based on Garmin data, the airplane had a recorded total fuel quantity of 118 gallons at the time of startup, consisting of 60 gallons in the left wing tank and 58 gals in the right wing tank. The last recorded data point indicated 57 gallons in the left tank and 60 gals in the right tank, totaling 117 gals. Fuel pressure was consistent from startup to the last record data point, varying from 30 to 35 psi. No data was able to be recovered from the turbine start limiting management system. Figure 1 Accident Sequence 1. 8:24:02 - Engine starts to spool back. 2. 8:24:03 - Flaps retracted. 3. 8:24:07 - Autopilot engaged. Pilot starts data input in to autopilot (IAS). 4. 8:24:16 - Data entry complete, desired IAS set to 165kts. 5. 8:24:20 - Engine is flamed out. 6. 8:24:27 – GCU FAIL illuminates 7. 8:24:49 – End of recording 8. Accident location Postaccident examination of the airframe fuel system did not reveal any anomalies that would have restricted fuel flow to the engine. The fuel filter located at the bottom of the header tank was impact damaged and the filter media was not recovered. Fuel lines were examined and found to be continuous with no anomalies or blockages noted. The fuel strainer was removed from the engine-driven fuel pump and examined; and some small particles of unknown origin were noted in the housing. The engine-driven fuel pump and fuel control unit (FCU) were removed for functional testing at an overhaul facility. External damage was noted to both units consistent with the impact sequence. A solenoid, throttle linkage arm, and condition lever rod were replaced with serviceable parts on the FCU, and hardware was replaced on the fuel pump. Both units were installed onto a test engine, and leak tests were normal. The FCU was bled, and the engine started and ran at a lower power setting. It was then shutdown and bled again. The engine was started a second time and operated at rated power with the fuel pump both on and off with no anomalies noted. The engine power was manipulated from low to high several times with no anomalies noted. The engine was shut down and the units were sent to the manufacturer for disassembly. Although internal wear to the engine-driven fuel pump was noted, the FCU was unremarkable, and no anomalies were detected that could have resulted in a loss of engine power. -
Analysis
The pilot reported that he took off at a reduced winter takeoff power setting. Once airborne and established on a climb, he retracted the landing gear and flaps, added climb power in increments, and then noticed a failure displayed on the generator control unit annunciator. About the same time, the pilot noticed the engine was quieter and the airspeed was decreasing. Onboard data indicated that, upon reaching 650 ft above ground level, about 50 seconds after the takeoff roll was initiated, the engine power reduced to idle with a simultaneous decrease in fuel flow. Several seconds later, a generator control unit failure warning illuminated, and the voltage began to slowly decrease, consistent with the generator turning off. The airplane continued to descend straight ahead and impacted trees and terrain about one nautical mile from the departure end of the runway. Both wings, the empennage, and the engine separated from the fuselage. Following the accident, the condition lever was in an aft position. The pilot stated that, due to the altitude at the time he identified the loss of engine power, he did not take any actions to feather the propeller or restart the engine. A postaccident examination of the engine and related systems revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The recorded engine data is consistent with a reduction in commanded engine power and ultimately an in-flight shutdown. While it is possible that the condition lever came back with the flap activation and was not noted by the pilot, investigators were not able to determine when or how the condition lever was moved aft.
Probable cause
The total loss of engine power after takeoff for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LANCAIR
Model
IV
Amateur built
true
Engines
1 Turbo prop
Registration number
N994PT
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
LIV-407
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-04T04:20:18Z guid: 104465 uri: 104465 title: ERA22FA095 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104442/pdf description:
Unique identifier
104442
NTSB case number
ERA22FA095
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-26T13:04:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-01-08T00:04:44.794Z
Event type
Accident
Location
Jacksonville, Florida
Airport
HERLONG RECREATIONAL (HEG)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On December 26, 2021, at 1104 eastern standard time, a Mooney M20J, N3707H, was substantially damaged when it was involved in an accident in Jacksonville, Florida. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.   According to ADS-B tracking data, the airplane departed the Herlong Recreational Airport (HEG), Jacksonville, Florida, about 1041 for a local flight to the north. The airplane returned to HEG and entered the left base leg of the traffic pattern for runway 25 about 1101. Review of an airport surveillance video recording revealed that the airplane entered a low approach to the runway about 50-100 ft above ground level (agl) with the landing gear extended but did not touch down. The groundspeeds recorded by the ADS-B data varied from about 50 to 56 knots during the low pass and departure until the recorded data ended. The airplane’s altitude was not available in the ADS-B data. The runway’s orientation was 245° true, and the wind reported near the time of the accident was from 260° true at 9 knots.   A witness located at the airport observed the airplane flying over the runway. When he first observed the airplane, it appeared to be flying “slowly” with a “very high angle of attack.” The nose of the airplane then lowered, and the noise of the engine rpm decreased slightly and momentarily, before increasing back to the same noise level. The engine sounded “normal” and “did not sputter, pop or falter at any time”; however, the airplane appeared to be “barely climbing.” When the airplane reached about ¾ of the way down the runway, the landing gear retracted, and the baggage door opened upward. The baggage door remained open and looked “like a sail” on top of the airplane. After the door opened, the airplane did not appear to climb any further. It “drifted or turned very slightly to the right” before the witness lost sight of it behind a tree line. The airplane was too far away from the airport surveillance video camera to see the condition of the baggage door.    A pilot in the HEG traffic pattern observed the airplane as it flew past the departure end of the runway. It appeared to be a “normal” departure along the extended runway centerline; however, when the airplane reached about 200-400 ft agl, the right wing dropped and the airplane “appeared to enter a spin.” The “attitude was almost vertical at this point” and the airplane continued “in this spin or spiral” until it impacted the ground. The pilot’s logbook was not located. He reported a total of 422 hours of flight experience during his last aviation medical examination on June 15, 2021. According to the airplane operating manual, the stall speeds were 55 knots with full flaps and landing gear extended, and 63 knots with the flaps and landing gear retracted. The conditions specified for these speeds were: maximum gross weight, forward center of gravity, power idle, and 0° bank angle. The baggage door was on the right side of the airplane, just aft of the wing trailing edge. It was hinged at its top and opened upward.   Examination of the accident scene revealed no debris path or ground scars in the vicinity of the wreckage. The airplane came to rest upright in a grass field, with the fuselage oriented on a heading of 287° true, about ½ nautical mile from the departure end of runway 25, and about 400 ft to the right of the extended runway centerline. The fuselage section from just forward of the horizontal stabilizer to the engine cowling was largely consumed by fire. Both wings remained largely intact, although both sustained leading edge crush damage and significant fire damage from the root area to about the outboard edge of the flaps. The flap actuator jackscrew position was consistent with flaps extended to the 15° (takeoff) flap setting. Both ailerons remained attached, and flight control continuity was confirmed from the left aileron to the left-wing root area. Continuity from the right-wing root area was confirmed though the impact-damaged bell crank and an overload fracture of the push pull tube leading to the control horn. Continuity was established from the elevator and rudder control surfaces to the area of the rear seats. The fractured pitch trim torque tube was found in a position consistent with the trim at or near the “takeoff” setting. Remnants of the three landing gear were found in the retracted positions.   The baggage door piano hinge remained mostly intact and remained partially attached to its mount. About 2” of aluminum structure remained on either side of the hinge along most of its length. The forward ends of the aluminum sections were partially melted. The latching mechanism was found largely intact but fire damaged, with none of the door structure attached. The lock cylinder and exterior latch handle were not found; however, silver/grey molten metal remained on the center section of the assembly. Both engagement rods remained intact and attached to the assembly. The fuselage fittings that engage with the rod ends were not found.   The propeller hub remained attached to the engine crankshaft flange with the hub and spinner partially buried in soft, sandy soil. One propeller blade remained attached to the hub, above ground and undamaged, except for loose snap rings and shims in the hub. The other blade was separated from the hub and buried in the impact crater. It was bent slightly forward and exhibited abrasion of the paint along the length of the leading edge. Radial score marks, consistent with starter ring gear rotation, were present on the forward section of starter drive housing.   The engine crankshaft was rotated by hand at the propeller hub. The crankshaft rotated smoothly with no binding. Valvetrain and crankshaft continuity to the accessory section were confirmed, and thumb compression and suction was obtained on each cylinder. The oil suction screen was absent of debris. The oil filter was fire damaged, and the internal filter element was charred, with no metallic debris present. All spark plug electrodes were grey in color and appeared “worn – normal” when compared to a Champion Check-a-Plug chart. The single-drive dual magneto was found separated from the engine and fire damaged, which precluded testing. The engine-driven fuel pump was separated from the engine and partially melted, precluding testing. All four fuel injector nozzles were removed and found unobstructed. The turbocharger inlet and exhaust tubing were partially crushed; the shaft spun freely when rotated by hand, and no damage was found on the compressor or turbine blades.   The Office of the Medical Examiner, Jacksonville, Florida, performed an autopsy on the pilot. The cause of death was blunt impact trauma. Toxicology tests performed by NMS Labs at the request of the pathologist identified caffeine and amphetamine at 12 ng/ml in cavity blood. Toxicology testing performed by the Federal Aviation Administration’s Forensic Sciences Laboratory identified diphenhydramine at 21 ng/ml and amphetamine at 12 ng/ml in cavity blood and identified both in liver tissue. -
Analysis
The pilot departed on a local 20-minute flight before returning to the airport traffic pattern. After performing a low approach to the runway, the airplane began to climb slowly from an altitude of about 50-100 ft. While over the runway, just as the landing gear were raised, the baggage door fully opened. A witness reported that after the door opened, the airplane stopped climbing and began a slight turn to the right. Another witness reported that as the airplane was at an altitude of 200-400 ft, along the runway extended centerline, the right wing “dropped” and the airplane appeared to enter a spin, which continued until it impacted the ground. The airplane came to rest upright in a field, with no debris path or ground scars in the vicinity of the wreckage. It was partially consumed by a postcrash fire. Examination of the airplane revealed no preimpact anomalies that would have precluded normal operation. The witness descriptions as well as the lack of any lateral debris path or ground scars at the accident site were consistent with an aerodynamic stall/spin. Automatic dependent surveillance – broadcast (ADS-B) data indicated that as the airplane overflew the runway, its groundspeed varied between about 50 and 56 knots. The reported wind at the time of the accident was a headwind of 8-9 knots. These speeds are close to the airplane’s published stall speeds, which vary from about 55 to 63 knots, depending on flap and landing gear configuration. Based on this information, it is likely that the opening of the baggage door startled and/or distracted the pilot, drawing his attention away from maintaining the airspeed. The airplane then likely slowed, which led to a stall and subsequent spin. Toxicology results identified low levels of both amphetamine and diphenhydramine in the pilot’s cavity blood. The reason for the pilot’s use of amphetamine could not be determined from the available information; personal health records could not be obtained. Thus, whether he was at increased risk for distraction from an underlying attention deficit disorder is unknown and any effects from such a condition could not be determined. Given the low level of diphenhydramine in postmortem cavity blood, it is unlikely that any effects from his use of diphenhydramine contributed to the accident.
Probable cause
The pilot’s failure to maintain airspeed during initial climb, which resulted in an aerodynamic stall/spin. Contributing was the pilot’s likely distraction due to the opening of the baggage door.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20J
Amateur built
false
Engines
1 Reciprocating
Registration number
N3707H
Operator
STERLING SILVER FLYERS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-0907
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-08T00:04:44Z guid: 104442 uri: 104442 title: CEN22FA082 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104443/pdf description:
Unique identifier
104443
NTSB case number
CEN22FA082
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-26T19:29:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2021-12-29T10:13:03.499Z
Event type
Accident
Location
Hardy, Arkansas
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a "loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth." This document lists flight factors contributing to spatial disorientation: changes in angular acceleration, flight in IFR conditions, low-level flight over water, frequent transfer from VFR to IFR conditions, and unperceived changes in aircraft attitude. This document concludes with, "anytime there is low or no visual cue coming from outside of the aircraft, you are a candidate for spatial disorientation." The FAA's Airplane Flying Handbook, FAA-H-8083-3C, describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part: The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - The airplane was not equipped for instrument flight. The airplane was modified via an FAA-approved supplemental type certificate to utilize automotive gasoline. Investigators were not able to determine how much fuel was on board at the time of departure. The airplane’s maintenance records were not available for review. - On December 26, 2021, about 1729 central standard time, a Cessna 172E airplane, N5798T, was destroyed when it was involved in an accident near Hardy, Arkansas. The private pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of flight track data indicated that the airplane was airborne before it was visible on radar. The airplane first appeared about 13 nm north of the Walnut Ridge Regional Airport (ARG), Walnut Ridge, Arkansas, at 1627, at an altitude of about 2,500 ft. The airplane flew generally south toward ARG until track data was lost at about 1643, 3.5 nm north of ARG. The airplane’s track data reappeared at 1653, about 3 nm north of ARG, climbing from 2,800 ft. The airplane flew left and right several times in a back and forth “s-type" movement and then straightened out, flew west-north-west, and climbed to an altitude of about 4,500 ft, then descended lower in the latter part of the flight. While en route, the pilot contacted air traffic control and requested the weather at his destination airport along with the weather at additional airports. When queried, he stated he was over his destination airport. The pilot reported that he wanted to land because he had less than a quarter tank of fuel left, and he was going to continue flying west. The pilot then informed air traffic control that he was setting up to land at an alternate airport when radar contact was lost. At 1722, the airplane crossed over the Sharp County Regional Airport (CVK), Ash Flat, Arkansas, from east to west at an altitude of about 4,000 ft. When the airplane was almost 2.5 nm west-north-west of CVK, it turned right, descended slowly, and flew a track consistent with an attempt to make an approach to CVK. The airplane then entered a tight left turn and traveled to the north. During this time there were abrupt changes in ground speed, altitude, and the direction of flight. The airplane entered at least one sharp counterclockwise 360° turn and flew north-north-east until track data was lost about 1728. The Fulton County (Arkansas) Sheriff’s Office was provided copies of text messages the passenger sent to a family member while in flight. One text message stated, “ran into weather can’t see anything” and another text message later stated, “out of gas in air.” The airplane, which was located on heavily wooded private property in the Ozark mountains, was destroyed by the impact sequence. - An autopsy of the pilot was performed by the Arkansas State Crime Laboratory in Little Rock, Arkansas. The autopsy report was reviewed by the NTSB Investigator-In-Charge. The cause of death was multiple blunt force injuries - A search of archived ForeFlight information indicated that the pilot did have a ForeFlight account and could have looked at “live” weather data, but that data is not logged. The pilot did not request a weather briefing or review static weather imagery before the accident flight. A review of meteorological data showed that a warm frontal boundary was located over the area of the accident site, with small temperature-dew point spreads, allowing for abundant moisture for cloud, fog, and drizzle formation. An inversion with the inversion top near 5,000 ft mean sea level (msl) was over ARG and over the area of the accident site. In addition to the low instrument flight rules (LIFR) conditions, there were relatively strong wind conditions from the surface to 8,000 ft msl that would have led to low-level wind shear. As noted by pilot reports and the 1700 High-Resolution Rapid Refresh sounding, the cloud tops of the first layer of clouds were likely between 2,700 and 3,500 ft msl, with additional high clouds above that noted on the GOES-16 infrared imagery. An AIRman’s METeorological Information (AIRMET) Sierra for instrument flight rules (IFR) conditions was valid for the accident site at the accident time along with Center Weather Advisory 106, which forecast LIFR conditions. The freezing level was above 12,000 ft, which was above the accident flight’s flight level. The AIRMET for IFR conditions were noted on the Graphical Forecasts for Aviation, and were valid before the accident flight departed. A witness, located about 1 mile north of the accident site, reported that he observed “heavy fog” in the area at the time of the accident and he estimated the visibility to be about 500 ft. Astronomical conditions indicated the accident occurred right after the conclusion of civil twilight, which occurred at 1726. Sunset occurred at 1657. - According to Federal Aviation Administration (FAA) records, the pilot did not hold an instrument rating. The pilot’s logbook had an entry for a flight review; however, the date block was found empty. The entry was signed by the flight instructor on November 14, 2019. - The airplane came to rest in a heavily wooded area on private property. The area was composed of various deciduous trees about 50 ft tall and a collapsed and abandoned house (the house was collapsed before the accident). The airplane came to rest, nose down, and created a 6 ft deep by 6 ft wide impact crater. The engine and the propeller were buried in the dirt. There was no postimpact fire or evidence of an explosion. No smell of fuel was present, and no signs of fuel were observed in the wreckage. All major structural components of the airplane were accounted for, and the wreckage was confined to the immediate area around the impact crater. The airplane was destroyed. Several of the 50 ft trees had broken limbs; however, no trees appeared to have fallen due to an impact with the airplane. The damage to the various trees was consistent with a near-vertical descent through the trees that terminated in the ground. The accident site was at an elevation of 730 ft above msl. Flight control continuity was established from the control surfaces to inboard toward the cabin. Flight control continuity within the cabin could not be established due to the damage sustained. The left and right fuel tanks were both breached from the accident sequence. The right and left fuel tank caps were found open from the filler opening but remained connected with the chain lanyard. No signs of fuel were found in the fuel tanks. The insides of both tanks were examined, and no issues were noted. No major debris was found within the fuel system that would have inhibited fuel delivery from either tank. Airframe to engine control continuity could not be determined due to the impact damage. The cockpit area was destroyed along with the various instrumentation. The engine and engine accessories sustained impact damage. The propeller sustained impact damage that separated the hub and both propeller blades were found separated. The hub sustained several impact fractures. Chordwise scratching was observed on both blades. Examination of the airframe and the engine did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The non-instrument-rated private pilot was conducting a visual flight rules cross-country flight over mountainous terrain with a passenger in an airplane that was not equipped for instrument flight. There is no evidence that the pilot received a preflight weather briefing before the flight and the amount of fuel onboard the airplane at takeoff is unknown. While en route, the pilot contacted air traffic control and requested the weather at his destination airport along with the weather at additional airports. When queried, he stated he was over his destination airport. Instrument meteorological conditions prevailed at the destination airport at the time. The pilot reported that he wanted to land because he had less than a quarter tank of fuel left, and he was going to continue flying west. Weather conditions further to the west were showing visual meteorological conditions at the time. The pilot informed air traffic control that he was setting up to land at an alternate airport when radar contact was lost. Radar data showed the airplane was at an altitude of about 4,000 ft, about 2.5 nautical miles (nm) from the airport, when it turned right, descended slowly, and flew a track consistent with an attempt to make an approach. The airplane then entered a tight left turn and traveled to the north. During this time there were abrupt changes in ground speed, altitude, and the direction of flight. The airplane executed at least one sharp counterclockwise 360° turn before the data was lost. A review of meteorological data showed that low cloud ceilings, low visibility, and low-level windshear prevailed at the accident site. Based on the weather conditions and the flight track data, it is likely that the pilot encountered low cloud ceilings and low visibility conditions. The flight track data was consistent with the known effects of spatial disorientation. It is likely there were no outside visual references, the pilot had an increase in workload due to spatial disorientation, and he was unable to recover the airplane from its descent. The airplane impacted trees and terrain with a near-vertical descent angle. The airplane was destroyed. One text messages that the passenger sent to a family member while in flight stated, “ran into weather can’t see anything” and another text message later stated, “out of gas in air.” Examination of the airframe and the engine did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. There was no evidence of fuel at the accident site. The pilot had first reported to air traffic control that he had a low fuel status and then later reported that he had no fuel. The fuel exhaustion likely resulted in a loss of engine power; however, the pilot did not report this to air traffic control. It is likely that the pilot decided to continue visual flight into an area of instrument meteorological conditions due to his low fuel status. The low fuel status eventually resulted in fuel exhaustion and a subsequent loss of engine power. The pilot’s continued flight into instrument meteorological conditions resulted in spatial disorientation and a loss of airplane control.
Probable cause
The non-instrument rated pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation. Contributing to the accident was a loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N5798T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17251698
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2021-12-29T10:13:03Z guid: 104443 uri: 104443 title: CEN22LA085 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104451/pdf description:
Unique identifier
104451
NTSB case number
CEN22LA085
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-28T13:50:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-01-03T20:41:30.158Z
Event type
Accident
Location
West Helena, Arkansas
Airport
THOMPSON-ROBBINS (HEE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On December 28, 2021, about 1150 central standard time, a Beech A100 airplane, N93GT, was substantially damaged when it was involved in an accident near West Helena, Arkansas. The pilot and 4 passengers were not injured. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. The airplane had just been in maintenance on the day before the accident to troubleshoot a propeller feather issue. According to a work order, a mechanic found the low-pressure switch on the left engine to be inoperative, replaced the switch, and performed multiple ground runs and system tests. No further defects were found, and the airplane was returned to service. The pilot was briefed on the issue by maintenance. The pilot then flew the airplane solo from Batesville Regional Airport (PMU), Batesville, Mississippi, to Thompson-Robbins Airport (HEE), West Helena, Arkansas, on the morning of December 28, 2021. The pilot reported that there were no mechanical issues during the flight. The pilot arrived at HEE about 1040, and boarded 4 passengers for a flight to Camilla-Mitchell County Airport (CXU), Camilla, Georgia, and taxied the airplane to runway 18 at HEE for takeoff. Immediately after rotation, the pilot noticed that the engines were not producing normal thrust. He also stated that both propellers were going into feather. There was not enough runway remaining to land safely, so the pilot retracted the landing gear and searched for a suitable emergency landing area. The pilot was able to maneuver the airplane back to runway 18. With the combination of low altitude and insufficient thrust, the pilot was not able to slow the descent to the runway. Upon touchdown, the left tire blew, and the airplane skidded onto the grass adjacent to the runway, which resulted in substantial damage to the left wing’s spar. According to the pilot, he was aware of the emergency procedure for an unexpected propeller feathering. He stated that he was able to reduce power as required to keep the engine within the torque limits, but due to low altitude and heavy workload, he was unable to safely remove his hands from the controls to pull the propeller governor idle stop circuit breaker. An examination of the airplane was conducted on February 23, 2023. Examination of the cockpit control pedestal and feathering systems did not reveal any anomalies. All propeller condition lever controls were intact and had a full range of motion. Both left and right engine throttle controls were intact and had a full range of motion. Examination of all accessible wiring and components within the engine nacelles, as well as those contained within the cabin of the aircraft and rigging under the floor panels, revealed no anomalies. Examination of both engines’ propeller governors, FCUs, and beta valves did not reveal any anomalies. -
Analysis
The pilot reported that immediately after takeoff, both propeller assemblies went into a feathered condition. The pilot was able to maneuver the airplane back to a runway. After a hard landing, the left tire blew, the airplane exited the runway, and the airplane’s left wing sustained substantial damage. On the day before the accident flight, the airplane underwent maintenance to troubleshoot a propeller autofeather issue. A mechanic tested the autofeather system and replaced a low-pressure switch. After the maintenance, the mechanic conducted operational checks and performed ground runs; no defects were found. The airplane was returned to service, and the pilot flew the airplane the next day, before the accident flight, without any reported mechanical issues. Postaccident examinations of the cockpit control pedestal and feathering systems did not reveal any anomalies. All propeller condition lever controls were intact and had a full range of motion. Both left and right engine throttle controls were intact and had a full range of motion. Inspections of all accessible wiring and components within the engine nacelles, as well as those contained within the cabin of the aircraft and rigging under the floor panels, revealed no anomalies. Examination of both engines’ propeller governors, fuel control units (FCUs) and beta valves did not reveal any anomalies. These detailed examinations could not determine the reason for the reported propeller feather issue on takeoff.
Probable cause
The malfunction of the propeller autofeather system after takeoff for undetermined reasons, which resulted in both propellers going into feather and a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A100
Amateur built
false
Engines
2 Turbo prop
Registration number
N93GT
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
B-179
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-03T20:41:30Z guid: 104451 uri: 104451 title: ERA22FA096 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104453/pdf description:
Unique identifier
104453
NTSB case number
ERA22FA096
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-29T16:25:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-01-06T18:02:09.758Z
Event type
Accident
Location
Cosby, Tennessee
Airport
GATLINBURG-PIGEON FORGE (GKT)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
The helicopter was not certificated for flight in instrument meteorological conditions. - On December 29, 2021, at 1425 eastern standard time, a Robinson Helicopter Company R-44 II, N544SC, was substantially damaged when it was involved in an accident near Cosby, Tennessee. The commercial pilot received serious injuries and the passenger was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   According to personnel at Gatlinburg-Pigeon Forge Airport (GKT), Sevierville, Tennessee, the pilot and passenger traveled from Utah to pick up the helicopter after leasing it from the owner. They arrived at the service center where the helicopter had been stored about 0830 on the day of the accident. The pilot reviewed the lease agreement and conducted a local flight around the GKT airport traffic pattern to assess the helicopter per the lease agreement.   According to personnel at the service center, “the weather throughout the day was changing from marginal VFR conditions to IFR conditions.” The pilot had conversations with the service center employees about leaving the area but was cautioned by all of them he spoke with about the dangers of flying in the Smoky Mountains in marginal weather. One person showed him a book in their training room filled with controlled flight into terrain (CFIT) accidents that occurred in the area. The pilot’s response was “those are hills,” and informed him he had 14 years of experience of mountain flying. Additionally, a local helicopter air ambulance pilot who worked on the airport met the pilot and asked about his intentions. The pilot stated he planned on departing towards Asheville and was going to follow Interstate 40 (I-40) through the gorge to Raleigh, North Carolina, where he would visit relatives before heading back west. The other helicopter pilot told him that the mountains east of GKT were 6,000 ft and “there was no way he would make it there.” He also stated there were powerlines above the I-40 gorge.   About 1413, the pilot and passenger departed GKT eastbound. Federal Aviation Administration radar data showed the helicopter flying through the valleys in an easterly/southeasterly direction at altitudes between 1,200 ft and 1,750 ft. The data was not continuous along the route. A GoPro video camera was mounted inside the cockpit and was recording during the flight. The camera and its memory card were forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for examination and analysis. Automatic dependent surveillance-broadcast (ADS-B) data for the flight began about ½ nm east of the departure end of runway 10, at 1413:20. The video began at 1414:54, when the helicopter was already in flight. When the video began, there was rising terrain ahead of the helicopter, portions of which contained mountain top obscuration. The cloud layer appeared broken at the helicopter’s current position, with thickening ahead of the helicopter and up along the horizon. As the helicopter approached an area of low visibility and rising terrain, the helicopter continued in a gradual ascent. At 1424:34, the visibility started to greatly decrease. The helicopter’s groundspeed (and indicated airspeed) at first showed a decreasing trend. By 1424:48, the manifold pressure was reduced and the groundspeed and indicated airspeed decreased and reached a minimum of less than 20 knots. As the indicated airspeed reached a minimum, manifold pressure increased, the helicopter pitched forward, and airspeed increased slightly. Visible landmarks under the helicopter suggested it again had a forward component of speed. As the helicopter continued to fly forward, visibility decreased even further, eventually to “zero” at 1425:07. About the time this occurred, the manifold pressure went through the red arc range to a maximum of about 27 inHg (beyond the red arc range). The helicopter then pitched forward and airspeed rapidly increased to about 85 knots. During this time, the manifold pressure indicated steadily above the red arc (above 27 inHg). The helicopter then appeared to yaw rapidly to the right, the airspeed suddenly displayed “zero” knots, and the altitude decreased. The low rotor rpm warning light and aural warning alerted. The helicopter emerged from the cloud layer, first in a right roll and right yaw condition that quickly reversed to a left roll and left yaw condition. The helicopter then descended rapidly into a tree line, impacting the tops of the trees in a left yaw and level roll condition. As the helicopter descended into the tree line, the main rotor blades struck tree branches and tree trunks. Reflections in the windshield suggested the low rotor rpm light (yellow), and the low engine oil pressure light (red) illuminated during impact. The helicopter came to rest amongst the trees at ground level. There was no evidence in the recording that suggested that there were preimpact mechanical malfunctions or failures that would have precluded normal operation prior to the helicopter entering an extremely low visibility condition. Local law enforcement personnel interviewed the pilot after the accident. He stated that he did recall the accident. He further stated that he remembered losing oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see. - The pilot’s total flight experience was obtained from his latest Federal Aviation Administration first-class medical certificate application, dated 12/7/2021. A pilot logbook was found in the wreckage; however, it was water-damaged and partially illegible and a total flight time could not be determined. - The helicopter came to rest on a heading of 210°, on steep, wooded terrain. There was no fire. The cabin impacted the ground and was crushed forward with the tail boom raised behind the cabin. The tail rotor was separated and resting on the right side of the wreckage. Examination of the wreckage revealed all airframe, main rotor, tail rotor, and powerplant components were accounted for at the scene. The main and auxiliary fuel tanks remained attached to the fuselage. The auxiliary fuel tank was examined and appeared to be full. Fuel was collected from both tanks with no contamination noted. Flight control continuity was confirmed from all flight control surfaces to the flight controls in the cockpit.   The engine was examined and remained attached to the airframe with minor impact damage. The engine compartment was free of oil or fuel residue; there was no evidence of a loss of engine oil in flight. Both main rotor blades remained attached to the main rotor hub, and one blade was bent, but complete. The other blade was bent and impact-separated into three pieces. The majority of the blade was attached to the main rotor hub, with 3 ft of the tip separated in two sections: about 2.5 ft of blade material and the weighted tip. Both sections were located near the main wreckage to the north. After recovery of the wreckage to a salvage storage facility, the engine was examined in greater detail. The engine mount and structural tubing aft of the firewall were impact damaged. The engine-driven fuel pump overboard drain line fitting was impact-separated from the pump. The fuel strainer was impact damaged. The fuel strainer screen was absent of debris. The fuselage was suspended from a lift. The upper spark plugs were removed and the engine crankshaft was rotated by turning the cooling fan. Continuity of the crankshaft to the rear gears and to the valvetrain was confirmed. The interiors of the cylinders were viewed using a lighted borescope and no damage to the pistons or valves was noted. The fuel strainer was bypassed using locally-sourced hoses and fittings. An external fuel source was plumbed to the aircraft fuel system and serviced with aviation gasoline. An external battery was connected to the aircraft starter and to the airframe electric fuel pump. When the electric fuel pump was energized, fuel leaked around the fuel injector servo throttle shaft and the attempt to run the engine was abandoned. Closer examination of the throttle shaft revealed that it was bent consistent with contact with the aircraft firewall during the accident sequence. All of the spark plugs and the rocker covers were removed. The aircraft engine oil pressure gauge was energized using an external battery and the engine crankshaft was rotated by energizing the engine starter motor. The oil pressure gage indicated about 60 PSI. The fuel injector servo remained attached to the engine and was impact damaged. The servo was removed and partially disassembled. The rubber diaphragms were observed intact. The servo fuel inlet screen was unobstructed. The fuel flow divider remained attached to the engine. No damage was noted and it was not removed. The two-piece fuel injector nozzles were unobstructed. The engine-driven fuel pump remained attached to the engine. No damage was noted and it was not removed. Both magnetos remained attached to the engine and no damage was noted. Both were removed and each produced spark from all ignition towers when rotated by hand. The spark plug electrodes exhibited gray coloration and normal wear condition when compared to a Champion Check-A-Plug chart. The electrodes of the Nos. 2 top, 6 top, 2 bottom, 4 bottom and 6 bottom spark plugs were oil soaked. The engine oil dipstick indicated about 5 quarts of oil in the engine oil sump. No oil was observed on the exterior of the engine. The oil suction screen was absent of debris. The oil filter media was absent of metallic debris. Examination of the airframe and engine revealed no malfunctions or anomalies that would have precluded normal operation. -
Analysis
The pilot was preparing for a cross-country flight in the newly-leased, non-instrument flight rules (IFR) equipped helicopter. Per the lease agreement, he flew in the local traffic pattern to assess the helicopter without incident. The weather reportedly deteriorated during the day, changing from marginal visual flight rules (VFR) conditions to IFR conditions. Local personnel warned him of the hazards of flying through the Smoky Mountains in such conditions; however, the pilot responded, “those are hills” and he had 14 years of mountain flying experience. The pilot subsequently took off with his passenger toward mountainous terrain. On-board video captured most of the flight and all of the accident sequence, revealing that the pilot proceeded to the east, flying along valleys and roads, as the mountains ahead were obscured in low ceilings. The flight continued as the visibility eventually deteriorated to “zero” and the helicopter entered instrument meteorological conditions. The were no attempts to reverse course to get to better weather. The pilot eventually lost control of the helicopter and crashed into a tree line in a steep descent. The helicopter was substantially damaged, the pilot was seriously injured, and his passenger was fatally injured. The pilot would later report to law enforcement personnel that he remembered losing engine oil pressure and the main rotor began to make a loud noise, so he performed an autorotation; however, with the cloud cover, he could not see. Postaccident examination of the airframe and engine revealed no evidence of a malfunction or anomaly that would have precluded normal operation. There was no evidence of a loss of engine oil or oil pressure. The on-board video did not support the pilot’s claims of an inflight loss of oil pressure or a main rotor malfunction, nor did it indicate that an autorotation was performed.
Probable cause
The pilot’s intentional, continued flight into instrument meteorological conditions in a helicopter that was not certified for instrument conditions, which resulted in a loss of helicopter control and a collision with trees and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N544SC
Operator
Lyfted LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
10884
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-06T18:02:09Z guid: 104453 uri: 104453 title: ERA22LA097 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104454/pdf description:
Unique identifier
104454
NTSB case number
ERA22LA097
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-29T18:22:00Z
Publication date
2023-05-10T04:00:00Z
Report type
Final
Last updated
2021-12-30T07:03:19.718Z
Event type
Accident
Location
Marathon, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Factual narrative
On December 29, 2021, at 1622 eastern standard time, a Cessna 207 airplane, N1596U, sustained minor damage when it was involved in an accident in the Florida Bay near Marathon, Florida. The pilot sustained serious injuries and the two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on-demand air carrier flight. The flight was being operated by ExecAir of Naples at the time of the accident. According to the pilot, the first flight of the day was without incident from Naples Municipal Airport (APF), Naples, Florida, to The Florida Keys Marathon International Airport (MTH), Marathon, Florida. The accident occurred on the return flight to APF. The preflight, engine start-up, run-up, takeoff, and initial climb were uneventful, and the flight progressed on-course over the water. After the airplane reached about 3,800 ft mean sea level (msl), the airplane “began to shake and lose power.” The pilot observed normal engine instrument readings and saw that the oil pressure was “still good”; however, power was not restored despite checking and adjusting throttle, propeller, and mixture controls. The pilot established best glide airspeed, transmitted a mayday call, and turned back toward MTH. During the descent, she noticed that oil was leaking from the engine cowling area, and while descending through about 1,000 ft msl, she realized that she would need to perform a forced ditching given the airplane’s distance from land. After landing in open water, the airplane remained upright, and the occupants egressed. Shortly after the accident, a passing recreational vessel rescued the occupants. The airplane was subsequently recovered from the water and examined by the National Transportation Safety Board (NTSB). A large fracture hole and loose internal engine components were observed at the top aft portion of the engine case, in the area of the No. 2 cylinder. The engine showed little sign of impact damage. Saltwater corrosion was present throughout the engine and its accessories, consistent with the engine being submerged in the ocean for multiple days while awaiting recovery. Figure 1 provides an overview of the engine damage. Figure 1: View of the engine damage originating at the No. 2 cylinder area. All six cylinders were examined with a borescope and no other damage was visible to the valves or pistons. The No. 2 cylinder connecting rod crankshaft end was found to be heavily fragmented and had broken into several pieces. Several fragments of the connecting rod were located in the oil pan and bearing material belonging to the No. 2 cylinder connecting rod attachment area was also located in the oil pan. The crankshaft journal for the No. 2 connecting rod and its oil transfer hole displayed wear marks, heat transfer, and deformation of the oil transfer hole. There was a small fragment of debris located in the oil transfer hole that was consistent in color to the fragmented bearing material located in the oil pan. This oil transfer hole displayed no other deformation or blockage at the other end of the oil entry hole. All other oil transfer holes along the entirety of the crankshaft appeared normal. The No. 2 connecting rod assembly and its bearing pieces, and bearings from the Nos. 1 and 3 connecting rods were sent to the NTSB Materials Laboratory for forensic examination. The examination found that the crankshaft end of the No. 2 connecting rod was tinted black, consistent with exposure to high heat during operation, and its bearing was thinned, fractured, and severely deformed with dark heat tinting. The bearing halves for the No. 3 connecting rod were darkened near the middle of the bearing around the circumference with displaced and smeared babbitt material observed on the interior surfaces. The bearing halves for the No. 1 connecting rod had a nominal appearance with no indication of abnormal wear or damage. Portions of the No. 2 connecting rod and its connecting rod bolts exhibited areas of substantial post-fracture damage; however, both components exhibited features consistent with fatigue. Figure 2 provides an overview of the crankshaft oil transfer hole at the No. 2 connecting rod/ bearing attachment area and an overview of the submitted components to the NTSB Materials Laboratory. Figure 2: View of the crankshaft oil transfer hole at the No. 2 connecting rod/ bearing attachment area and view of the No. 2 connecting rod and Nos. 1 and 3 connecting rod bearings. According to the maintenance records, the total airframe time was 13,496 hours, the engine total time since new was 3,728 hours, and the total time since major engine overhaul was 861 hours. The most recent engine overhaul occurred on December 10, 2014, and the engine was subsequently installed on the airplane January 20, 2016. Two recent maintenance events occurred shortly before the accident. On November 23, 2021, 7.1 hours before accident, the Nos. 2 and 6 cylinders were removed and replaced with new Superior Cylinders (P/N SA52006-A20P cylinder kits). The oil was also changed, and the left exhaust collector was removed and replaced with a new unit. According to the mechanic who performed the work, the No. 2 cylinder was replaced due to “excessive ring blow by.” The No. 6 cylinder was replaced due to an exhaust stud that had fractured during the work on the No. 2 cylinder, so instead of making repairs, the entire cylinder and left exhaust collector was replaced. On December 23, 2021, an overhauled propeller and propeller governor were reinstalled, 2.2 hours before the accident. The mechanic further reported that no oil contamination was observed during any of the recent work, with the exception of excessive carbon. No recent oil analysis had been performed on any oil sample. -
Analysis
Shortly after departure, the engine lost total power and the pilot was forced to ditch in open water; the occupants egressed and were subsequently rescued by a recreational vessel. Examination of the engine revealed a fracture hole near the No. 2 cylinder, which was likely the result of the No. 2 cylinder connecting rod fracturing in fatigue as a result of high heat and high stress associated with failure of the No. 2 bearing. The fatigue fracture displayed multiple origins consistent with relatively high cyclic stress, which likely occurred as excessive clearances developed between the bearing and the crankshaft journal. The No. 2 connecting rod bearing may have failed due to a material defect in the bearing itself or due to a disruption in the oil lubrication supply to the bearing/journal interface. Either situation can cause similar damage patterns to develop, including excessive heating and subsequent bearing failure.
Probable cause
A total loss of engine power due to the failure of the No. 2 bearing, which resulted in the No. 2 connecting rod failing due to fatigue, high heat, and stress.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
207
Amateur built
false
Engines
1 Reciprocating
Registration number
N1596U
Operator
ExecAir of Naples
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
20700196
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2021-12-30T07:03:19Z guid: 104454 uri: 104454 title: CEN22LA087 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104461/pdf description:
Unique identifier
104461
NTSB case number
CEN22LA087
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-30T17:14:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2021-12-31T08:19:31.628Z
Event type
Accident
Location
Golden, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On December 30, 2021, about 1514 central standard time, a J&J Ultralights Seawing, N285SW, was substantially damaged when it was involved in an accident near Golden, Missouri. The noncertificated pilot sustained fatal injuries. The aircraft was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A video of the accident showed that, after takeoff, the aircraft pitched up and banked left, then transitioned into a steep dive. After recovery toward level flight, the aircraft pitched up and banked left again. While in the second left turn, the aircraft entered a steep dive and impacted a house, which resulted in damage to both wings, fuselage and empennage. Engine noise was observed throughout the video until ground impact. Examination of the engine and airframe revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation. The pilot’s certificate was revoked on January 23, 2020, for his failure to report two suspensions of his driver’s license and a conviction for unlawful alcohol concentration. The pilot purchased the accident aircraft about 6 months before the accident, and he completed two introductory flights in a weight-shift control (WSC) aircraft that handled substantially differently than the accident aircraft. Family members of the pilot reported that the accident flight was the pilot’s first flight in the accident aircraft. The previous owner stated that the flight characteristics of the accident aircraft included a more abrupt stall than other WSC aircraft and a small "window" between cruise and stall speeds. He described the stall as a "parachute straight forward" type of maneuver that required a substantial amount of altitude for recovery. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory identified delta-9-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis, at 3.4 ng/ml in cavity blood and 2.3 ng/ml in urine; its inactive metabolite, carboxy-delta-9-THC, at 38.3 ng/ml in cavity blood and 321.4 ng/ml in urine; and its active metabolite, 11-hydroxy-delta-9-THC, was inconclusive in cavity blood and at 23.7 ng/ml in urine. -
Analysis
The noncertificated pilot departed on his first flight in his recently purchased weight-shift control (WSC) aircraft. After takeoff, the pilot made a steep left bank turn that included a rapid climb and descent. The pilot leveled the aircraft and made a second steep bank turn with a rapid climb, then the aircraft entered a dive and impacted a house. The wings, empennage, and fuselage sustained substantial damage. A postaccident examination revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation. The pilot completed two flights in a different WSC aircraft about 6 months before the accident. According to the previous owner, the accident aircraft stalled more abruptly than other WSC aircraft and a substantial amount of altitude was required to recover from a stall. Although toxicology testing indicated the pilot used cannabis at some point before the accident flight, the detected blood levels could not be used to infer the level of impairment. Based on the circumstances of the accident, the effect of cannabis usage was determined not to be a likely factor in the accident.
Probable cause
The noncertificated pilot’s failure to maintain aircraft control while aggressively maneuvering at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
J&J ULTRALIGHTS
Model
SEAWING
Amateur built
false
Engines
1 Reciprocating
Registration number
N285SW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
10001234582
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2021-12-31T08:19:31Z guid: 104461 uri: 104461 title: CEN22LA091 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104485/pdf description:
Unique identifier
104485
NTSB case number
CEN22LA091
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-30T17:50:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-01-06T21:48:51.71Z
Event type
Accident
Location
Presidio, Texas
Airport
PRESIDIO LELY INTL (PRS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 6 serious, 0 minor
Factual narrative
On December 30, 2021, at 1550 central standard time, a Piper PA-28-235 airplane, N8591W, was substantially damaged when it was involved in an accident near Presidio Lely International Airport (PRS), Presidio, Texas. The pilot and 5 passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The responding Federal Aviation Administration (FAA) inspector reported that the airplane had just departed from PRS and then impacted terrain about 600 yards northwest of the departure end of runway 35. The airplane came to rest upright and sustained substantial damage to both wings and the fuselage. The non-certificated pilot fled the scene and was not available during the investigation. The passengers were transported to medical facilities for treatment and did not provide any information for the investigation. Postaccident examination and photos of the airplane revealed that the airplane impacted the ground with a high pitch attitude and came to rest about 50 yards from the initial impact point. The fuel selector valve was positioned to the left wing tip fuel tank, and the tank did not contain any fuel. The left main fuel tank was breached due to impact damage and did not contain any fuel. The right main fuel tank and tip tank were intact and did not contain any fuel. The elevator trim position was found slightly up from neutral. The propeller sustained damage during the accident sequence and the blades exhibited S-bending, forward curled tips, and chordwise abrasions. The examination did not reveal any mechanical malfunctions or anomalies with the airplane that would have precluded normal operation. Local law enforcement stated to the FAA inspector that the total weight of the occupants and baggage was about 1,153 lbs. One passenger was seated in the right front seat, three passengers were in the rear seats, and one passenger was occupying the aft baggage compartment. Local law enforcement also provided a fuel receipt to the FAA inspector that showed the airplane had been fueled with 42.23 gallons of fuel about 2 hours before the accident flight. The fuel was purchased by the pilot at Winkler County Airport (INK), Wink, Texas, which was about 142 nm north-northeast of PRS. The estimated takeoff weight of the airplane was between 2,642 lbs and 2,775 lbs, and the maximum gross weight of the airplane was 2,900 lbs. The estimated center of gravity was between +93.89 and +93.94 inches aft of datum, which was aft of the allowable limit of +93.5 inches aft of datum. -
Analysis
The non-certificated pilot and 5 passengers intended to complete a personal flight. After takeoff, the airplane impacted the ground about 600 yards from the end of the runway. The airplane came to rest upright about 50 yards from the initial impact point. The pilot fled the scene and was not available during the investigation. The passengers were transported to medical facilities for treatment and did not provide any information for the investigation. Postaccident examination of the airplane revealed signs that the engine was producing power at the time of impact. There was no evidence of fuel in any of the fuel tanks or on the ground near the airplane, but one fuel tank was breached at the leading edge during the accident sequence. The examination did not reveal any preaccident mechanical malfunctions or anomalies that would have precluded normal operation. Local law enforcement stated that the total weight of the occupants was about 1,153 lbs. A fuel receipt showed that the airplane had been fueled with 42.23 gallons of fuel about 2 hours before the accident flight, at another airport about 142 nautical miles (nm) away. Due to the damage to the airplane, the investigation was unable to determine the amount of fuel onboard at the time of the accident. The estimated takeoff weight of the airplane was between 2,642 lbs and 2,775 lbs, and the maximum gross weight of the airplane was 2,900 lbs. The estimated center of gravity was between +93.89 and +93.94 inches aft of datum, which was aft of the allowable limit of +93.5 inches aft of datum. It is likely that the pilot did not complete a preflight weight and balance calculation, which would have determined that the center of gravity would have been aft of the allowable limits. The aft center of gravity would have reduced the longitudinal stability during the climb out.
Probable cause
The non-certificated pilot’s failure to perform a preflight weight and balance calculation and his decision to operate the airplane beyond the allowable center of gravity limitations, which resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N8591W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-10103
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-06T21:48:51Z guid: 104485 uri: 104485 title: ERA22FA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104462/pdf description:
Unique identifier
104462
NTSB case number
ERA22FA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-30T22:25:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-01-02T21:57:56.528Z
Event type
Accident
Location
Bronson, Florida
Weather conditions
Instrument Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On December 30, 2021, about 2025 eastern standard time, a Robinson R44 II, N442VB, was destroyed when it was involved in an accident near Bronson, Florida. The pilot and three passengers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot was not instrument rated and the helicopter was not certified for flight in instrument conditions. The pilot departed a private residence located in Bronson, Florida, about 2023, destined for his personal residence in Bell, Florida. According to automatic dependent surveillance-broadcast data provided by the Federal Aviation Administration, the helicopter departed about 2.5 miles south of the accident site. The helicopter flew northwest about 1.5 miles, then turned right and flew northeast for 1 mile. During the last .5 miles, the helicopter descended from 700 ft mean sea level (msl), to 350 ft msl, then climbed back up to 625 ft msl. The last data point showed the helicopter descending again at 550 ft msl. A witness at the residence from which the pilot departed stated that the pilot was checking the weather and wanted to depart soon. He stated that the pilot said the fog and visibility was getting “bad” and his initial route home did not look good, and they needed to take another route home. A witness, who was out walking her dog, stated that she heard a helicopter about 2025. She looked for the helicopter but could not see it because it was too dark outside, and she did not see any lights. Seconds later, she heard the helicopter crash and a “large fireball” light up the sky. METEOROLOGICAL INFORMATION Williston Municipal Airport (X60), Williston, Florida, was located about 10 miles east-southeast of the accident site. At 2035, recorded weather at X60 included calm wind, visibility of 7 statute miles, mist, scattered clouds at 500 ft agl, temperature of 21°C, dew point temperature of 20°C, altimeter setting of 30.08 inches of mercury. The NWS Weather Forecast Office (WFO) in Tampa Bay, Florida, issued the following “Update” section of an Area Forecast Discussion (AFD) at 1908. This was the last AFD issued from this WFO before the accident. UPDATE... Atmospheric conditions are very favorable for widespread radiational dense fog over land and advection fog over marine zones this evening, tonight and into Friday morning. An expanding area of low clouds and sea fog has already developed from Sarasota County through Tampa Bay and into portions of the Nature Coast with near zero visibility reported in Venice early this evening. Later this evening expected fog development to expand and become widespread and very dense overnight. Expect Dense Fog Advisories to be issued as fog impacts more areas into tonight. WRECKAGE AND IMPACT INFORMATION The accident site was located in a wooded area and the wreckage path was about 225 ft long. The helicopter was heavily fragmented and scattered along a debris path on a heading of about 360° magnetic. The right skid was embedded in the ground at a 42° angle. An 8-foot-long section of the main rotor blade was embedded in the ground about 3 ft deep. The engine was located about 225 ft north of the main impact point. The main rotor gearbox and sections of the main rotor blades were located about 175 feet northeast of the main impact point. The main rotor gearbox was forwarded to the manufacturer for further examination. The examination revealed that the damage to the gearbox was impact related and no preimpact anomalies were noted. Examination of the engine did not reveal any preimpact mechanical malfunctions. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed by the Office of the Medical Examiner, District 8, Gainesville, Florida. The autopsy report was reviewed by the NTSB Investigator-In-Charge. According to the autopsy report, the cause of death was injuries sustained in a helicopter crash, and the manner of death was accident. -
Analysis
The noninstrument-rated pilot departed into night conditions with three passengers. Flight track information indicated that the helicopter flew northwest at altitudes between about 350 and 700 ft before impacting wooded terrain about 2.5 miles from the departure point. The helicopter was heavily fragmented, and the wreckage path was about 225 ft long. The examination of the airframe and engine did not reveal any preimpact mechanical anomalies that would have precluded normal operation. Atmospheric conditions were favorable to the development of widespread, dense radiational fog in the area of the accident site during the time the helicopter departed. The pilot was aware of these conditions, as he stated to an individual before he departed that the fog and visibility were “bad,” and that he needed to find another way home. The helicopter was not certified for instrument flight. As the pilot maneuvered the helicopter into reduced visibility, night conditions, it is likely he could not see outside visual references. When there is a lack of outside visual references, the pilot would have to use his flight instruments to understand the helicopter’s position in space. Based on the automatic dependent surveillance-broadcast (ADS-B) data, the helicopter’s trajectory changed several times in that last .5 miles. It is likely that the pilot was not referencing his flight instruments or was experiencing the effects of spatial disorientation. Based on the available information, it is likely that the pilot became spatially disoriented and lost control of the helicopter after departing on a visual flight rules flight into reduced visibility, night conditions
Probable cause
A loss of control due to spatial disorientation as a result of the noninstrument-rated pilot’s improper decision to attempt a visual flight rules flight at night into an area of known reduced visibility due to fog.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N442VB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
14296
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-02T21:57:56Z guid: 104462 uri: 104462 title: WPR22FA073 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104482/pdf description:
Unique identifier
104482
NTSB case number
WPR22FA073
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2021-12-31T15:30:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-01-11T23:38:28.024Z
Event type
Accident
Location
Marana, Arizona
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The National Library of Medicine provides information and guidance in an article titled, “Physiology Of Spatial Orientation,” which states spatial disorientation, as described by Benson, occurs when “the pilot fails to sense correctly the position, motion, or attitude of his aircraft or of himself within the fixed coordinate system provided by the surface of the Earth and the gravitational vertical.” The FAA Civil Aeromedical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a “loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth.” Factors contributing to spatial disorientation include changes in acceleration, flight in IFR conditions, frequent transfer between visual flight rules and IFR conditions, and unperceived changes in aircraft attitude.    The FAA’s Airplane Flying Handbook (FAA-H-8083-3B) describes some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following:   The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - On December 31, 2021, about 1330 mountain standard time, a Mooney M20C, N6796N, was destroyed when it was involved in an accident near Marana, Arizona. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot's family reported that he had departed Marana Regional Airport (AVQ), Marana, Arizona, on December 31, 2021, with an intended destination of French Valley Airport (F70), Murrieta/Temecula, California. Flight Service was notified by concerned family that the pilot had not arrived at the French Valley Airport and was 5 hours overdue. The Federal Aviation Administration (FAA) issued an Alert Notice shortly after. The airplane wreckage was located by a search and rescue (SAR) air unit the morning of January 4, 2022. There are no known witnesses to the accident sequence. The flight track data provided by SAR started about 2 ½ miles northwest of AVQ at 1929:38. The flight track data showed the accident airplane on a northwest heading; however, the data contained only general headings with no altitudes. About 1943:43, the flight track data showed the airplane made a left turn and continued on a southwest heading. The data showed that at 1952:40 the airplane started a series of turns until radar contact was lost at 2004:52. An animation of the flight track data with a weather overlay was also provided by SAR. The animation showed the airplane enter an area of weather, then enter into several turns before contact was lost. - An autopsy of the pilot was performed by the Pinal County Sheriff’s Office in Florence, Arizona. The cause of death was multiple blunt force trauma. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory detected 1150 ng/g of methamphetamine in liver and 113 ng/g muscle. In addition, 150 ng/g of amphetamine (the primary metabolite of methamphetamine) was found in liver. Amphetamine was also identified in muscle. Methamphetamine is a Schedule II controlled substance and is available in low doses by prescription to treat ADHD, ADD, obesity, and narcolepsy. It is also readily available as a street drug. Symptoms of street use of methamphetamine follow a typical pattern. In the early phase, users experience euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, a heightened sense of well-being, stereotypes behavior, feelings of increased physical strength, and poor impulse control. In addition, the heart rate, blood pressure, and respiratory rate increase and they may have palpitations, dry mouth, abdominal cramps, twitching, dilated pupils, faster reaction times, and increased strength. As the initial effects wear off users commonly experience dysphoria, restlessness, agitation, and nervousness; they may experience paranoia, violence, aggression, a lack of coordination, delusions, psychosis, and drug craving. Title 14 CFR Section 91.17 (a) states, in part, that No person may act or attempt to act as a crewmember of a civil aircraft (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) while having an alcohol concentration of 0.040 gm/dL or greater in a blood or breath specimen. - The AVQ airport’s automated weather observation station reported that, at 1335 mountain standard time, the wind was from 080° at 8 knots, visibility of 10 statute miles, ceiling broken at 3,800 ft agl, overcast at 9,000 ft agl, temperature of 19°C, dew point of 10°C, and altimeter setting of 29.54 inches of mercury. The Ak-Chin Regional Airport (A39), Maricopa, Arizona, Automated Weather Observing System (AWOS), located about 19 miles north-northeast of the accident location, reported that, 1355 mountain standard time, the wind was from 350° at 11 knots, visibility of 2 statute miles, moderate rain, mist, scattered clouds at 600 feet agl, ceiling broken at 2,300 feet agl, overcast clouds at 2,900 feet agl, temperature 12° C, dew point of 12°C, and altimeter setting of 29.63 inches of mercury. The area forecast discussion information for the accident time indicated marginal visual flight rules (MVFR) and localized instrument flight rules (IFR) weather, with a slight chance of thunderstorms, rain, and gusty wind conditions. An Airmen’s Meteorological Information (AIRMET) SIERRA advisory for instrument flight rule (IFR) conditions called for mountain obscuration, moderate turbulence between flight level (FL) 180 and FL390 and moderate icing between the freezing level and FL200 were active for the accident location at the accident time. A High-Resolution Rapid Refresh (HRRR) model sounding near the accident site at 1300 identified cloudy conditions from about 3,700 to 11,200 ft msl. There were no air traffic control services provided to the pilot during the accident flight. It is unknown if the pilot obtained a preflight weather briefing. - At the time of the accident, the pilot had accumulated about 540 total hours of flight experience, of which 4.5 hours were in simulated instrument conditions. - Examination of the accident site revealed that the airplane impacted open desert terrain about 56 miles northwest of the Marana Regional Airport at an elevation of 2,162 ft msl. The wreckage debris path was about 960 ft in length, and oriented on a heading of about 308°. All major structural components were observed throughout the debris path. Figure 1: Aerial view of accident site. Flight control continuity was not established due to impact damage and multiple separations of the flight control cables throughout the entire airplane. Examination of the engine revealed no evidence of any preexisting anomalies that would have precluded normal operation. -
Analysis
The non-instrument-rated pilot departed into visual meteorological conditions (VMC) on a day cross-country flight. Concerned family members contacted flight service when the pilot was overdue at the destination airport. The wreckage was located 4 days later in dessert terrain about 56 miles from the departure airport. Flight track data indicated that after departure the airplane proceeded northwest toward the destination airport before it turned to the southwest. The airplane continued to the southwest, where it made a series of turns until radar contact was lost. Review of weather information near the accident location at the time of the accident indicated instrument meteorological conditions (IMC), including low ceilings and visibility, were most likely present at the time of the accident. It is unknown if the pilot obtained a preflight weather briefing. All major structural components of the airplane were located within the wreckage path. Postaccident examination of the airframe and engine revealed no evidence of any preexisting anomalies that would have precluded normal operation. Postmortem toxicology testing revealed varying levels of methamphetamine in the pilot’s liver and muscle tissue. The methamphetamine levels detected are consistent with the pilot’s use of methamphetamine before the flight. It is likely that the psychoactive effects from the pilot’s use of methamphetamine contributed to his decision to fly into conditions that he was not trained for. The non-instrument-rated pilot’s flight into IMC would have made airplane control by visual references difficult, especially while maneuvering. When there were no outside visual references, pilots must rely on use of flight instruments to understand their position in space. Based on the postaccident flight track data, the pilot made a series of turns that were inconsistent with his intended flight path and were likely the result of the pilot experiencing spatial disorientation. It is likely the pilot did not reference the flight instruments or was experiencing an increase in workload because of spatial disorientation, and did not recover the airplane from its descent.
Probable cause
The pilot’s loss of airplane control due to spatial disorientation after entering instrument meteorological conditions. Contributing to the accident was the pilot’s impairment due to use of methamphetamine before the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20C
Amateur built
false
Engines
1 Reciprocating
Registration number
N6796N
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
680099
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-11T23:38:28Z guid: 104482 uri: 104482 title: ERA22LA099 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104484/pdf description:
Unique identifier
104484
NTSB case number
ERA22LA099
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-01T14:11:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-01-14T00:17:59.879Z
Event type
Accident
Location
Southeast Arcadia, Florida
Airport
ARCADIA MUNI (X06)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On January 1, 2022, about 1211 eastern standard time, a Mooney M20C, N79396, was substantially damaged when it was involved in an accident near Arcadia Municipal Airport (X06), Arcadia, Florida. The private pilot and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he performed a preflight inspection before departing from Pilot Country Airport (X05), Brooksville, Florida, about 1100. He verified that the airplane had 19 gallons of fuel onboard, which he determined was sufficient to complete the 76.5-nautical mile flight (and have a 1-hour reserve) to X06, where he planned to purchase fuel. The pilot stated that the flight to X06 was uneventful until he turned onto final approach to land. He indicated that, with the fuel selector set to the right-wing tank while the airplane was at an altitude of 300 to 400 ft, the engine suddenly stopped producing power. The pilot reported that the fuel gauge showed about 4 gallons of fuel in the right tank and that the fuel boost pump was turned on. The pilot also reported that the carburetor ice temperature sensor indicated 60°F. The pilot stated that the airplane was unable to maintain altitude and that he landed in a field adjacent to the runway. The right wing and left horizontal stabilizer struck a tree, which resulted in substantial damage. The pilot reported a strong smell of fuel as he and the passenger were exiting the airplane. According to recovery personnel, both wing fuel tanks were breached from impact and contained no usable fuel. A test run of the engine found that the engine ran normally through all power settings. Postaccident examination of the engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. A review of the airplane’s fueling history revealed that the pilot last fueled the airplane with 41.8 gallons of 100 low-lead fuel 5 days before the accident. The airplane has a total usable fuel load of 52 gallons. The pilot stated that he had flown about 4 hours since last refueling the airplane. -
Analysis
The pilot reported that he was making a personal flight and that he would buy fuel after arriving at the destination airport. While on final approach to land, the engine suddenly stopped producing power. The pilot stated that the fuel gauge showed about 4 gallons of fuel in the right tank (the fuel selector was set to the right-wing tank) and that the fuel boost pump was turned on. The pilot stated that the airplane was unable to maintain altitude and that he performed a forced landing to a field, during which the right wing and fuselage were substantially damaged. Postaccident engine test runs found that the engine performed normally through all power settings. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Although the weather conditions at the time of the accident were conducive to the accumulation of carburetor icing at glide power, the pilot reported that the carburetor heat temperature gauge indicated 60°F. The pilot reported that he had flown about 4 hours since last refueling the airplane and that the airplane had 19 gallons of fuel for the flight. According to these numbers, the airplane would have burned about 8.0 to 8.5 gallons of fuel per hour. As such, the airplane would have had enough fuel to complete the 76.5-nautical mile flight. Because the airplane had sufficient fuel to complete the flight and no mechanical issues were identified that would have precluded normal operation, the reason for the loss of engine power could not be determined based on the available evidence for this accident.
Probable cause
The total loss of engine power for reasons that could not be determined based on the available evidence for this investigation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20C
Amateur built
false
Engines
1 Reciprocating
Registration number
N79396
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2932
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-14T00:17:59Z guid: 104484 uri: 104484 title: CEN22LA093 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104489/pdf description:
Unique identifier
104489
NTSB case number
CEN22LA093
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-02T12:40:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-01-06T21:18:10.708Z
Event type
Accident
Location
Montrose, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 2, 2022, about 1040 mountain standard time, a Zenith CH750, N750DP, was substantially damaged when it was involved in an accident near Montrose, Colorado. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, before taking off, he added 23 gallons of 92 octane, ethanolfree automotive gas to the fuel tanks. After the fuel settled, he checked the sump in the fuel tanks and observed no contamination or water in the fuel. About 30 minutes after departure and while in cruise flight at an altitude of about 10,500 ft mean sea level, the pilot observed the fuel pressure decrease from 44 to 39 pounds per square inch (psi). The fuel pressure then increased to 40 psi before decreasing to 0 psi as the engine speed decreased to 0 rpm. For about the next 3 to 5 minutes, the fuel pressure and engine speed fluctuated between a normal psi and rpm, respectively, and zero. The pilot activated the backup fuel pump with no effect noted. The pilot decided to execute a forced landing on top of a snow-covered plateau about 20 miles south of Montrose. During the landing, the nosewheel dug into the snow, causing the airplane to flip over, which resulted in substantial damage to both wings. During a postaccident examination, fuel was supplied to the airplane’s engine, which started without hesitation. After the engine warmed up, the throttle was increased, and the engine continued to run at almost full power. When the backup engine control unit was activated, the engine coughed and then quit. After the unit was turned off, the engine restarted, but the engine quit when the unit was turned back on again. The airplane was installed with a Dynon Skyview electronic device. The data retrieved from the device showed that, between about 1035 and 1037, the fuel flow rate decreased from 5.9 to about 5.0 gallons per hour with no other changes noted. About 1037, the engine rpm and fuel pressure both decreased to zero, returned to their original value, and then decreased back to zero. These fluctuations continued until the data ended about 1040:30. During this same timeframe, the fuel flow rate steadily decreased, the oil pressure fluctuated between about 60 and 75 psi, and the amperage fluctuated between about 5.7 and 9.5 amperes. -
Analysis
The pilot stated that, about 30 minutes after departure and while in cruise flight at an altitude of about 10,500 ft mean sea level, he observed the fuel pressure decrease from 44 to 39 pounds per square inch (psi), increase to 40 psi, and decreased to 0 psi as the engine speed decreased to 0 rpm. For about the next 3 to 5 minutes, the fuel pressure and RPMs fluctuated between normal and zero. He activated the backup fuel pump with no effect noted. The airplane sustained substantial damage to both wings during the forced landing. A postaccident examination revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Engine runs were performed with no anomalies noted that were consistent with the pilot’s statements and onboard recorded data. The onboard recorded data showed fluctuations in fuel pressure and intermittent operation of the engine consistent with the pilot’s statement. As a result, the reason for the partial loss of engine power could not be determined based on the available evidence for this investigation.
Probable cause
A partial loss of engine power for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
CH750
Amateur built
true
Engines
1 Reciprocating
Registration number
N750DP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7588
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-06T21:18:10Z guid: 104489 uri: 104489 title: CEN22LA102 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104535/pdf description:
Unique identifier
104535
NTSB case number
CEN22LA102
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-02T17:30:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-01-20T21:28:39.742Z
Event type
Accident
Location
Grand Forks, North Dakota
Airport
Grand Forks Int'l (GFK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 2, 2022, about 1530 central standard time, a Piper PA-24-250 airplane, N5844P, was substantially damaged when it was involved in an accident at the Grand Forks International Airport (GFK), Grand Forks, North Dakota. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the landing gear did not extend properly as he approached the intended destination airport. His attempts to extend the landing manually were not successful and he decided to divert to a tower-controlled airport. The tower controller subsequently confirmed that the landing gear appeared to be “a few inches down from the retracted position” but was not fully extended. The pilot noted that the airplane was equipped with an aftermarket engine cowling installation with an electrically actuated nose landing gear door system. Before using the emergency gear extension system, the door must be released. The door release lever installed in the cockpit extended about one-half inch before “heavy resistance” was felt. Consultation with a mechanic via the radio and further efforts to fully extend the landing gear were not successful. He executed an emergency gear-up landing. The airframe sustained damage to the lower fuselage during the landing. A postaccident examination of the landing gear system was performed by Federal Aviation Administration inspectors after the airplane was repositioned to a hangar at the airport. The landing motor jack screw corresponded to the retracted position at the time of the exam. Electrical power did not appear to be reaching the gear extension motor. When the nose landing gear doors were released (opened), the landing gear was able to be extended manually. Although the inspectors confirmed an anomaly with both the primary and secondary extension/retraction systems, they were not able to determine the exact source of the problem. -
Analysis
The pilot reported that the landing gear did not extend properly as he approached the intended destination airport. His attempts to extend the landing gear manually were not successful, and he decided to divert to a tower-controlled airport. The tower controller subsequently confirmed that the landing gear appeared to be “a few inches down from the retracted position” but was not fully extended. He ultimately executed an emergency gear-up landing. A postaccident examination of the landing gear system was performed after the airplane was repositioned to a hangar at the airport. The landing gear motor jack screw corresponded to the retracted position at the time of the exam. Electrical power did not appear to be reaching the gear extension motor. When the nose landing gear doors were released (opened), the landing gear was able to be extended manually. Although, the examination confirmed an anomaly with both the primary and secondary extension/retraction systems, it did not determine the exact problem.
Probable cause
Failure of the landing gear to properly extend before landing for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N5844P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
24-925
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-20T21:28:39Z guid: 104535 uri: 104535 title: CEN22LA097 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104508/pdf description:
Unique identifier
104508
NTSB case number
CEN22LA097
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-04T13:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-01-13T19:07:09.809Z
Event type
Accident
Location
Matagorda Island, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 4, 2022, about 1130 central standard time, an Aviat A-1B airplane, N188DS, was substantially damaged when it was involved in an accident on Matagorda Island, Texas. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and passenger departed about 1005 and proceeded to the northeast at a cruise altitude about 3,500 ft mean sea level. The pilot reported that he performed a precautionary landing for unspecified reasons to a beach. During the landing roll, the airplane veered left and collided with a sand dune. The fuselage and both wings sustained substantial damage. When reporting the accident to his insurance company, the pilot reported that he landed to take a picture. He did not report any mechanical malfunctions with the airplane. A postaccident photo of the airplane revealed that one propeller blade exhibited leading edge polishing; the other propeller blade was obscured. The airplane was not examined following the accident. -
Analysis
The pilot reported that he was performing a precautionary landing on a beach when the airplane veered left and impacted a sand dune, resulting in substantial damage. Following the accident, he reported to his insurance company that there were no mechanical malfunctions with the airplane and that he chose to land on the beach to take a photo. The airplane was not examined following the accident; however, the circumstances are consistent with the pilot’s loss of directional control during an off-airport landing.
Probable cause
The pilot’s loss of directional control during an intentional off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N188DS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2326
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-13T19:07:09Z guid: 104508 uri: 104508 title: HMD22LR001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104503/pdf description:
Unique identifier
104503
NTSB case number
HMD22LR001
Transportation mode
Hazmat
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-08T11:53:00Z
Publication date
2023-10-13T04:00:00Z
Report type
Final
Last updated
2023-09-27T04:00:00Z
Event type
Accident
Location
Oklaunion, Texas
Injuries
0 fatal, 0 serious, 0 minor
Chemical released
Alcohols, n.o.s. (denatured ethanol)
Hazard class
Flammable Liquid
Hazardous material operator
BNSF Railway
State of material
Liquid
Container type
tank car
Department of Transportation container specifications
DOT-117J100W
Probable cause
Will not be determined by NTSB due to the limited investigation for tank car performance.
Has safety recommendations
true

Vehicle 1

Findings
creator: NTSB last-modified: 2023-09-27T04:00:00Z guid: 104503 uri: 104503 title: CEN22LA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104509/pdf description:
Unique identifier
104509
NTSB case number
CEN22LA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-08T17:30:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-02-07T22:47:16.601Z
Event type
Accident
Location
Youngstown, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 8, 2022, about 1530 eastern standard time, a Cessna 172G airplane, N3964L, was substantially damaged when it was involved in an accident near Youngstown, Ohio. The private pilot and two passengers sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. The airplane was modified with a Federal Aviation Administration (FAA)-approved supplemental type certificate to utilize automotive fuel (commonly called “MOGAS”), which the pilot used to fuel the airplane before the accident flight. Before the flight began, the pilot reported there was 7 gallons in the right fuel tank and less than 2 gallons in the left fuel tank, as he checked the fuel levels with a sight gauge. The pilot added 3.8 gallons of fuel to the left fuel tank. The right fuel gauge indicated “one quarter of a tank” and the left fuel gauge indicated “slightly less than half a tank.” The pilot reported the purpose of the flight was to verify the proper operation of a newly installed automatic dependent surveillance-broadcast system in the airplane. After the confirmation of accuracy, the pilot entered the downwind leg of the traffic pattern. At the midfield point, the pilot added 10° flaps and applied full carburetor heat. The engine then “stumbled and quit.” The pilot attempted to restart the engine to no avail. The pilot had the fuel tank selector in the BOTH position, and he reported he did not change its position at any time. The pilot increased the flaps to 40° and he executed a teardrop-style left turn to the runway. He reported he was below the tree line but was still too high to make a touchdown. The airplane “floated long” and landed on airport property beyond the runway into trees, at stall speed. The airplane came to rest with the left wing pointing down toward the ground and the right wing toward the sky. The three occupants were able to egress from the airplane without further incident. The airplane sustained substantial damage to the left wing and fuselage. Postaccident examination of the airplane found both fuel tanks intact, with no signs of a fuel leak on the airframe. About a quarter of a gallon of fuel was drained from the right fuel tank and about 4 gallons of fuel were drained from the left fuel tank. The fuel tank selector was found in the BOTH position. Airframe to engine control continuity was confirmed. An examination of the engine revealed no mechanical anomalies. A review of the meteorological conditions near the time of the accident, showed that the formation of carburetor icing was not likely for the usage of aviation gasoline. The FAA has published Advisory Circular (AC) 91-33A Use of Alternate Grades of Aviation Gasoline for Grade 80/87 and Use of Automotive Gasoline. This document discusses carburetor icing and states: FAA Technical Center testing indicates that carburetor icing will occur in less time and at higher ambient temperatures with automotive gasoline than with aviation gasoline. Therefore, pilots using automotive gasoline should be familiar with the induction system icing prevention procedures of the FAA AC 20-113 and be prepared to use these procedures at higher ambient temperatures and lower humidities than when using aviation gasolines. -
Analysis
The pilot reported he departed with 7 gallons of automotive fuel in the right fuel tank and 5.8 gallons of automotive fuel gallons in the left fuel tank and that he checked the fuel levels with a sight gauge. The right fuel gauge indicated “one quarter of a tank” and the left fuel gauge indicated “slightly less than half a tank.” After the completion of the local flight, the pilot entered the downwind leg of the traffic pattern. At the midfield point, the pilot added 10° flaps and applied full carburetor heat. The engine then “stumbled and quit.” The pilot attempted to restart the engine to no avail. The pilot had the fuel tank selector in the BOTH position. The pilot increased the flaps to 40° and executed a teardrop-style left turn to the runway. The airplane “floated long” and landed on airport property beyond the runway into trees, at stall speed. The airplane came to rest with the left wing pointing down toward the ground and the right wing toward the sky. The three occupants were able to egress from the airplane without further incident. The airplane sustained substantial damage to the left wing and fuselage. Postaccident examination of the airplane found both fuel tanks intact, with no signs of a fuel leak on the airframe. About a quarter of a gallon of fuel was drained from the right fuel tank and about four gallons of fuel was drained from the left fuel tank. The fuel tank selector was found in the BOTH position. Airframe to engine control continuity was confirmed. An examination of the engine revealed no mechanical anomalies. The reason for the loss of engine power could not be determined based on the available evidence. A review of the meteorological conditions near the time of the accident, showed that the formation of carburetor icing was not likely for the usage of aviation gasoline. However, the airplane was modified to use automotive gasoline, which the pilot used to fill the airplane with prior to the flight. References have stated that carburetor icing will occur in less time and at higher ambient temperatures with automotive gasoline than with aviation gasoline. Based on the available evidence, it could not be determined what, if any role, carburetor icing may have played in the accident.
Probable cause
A loss of engine power for reasons that could not be determined based on available information, which resulted in a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N3964L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
17254133
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-07T22:47:16Z guid: 104509 uri: 104509 title: CEN22FA096 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104504/pdf description:
Unique identifier
104504
NTSB case number
CEN22FA096
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-08T21:19:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-01-19T23:37:22.573Z
Event type
Accident
Location
Defiance, Missouri
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation FAA Publication "Spatial Disorientation Visual Illusions" (OK-11-1550) , states in part "false visual reference illusions may cause you to orient your aircraft in relation to a false horizon; these illusions are caused by flying over a banked cloud, night flying over featureless terrain with ground lights that are indistinguishable from a dark sky with stars, or night flying over a featureless terrain with a clearly defined pattern of ground lights and a dark starless sky." The publication further provides guidance on the prevention of spatial disorientation. One of the preventive measures was "when flying at night or in reduced visibility, use and rely on your flight instruments." It further states "if you experience a visual illusion during flight (most pilots do at one time or another), have confidence in your instruments and ignore all conflicting signals your body gives you. Accidents usually happen as a result of a pilot's indecision to rely on the instruments." AirNet II Spatial Disorientation Training The AirNet II training curriculum for the B58 included ground training, a minimum of six sessions in a Frasca fixed training device (FTD), and a minimum of five sessions in a B58. Of the six FTD sessions, five included “unusual attitude” maneuvers. Of the five sessions to be conducted in the B58, three included “unusual attitude” maneuvers. The maneuvers included a completion standard that a “pilot should be demonstrating proficiency to commercial PTS (practical test standards) during maneuvers.” The director of operations stated that in addition to the practical in the Frasca and the airplane, there was also a briefing session before the lesson and a debriefing session following the lesson for the instructor and student to discuss spatial disorientation and unusual attitudes. - The airplane was equipped with a “throw-over” type control column, which controlled the elevator and ailerons. To change the yoke from one side of the cockpit to the other, the pilots could pull a T-handle latch on the back of the control arm, then the yoke could be positioned as desired. An optional dual control column that was required for flight instruction existed but was not installed on the accident airplane. The flight instruments were located on the left side of the panel directly in front of the pilot's seat (see figure 2). Flight instrumentation included attitude and directional gyros, airspeed, altimeter, vertical speed, and turn coordinator. A magnetic compass was mounted above center of the instrument panel. Figure 2. Instrument panel similar to accident airplane (Note: dual yoke was not installed on the accident airplane) Vacuum pressure for the attitude gyro was supplied by two, engine-driven, dry pressure pumps interconnected to form a single system. The directional gyro was powered electrically. The airplane was equipped with a Bendix King KFC-200 flight control system (autopilot). The docket for this investigation contains information on the autopilot and its operation. - On January 8, 2022, about 1919 central standard time, a Beech B58 airplane, N585CK, was destroyed when it was involved in an accident near Defiance, Missouri. The two commercial pilots sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. About 1859, the accident flight contacted the air traffic control (ATC) ground controller at Spirit of St. Louis Airport (SUS), Chesterfield, Missouri, and received an instrument flight rules (IFR) clearance to Centennial Airport (APA), Denver, Colorado. About 1901, the ATC ground controller issued taxi instructions to runway 26L and about 1908, the flight received takeoff clearance and was instructed to turn right after takeoff to a heading of 310°. According to automatic dependent surveillance-broadcast (ADS-B) data, the airplane departed SUS at 1910. After leveling off at 8,000 ft mean sea level (msl) while on a westerly heading, the airplane made a gradual left turn toward the southeast. The airplane continued turning left and descended rapidly. The controller queried about the airplane’s incorrect altitude and direction of flight. A jumbled radio transmission was made by the copilot and no distress call was received. During the final 10 seconds of captured ADS-B data, the airplane descended from 7,500 to 4,700 ft msl. The airplane impacted forested terrain about 0.40-mile northwest of the last recorded ADS-B data (see figure 1). Two surveillance systems located less than 1 mile from the accident site recorded audio of an airplane with engine noise increasing and the ground impact. Figure 1. ADS-B Data and Impact Site - A warm frontal boundary existed at the accident site, with IFR conditions at SUS. Clouds likely extended from 1,000 ft above ground level through 10,500 ft msl over the accident site, based on satellite data and an upper air sounding. There were no non-convective or convective Significant Meteorological Information (SIGMET) advisories valid for the accident site at the accident time. Icing conditions were not present below 11,000 ft msl. An Airmen’s Meteorological Information (AIRMET) for IFR conditions was valid for the accident site at the accident time, as well as an AIRMET for low level wind shear. Strong low- and mid-level wind conditions existed in the area, with moderate turbulence likely at 8,000 ft msl. - According to the company chief pilot and director of operations, the copilot was qualified to operate as the pilot in command (PIC) on all Part 135 flights in the B58. The pilot had not obtained the required experience to operate as a PIC on Part 135 flights and was a PIC on Part 91 flights to gain the required experience. According to the operator’s documentation, both pilots were instrument current at the time of the accident. Federal Aviation Administration (FAA) personnel assigned to the accident conducted an interview with the boyfriend of the pilot on January 11, 2022. The boyfriend stated that the pilot had contacted him via text message on the night of the accident just before departure from SUS. She had reported to him that she “had concerns about this flight in particular due to the weather and her and the other pilot’s skill set.” Additionally, her concern was that the other pilot had not done a lot of IFR flight, and she was “not very confident in his IFR abilities.” Before employment with AirNet II, the flying experience of both pilots predominantly involved visual flight rules operations. - The airplane impacted into forested terrain (see figure 3). The debris path was on a westerly heading and highly fragmentary. Broken tree limbs indicated the airplane was in a steep descent with a left-wing-low attitude at impact. Figure 3. Overhead view of accident site All of the observed flight control cable separations exhibited signatures of tension overload. One flap actuator was recovered and appeared to be in the flaps retracted position. No signs of heat distress were observed on the cabin heater. Both three-blade propeller assemblies were highly fragmented. The propeller blades that were recovered at the accident site exhibited varying degrees of chordwise/rotational scoring, leading edge gouging, bending, and twisting. The cockpit was fractured with no intact flight instruments and no switch positions were identifiable. The vacuum powered attitude gyro rotor and housing, which were found outside of the instrument case, showed indications of rotation at impact. The electrically powered heading gyro rotor was found outside of the remote case and had indications of rotation at impact. No preaccident mechanical failures or malfunctions with the airplane were observed that would have precluded normal operation. -
Analysis
The commercial pilots departed during night, instrument conditions on a positioning flight. After leveling off at 8,000 ft mean sea level with moderate turbulence conditions likely, the airplane slowly turned left from a west to southeast heading. The airplane continued turning left and entered a rapid descent until terrain impact. The airplane was destroyed when it impacted terrain. Examination revealed no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Although the pilot and copilot were both instrument current, their flying experience predominantly involved visual flight rules operations. The pilot in command (PIC) did not have the required experience to operate as PIC on Part 135 flights and was the PIC of this Part 91 positioning flight to gain experience. Immediately before the accident flight, the pilot communicated to her boyfriend that she had concerns about the flight due to the weather, along with her and the copilot’s instrument flying skills. The pilot likely became spatially disoriented during night instrument conditions that included moderate turbulence. Because of the airplane’s single set of flight instruments and “throwover yoke” control column, which required pulling a T-handle latch on the back of the control arm to change the yoke from one side of the cockpit to the other, the copilot likely wasn’t able to assume control of the airplane. As a result, the copilot wasn’t able to recover control of the airplane from its unusual attitude before impact with terrain.
Probable cause
The pilot’s loss of airplane control while flying in night instrument conditions due to spatial disorientation and the flight crew’s inability to recover from an unusual airplane attitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
58
Amateur built
false
Engines
2 Reciprocating
Registration number
N585CK
Operator
Airnet II LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
TH-1299
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-01-19T23:37:22Z guid: 104504 uri: 104504 title: WPR22LA076 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104510/pdf description:
Unique identifier
104510
NTSB case number
WPR22LA076
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-09T16:09:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-01-20T04:16:58.718Z
Event type
Accident
Location
Los Angeles, California
Airport
WHITEMAN (WHP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On January 09, 2022, about 1409 Pacific standard time, a Cessna 172H, N8056L, was substantially damaged when it was involved in an accident near Los Angeles, California. The private pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the accident occurred during the airplane's first flight of the day. The airplane was stored outdoors for several weeks prior to the accident flight. During the pilot’s preflight airplane inspection, he observed water in the fuel tanks. He reported that he took a fuel sample from the left wing fuel tank, because he could see water in the tank through the filler port. He extracted about one ounce of water from the left tank and derived that, “there wasn't that much water in the fuel system.” The pilot reported that the airplane was fueled several weeks prior to the accident. He affirmed that the left wing fuel tank contained 2 gallons of 100LL and the right wing fuel tank contained 16 gallons of 100LL before starting the engine. He started the engine with the fuel selector in the BOTH tank position and ran the engine about 2 minutes, before he contacted the Whiteman Airport, Los Angeles, California (WHP) ground controller at 1404. He subsequently contacted the tower controller at 1406 to report holding short of runway 12 for departure. The pilot recalled that the flaps were set to 0° and the mixture was rich, but he could not recall if the airplane had a trim wheel. At 1408 the accident airplane was cleared for takeoff from runway 12, and the pilot taxied onto the active runway and applied full power initiating the takeoff roll. During the initial climb, about 200 ft, the engine lost power. He attempted to restart the engine by turning the ignition key to engage the starter, but the engine did not restart. At 1409 the pilot transmitted a May Day call to the tower controller and initiated a turn to the right. At 1410 the airplane impacted the ground and came to rest on an active railroad crossing. Moments later, bystanders extracted the pilot from the accident airplane, just before the airplane was struck by a Metrolink passenger train. Climatological observation records from the National Oceanic and Atmospheric Administration revealed that during the weeks leading up to the accident, rain was observed in and around WHP. The observation indicated that the presence of rain was detected a total of 18 days while the airplane was stored outdoors. Postaccident examination of the accident airframe revealed that the right wing tank fuel cap was present, but missing the silicone vent. The right fuel cap rubber gasket was hard to the touch, brittle, and portions of the outer gasket had deteriorated and were missing. The left wing tank fuel cap was present, but the rubber gasket was hard to the touch, brittle, and portions of the outer gasket had deteriorated and were missing. Continuity of the fuel system was observed from the left and right wing fuel tank inboard fuel pickups, through the fuel selector and gascolator using compressed air to verify volumetric flow. The gascolator was disassembled and revealed about 1 teaspoon of a white, granulated, corrosion substance. Internally, the gascolater bowl was pitted, and the filter screen revealed a vivid line of corrosion emanating from the top left to the bottom right, consistent with the accident airplane’s postimpact resting position. The presence of rust and the corroded substance were observed throughout the gascolator. The carburetor was disassembled and about ½ teaspoon of the corroded substance was extracted from the fuel inlet screen. Rust, and the corroded substance were observed throughout the carburetor. Postaccident examination of the airplane’s engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have prevented normal operation. -
Analysis
The pilot reported that the airplane was stored outdoors for several weeks before the accident flight. The pilot observed water in the left fuel tank during the preflight inspection and he extracted about 1 ounce of water before he derived that there wasn’t much water in the fuel system. He started the engine, taxied onto the runway, and took off to the southeast. During the initial climb, the engine lost power about 200 ft above ground level. The pilot declared an emergency to the tower controller and initiated a descending right turn. The airplane impacted the ground and came to rest on an active railroad crossing. The pilot was extracted from the accident airplane moments before it was struck by a passenger train. During the weeks prior to the accident, it had rained for 18 days. Postaccident examination of the airframe revealed that the right and left wing tank fuel cap gaskets were deteriorated and were not intact. Excessive quantities of corrosion and rust were observed throughout the gascolator and the carburetor. Postaccident examination of the airplane’s engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have prevented normal operation. It is likely that the deteriorated fuel caps allowed water to enter the fuel tanks when rain was present and that water remained in the airplane's fuel system after the pilot’s preflight inspection and engine runup. A total loss of power during the initial climbout likely occurred when the contaminated fuel reached the engine.
Probable cause
The pilot’s inadequate preflight inspection during which he failed to remove all water contamination in the fuel system, which resulted in a total loss of engine power on takeoff. Contributing to the accident was the condition of the fuel caps, which allowed the water to enter the fuel system.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172H
Amateur built
false
Engines
1 Reciprocating
Registration number
N8056L
Operator
MARK JENKINS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17256256
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-20T04:16:58Z guid: 104510 uri: 104510 title: ERA22LA104 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104516/pdf description:
Unique identifier
104516
NTSB case number
ERA22LA104
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-11T14:47:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-01-19T21:42:16.087Z
Event type
Accident
Location
Edisto Island, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 11, 2022, about 1247 eastern standard time (EST), a Piper, PA-32-300, N475RT, was substantially damaged when it was involved in an accident near Edisto Island, South Carolina. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner of the airplane, the first leg of the flight was uneventful. After landing at Columbus County Municipal Airport (CPC), Whiteville, North Carolina to get fuel, he resumed the flight to Florida. After departure, about 15 minutes into the flight, while cruising at 4,500 ft mean sea level, the engine started to sputter, then stopped, followed immediately by oil coming out of the engine cowling onto the windshield, partially limiting his field of view. Seeing no immediate landing location ahead of him, the pilot maintained 100 mph, turned 180° and declared an emergency. The pilot observed a straight road between two fields out of his side window and proceeded towards the area. After setting up for a short final to the road, he observed an electrified livestock fence on both sides of the road, but he was already committed for landing and was unable to avoid the fence. After touching down, both wings struck the fence. The airplane veered to the right traveled through the fence, and into a field for about 300 ft before coming to rest. The airplane came to rest upright. The right wing contained a large tear in the leading edge and the right landing gear collapsed. Closer examination of the engine revealed oil spray and a hole located on top of the No. 6 cylinder. The airplane was transported to a secured facility and the engine, and its components were subsequently examined. One propeller blade was twisted with its blade tip torn off. The other blade was bent aft about mid span. The propeller governor remained attached to the engine. The propeller governor gasket was found free of debris. All other components were free of preimpact or anomalous damage. All the spark plugs appeared slightly dark in color but were otherwise considered normal wear in accordance with the Champion Aviation Check-A-Plug chart. Two holes were found at the rear of the engine above the Nos. 5 and 6 connecting rods, exposing the camshaft. Crankshaft continuity could not be established because of internal damage that prevented movement. Upon disassembly, the Nos. 5 and 6 connecting rods were found broken at the connecting rod caps with no heat signatures present. One connecting rod cap bolt remained intact (bent) with visible threads and a missing nut. Both connecting rod caps were broken into pieces. Minor scoring was noted on the adjacent bearings and surfaces. The engine oil pump also showed minor scoring on the pump housing and there was ferrous material located in the pleats of the oil filter. The Nos. 5 and 6 piston crowns and cylinder head domes exhibited features consistent with detonation. The piston crowns were smooth and clean and had the appearance of being sandblasted with the compression and oil rings compressed into the ring walls. The internal retaining ring (circlip), washer, and roller were found separated from one of the counterweights. All of the internal retaining rings exhibited anomalous damage; their eyelets were broken off. One of the counterweight circlips had features consistent with fatigue and subsequent failure. The failed circlip corresponded to a counterweight roller that was ejected from the counterweight assembly. In addition, the No. 6 connecting rod showed evidence of fatigue failure in multiple areas. The areas showing fatigue were located on the main body of the rod and on the cap, along the bearing surfaces in the area where the connecting rod bolt joined them together, and where the I-beam of the rod transitioned to the bearing end of the rod. In addition, the Nos. 5 and 6 piston crowns, valve faces, and cylinder head domes were clean and free of combustion residue. The engine had accrued about 555 hours since overhaul by the manufacturer in 2011. -
Analysis
Shortly after takeoff the engine started to “sputter,” then stopped producing power; oil then blew out of the engine cowling onto the windshield. The pilot made a forced landing in a field and the airplane contacted a wire fence, resulting in substantial damage to the airframe. A postaccident inspection of the engine revealed that the engine crankcase was ruptured in two places near the Nos. 5 and 6 cylinders. Subsequent detailed examinations showed the Nos. 5 and 6 connecting rods were fractured and that a counterweight retaining ring (circlip) was missing its eyelets and had separated from the counterweight assembly. Additional metallurgical examination revealed that the counterweight retaining ring failed due to fatigue. The failure allowed the counterweight roller to eject from the counterweight. Additionally, the No. 6 connecting rod exhibited evidence of a fatigue failure in multiple locations and the Nos. 5 and 6 pistons showed evidence of detonation. It is likely that the fatigue failure of the retaining ring or the fatigue failure of the No. 6 connecting rod occurred and propagated throughout the engine until a catastrophic failure resulted. The failure sequence could not be determined, but it is likely that the piston detonation exacerbated the process.
Probable cause
A loss of engine power due to the fatigue failure of the crankshaft counterweight retaining ring and the No. 6 connecting rod.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N475RT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32-7540028
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-19T21:42:16Z guid: 104516 uri: 104516 title: ERA22FA105 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104517/pdf description:
Unique identifier
104517
NTSB case number
ERA22FA105
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-11T14:55:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-01-19T01:11:17.557Z
Event type
Accident
Location
Drexel Hill, Pennsylvania
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
For the helicopter's AFCS, SAS actuators provide short-term attitude hold and rate damping (stabilization) in the pitch, roll, and yaw axes. The SAS actuators have limited control authority of about 12% in the pitch axis, 14% in the roll axis, and 18.5% in the yaw axis, but can reach their control limit within seconds. The inputs by the SAS actuators are not transmitted to the cockpit cyclic control and pedals. The AFCS pitch and roll trim actuators provide long-term attitude hold in their respective axes as well as control of the helicopter when the autopilot upper modes are active. In contrast to the SAS actuators, the trim actuators have full control authority of the cockpit cyclic control in the pitch and roll axes, but their rate of movement is limited. A pilot can temporarily override the trim actuators by using the cyclic-mounted force trim release button or by forcefully pushing against the cyclic control. Lastly, the cyclic-mounted SAS/AP CUT button, which is inset to prevent unintended activation, will immediately disengage all AFCS functions, resulting in an unstabilized helicopter necessitating constant control inputs by the pilot to maintain attitude. - On January 11, 2022, about 1255 eastern standard time, a Eurocopter EC135 P2+, N531LN, was substantially damaged when it was involved in an accident in Drexel Hill, Pennsylvania. The airline transport pilot was seriously injured. The two medical crewmembers and the patient were not injured. The helicopter was operated by Air Methods Corporation as a Title Code of Federal Regulations Part 135 air ambulance flight. Automatic dependent surveillance - broadcast (ADS-B) data revealed that the helicopter departed Chambersburg Hospital Heliport (PA60) about 1205 and was destined for Children’s Hospital of Philadelphia Heliport (9PN2), Philadelphia, Pennsylvania. The track showed the helicopter in a cruise profile on an easterly track about 3,500 ft mean sea level (msl). About 1243, the helicopter descended and leveled about 2,800 ft msl, and then descended and leveled at 1,500 ft msl, tracking directly toward 9PN2. At 1253:11, the helicopter track depicted a series of heading and altitude excursions. The plots depicted altitudes between 1,700 ft msl and 1,250 ft msl before the target disappeared at 1253:17. In a written statement, a witness whose home was directly beneath the helicopter’s flight path said that he was an aviation enthusiast and was familiar with the many helicopters flying to and from area hospitals. He said that his attention was drawn to the accident helicopter because it was, “very low and louder than normal” and that the “tone” of the rotors was unfamiliar. According to the witness, the helicopter was “in a nose down attitude… far less than 1,000 ft above the ground… [and] rotating around its longitudinal axis.” A doorbell camera about 1 mile from the accident site, and approximately beneath the helicopter’s flight path, captured both audio and video of the helicopter’s initial descent from its cruise altitude. The sound could be heard before the helicopter entered the frame. The helicopter’s departure from controlled flight was not captured, as it was blocked by a porch awning on the front of the house. A high-pitched whine was heard, increasing in volume and pitch before the helicopter appeared beneath the awning above the camera in a near-vertical, nose-down descent. The helicopter’s angle of descent shallowed as it disappeared behind a tree line. The volume and pitch of the sound continued to increase for a time after the helicopter disappeared and before the sound ultimately faded. A second witness nearby said that he saw a helicopter, “very low…very loud…banked right and left out of control, then appeared to straighten…” before it disappeared from view. Brief video clips from open-source media outlets showed the helicopter upright, in a steep descent, exhibiting small but rapid changes in each axis (pitch, roll, yaw). Another home doorbell camera captured the last second of flight as the helicopter appeared level in the frame, in a slight nose-up attitude, as it impacted the ground, separating the tailboom, then disappeared from view. The pilot made himself available for interview, but the interview was postponed due to his medical condition. Subsequent conversations between the pilot and the Investigator-In-Charge over the months following the accident revealed that the pilot had no memory of the accident flight. In an interview with the operator during September 2023, the pilot recalled details of planning the flight, as he had not flown to 9PN2 “in a while.” He said that he was in cruise flight at 5,000 ft, then initiated a descent to “clear the first shelf of the airspace” surrounding Philadelphia. The pilot further stated, “I have no recollection of the initial incident. I remember being on the controls and fighting the aircraft in a dive…I realized the collective was fully up when the aircraft finally leveled off but the aircraft was still descending.” The pilot described assessing and rejecting multiple forced landing sites before selecting the point of touchdown. He said, “Since I didn’t think I had any collective left, I pointed towards the landing area and pulled aft cyclic during landing. This all happened in 15 seconds or less.” The flight nurse and flight medic were interviewed by a Federal Aviation Administration (FAA) aviation safety inspector. According to the flight medic, the flight was routine, and they were within 10 minutes of landing at 9PN2. He and the flight nurse were out of their seats treating the patient when a loud “bang” was heard, and the helicopter banked sharply right and continued into a right roll. The medic said that the helicopter rolled inverted, perhaps multiple times, and that he and the nurse were “pinned to the ceiling” and internal communication was lost. The helicopter was leveled, the patient was secured, the crewmembers secured themselves in their seats, and they braced for landing. Following the accident, the flight nurse evacuated the patient, and then evacuated the pilot while the medic shut down both engines. The nurse travelled with the patient while the medic travelled with the pilot to area hospitals. - The pilot held an airline transport pilot certificate with ratings for airplane multiengine land and rotorcraft-helicopter, with private pilot privileges for airplane single engine land. The pilot’s most recent second-class FAA medical certificate was issued on August 26, 2021.   The operator reported that the pilot had accrued 4,123 total hours of flight experience, of which 3,400 hours were in helicopters and 185 hours were in the accident helicopter make and model. - An EC135 P2+ simulator was used to determine the helicopter response to various scenarios involving abrupt disconnection of the AFCS during high-speed cruise flight without hands on the flight controls. These scenarios included disconnection of the autopilot, specifically the altitude hold and heading hold upper modes, as well as disconnection of the entirety of the AFCS, including all stabilization systems, using the “SAS/AP CUT” button on the cyclic grip. In all scenarios except those involving the SAS/AP CUT button, the helicopter remained stabilized. In scenarios involving the SAS/AP CUT button, the helicopter became unstabilized and required high pilot workload to regain control of the helicopter. When a dual engine control failure was introduced to these scenarios involving disconnection of the AFCS, the pilot workload to land the helicopter increased. The most difficult scenario for the simulator pilot involved a dual engine control failure coupled with a complete disconnection of the entirety of the AFCS using the SAS/AP CUT button. - Examination of the accident site revealed that the helicopter initially impacted the ground upright and came to rest on its left side next to a building on a heading of about 220°. All components of the helicopter were accounted for at the accident site. Examination of the main rotor, tail rotor, and their drive systems revealed no preimpact failures. Both freewheeling units exhibited normal functionality when manually moved in both drive and freewheeling directions. Both engines remained installed and their exhaust pipes exhibited impact deformation as well as thermal damage to the drain lines and cowlings adjacent to the exhaust pipes. Examination of both engines revealed no anomalous damage on all first stage compressor blades and all power turbine blades. Examination of the flight control system, including the automatic flight control system (AFCS), found no evidence of preimpact fractures, disconnections, or restrictions in their freedom of movement. Both collective-mounted engine twist grips remained in the normal fly position. Testing and disassembly examination of the main rotor actuators, fenestron actuator, and the hydraulic supply systems found no functional anomalies that precluded their normal operation. A piece of black-colored debris was observed captured within the No. 1 hydraulic filter (pre-filtration) and black-colored foreign material was adhered to the installation orifice for the No. 1 hydraulic filter (post-filtration). Spectroscopy of the black-colored debris and foreign material revealed peaks in carbon and oxygen. Similar debris and foreign material were not present elsewhere in the No. 1 hydraulic system or in the main rotor actuators. Testing of the smart electromechanical actuators (SEMA), the pitch and roll trim actuators, and various AFCS sensors resulted in no anomalous findings that would have precluded their normal operation. Fault and exceedance data were downloaded from the engine data collection units (DCU), the cockpit warning unit, the vehicle and engine multifunction display (VEMD), the caution and advisory display (CAD), and the two flight control display modules (FCDM). The No. 1 FCDM recorded no faults while the No. 2 FCDM recorded 11 faults for the accident flight. These faults all occurred between 48 minutes and 7.5 seconds to 48 minutes and 10 seconds into the accident flight and included various air data and flight display discrepancies, including a failure indicating that the No. 1 FCDM was not operating. The VEMD data showed the accident flight had a duration of about 50 minutes with 12 associated failure entries. Within the VEMD data, at 48 minutes and 8 seconds into the accident flight, there were exceedances in mast moment, rotor speed (Nr), and engine power turbine speed (Nf) while engine torque was at 0%. Additionally, at 49 minutes and 45 seconds into the accident flight, main transmission oil pressure was at 1.45 psi (0.1 bar). The warning unit data, which does not have timestamped data entries like the VEMD and DCU data, revealed three separate Nr excursions from normal (100%) to above 112%. Autopilot failure warnings were also recorded in the warning unit data. The recovered DCU data recorded engine time versus flight time, thus the DCU data entries could not be synchronized to the VEMD and FCDM data. The DCU data for each engine showed that during the accident flight, their respective Nf values recorded a peak of 126.79% at near-zero torque values. As a result of the Nf overspeeds, the DCU data showed that both engine control systems had, for their respective engine, reduced fuel flow to a minimum and subsequently reverted the engine control to manual mode. When an engine fuel control is in manual mode, the pilot is required to manipulate the respective engine twist grip, mounted on the collective control, to manually control fuel flow to that engine. If the engine twist grip remains in the normal fly position while the engine is in manual mode, the engine will continue to run at the last known fuel flow rate until the pilot intervenes by manipulating the engine twist grip. The last recorded parametric data line from the DCUs showed that, nearly 2 minutes after the Nf overspeed occurred, the engine gas generator speed (Ng) was between 23-29%, torque was at 0%, and Nf was at 0%. For additional details on the examination of the helicopter and its various components, see the Airworthiness Group Chair’s Factual Report in the docket. -
Analysis
Flight track data from the helicopter air ambulance flight indicated that, while in cruise flight at an altitude of about 1,500 ft mean sea level (msl), the helicopter departed normal cruise flight with an abrupt increase in altitude, followed by a dive. The recovered data from various sources onboard the helicopter did not contain information as to whether the helicopter rolled inverted during this altitude excursion, as recalled by the crewmembers. Surveillance video showed the helicopter in a near-vertical, nose-down, spiraling descent. The pilot arrested the rotation and recovered the helicopter from the dive but was unable to climb or hover due to insufficient engine power, thereby resulting in a hard landing to a city street and substantial damage to the helicopter. Examination of the helicopter revealed no evidence of malfunction that would result in an abrupt departure from cruise flight. Because of the limited control authority of the Stability Augmentation System (SAS) actuators, it is unlikely that a malfunction of a SAS actuator would have resulted in an inflight upset before the pilot could react to the malfunction. Additionally, a malfunction of a trim actuator would not result in an inflight upset as the pilot would notice an attitude deviation before the trim actuator, whose rate of movement is limited by design, would be able to move the helicopter into an unusual attitude. Data indicated that a main rotor system overspeed, which likely occurred during the dive maneuver, resulted in the overspeed of both engine power turbines due to the sudden reduction in load from the main rotor. As a result of the power turbine overspeed, both engine control systems, independent of each other, functioned as designed and reverted to manual mode while at a minimum fuel flow rate. Both engines continued to run at low power without automatic governing, resulting in insufficient power to continue normal flight as the engine twist grips remained in the normal fly position for the duration of the flight.
Probable cause
An inflight attitude upset for undetermined reasons that resulted in a rotor system overspeed, a reduction of power from both engines, and a subsequent hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER DEUTSCHLAND GMBH
Model
EC135 P2+
Amateur built
false
Engines
2 Turbo shaft
Registration number
N531LN
Operator
AIR METHODS CORP
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Medical flight type
Medical emergency
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
0474
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-19T01:11:17Z guid: 104517 uri: 104517 title: ERA22LA107 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104523/pdf description:
Unique identifier
104523
NTSB case number
ERA22LA107
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-12T16:27:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-01-14T01:10:24.912Z
Event type
Accident
Location
Winter Haven, Florida
Airport
JACK BROWNS (F57)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On January 12, 2022, about 1427 eastern standard time, a Piper J3C-65 airplane, N88509, was substantially damaged when it was involved in an accident near Winter Haven, Florida. The flight instructor and pilot receiving instruction sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the airline transport pilot receiving instruction had not flown a float-equipped airplane in 3 years, so the flight instructor considered the training flights as review. The flight instructor stated that, during their 2-hour morning flight, the pilot receiving instruction sat in the front seat and that he tended to “fly too slow” after takeoff and “turn sharply.” The instructor further stated that he had to “push the nose down on several occasions.” After eating lunch and refueling the airplane, the afternoon flight began, with the pilot receiving instruction sitting in the rear seat. The instructor estimated that they flew about 1 hour when the accident occurred. Although the flight instructor did not recall the details of the accident, he did recall thinking that the pilot receiving instruction might not have been able to see the instruments well from the rear seat or that he was being inattentive. The pilot receiving instruction had no recollection of the accident flight. A witness near the accident site stated that he saw the accident airplane fly one low pass over the lake, circle to the right, and then come around and descend again toward the lake. The witness stated that airplanes typically either land on the lake or fly a low pass but that the accident airplane made a small splash on the second pass when the right float touched the water. The airplane then “accelerated up” a couple hundred feet and started veering to the right in a “big arc.” The witness also stated that the turn “seemed like a steep angle” and that, at the top of the arc, he saw “the whole top of the airplane and it just continued downward.” The witness could not hear the engine when the airplane was descending. He stated that the airplane impacted the ground in a near-vertical nose-down attitude and that the airplane stayed in that position for a short time before the tail settled toward the ground. During a postaccident interview, the flight instructor stated that the witness’ description of the second pass sounded as if it were a go-around maneuver. The flight instructor also stated that the pilot receiving instruction had been “making really steep turns and he was too slow on airspeed.” The instructor added that he did not correct it in time. Postaccident examination of the wreckage revealed that the airplane came to rest in a near-vertical nose-down attitude with no ground scars or tree damage leading toward the wreckage, consistent with a near-vertical flightpath angle. The left wing sustained substantial damage. Control cable continuity from the cockpit area to the respective ailerons, rudder, and elevator control surfaces were confirmed. Further examination of the airplane revealed that the engine remained attached to the airframe with the propeller attached and canted left. Both propeller blades exhibited leading-edge abrasion. One propeller blade was cut to facilitate propeller rotation. All the spark plugs were removed and visually examined, and their condition was noted as normal-to-worn-out based on Champion Aviation’s Check-A-Plug Guide. Rotation of the engine’s crankshaft produced compression on all cylinders, and normal valvetrain movement was observed when the crankshaft was rotated. Examination of the engine’s cylinders with a lighted borescope revealed no damage to the cylinders or pistons. Both magnetos produced spark at all towers when their input drives were rotated. Borescope examination of all cylinders revealed carbon deposits consistent with a rich mixture and/or the use of automotive fuel. All cylinders passed a cold compression check. Fuel was present in the carburetor bowl and was absent of water or debris. Examination of the engine revealed no preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed that the atmospheric conditions at the time of the accident were conducive to “serious icing at glide power.” The flight instructor explained, during a postaccident interview, that carburetor heat was used on all approaches and would have been turned off at the initiation of the go-around maneuver. -
Analysis
The pilot receiving instruction had not flown a float-equipped airplane in 3 years, so the flight instructor considered the training flights as review. The flight instructor stated that, during their 2-hour morning flight, the pilot receiving instruction sat in the front seat and that he tended to “fly too slow” and “turn sharply.” The instructor had to “push the nose down on several occasions.” After eating lunch and refueling the airplane, the afternoon flight began, with the pilot receiving instruction sitting in the rear seat. The flight instructor estimated that they had been flying for about 1 hour when the accident occurred. Neither the flight instructor nor the pilot receiving instruction had recollection of the accident, but the flight instructor recalled thinking that the pilot receiving instruction might not have been able to see the instruments well from the rear seat or that he was being inattentive. A witness stated that the airplane made two passes over a lake and that, as the airplane descended toward the lake during the second pass, the right float made a small splash as it touched the water. The airplane then climbed a couple hundred feet, turned to the right in a steep angle, and descended toward the ground in a near-vertical nose-down attitude. The witness did not hear the engine during the descent. Postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Given the reported application of carburetor heat during all approaches, it is unlikely that carburetor icing affected engine performance. After learning about the witness’ observations, the flight instructor stated that the pilot receiving instruction had been “making really steep turns” and “was too slow on airspeed.” The flight instructor further stated that he was too slow to correct the pilot. Thus, it is likely that the pilot receiving instruction maintained insufficient airspeed and banked too steeply, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall, and that the flight instructor did not take action in time to prevent the accident.
Probable cause
The pilot receiving instruction’s failure to maintain airspeed during a turn, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall. Contributing to the accident was the flight instructor’s failure to take remedial action in a timely manner.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C
Amateur built
false
Engines
1 Reciprocating
Registration number
N88509
Operator
Jack Brown's Seaplane Base, Inc
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
16133
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-14T01:10:24Z guid: 104523 uri: 104523 title: WPR22LA088 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104572/pdf description:
Unique identifier
104572
NTSB case number
WPR22LA088
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-13T15:06:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-03-11T00:33:00.554Z
Event type
Accident
Location
Phoenix, Arizona
Airport
PHOENIX-MESA GATEWAY (IWA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 13, 2022, about 1306 mountain standard time, an Extra Flugzeugbau GMBH, EA-300L airplane, N203EX, was substantially damaged when it was involved in an accident near Phoenix, Arizona. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot reported that the right wheel brake failed during the landing roll and the tailwheel-equipped airplane subsequently ground looped. During the accident sequence, the right main landing gear collapsed, and the right aileron was substantially damaged. The pilot stated the preflight, taxi, takeoff, and flight was uneventful until the landing roll. Postaccident examination of the brake by a Federal Aviation Administration inspector revealed that the brake pad had separated from the brake assembly. The brake pad was found on the airplane’s taxi route. Examination revealed that the pad did not fit into the assembly properly, which could result in its coming loose and separating. Additionally, the brake pad was not authorized for use in the accident airplane make and model. -
Analysis
The pilot reported that, following an uneventful flight, the right main wheel brake failed during the landing roll and the tailwheel-equipped airplane subsequently ground looped, resulting in a collapse of the right main landing gear and substantial damage to the right aileron. Postaccident examination revealed that the brake pad had separated from the brake assembly. The brake pad was found on the airplane’s taxi route. Examination revealed that the pad did not properly fit into the assembly, which could result in its coming loose and separating. Additionally, the brake pad was not authorized for use in the accident airplane make and model.
Probable cause
The failure of the right brake due to the separation of the brake pad from the brake assembly. Also causal was the improper maintenance of the airplane, which resulted in the use of a brake pad that was inappropriate for the airplane make and model.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EXTRA FLUGZEUGBAU GMBH
Model
EA 300/L
Amateur built
false
Engines
1 Reciprocating
Registration number
N203EX
Operator
AVIATION PERFORMANCE SOLUTIONS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1203
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-11T00:33:00Z guid: 104572 uri: 104572 title: ERA22LA109 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104526/pdf description:
Unique identifier
104526
NTSB case number
ERA22LA109
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-13T15:26:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-01-20T00:16:52.201Z
Event type
Accident
Location
Lexington, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 13, 2022, about 1326 eastern standard time, a Cirrus SR-22, N879CD, was substantially damaged when it was involved in an accident near Lexington, South Carolina. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, a preflight inspection of the airplane was conducted with no anomalies noted. He stated, “I checked the oil quantity and added one quart of oil.” The pilot conducted a run-up and departed for Charleston Air Force Base/International Airport (CHS), Charleston, South Carolina, on a visual flight rules (VFR) flight plan about 1300. About 20 minutes into the flight, at 5,500 ft, the pilot reported seeing a red oil annunciator light illuminate, which was followed by the oil pressure gauge falling to zero pressure. The pilot stated that the engine tachometer was near red line and that the engine sounded like it was over speeding, so he reduced the throttle to slow the engine. Soon thereafter, the engine stopped producing power and smoke emanated from the engine compartment. He radioed air traffic control and reported an emergency, then started looking for a place to land. He was over the middle of a large lake (Lake Murray), so he held off deploying the Cirrus Airframe Parachute System (CAPS) until he was closer to the shoreline. At 2,000 ft he deployed the CAPS and the airplane slowly descended to the water. The airplane remained afloat for a few minutes and continued to drift toward the shoreline with the parachute still inflated; however, the airplane eventually started to float further from the shore. At that point, the pilot and passenger exited the airplane and swam to the shoreline. Examination of the airplane by a Federal Aviation Administration inspector after its recovery from the lake revealed substantial damage to the fuselage and left elevator. Additionally, the engine exhibited a hole on the top of the case near the No. 6 cylinder. Postaccident examination of the engine revealed that all crankshaft connecting rod journals showed evidence of lubrication distress. Additionally, the No. 3 main journal bearing had shifted, resulting in the blockage of the oil ports and elongation of the crankcase lock slot. The No. 6 connecting rod bearing was fused to the crankshaft journal. The No. 1 cylinder rod bearings were fused together on the crankshaft, and the bearing surface was smeared and torn. The bearing metal had melted and re-solidified along the edges. Review of maintenance logbook records revealed that on December 4, 2015, the No. 2 cylinder was removed, repaired, and reinstalled at tachometer time 1,906.9 hours. The accident occurred at tachometer time 2,420 hrs. The engine had a manufacturer specified time between overhaul of 2,000 hours in service; however, there was no record of the engine having been overhauled. -
Analysis
The pilot reported that during cruise flight the oil annunciator light illuminated, the oil pressure decreased to zero, and the engine tachometer neared its maximum limit. Soon thereafter, the engine lost power. During the forced landing, the pilot activated the whole airplane parachute system at an altitude of about 2,000 ft above ground level. The airplane descended via the parachute and landed upright in a lake. The pilot and passenger were able to swim to shore and were not injured. The airplane’s fuselage and left elevator were substantially damaged during the landing. Postaccident examination of the engine revealed that all of the crankshaft connecting rod journals showed evidence of lubrication distress. Additionally, the No. 3 main journal bearing shifted, resulting in the blockage of the oil ports and elongation of the crankcase lock slot. The No. 6 connecting rod bearing was fused to the crankshaft journal. The No. 1 cylinder rod bearings were fused together on the crankshaft, and the bearing surface was smeared and torn. The bearing metal melted and re-solidified along the edges. It is likely that the shift of the No. 3 main journal bearing blocked the oil port and restricted oil to the engine and propeller, resulting in destruction of the bearing of the No. 6 cylinder. This likely resulted in the fracture of the connecting rod, breach of the crankcase, and the catastrophic failure of the engine. The engine overspeed reported by the pilot is consistent with a loss of oil pressure to the propeller governor, which would have lowered the blade pitch and increased engine rpm. Review of maintenance logbook records revealed the No. 2 cylinder was replaced about 500 hours before the accident flight, at which time the engine had accumulated about 2,420 hrs. It is possible that the crankcase thru bolts were incorrectly torqued after the No. 2 cylinder change about 500 hours before the accident flight, which could have resulted in a shift of the No. 3 main journal bearing.
Probable cause
A loss of engine power due to a shift of the No. 3 main journal bearing, which resulted in blocked oil ports that restricted oil to the engine’s internal components and a subsequent catastrophic engine failure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N879CD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0292
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-20T00:16:52Z guid: 104526 uri: 104526 title: CEN22FA100 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104527/pdf description:
Unique identifier
104527
NTSB case number
CEN22FA100
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-14T12:01:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2022-04-15T02:39:22.92Z
Event type
Accident
Location
Houma, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On January 14, 2022, about 1001 central standard time, a Bell 407, N167RL, was destroyed when it was involved in an accident near Houma, Louisiana. The commercial pilot and a passenger sustained fatal injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 on-demand passenger flight. The helicopter was equipped with an Appareo Vision 1000, which captured cockpit imagery of the accident flight. The recorded video indicated that the flight was proceeding normally until about 10:00:50, when the pilot’s head began to fall back in a motion not consistent with scanning for traffic or with directed attention. The helicopter was traveling at a speed of about 123 knots and an altitude about 1,220 ft mean sea level. The pilot’s movements after this time appeared to be undirected and solely in response to the g-forces resulting from aircraft motion. The pilot’s head began to move toward the right and upward until the end of the recording. The pilot’s motion remained consistent with an undirected response to aircraft motion. The view outside the windscreen was consistent with a nose-down, inverted attitude just before the end of the recording. A witness near the accident site stated that he saw the helicopter descend into terrain in a nose-down attitude and did not see any parts separate from the helicopter while it was airborne. - The 30-year-old male pilot held a second-class Federal Aviation Administration (FAA) medical certificate with a limitation for corrective lenses. At the time of the most recent exam, he reported no medications or medical conditions. No significant medical concerns were identified. Department of Veterans Affairs disability records showed that the pilot had a history of migraines and tinnitus, but had no diagnosis of traumatic brain injury. According to the autopsy, the pilot’s cause of death was massive total body trauma and the manner of death was accident. The examination was limited by extensive trauma. The cardiovascular system showed no evidence of natural disease. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected ethanol in the pilot’s liver, lung, kidney, and muscle tissue at 0.056 grams per hectogram (gm/hg), 0.012 gm/hg, 0.055 gm/hg, and 0.039 gm/hg, respectively (grams per hectogram in tissue samples are directly comparable to grams per deciliter in blood samples). N-butanol was detected in liver, kidney, and muscle tissues, but was not detected in lung tissue. N-propanol was detected in kidney and muscle tissues but was not detected in his liver and lung tissues. The non-impairing over-the-counter antihistamine, fexofenadine, and its metabolite, azacyclonol, were detected in the pilot’s liver and muscle tissue. - A postaccident examination of the helicopter revealed there was no mechanical failure or malfunction that would have precluded normal operation. -
Analysis
The pilot and passenger departed in the helicopter on the on-demand passenger flight. Cockpit imagery indicated that, while enroute, the pilot experienced a sudden loss of consciousness. The helicopter departed controlled flight and impacted terrain. Examination of the helicopter revealed no mechanical anomalies that would have precluded normal operation. Autopsy of the pilot was limited due to extensive traumatic injury. While the pilot’s cardiovascular system showed no evidence of natural disease, an arrhythmia or other electrical disorder would not leave evidence on autopsy; thus, the cause of the pilot’s sudden incapacitation could not be determined. Varying levels of ethanol were detected in the pilot’s liver, lung, kidney, and muscle tissue. Butanol and propanol were also detected in some tissues. Given the differing ethanol tissue concentrations, the state the body was recovered, and the presence of butanol and propanol in some tissues, it is likely that the identified ethanol was from sources other than ingestion.
Probable cause
The pilot’s sudden loss of consciousness for undetermined reasons during cruise flight, which resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N167RL
Operator
Rotorcraft Leasing Company, LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
53167
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-04-15T02:39:22Z guid: 104527 uri: 104527 title: WPR22LA080 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104529/pdf description:
Unique identifier
104529
NTSB case number
WPR22LA080
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-14T14:48:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-01-25T23:52:52.714Z
Event type
Accident
Location
Spanish Fork, Utah
Airport
SPANISH FORK MUNI/WOODHOUSE FLD (SPK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On January 14, 2022, about 1248 mountain standard time, an experimental amateur-built Zenith CH 750 (Cruzer), N145WT, was substantially damaged when it was involved in an accident near Spanish Fork, Utah. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that this was his first flight in the accident airplane since he was involved in a landing incident that took place in the same airplane about 18 months earlier. Before the accident flight, he fast-taxied the airplane down the runway to check the operability of the flight control system and engine controls and did not observe any anomalies. Shortly after takeoff when the airplane was about 5 nautical miles away from the airport, the pilot observed a slow decay in engine power and was suddenly unable to maintain altitude. He immediately started a left turn to return to the airport and he advanced the throttle to the full power setting but was unsuccessful in restoring power to the engine. According to a witness, the airplane entered a steep left turn at approximately 80 ft above ground level that quickly transitioned into a nose-down dive before it disappeared from view behind obstacles. The pilot stated that the airplane slowed during the turn and impacted the roof of a building. The airplane sustained substantial damage to the fuselage and both wings. The airplane was equipped with a Honda VTEC automotive engine. Postaccident examination revealed that mechanical continuity was established throughout the rotating group, reduction gearbox, engine flywheel, crankshaft and accessory section as the crankshaft was manually by hand rotated at the prop hub. Thumb compression was achieved at all four cylinders. Examination of the cylinders combustion chamber interior components using a lighted borescope revealed normal piston face and cylinder wall signatures, and no indications of a catastrophic engine failure. The ignition coils were tightly secured to their respective spark plugs and the ECU harnesses were connected to each coil. The coils were all normal in appearance and did not exhibit any debris or discoloration when visually inspected. All four of the spark plugs were gray in appearance, consistent with normal wear and the center electrodes were unremarkable. A postaccident engine run did not reveal any preimpact anomalies. An inspection of the elevator, flaperon, and rudder controls did not reveal any abnormalities.   The engine was equipped with a catalytic converter that was used to convert toxic exhaust gases produced during combustion. The converter was comprised of a honeycomb ceramic substrate secured within the case that directed the exhaust gas airflow towards the tailpipe. Although the converter remained securely attached to the engine case, the bottom half of the internal ceramic substrate had broken into numerous large pieces. Figure 1. Interior catalytic converter substrate as observed through tailpipe Figure 2. Top and bottom halves of catalytic converter with exposed substrate (top is on the left side, bottom on the right side) The pilot reported that following a landing incident that occurred 18 months before the accident, he noticed gray fragments coming from the tailpipe, which was bent as a result of impact damage. The pilot subsequently repaired the tailpipe by straightening it and re-welded it back to the catalytic converter. The pilot reported he noticed small white particles come out of the tailpipe the first time he started the engine after the incident and then once again a piece that was the size of a quarter to a half-dollar came out on the second or third engine start. He did not inspect, repair, or replace the catalytic converter before the accident flight. According to a representative of the engine manufacturer who reviewed the engine examination report, as backpressure is required for the engine to function, an obstructed exhaust can affect engine backpressure and result in a partial loss of engine power. The engine kit manufacturer, and company responsible for retrofitting the automotive engine for aviation applications, also stated that an obstructed catalytic converter could prevent the engine from producing power. -
Analysis
The pilot departed on the local accident flight after having repaired his airplane following a landing incident that occurred 18 months earlier. Shortly after departure, he observed a partial loss of engine power and was unable to maintain altitude. He immediately returned to the airport, but, while maneuvering toward the runway, he made a tight left turn, which likely resulted in an exceedance of the airplane’s critical angle of attack and an accelerated stall. The airplane entered a nose-down dive and impacted a rooftop. Postaccident examination of the airframe did not reveal any preimpact mechanical anomalies that could have precluded the pilot from controlling the airplane. Examination of the engine revealed that most of the internal components were likely operational at the time of impact. However, the catalytic converter contained several broken pieces of ceramic substrate that had separated during the previous accident. As there were no other preimpact mechanical anomalies with the engine, it is likely that broken substrate blocked the engine exhaust gas path following combustion, which resulted in a partial loss of engine power during the accident flight. The pilot straightened the bent exhaust tailpipe after the landing incident and re-welded the catalytic converter. However, he did not inspect, repair, or replace the catalytic converter before the accident flight even after debris was emitted from the tailpipe on subsequent engine starts.
Probable cause
A partial loss of engine power due to an obstructed catalytic converter, which most likely resulted from the pilot’s failure to properly repair or replace it after it was likely damaged during a previous incident. Contributing to the accident was the pilot’s failure to maintain adequate airspeed during the forced landing, which led to an exceedance of the airplane’s critical angle-of-attack and an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WALTER TACHIKI
Model
TACHIKI 750 CRUZER
Amateur built
false
Engines
1 Reciprocating
Registration number
N145WT
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
WTI
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-25T23:52:52Z guid: 104529 uri: 104529 title: ANC22LA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104533/pdf description:
Unique identifier
104533
NTSB case number
ANC22LA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-15T11:55:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-01-20T02:52:17.153Z
Event type
Accident
Location
Hana, Hawaii
Airport
Hana Airport (HNM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On January 15, 2022, about 0955 Hawaii-Aleutian standard time, a Flight Design CTLS light sport airplane, N992SA, sustained substantial damage when it was involved in an accident near Hana, Hawaii. The pilot sustained serious injuries, and the pilot-rated passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and the passenger conducted several touch-and-go landings before departing to their destination. During the accident takeoff, the airplane performed normally until about 75 ft above ground level, when the pilot noted that the airplane had “no power to climb” and was “sinking.” The airplane descended into trees and impacted the ground in a nearvertical attitude just past the departure end of the runway, resulting in substantial damage to the fuselage and wings. Two pilot-rated witnesses reported that they heard no unusual sounds. The witnesses noticed that the airplane had an “unusually high” nose-up attitude during takeoff. The pilot-rated passenger reported that the pilot pitched the airplane “higher than he needed” and “held the high pitch attitude” until the airplane descended into the trees. A Dynon EMS-D120 engine monitoring system was removed from the airplane and sent for data download at the NTSB Recorders Laboratory. The flight data indicated that, about 40 seconds before impact, the engine RPM increased from idle to maximum RPM and maintained maximum engine RPM to the end of recording. A postaccident examination of the engine was conducted by an accident investigator from the engine manufacturer with oversight provided by an inspector from the Federal Aviation Administration. The examination revealed all spark plugs appeared normal with no anomalies, carburetor main jet was clear of obstruction and floats were within weight limitation. The fuel shut off was operational, and no obstructions observed in the fuel lines. All engine rocker arms, valves, valve springs were intact and operated normally. No anomalies seen with the exhaust system. Gearbox was in good condition and the propeller shaft rotated smoothly. Continuity was established with the crankshaft when the engine was rotated. Thumb compression was observed in all cylinders. -
Analysis
The pilot and pilot-rated passenger completed several takeoffs and landings before departing to their destination. The pilot reported that, during the accident takeoff, the airplane “had no power to climb” and was “sinking.” The airplane descended into trees and impacted terrain in a near-vertical attitude just past the departure end of the runway. The pilot-rated passenger stated that the pilot pitched the airplane “higher than he needed” and “held the high pitch attitude” until the airplane descended into the trees, and pilot-rated witnesses reported that the airplane exhibited an “unusually high” nose-up pitch attitude during the takeoff. Postaccident examination of the engine and engine monitoring system data revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation of the engine. Given the passenger and witness statements regarding the airplane’s nose-high pitch attitude, it is likely that the pilot exceeded the airplane’s critical angle of attack during the initial climb after takeoff, resulting in an aerodynamic stall and subsequent impact with terrain.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FLIGHT DESIGN GMBH
Model
CTLS
Amateur built
false
Engines
1 Reciprocating
Registration number
N992SA
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
08-02-06
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-20T02:52:17Z guid: 104533 uri: 104533 title: ANC22LA014 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104543/pdf description:
Unique identifier
104543
NTSB case number
ANC22LA014
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-15T14:30:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-01-27T05:38:54.048Z
Event type
Accident
Location
El Cajon, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 15, 2022, about 1230 Pacific standard time, a Bell 205A-1 helicopter, N502HQ, sustained substantial damage when it was involved in an accident near El Cajon, California. The flight instructor and the pilot receiving instruction were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that he was demonstrating an autorotation to the pilot receiving instruction as part of the company’s flight training program. The flight instructor entered the autorotation at an altitude of about 1,500 to 2,000 ft above ground level and reduced the engine’s power to flight idle during the descent. When the helicopter reached its power recovery altitude, the instructor attempted to increase the engine’s power, but the engine did not respond. Subsequently, he attempted to recover engine power three times but was unable to do so. The pilot then committed to a touchdown autorotation. On touchdown, the helicopter rocked forward and then aft on its skids, and the main rotor blades struck the tailboom, which sustained substantial damage.   A postaccident examination of the engine, governor, and fuel control (which included a full engine run in accordance with the engine manufacturer’s overhaul manual, full vibration analysis with all parameters within limits. Functional test on the governor to check flow rates and reaction time moving from each parameter to another. Functional test of fuel regulator emergency solenoid, acceleration flow rates were checked, main components of the computer assembly were checked, and borescope inspection) revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The flight instructor stated that he was demonstrating an autorotation to the pilot receiving instruction as part of the company’s flight training program. The flight instructor entered the autorotation at an altitude of about 1,500 to 2,000 ft above ground level and reduced the engine’s power to flight idle during the descent. When the helicopter reached its power recovery altitude, the instructor attempted to increase the engine’s power; however, the engine did not respond. Subsequently, he attempted to recover engine power three times but was unsuccessful. The pilot committed to a touchdown autorotation. On touchdown, the helicopter rocked forward then aft on its skids, and the main rotor blades struck the tailboom, which sustained substantial damage. A postaccident examination of the engine, governor, and fuel control revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. As a result, the reason for the partial loss of engine power could not be determined from the available evidence for this investigation.
Probable cause
A partial loss of engine power for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
205A-1
Amateur built
false
Engines
1 Turbo shaft
Registration number
N502HQ
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
30172
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-27T05:38:54Z guid: 104543 uri: 104543 title: WPR22LA081 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104534/pdf description:
Unique identifier
104534
NTSB case number
WPR22LA081
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-18T00:56:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-01-25T05:05:07.713Z
Event type
Accident
Location
Scottsdale, Arizona
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On January 17, 2022, about 2256 mountain standard time, a Piper PA-28 airplane, N5276W, was substantially damaged when it was involved in an accident near Scottsdale, Arizona. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, about halfway through the night cross-country flight, he noticed the engine oil pressure gauge was indicating lower than it had been earlier in the flight. Although the engine was running fine, he started to look at the possibilities of gliding to an airport, if needed. The pilot decided that he was not in an emergency situation but altered his intended flight path, which was over a mountainous area, to overfly a southbound highway. After passing the highway and nearing the Sky Ranch at Carefree (18AZ), Carefree, Arizona, the oil pressure dropped to near zero and the pilot started to make plans for an emergency landing. He attempted to turn on the lights at 18AZ but was unsuccessful. He decided to continue the flight to Falcon Field (FFZ), Mesa, Arizona, which was about 22 nautical miles southeast of his position. Near Fountain Hills, Arizona, the engine noise started to change, followed by a drop in power. He said the engine oil pressure gauge indicated zero, and he subsequently added full power as he was looking for a place to land. Soon afterwards, the engine made “horrible noises” and lost all power. The pilot landed the airplane on a narrow, graveled road between a chain link fence and a water canal, impacting the fence with the right wing. The airplane sustained substantial damage to the right wing, both ailerons, the left horizontal stabilizer, and the left elevator. Postaccident examination of engine revealed that the lower side of the engine, lower cowling, firewall, and aircraft belly were covered in an oil residue. The crankshaft could only be rotated by hand about 270°. The engine was disassembled. The crankshaft oil seal area was wet with oil and the split style oil seal was installed with a solid ring stretch oil seal spring. The oil dipstick indicated no oil, and the oil sump was undamaged and contained no oil. The crankcase breather hose was oil soaked. The No. 2 connecting rod was separated from the crankshaft. The No. 2 connecting rod crankshaft journal and connecting rod bearing revealed thermal distress and material deformation. The No. 3 cylinder combustion chamber and piston were covered in oil. The No. 3 piston oil control ring was stuck in the respective ring land. The No. 3 cylinder exhaust pipe exhibited a darker color of combustion deposits when compared to the other exhaust pipes. The maintenance documentation revealed that the last annual inspection was completed on December 14, 2021. At that time the engine had 2,523 hours of operation since major overhaul. An “engine miss” was reported, and on January 7, 2022, the No. 3 cylinder spark plugs were found both fouled with oil. -
Analysis
The pilot was conducting a night cross-country flight when he noticed the engine oil pressure gauge indicating lower that it had been earlier in the flight. Although the engine was running fine, he started to look at the possibilities of gliding to an airport if needed. The pilot decided that he was not in an emergency situation; however, he altered his intended flight path to avoid a mountainous area and remain over a highway. After passing the highway and nearing an airport, the oil pressure dropped to near zero and the pilot started to make plans for an emergency landing. He attempted to turn the lights on at a nearby airport but was unsuccessful. The pilot decided to continue to another airport, which was about 22 nautical miles from his position. About halfway to the next airport, the engine noise started to change, followed by a reduction of engine power. He said the engine oil pressure gauge indicated zero and he subsequently added full power while looking for a place to land. Soon afterwards, the engine made “horrible noises” and lost all power. The pilot landed the airplane on a narrow graveled road between a chain link fence and a water canal. During the landing sequence, the right wing struck the fence, which resulted in substantial damage to the right wing, both ailerons, the left horizontal stabilizer, and the left elevator. Postaccident examination of the engine revealed that the No. 3 piston oil control ring was stuck in its ring land resulting in an excessive blow-by condition. The blow-by condition caused the engine crankcase to pressurize and vent oil from the crankshaft oil seal, crankcase breather system, and the No. 3 combustion chamber until the sump was depleted of oil. This oil depletion resulted in the thermal distress and material deformation of the No. 2 connecting rod bearing and crankshaft journal and the subsequent separation of the No. 2 connecting rod.
Probable cause
A loss of engine power due to oil exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28
Amateur built
false
Engines
1 Reciprocating
Registration number
N5276W
Operator
THIRD STEP 2 LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-323
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-25T05:05:07Z guid: 104534 uri: 104534 title: CEN22LA103 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104536/pdf description:
Unique identifier
104536
NTSB case number
CEN22LA103
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-18T13:00:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-01-19T03:10:20.311Z
Event type
Accident
Location
Sturtevant, Wisconsin
Airport
SYLVANIA (C89)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On January 18, 2022, about 1100 central standard time, a Cessna 120 airplane, N90129, was substantially damaged when it was involved in an accident near Sturtevant, Wisconsin. The private pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Security camera footage was obtained from the Sylvania Airport (C89), Sturtevant, Wisconsin. A review of the footage showed the airplane was attempting to depart to the east, using runway 08R. The takeoff roll was initiated and about a quarter way down the length of the runway, the airplane departed the runway to the left (north). The footage showed the airplane travel over a flat grass field with the engine running. The footage did not show the airplane become airborne at any time, and the tailwheel appeared to remain on the ground during the runway excursion. The airplane came to rest after it impacted the cabin of an unoccupied, parked fuel truck. The pilot reported he recalled taxiing for takeoff and applying engine power for the takeoff, however he was unable to recall any additional events. The airplane sustained substantial damage to the left wing, the left-wing lift struts, and the fuselage. Postaccident examination of the airframe revealed no mechanical anomalies. Flight control continuity and airframe to engine control continuity was established. The main landing gear brake lines sustained impact damage, which precluded a system brake test. The main wheels were found free to rotate, and the brake pads and rotors for both wheels showed minimal wear. No signs of foreign object debris jamming or restricting operation of the cockpit controls was noticed. The pilot had reported no medical conditions and no use of medications to the FAA. Ketamine, fentanyl, propofol, and lidocaine were administered in the prehospital and immediate stages of his hospital care. No note is made in the hospital documentation of any identification of underlying natural disease such as a stroke or heart attack that may have been affecting the pilot prior to the collision of his airplane with the fuel truck. Toxicology testing was performed by the FAA’s Forensic Sciences Laboratory on blood and urine left over from specimens obtained during the pilot’s initial hospital admission. The results included medications administered during his post-crash care including ketamine and its metabolite norketamine, fentanyl and its metabolite norfentanyl, lidocaine, and propofol. In addition, atorvastatin, famotidine, and fexofenadine were identified, which are non-impairing medications. -
Analysis
A review airport security camera footage showed the airplane was attempting to depart to the east. About a quarter way down the length of the runway after the beginning of the takeoff roll, the airplane departed the runway to the left (north). Airport security video footage showed the airplane travel over a flat grass field with the engine running. The footage did not show the airplane become airborne at any time, and the tailwheel appeared to remain on the ground during the runway excursion. The airplane came to rest after it impacted the cabin of an unoccupied, parked fuel truck. The pilot reported he recalled taxiing for takeoff and applying engine power for the takeoff; however, he was unable to recall any additional events. Postaccident examination of the airframe revealed no mechanical anomalies. The postaccident emergency care did not identify any medical conditions the pilot had that might have contributed to the accident. The pilot’s pre-accident use of atorvastatin, famotidine, and fexofenadine, all non-impairing medications identified by toxicology testing of the pilot’s samples, also did not contribute to the circumstances of this accident. It is likely a loss of control occurred during the takeoff, which resulted in a runway excursion and a collision with an object. Based on the available evidence, the reason for the loss of control could not be determined.
Probable cause
The pilot’s loss of directional control during the takeoff for reasons that could not be determined based on the available evidence, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
120
Amateur built
false
Engines
1 Reciprocating
Registration number
N90129
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
9190
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-19T03:10:20Z guid: 104536 uri: 104536 title: DCA22LA069 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104551/pdf description:
Unique identifier
104551
NTSB case number
DCA22LA069
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-22T13:57:00Z
Publication date
2023-12-12T05:00:00Z
Report type
Final
Last updated
2022-03-08T18:34:04.637Z
Event type
Accident
Location
Hayden, Colorado
Airport
Yampa Valley International Airport (HDN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
JetBlue Airways flight 1748 incurred a tail strike on takeoff from runway 10 at Yampa Valley Airport (HDN) resulting in substantial damage to the airplane. About 1148 mountain standard time JetBlue’s 1748 flight crew announced on the common traffic advisory frequency (CTAF) that they were leaving the ramp area to taxi to runway 10 for departure. A few seconds later, a Beechcraft B300 King Air, N350J, on an instrument flight rules (IFR) flight plan reported on the local CTAF that they were “about 9 minutes out, for ten, coming in from the east, descending out of 17,000 ft”. The Universal Communications Frequency (UNICOM) operator responded to N350J stating that there were “multiple aircraft inbound” and winds were calm and provided the altimeter setting. After this exchange, the JetBlue crew began discussing the active runway and the multiple inbound airplanes using runway 10. Two minutes later, the JetBlue flight crew contacted Denver air route traffic control center (ARTCC) and reported that they were at HDN, preparing for engine start and would be ready for departure in about 6 or 7 minutes. The Denver controller asked the flight crew if they were planning on departing from runway 10, to which the crew concurred, and the Denver ARTCC controller instructed them to contact him when they were ready for departure. About the time the JetBlue flight crew was starting their second engine and conducting engine checks, the King Air flight crew was contacting Denver ARTCC to cancel their IFR flight plan because they had visually acquired HDN and intended to land on runway 28. The Denver ARTCC controller acknowledged the IFR cancellation, instructed them to squawk 1200 in the aircraft’s transponder and approved a radio frequency change. The King Air’s flight crew subsequently announced, about 1153 on CTAF that they were “going to go ahead and land two eight” and were “straight-in two eight right now”. About 10 seconds later, the JetBlue flight crew announced on CTAF they were leaving the ramp area and were taxiing to runway 10 for departure. HDN UNICOM reported that multiple airplanes were inbound, and the winds were calm. While the JetBlue flight crew was performing an after-start checklist, the King Air announced on CTAF they were on a “12-mile final two eight straight-in”. About 45 seconds later, the King Air asked on CTAF if anyone was about to depart from runway 10, and the JetBlue flight crew replied that they intended to hold on the taxiway near the end of runway 10 and wait for a clearance from Denver ARTCC. The King Air replied they were on a "10-mile final, two eight, straight-in”. The JetBlue flight crew said “alright, copy” and that they would keep an eye out for them. See figure 1 for HDN runway layout. NOT FOR NAVIGATION Figure 1: Excerpt from Jeppesen Airport Chart for Yampa Valley Airport (HDN). About 1155, the JetBlue flight crew contacted Denver ARTCC and reported they were ready for departure on runway 10 at HDN. The Denver center controller cleared them to Fort Lauderdale/Hollywood International Airport (FLL), Fort Lauderdale, Florida, as filed, with a 2-minute clearance void time. The flight crew read back the clearance including the 2-minute void time restriction. According to the Aeronautical Information Manual (AIM), a pilot may receive a clearance, when operating from an airport without a control tower, which contains a restriction for the clearance to be void if not airborne by a specific time. A pilot who does not depart before the clearance void time must advise air traffic control (ATC) as soon as possible of their intentions. At 1156, the JetBlue flight crew announced on CTAF that they had received their clearance and would be departing on “runway one zero”. Within 5 seconds, the King Air’s flight crew reported they “had a king air on final two eight” and that they “had been calling.” JetBlue’s flight crew replied on CTAF that they thought the King Air was “8 or 9 miles out”, to which the King Air replied they were 4 miles out, “even less than that.” The JetBlue first officer, (pilot monitoring (PM)) stated that they looked for the airplane both visually and on their onboard traffic alert and collision avoidance system (TCAS) and did not see any air traffic. JetBlue flight crew acknowledged the King Air, looked for traffic approaching runway 10, and announced on CTAF that they were beginning their takeoff from runway 10 at HDN. The King Air’s flight crew replied that they were on a short final and “I hope you don’t hit us.” According to ADS-B data, when JetBlue taxied onto runway 10 the King Air was on a reciprocal course 4.91 nautical miles from JetBlue. JetBlue’s crew increased thrust for takeoff about 1157. About 11 seconds later, just prior to the 80 knots call out, the PM asked the PF if the King Air was on runway 28. The captain (pilot flying (PF)) asked “is he?” to which the PM said “Yes, he is on 28, do you see him?” to which the PF said no. After the event, the JetBlue first officer explained that he observed traffic directly ahead on the TCAS during the takeoff run and pointed it out on the display to the captain. About 20 seconds after JetBlue started their take off on runway 10, the flight crew of the King Air asked JetBlue if they were going to do a quick turn-out, to which they replied, “yes sir.” Concurrent to this conversation, JetBlue’s captain pitched the airplane up, 24 knots before rotation speed, to avoid the approaching King Air and subsequently struck the tail of the airplane on the runway’s surface. He began a climbing right turn away from the traffic indicated on the TCAS. JetBlue’s captain and first officer both stated they never visually acquired the approaching King Air. According to ADS-B data, when JetBlue began its right turn after departure from runway 10 the King Air was on a reciprocal course with 2.27 nautical miles of separation between the converging airplanes. See figure 2. Figure 2: ADS-B data overlayed on Google Earth image. Based on FDR data, the tail strike occurred about 1157, the crew continued their departure procedures and discussed if they experienced a tail strike, initially deciding to continue the flight to FLL. At 1203, they asked the flight attendants what they felt in the back of the airplane, to which the flight attendants stated they felt a tail strike. At this time, the aircraft was about 16,000 feet in altitude. Within 2 minutes of getting the flight attendant feedback, about 20,000 feet altitude, they contacted the airline’s maintenance controller for guidance although the aircraft had not annunciated any warnings regarding a pressurization issue. About 5 minutes later, when climbing through 26,000 feet, the maintenance controller recommended they land immediately so the airplane could be inspected for damage. They leveled the aircraft at FL310 and decided to divert to DEN, where they made a safe landing. King Air N350J CTAF Communications FAA Advisory Circular 90-66b describes the “self-announce” procedure that pilots use at uncontrolled airports, such as HDN, where pilots broadcast their call sign, position, altitude, and intended activity on the designated CTAF. In this event, N350J made several calls on CTAF including their original intent to land on runway 10, and then their decision to switch to runway 28. However, the composition of these calls had the potential to be clearer. In order to help identify one airport from another, AC 90-66b states that “the correct airport name should be spoken at the beginning and end of each self-announce transmission.“ In particular, the repetition of the airport name at the end of a transmission also reinforces the airport to which the transmission relates to others on the frequency in case the first annunciation of the name was missed or garbled. All calls N350J made omitted identifying the airport at least once at the beginning or end of the transmission and sometimes they completely omitted the airport name. This non-standard phraseology reduced the effectiveness of their radio calls by providing opportunity for their call to be dismissed as relating to a different airport, or not relevant for the airport at hand. It is common for pilots to omit the word “runway” when referencing an airport’s runway numbers, however standard ATC phraseology (as referenced in FAA Order 7110.10, 11-1-13 Number Usage) uses the word “runway” followed by the separate digits of the runway designation. For this airport, references to the runways would be expected to be “runway one zero” and “runway two eight.” All N350J’s radio calls omit “runway” when indicating the runway “two eight” they intended to land on. While context clues in the transmission can be used to ascertain the correct meaning of “two eight,” the prefix of “runway” would have provided a cue to listen that would have been more difficult to overlook in the face of expectation bias. Expectation bias is further discussed below. UNICOM Communication HDN had a Universal Communications Frequency (UNICOM), which is a nongovernment air/ground radio communication station that may provide airport information. UNICOM operators are not required to communicate with pilots, and if they do, there are no standards for the information conveyed. During this event, the UNICOM operator communicated with both JetBlue and N350J stating that “multiple airplanes” were inbound and that winds were calm. The UNICOM operator had the opportunity to improve the situational awareness in the pattern by including runway in use information in his brief. For example, when briefing N350J, he could have added that the latest call (which was from JetBlue) was using runway 10. Further, when briefing JetBlue when they left the gate, the UNICOM operator had the opportunity to advise them that an aircraft was inbound for runway 28 instead of noting only that “multiple aircraft inbound.” JetBlue Crew Expectation Throughout JetBlue’s pushback from the gate, taxi, and beginning of takeoff roll, the JetBlue crew believed the King Air traffic was approaching runway 10. In response to hearing that the King air was on a 4-mile final, they expedited their departure so they would not interfere with the King Air’s landing, which they believed was going to happen behind them once they departed runway 10. This assumption also caused them to only scan for traffic on the approach end of runway 10 before entering the runway. Expectation bias is a psychological concept which causes an incorrect belief to persist despite available contradictory evidence. In this case, the crew’s expectation that the King Air was arriving on runway 10, biased their perception of incoming information such that contradictory evidence (radio calls indicating the King Air was landing on runway 28) was ignored or manipulated in the brain to be consistent with the person’s current expectation. This bias occurs as part of basic information processing, and a person may not be actively aware of such biases at the perceptual level. The crew’s initial assessment of the situation was correct, as N350J initially checked into the CTAF indicating they were inbound to Runway 10. While one of N350J’s calls (12 mile straight in) conflicted with checklist completion in the cockpit, the remainder of the calls did not conflict with attentional resources needed in the cockpit and the crew directly engaged several times with N350J on the CTAF. Despite these conversations, the detail of N350J arriving on the opposite runway and being a head on conflict, was not actualized by the crew until their takeoff roll as a result of expectation bias. JetBlue flights out of HND were seasonal and normally departed and arrived on runway 10. This combined with the flight crew’s limited experience flying out of non-towered airports, and time sensitive nature of the takeoff clearance could have exacerbated their expectation bias. JetBlue Crew Inflight Response to Possible Tail Strike JetBlue’s Flight Crew Operating Manual (FCOM) Volume I cautions that “if a tail strike occurs, avoid flying at an altitude that requires pressurizing the cabin and to return to the originating airport for a damage assessment.” The QRH procedure for a tail strike is to land as soon as possible and that a pilot should climb at a maximum of 500 feet per minute (fpm) and descend at a maximum rate of 1000 fpm to minimize pressure changes all the while not exceeding 10,000 ft msl or minimum safe altitude. The JetBlue crew took about 6 minutes to establish they had a tail strike. At this point, they were climbing through 16,000 feet. The terrain east of HDN along the flight’s path prompted established minimum safe altitudes at 16,600 feet. Based on the procedure, this would have been an appropriate time to conduct the QRH procedure since both sets of guidance refer to actions “when a tail strike is experienced” rather than when a tail strike is “suspected.” However, the crew did not discuss the QRH, and recorded climb/descent rates and altitudes reached above 16,600 suggest they did not reference the QRH. Higher than normal workload in the cockpit from discussion of the event, liaising with company maintenance, and the resulting diversion may explain their omission of this checklist after they confirmed the tail strike. Past Investigation, Quincy, IL The National Transportation Safety Board (NTSB) investigated an accident that occurred at an uncontrolled airfield that had a much different outcome. It occurred at Quincy Municipal Airport, near Quincy, Illinois, on November 19, 1996, when United Express flight 5925, a Beechcraft 1900C collided with a Beechcraft King Air A90. Flight 5925 was completing its landing roll on runway 13, and the King Air was in its takeoff roll on runway 04. The collision occurred at the intersection of the two runways. All 10 passengers and two crewmembers aboard flight 5925 and the two pilots aboard the King Air were killed. The NTSB determined that the probable cause of the Quincy accident was the failure of the pilots in the King Air A90 to effectively monitor the CTAF or to properly scan for traffic, resulting in their commencing a takeoff roll when flight 5925 was landing on an intersecting runway. The Board also determined that contributing to the cause of the accident was an interrupted radio transmission from a pilot from another airplane, which led to flight 5925 pilots’ misunderstanding of the transmission as an indication from the King Air that it would not take off until after flight 5925 had cleared the runway. JetBlue Safety Actions following Flight 1748 Tail Strike JetBlue’s safety team worked with JetBlue University instructors to develop training curriculum for flightcrew on non-towered operations, un-annunciated failures and QRH procedures, and time compression that would be a two-hour brief using JFK to Burlington with an arrival or departure after the tower has closed as an example.
Probable cause
The captain’s rotation of the airplane pitch before the rotation speed on takeoff due to his surprise about encountering head on landing traffic, which resulted in an exceedance of the airplane’s pitch limit and a subsequent tail strike. Contributing to the accident was the flight crew’s expectation bias that the incoming aircraft was landing on the same runway as they were departing from, and the conflicting traffic’s nonstandard use of phraseology when making position calls on the common traffic advisory frequency.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A320-232
Amateur built
false
Engines
2 Turbo fan
Registration number
N760JB
Operator
JETBLUE AIRWAYS CORP
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
3659
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-08T18:34:04Z guid: 104551 uri: 104551 title: WPR22LA084 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104563/pdf description:
Unique identifier
104563
NTSB case number
WPR22LA084
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-23T12:30:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-02-09T01:42:50.748Z
Event type
Accident
Location
Gustine, California
Airport
Los Banos (LSN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 23, 2022, about 1030 Pacific standard time, a Bell UH-1E, N333XL, was substantially damaged when it was involved in an accident near Gustine, California. The pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was applying herbicide to a wheat field and that the accident occurred on the third load of the day and after the pilot had been operating the helicopter for about 45 minutes. At the apex of a turn, the pilot lost control of the helicopter, and it descended and struck terrain, which substantially damaged the main rotor system, tailboom, and fuselage. The pilot turned off the fuel boost and the master electrical switch and exited the helicopter through the roof window. The pilot reported that he had checked the oil level of the 90° gearbox before the flight but did not recall the quantity of oil at the time. A review of postaccident photos provided by the pilot revealed the helicopter came to rest on its left side in an open, level field. All major components were located in the debris area around the airframe. The tailboom had partially separated from the fuselage. One main rotor blade separated from the hub about 24 inches outboard of the blade grip. The other main rotor blade remained attached and exhibited upward bending about 24 inches from the blade grip. The tail rotor assembly and the 90° gearbox remained attached to the top of the vertical stabilizer. The 90° gearbox had an internal gear that had breached the housing. The green paint around the breach was thermally damaged, and no evidence of oil was observed around the exposed area of the gearbox. The 90° gearbox was shipped to the National Transportation Safety Board (NTSB) Materials Laboratory. Examination of the 90° gearbox revealed that the housing and the parts within the housing were dry and covered with a black deposit of fine metallic particles and that they contained no evidence of lubricating oil/fluid (see figures 1and 2). The gear and bearings exhibited evidence of heat damage and deformation. The pinion exhibited severe heat and wear damage, which is also shown in figure 2. Figure 1. Overall view of the 90° gearbox assembly showing a portion of the exposed gear that breached the gearbox housing. Figure 2. View of the internal components of the 90° gearbox and the damage to the pinion. The interior of the housing was covered in soot. When a flashlight was aimed at the oil level sight glass, no light passed through it (figure 3). Figure 3. Oil level sight glass for the 90° gearbox. Review of the airplane’s maintenance records revealed that, on October 23, 2007, the 90° gearbox was installed on the accident helicopter at an airframe time of 8,412 hours. The gearbox had 260.9 hours since overhaul. The gearbox complied with Federal Aviation Administration Airworthiness Directive 90-10-05, dated June 5, 1990, which was issued to prevent the failure of the tail rotor gearbox duplex bearing. On February 15, 2022 (23 days after the accident), the 90° gearbox was removed for examination; at that time, the helicopter had an airframe time of 9,025.8 hours, and the gearbox had accumulated 3,124.5 historical hours and 298.9 hours since overhaul. -
Analysis
The pilot was conducting aerial spray applications of a chemical to a field. He had checked the oil quantity of the 90° gearbox during the preflight check but did not recall the quantity of oil at the time. The pilot had operated the helicopter for about 45 minutes and, while making a turn, lost control of the helicopter. The helicopter descended and impacted terrain. Maintenance records revealed no anomalies. Postaccident examination of the 90° gearbox revealed severe damage to the internal components and no evidence of lubricating oil inside the housing. The pinion was severely deformed, which resulted in the loss of rotational drive to the tail rotor assembly and the subsequent loss of control. Examination of the oil level sight glass revealed that the inside was covered with a material that did not allow for sufficient viewing of the oil level. It is likely that, when the pilot looked at the oil level sight glass during his preflight check, he interpreted what he saw as an adequate amount of oil.
Probable cause
Failure of the 90° gearbox due to the lack of lubricating oil, which resulted in a loss of rotational drive to the tail rotor and a subsequent loss of control of the helicopter.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
UH-1E
Amateur built
false
Engines
1 Turbo shaft
Registration number
N333XL
Operator
Marquis Aviation
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
154951
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-09T01:42:50Z guid: 104563 uri: 104563 title: CEN22LA106 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104548/pdf description:
Unique identifier
104548
NTSB case number
CEN22LA106
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-23T19:28:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-02-07T22:25:38.482Z
Event type
Accident
Location
Lampasas, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On January 23, 2022, about 1728 central standard time, a de Havilland Tiger Moth DH-82A, N5300, was substantially damaged when it was involved in an accident near Lampasas, Texas. The pilot and passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that about 20 minutes into the pleasure flight the engine began to run rough, and he immediately turned the airplane back toward the departure airport, checked that the fuel was on, mixture was rich, and the throttle was open. The engine continued to lose power and he decided to divert to a different private airport. The engine was producing partial power but not enough to maintain altitude. As the airplane approached the private airport, the pilot perceived that the airplane was too high, and he turned the airplane. During the turn he realized that he had misjudged the height and decided that completing the turn was not a good idea, leveled the wings, and committed to going straight ahead. The area where the airplane landed was terraced and as it touched down the airplane hit one of the terraced areas, skipped, nosed over, and came to rest inverted. The airplane sustained substantial damage to the rudder, engine mounts, and lower right wing. After the accident, the pilot, who is also a mechanic, performed an examination of the airplane and engine. The engine was able to rotate, and compression was confirmed on all cylinders. While examining the valve system for the No. 2 cylinder he found that the ball end of the exhaust valve rocker arm was not seated in the end of the pushrod. He also found that one of the bolts securing the rocker arm assembly had the bolt head separated from its shank. The missing bolt head was in the rocker cover. -
Analysis
The airplane’s engine lost partial power and the pilot was unable to maintain altitude. He executed a forced landing to a terraced farm field. During the landing, the airplane struck one of the terraced areas and nosed over. The airplane sustained substantial damage to the rudder, engine mounts, and lower right wing. Postaccident examination of the engine revealed that the ball end of the No. 2 cylinder exhaust valve rocker was not seated in the pushrod. Additionally, the head of one of the bolts securing the rocker arm bracket had fractured and the bolt head was found in the rocker cover. Based on the available evidence it is likely that the fractured bolt head allowed enough movement of the No. 2 cylinder rocker arm bracket for the pushrod to become separated from the ball end of the rocker arm. This prevented the exhaust valve for the No.2 cylinder from opening and thereby reducing the power output of the engine.
Probable cause
The failure of a bolt in the engine valve system which resulted in malfunction of the engine exhaust valve system and a partial loss of engine power. The rough terrain encountered during the forced landing contributed to the outcome.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
TIGER MOTH DH 82A
Amateur built
false
Engines
1 Reciprocating
Registration number
N5300
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
T-5703
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-07T22:25:38Z guid: 104548 uri: 104548 title: WPR22LA083 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104557/pdf description:
Unique identifier
104557
NTSB case number
WPR22LA083
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-26T12:55:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-01-28T06:41:13.415Z
Event type
Accident
Location
Williams, Arizona
Airport
H A CLARK MEML FLD (CMR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On January 26, 2022, about 1055 mountain standard time, a Beech F33A airplane, N1HH, was substantially damaged when it was involved in an accident near Williams, Arizona. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed and turned left to the west. While climbing through about 700 to 800 ft above ground level, the engine lost power and the pilot initiated a right turn back toward the airport. The pilot stated that he realized he was unable to make it to the airport and elected to land in an open desert field. The airplane subsequently landed hard and impacted vegetation during the landing roll. The pilot stated that he had topped off the right fuel tanks before the flight and that the fuel selector was placed to the right main tank position. On previous flights, the pilot had observed “minor heating” in two of the engine cylinders and informed his mechanic. His mechanic directed him to turn on the fuel boost pump when the pilot observed the overheating, and the pilot stated that this method had “worked great until the day of the accident.” On the day of the accident, the two cylinders began to heat up, and the pilot activated the boost pump. Shortly thereafter, the engine lost total power. The mechanic reported that the pilot was “in a rush” to take possession of the accident airplane and indicated an urgent desire to fly from Arizona to California. After releasing the airplane, the pilot called and indicated that the airplane "was running great, but cylinder number 2 was still running ‘Hot’." The mechanic suggested that the pilot note exhaust gas temperature (EGT), cylinder head temperature (CHT), and fuel flow indications and bring the accident airplane in for further maintenance. He did not recall suggesting that the pilot use the auxiliary fuel boost pump during takeoff or climb. The airplane was equipped with an electric auxiliary fuel boost pump that could be manually activated by the pilot via a cockpit switch. The auxiliary fuel pump placard stated, “Take-off and land with AUX fuel pump off except in case of loss of fuel press.” The airplane’s pilot operating handbook (POH), section IV, Normal Procedures, Before Take-Off, states, “Auxiliary Fuel Pump – CHECK OFF”. The airplane was also equipped with an Insight Instrument engine monitoring system. The data showed that, during the accident flight, the fuel flow increased from 23.4 to 28.7 gph with a peak fuel flow of 30.8 gph, followed by a sudden decrease, with a corresponding drop in CHT and EGT. The Continental Motors service information directive (SID) SID97-3F recommended that the fuel flow setting should be between 23.2 – 24.9 gph.  Postaccident examination showed bending and crushing near the roots of both wings. Flight control continuity was established from all primary flight control surfaces to the cockpit controls. There was no evidence of any preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. -
Analysis
The pilot reported that, during previous flights, he had observed overheating of two of the engine cylinders, and activation of the auxiliary fuel boost pump had worked to resolve the overheating. Shortly after takeoff on the accident flight, the pilot observed cylinder heating and activated the boost pump, after which the engine lost total power. The pilot performed a forced landing in an open desert field. The airplane landed hard and impacted vegetation during the landing roll, resulting in substantial damage to the airplane. Data retrieved from the airplane’s engine monitoring system showed that the fuel flow rate increased from 23.4 gallons per hour (gph) to 28.7 gph, with a peak fuel flow of 30.8 gph, followed by a sudden decrease. The engine manufacturer recommended that the fuel flow setting should be between 23.2 – 24.9 gph. Both the pilot operating handbook for the airplane and a placard on the auxiliary boost pump indicated that the pump should be off during takeoff and only turned on in the event of a loss of fuel pressure. It is likely that the pilot’s activation of the auxiliary fuel boost pump resulted in excess fuel being delivered to the engine during the initial climb, which resulted in the total loss of engine power. A postaccident examination of the airframe and engine revealed no evidence of mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The pilot’s activation of the auxiliary fuel boost pump shortly after takeoff, which resulted in an excess amount of fuel to the engine and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
F33A
Amateur built
false
Engines
1 Reciprocating
Registration number
N1HH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CE-611
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-01-28T06:41:13Z guid: 104557 uri: 104557 title: WPR22LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104575/pdf description:
Unique identifier
104575
NTSB case number
WPR22LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-28T16:25:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-02-12T19:33:30.604Z
Event type
Accident
Location
Ravendale, California
Airport
RAVENDALE (O39)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On January 28, 2022, about 1443 mountain standard time, a Textron Aviation T240 airplane, N420WT, was substantially damaged when it was involved in an accident near Ravendale, California. The two pilots and one passenger onboard were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The instructor pilot reported that they had flown earlier in the day and the flights were uneventful with no anomalous engine readings. During the accident flight, they conducted a go-around during the approach followed by an uneventful landing. They taxied back for takeoff on runway 17 and had planned to do a short field takeoff. The pilot reported that the wing tanks contained about 20 gallons per side and that he departed with the right tank selected. During takeoff, about 100 ft agl and near the end of the runway, they experienced a sudden loss of engine power. The instructor pilot took control of the airplane, lowered the nose, and extended the flaps for the off airport forced landing. The airplane touched down on snow-covered terrain, impacting brush as it came to rest after about 80 feet of sliding. The pilots and passenger egressed the airplane and the fuselage sustained substantial damage. The airport elevation at O39 is 5,306 ft above mean sea level (msl) and the density altitude at the time of the accident was calculated to be 5,084 ft msl. A video recording with sound was provided by the pilot and it showed an over-the-shoulder view of both front seat occupants of the airplane. The video showed the airplane traveling down the runway and then the airplane starting to pitch up. The left-seated instructor pilot stated, “yeah pull it off come on.” As the instructor pilot called for rotation, the primary flight display (PFD) displayed a yellow caution message, and a tone was audible. The PFD annunciated in yellow: STALL WARN COLD PITOT COLD. The yellow caution remained for the rest of the recording until the camera’s view was changed at impact. As the airplane began to climb out there were no anomalies noted on the multi-function display (MFD). The airspeed increased to 80 knots and the airplane continued to climb and accelerate. The PFD showed the pitch attitude was about 14° nose up at an airspeed of 85 knots and an altitude of 5,300 ft msl. Soon after, the manifold pressure, RPM, and exhaust gas temperatures (EGT) for all cylinders began a rapid decrease. At this time, the airspeed was about 87 knots and the airplane’s pitch attitude was about 12.5° nose up. The instructor pilot took control of the airplane and entered a left bank and began flying toward a gravel road. The PFD showed the airplane was about 10° nose up, in about a25° left bank, at an airspeed of 74.5 knots, and at an altitude of 5,370 feet msl. The pilot brought the airplane to wings level as the airplane approached the gravel road and he flared the aircraft before impacting the terrain. During the postaccident examination of the wreckage, the right induction tube, which connects the turbocharger compressor outlet to the intercooler inlet, was found separated from the turbocharger compressor outlet flange. The examination revealed that two inches of the induction tube was installed into the 3-inch-long rubber coupling, leaving only 1 inch remaining to be installed on the turbocharger compressor outlet flange. The lower rubber coupling, and band clamps remained attached to the induction tube. A required heat shield was not attached to the lower clamps. Figure 1.Right side induction tube and rubber coupling. The left side induction tube connecting the turbocharger compressor outlet to the intercooler inlet remained attached to both. The required heat shield was attached to the lower clamps. The engine was installed on a test stand and it ran successfully at various RPM settings. The engine test run revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Maintenance records indicated that the last 100-hour inspection was performed on January 26, 2022. During this inspection the induction tubes would have been removed and inspected. Continental Motors Service Bulletin SB94-3A states the following, “WARNING…Loss of induction system coupling will result in a loss of turbo boost and subsequent loss of engine power.” According to Title 14 Part 43 Appendix D, during an annual inspection, lines, hoses, and clamps should be checked “for leaks, improper condition and looseness” and all systems should be checked for “improper installation, poor general condition, defects, and insecure attachment.” -
Analysis
The instructor pilot reported that during takeoff about 100 ft above ground level (agl) and near the end of the runway, the engine sustained a sudden loss of engine power. The pilot lowered the nose and extended the flaps for the off-airport forced landing. The airplane impacted the snow-covered terrain. Postaccident examination of the airplane indicated that the right induction tube connecting the turbocharger compressor outlet to the intercooler inlet had separated from the turbocharger compressor outlet flange. Two inches of the induction tube was installed into the 3-inch-long rubber coupling, leaving only 1 inch remaining to be installed on the turbocharger compressor outlet flange. It is likely that when the engine was at high RPM during the takeoff climb, the improperly installed lower rubber coupling separated from the turbocharger compressor outlet flange, resulting in the loss of engine power. The engine was installed on an engine test stand and it ran successfully at various RPM settings. The engine test run revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Maintenance records indicated that the last 100-hour inspection was performed two days before the accident. During this inspection the induction tubes would have been removed and inspected.
Probable cause
The inadequate maintenance and inspection of the engine induction system, which resulted in the separation of the right induction tube from the turbocharger compressor outlet and the subsequent loss of engine power during departure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Textron Aviation
Model
TTX Inc. T240
Amateur built
false
Engines
1 Reciprocating
Registration number
N420WT
Operator
SarkAir Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
T24002124
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2022-02-12T19:33:30Z guid: 104575 uri: 104575 title: WPR22FA087 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104567/pdf description:
Unique identifier
104567
NTSB case number
WPR22FA087
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-29T17:02:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-02-08T03:17:57.334Z
Event type
Accident
Location
Salem, Oregon
Airport
MCNARY FLD (SLE)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
A review of FAA Automatic Dependent Surveillance -Broadcast (ADS-B) data revealed that the airplane departed SLE on runway 34 about 4 minutes before the accident and the airplane remained in the airport’s left traffic pattern. The airplane’s flight track indicated that the airplane was established on the final leg of the airport traffic pattern and initiated an approach to runway 34. ADS-B radar returns indicated that the airplane crossed the runway 34 threshold about 175 ft above ground level (agl). The airplane’s ground speed indicated 70 knots as it continued the descent to 150 ft agl, traveling about 660 ft beyond the threshold. Radar returns indicated that during the last seconds of the flight, the airplane ascended to 200 ft agl, at a ground speed of 53 knots, and remained at 200 ft agl until the ground speed decreased to 46 knots, and a subsequent left roll ensued. The last radar return captured in the ADS-B data indicated the airplane’s altitude was 200 ft agl, at a ground speed of 44 knots, about 1 second before impact. - A review of the airplane’s engine logbook indicated that the last annual inspection was completed 51.9 hours before the accident flight. A subsequent inspection and service was conducted 15.6 hours before the accident flight, which included an oil change and cleaning of the oil suction screen. According, to an invoice and maintenance entry that had not yet been annotated within the logbook, an engine data monitor (EDM) was installed in the accident airplane 1.5 hours before the accident flight. According to the EDM non-volatile memory (NVM) data files, the accident flight was the second flight since the EDM was installed. Additionally, maintenance records indicated that about the same time that the EDM was installed, maintenance was performed to repair the autopilot pitch servo. The invoice work order indicated that the servo starting voltage and servo motor resistance, “were very much out of limits.” The servo was removed, sent out for repair, reinstalled and cable tensions were set. Subsequently, an operational check was conducted and verified on the ground. A review of the airplane’s airframe logbook indicated that a dual yoke assembly was installed in the airplane during the last annual inspection. However, examination of the airplane revealed that a single throw-over yoke remained installed. - The airplane was equipped with an engine data monitor (EDM). The glass panel engine monitor records data using non-volatile (NVM) memory. The NVM data was downloaded from the device which contained the engine parameters of the accident flight, as well as previous flights. The data indicated that normal engine operation parameters were sustained through the entirety of the accident flight in the traffic pattern. The fuel flow, fuel pressure and engine revolutions per minute did not increase while the airplane was on short final or during the last seconds of the accident flight. The engine exhaust gas temperature and cylinder head temperatures indicated a consistent and continual decrease, throughout the approach. The devices global positioning satellite function was not operational during the accident flight or any previous flight according to the NVM data files. However, the NVM data indicated that the outside air temperature during the accident flight was about 9° C, which was consistent with the reported temperature at the accident airport during the time of the accident. The devices NVM data from the accident flight log indicated a total flight time of 4.2 minutes, which was consistent with the airplane’s ADS-B radar data returns. The device’s NVM data indicated that at the start of the accident flight, the left tank fuel quantity was 14 gallons in the main, and 6.1 gallons in the left auxiliary fuel tank. The right main fuel tank contained 17.8 gallons and the right auxiliary fuel tank contained 8.8 gallons of fuel at the start of the accident flight, according to the NVM data. - On January 29, 2022, about 1502 Pacific daylight time, a Beechcraft K35 Bonanza, N9530R, sustained substantial damage when it was involved in an accident near Salem, Oregon. The private pilot and the passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Air traffic control (ATC) recordings confirmed the airplane departures the McNary Field Airport (SLE), Salem, Oregon, about 1458. The SLE weather at the time of the accident was identified as wind 050° at 3 knots, visibility 10 statute miles, with clear skies. The pilot requested to stay in the traffic pattern, and the tower controller instructed the pilot to remain in left closed traffic, subsequently clearing the pilot for takeoff on runway 34. The pilot took off, remained in the traffic pattern, and was cleared by the tower controller to land runway 34. Before touching down on the runway, the tower controller observed the airplane suddenly pitch up and enter a near vertical climb. Subsequently, the airplane veered left and entered a near vertical descent. The airplane impacted the ground, in a near vertical nose-down attitude. The ATC recording of the tower controller’s communication with the pilot revealed that no emergency declaration radio call was transmitted during the sequence of events leading up to the accident. - The Marion County Coroner’s Office, Clackamas, Oregon performed an autopsy on the pilot. The autopsy report listed the cause of death as “generalized blunt force trauma,” and the manner of death was an accident. The Federal Aviation Administration Forensic Toxicology Report was negative for all substances tested. No evidence of pilot incapacitation was identified. - A review of pilot logbooks indicated that the left seat occupant was an Federal Aviation Administration (FAA) certificated private pilot. The right seat occupant had received some flight training in 1993, and during the months before the accident flight had logged 2.7 flight hours of dual flight instruction with an FAA certificated flight instructor. The occupant in the right seat did not possess a FAA student pilot certificate. - The airplane sustained substantial damage to the cabin, forward and aft fuselage, and both wings. The airplane wreckage was located in the grass safety area on the left side of runway 34. The airplane’s left wing impacted the ground about 17 ft from the asphalt runway, as confirmed by the red position light lens fragments that marked the initial point of impact. The airplane’s nose cone, propeller, and engine impacted the ground about 32 ft west of the asphalt runway. The airplane’s nose cone was imbedded into the ground about 10 inches, and two propeller blades were located with the propeller hub. One propeller blade separated from the hub and was found in the impact crater. The engine remained attached to the firewall and main wreckage, which consisted of the fuselage, both wings with the left and right main landing gear attached, and the empennage. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The nose landing gear sustained impact damage, but the left and right main landing gear were extended and locked. The leading edges of both wings were crushed aft with virtually symmetrical impact damage. The left and right flaps were fully extended at 30° and the aileron direct cables were intact from the wing bellcranks to the control chain sprocket in the cockpit. The aileron chain was separated at the sprocket with evidence of the chain being pulled apart. The left aileron wing bellcrank arm attached to the interconnect cable was fractured at the bellcrank. No evidence of fatigue was observed in the fracture surface. The pitch trim actuator revealed a 15° down position. The elevator tab limits are 4.5° tab up, to 23° tab down. The ruddervator cables were continuous from the cockpit controls to the control surfaces. The left and right ruddervators, and the elevator trim tabs did not sustain impact damage. -
Analysis
The pilot of the accident airplane departed the runway, stating that he was planning to remain in the traffic pattern. The pilot was then cleared to land; on the final approach, after crossing the runway threshold and just before the airplane touched down the airplane pitched up, ascended about 50 ft, and subsequently rolled left before entering a near-vertical descent and then impacting the ground. The airplane’s autopilot was repaired 1.5 flight hours before the accident flight, wherein the auto-pilot pitch servo was sent out for repair, reinstalled, and cable tensions were set. Subsequently, an operational check was conducted, which verified proper installation on the ground. The autopilot pitch servo capability is exhausted by a pitch hold setting, meaning that inadvertent activation would merely maintain the airplane’s present pitch profile at the time of activation. Postaccident examination of the pitch trim actuator revealed a 15° tab down position. The elevator tab limits are 4.5° tab up, to 23° tab down. While the pitch servo had been recently installed, it is not likely that the autopilot was engaged in the airport traffic pattern and specifically during landing. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The cause of the abrupt nose-up pitch attitude during landing could not be determined. Pilot incapacitation was not a factor in this accident.
Probable cause
The airplane’s excessive nose-up pitch attitude during landing for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
K35
Amateur built
false
Engines
1 Reciprocating
Registration number
N9530R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-6077
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-08T03:17:57Z guid: 104567 uri: 104567 title: WPR22LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104574/pdf description:
Unique identifier
104574
NTSB case number
WPR22LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-30T16:30:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-02-01T00:21:27.536Z
Event type
Accident
Location
Ketchum, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 30, 2022, about 1430 mountain standard time, an experimental amateurbuilt Just Aircraft Superstol, N8794G, was substantially damaged when it was involved in an accident near Ketchum, Idaho. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.    The pilot reported that the engine lost total power while the airplane was in cruise flight at an altitude of about 9,000 ft mean sea level (about 1,500 to 2,000 ft above ground level) over mountainous terrain. The pilot switched fuel tanks and applied carburetor heat but was unable to restore engine power. As a result, the pilot initiated a forced landing to a snow-covered field. During the landing roll, the main landing gear tires settled into the snow, and the airplane nosed over. The pilot’s postaccident examination of the airplane revealed that the vertical stabilizer, rudder, and right-wing lift strut were structurally damaged. The pilot later reported that he thought the loss of engine power was due to carburetor ice. The pilot added that he examined the engine and observed no preimpact mechanical failures or malfunctions that would have precluded normal operation. The pilot stated that the airplane had “flown through a layer” that “had the right temperatures that would have quickly developed carburetor ice, which led to the loss of engine power.” -
Analysis
During a local area flight, while the airplane was in cruise flight at an altitude of about 9,000 ft mean sea level over mountainous terrain, the engine lost power. The pilot attempted to troubleshoot the problem, but he was unable to restore engine power. As a result, the pilot initiated a forced landing to a snowcovered field. During the landing roll, the main landing gear tires settled into the snow, and the airplane nosed over and came to rest inverted. The vertical stabilizer, rudder, and right-wing lift strut were substantially damaged. The pilot reported that his postaccident examination of the engine and airframe found no mechanical issues. The pilot thought that the airplane “flew through a layer” that “had the right temperatures that would have quickly developed carburetor ice.”
Probable cause
The total loss of engine power due to carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BLAKE D BARRYMORE
Model
JUST ACFT SUPERSTOL
Amateur built
true
Engines
1 Reciprocating
Registration number
N8794G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JA515-12-17
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-01T00:21:27Z guid: 104574 uri: 104574 title: ERA22LA112 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104580/pdf description:
Unique identifier
104580
NTSB case number
ERA22LA112
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-01-31T15:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-03-31T17:29:48.913Z
Event type
Accident
Location
Palm Coast, Florida
Airport
FLAGLER EXEC (FIN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On January 31, 2022, about 1253 eastern standard time, a Cessna 195 Airplane, N597K, was substantially damaged when it was involved in an accident near Palm Coast, Florida. The pilot and pilot-rated passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Spruce Creek Airport (7FL6), Daytona Beach, Florida, about 1239, destined for Flagler Executive Airport (FIN), Palm Coast, Florida. The pilot stated that before the flight, he performed a normal preflight inspection and flight planning for the flight from 7FL6 to FIN. The pilot advised that he did not take on any fuel as he had enough for the intended flight. After boarding the airplane, the pilot started the engine. The start was normal, and all the instruments indicated everything was normal. He taxied to runway 24 for takeoff, and while short of the runway he ran the engine at idle for about 5 minutes and verified all instruments were normal. Upon entering the runway for takeoff, he performed a complete run-up procedure and no abnormality was observed. He took off, and upon reaching 1,000 feet above msl, he configured the airplane for cruise. About 5 miles south of FIN, the engine lost power. The propeller continued to windmill, but produced no power. The pilot attempted to restart the engine without success. The pilot declared an emergency and informed ATC that he would be landing on Interstate 95 (I-95). While approaching and setting up for landing on I-95, the passenger informed the pilot that he had a semi-trailer truck on his right-side, so the pilot tried to maneuver to his left as much as possible. The right wing then contacted the truck, at which point the pilot lost control. The airplane cartwheeled and came to rest inverted off the right side of I-95. According to the passenger, while the pilot performed the preflight inspection of the airplane the passenger chatted with some other pilots in the hangar; he did not see the pilot performing the preflight inspection of the airplane. After the preflight was complete, the pilot assisted the passenger in boarding the airplane and getting buckled into the 5-point harness. After engine start, the pilot paused for about 5 minutes to warm up the engine oil and then performed an engine runup. Everything seemed normal. After takeoff, they turned north towards FIN and climbed to 1,000 feet. As they were approaching the area of the airport, the pilot contacted the control tower. Then they turned east towards the ocean, and the passenger started to talk about how nice it was. While he was speaking, the engine “rumbled,” and it was as if the pilot had throttled back. But the pilot said right away, “I did not do that” and turned towards the north. At this time, they were about 800 feet in altitude. The pilot immediately committed to landing on I-95, as there were trees everywhere, and told the control tower that “We will be on the highway.” When they were getting ready to land on the highway, the passenger pointed out a truck. When they touched down, they hit the truck. The passenger then closed his eyes as the impact was very violent. When they came to rest, they were upside down and he was “dangling upside down.” The passenger said that he was worried about fire, and they tried to immediately get out of the airplane. Once the passenger was out of the airplane, he did not see any fire or smoke, and there was no smell of fuel. The passenger advised that a lot of pilots from 7FL6 would go to FIN for lunch and to buy fuel, as it was about 50-cents-per-gallon cheaper than at 7FL6. He believed that the pilot was planning to get fuel there. The passenger also advised that after the accident the pilot was “absolutely confident” that he enough fuel for the 20-minute flight, and that the pilot said his fuel totalizer showed 23 gallons. According to the lead recovery specialist, during the wreckage recovery, there was no smell of fuel on scene, except for a slight smell of fuel near the engine. Additionally, no fuel was recovered from the airplane. The airplane was equipped with an onboard engine monitor that recorded exhaust gas temperature (EGT), cylinder head temperature (CHT), and shock cooling rate. The engine monitor’s device time was programmed by the pilot. The airplane’s onboard engine monitor was downloaded by the National Transportation Safety Board (NTSB) Recorders Laboratory. The data extracted included 21 sessions from April 15, 2021, through January 31, 2022. All parameters were recorded at a rate of one sample every six seconds. The accident flight was the last flight of the recording, and its duration was approximately 25 minutes. The device began recording at an approximate device time (dt) of 12:42:46. The last recorded parameter was as at 13:07:40 dt on January 31, 2022. Review of the extracted data from the accident flight indicated that after 13:06:00 dt, the EGT rapidly decreased, the shock cooling rate rapidly increased, and the CHT rapidly decreased. The fuel totalizer would have measured with high resolution the amount of fuel that flowed into the engine. Before the flight, though, the pilot would have had to enter into the unit the known quantity of fuel aboard, and then it would keep track of all fuel delivered to the engine. Examination of the airplane and engine revealed no preimpact malfunctions or failures that would have precluded normal operation. Additionally, the fuel strainer and the carburetor float chamber were absent of fuel. -
Analysis
The pilot and the pilot-rated passenger departed their home airport to fly to a nearby airport about 20 minutes away. The pilot stated that he did not add any fuel to the airplane before the flight, as he thought he had enough fuel for the intended 20-minute flight. He reported that before takeoff everything was normal. He took off, and upon reaching 1,000 feet above mean sea level (msl), he configured the airplane for cruise. The airplane was operating normally when, about 5 miles from the destination airport, the engine lost power. The propeller continued to windmill, but it produced no power. He attempted to restart the engine without success. The pilot declared an emergency and informed air traffic control (ATC) that he would be landing on an interstate. During the forced landing, the airplane’s right wing contacted a truck, and the airplane came to rest inverted off the right side of the interstate, incurring substantial damage. The passenger said that he was worried about fire, and immediately tried to get out of the airplane. Once the passenger was out of the airplane, though, he did not see any fire or smoke, and there was no smell of fuel. During the wreckage recovery, there was also no smell of fuel at the accident scene, with the exception of a slight smell of fuel near the engine. Additionally, no fuel could be recovered from the airplane. The postaccident examination of the airplane and engine also revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Additionally, the fuel strainer and the carburetor float chamber were absent of fuel. An engine monitor was installed on the airplane that recorded exhaust gas temperature (EGT), cylinder head temperature (CHT), and shock cooling rate. During the accident flight, it recorded a rapid decrease in EGT, a rapid increase in shock cooling, and a rapid decrease in CHT, all of which in combination were indications that were consistent with of a loss of fuel flow. The passenger stated that after the accident the pilot was “absolutely confident” that he had enough fuel for the 20-minute flight, and that the pilot said his fuel totalizer showed 23 gallons. However, the airplane’s fuel totalizer required that a known fuel quantity be programmed at the beginning of the flight. If an accurate quantity had not been entered by the pilot at some previous point, the information indicated by the fuel totalizer would not have been correct. Based on the available information, it is likely that the loss of power was due to the fuel system containing little or no usable fuel, as no fire occurred during the impact sequence, the passenger did not observe fire or smell fuel when he egressed, no fuel was able to be recovered on-scene during the wreckage recovery, the fuel strainer and carburetor float chamber were absent of fuel, and examination of the engine revealed no evidence of any preimpact failures or malfunctions which would have precluded normal operation. The circumstances of the accident were consistent with a total loss of engine power due to fuel exhaustion, which resulted from the pilot’s inadequate fuel planning and preflight inspection.
Probable cause
The pilot’s inadequate fuel planning and preflight inspection, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
195
Amateur built
false
Engines
1 Reciprocating
Registration number
N597K
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7403
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-31T17:29:48Z guid: 104580 uri: 104580 title: ERA22FA114 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104587/pdf description:
Unique identifier
104587
NTSB case number
ERA22FA114
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-01T12:06:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-02-07T23:22:38.798Z
Event type
Accident
Location
Danville, Virginia
Airport
Danville Regional Airport (DAN)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
FAA Carbon Monoxide and Exhaust System Guidance On November 24, 1972, the FAA issued advisory circular (AC) 20-32B "Carbon Monoxide (CO) Contamination in Aircraft—Detection and Prevention." The AC provided information on the potential dangers of carbon monoxide contamination from faulty engine exhaust systems or cabin heat exchangers. It also discussed means of detection and procedures to follow when contamination is suspected. In October 2009, the FAA issued report DOT/FAA/AR-09/49, "Detection and Prevention of Carbon Monoxide Exposure in General Aviation Aircraft." The report documented research on detection and prevention of CO exposure in general aviation aircraft, with the objective of identifying exhaust system design issues related to CO exposure, evaluating inspection methods and maintenance practices with respect to CO generation, and the identification of protocols to quickly alert users to the presence of excessive CO in the cockpit and cabin. On March 17, 2010, the FAA published Special Airworthiness Information Bulletin (SAIB) CE-10-19 R1. It recommended that owners and operators of general aviation aircraft consider the information in the DOT/FAA/AR-09/49 report and use CO detectors while operating their aircraft. The SAIB also recommended a cabin CO level check during every 100-hour or annual inspection, along with continued inspection of the complete engine exhaust system during 100-hr or annual inspections and at inspection intervals recommended by the aircraft and engine manufacturers in accordance with the applicable maintenance manual instructions. On August 16, 2010, the FAA also published SAIB CE-10-33R1, which reiterated the recommendation to use CO detectors as documented by SAIB CE-10-19R1. It recommended the replacement of mufflers on reciprocating engine-powered airplanes that use an exhaust system heat exchanger for cabin heat with more than 1,000 hours time-in-service (TIS) and at intervals of 1,000 hours TIS. It further recommended following guidance for exhaust system inspections and maintenance provided in SAIB CE-04-22, dated December 17, 2003, and AC 43-16A, Aviation Maintenance Alert, issued October 2006. The FAA also recommended continuing to inspect the complete exhaust system during annual inspections and at intervals recommended by the aircraft and engine manufacturers. SAIBs are for information only, their recommendations are not mandatory. Likewise, compliance with manufacturer-issued service letters is not mandatory. National Transportation Safety Board (NTSB) CO and Exhaust System Guidance On December 20, 2021, the NTSB called on the FAA a second time to require carbon monoxide detectors in general aviation aircraft. In June of 2004, the NTSB issued Safety Recommendation A-04-28 to the FAA to require installation of CO detectors in all single-engine airplanes with forward-mounted reciprocating engines. The FAA declined to require detectors and instead recommended that general aviation airplane owners and operators install them on a voluntary basis. The FAA also recommended exhaust system inspections and muffler replacements at intervals they believed would address equipment failures before they led to CO poisoning. Because the FAA did not require installation of CO detectors, Safety Recommendation A-04-28 was classified by the NTSB as "Closed – Unacceptable Action." On January 20, 2022, NTSB Recommendation A-22-001 called on FAA to require that all enclosed-cabin aircraft with reciprocating engines be equipped with a carbon monoxide detector that complies with an aviation-specific minimum performance standard with active aural or visual alerting. Additionally, Recommendation A-22-002 called on the Aircraft Owners and Pilots Association and Experimental Aircraft Association to inform their members about the dangers of CO poisoning in flight and encourage them to 1) install CO detectors with active aural or visual alerting and 2) proactively ensure thorough exhaust inspection during regular maintenance. The Recommendation identified 31 accidents between 1982 and 2020 attributed to CO poisoning. Twenty-three of those accidents were fatal, killing 42 people and seriously injuring four more. A CO detector was found in only one of the airplanes and it was not designed to provide an active audible or visual alert to the pilot, features the NTSB recommended in 2004. In each of these accidents, the pilot was not alerted to CO entering the cabin in enough time to counteract the effects of CO poisoning. - Review of maintenance records revealed that the airplane’s overhauled engines and propellers had accumulated 18.6 hours of operation before the accident. The airplane was equipped with an adhesive, disposable “spot” carbon monoxide (CO) detector. In the presence of CO, the spot would turn gray/black, and the spot would return to normal color after it is exposed to fresh air. The Pilot’s Operating Handbook (POH) and airplane checklist required the fuel selectors to be placed in the "main" position for takeoff. In the event of an engine failure during takeoff, the POH directed the pilot to feather the inoperative propeller and establish a 5° bank into the operating engine. With an engine shut down, in addition to the reduction in available power, the lateral/directional handling qualities of the airplane change significantly, and the indicated airspeed must be maintained faster than the Vmc of 80 knots to maintain directional control. The complete POH checklist for an engine failure after takeoff includes the following: 1. Mixtures - AS REQUIRED for flight altitude. 2. Propellers - FULL FORWARD. 3. Throttles - FULL FORWARD. 4. Landing Gear - CHECK UP. 5. Inoperative Engine: a. Throttle - CLOSE. b. Mixture - IDLE CUT-OFF. c. Propeller - FEATHER. 6. Establish Bank - 5° toward operative engine. 7. Wing Flaps - UP, if extended, in small increments. 8. Climb To Clear 50-Foot Obstacle - 92 KIAS. 9. Climb At Best Single-Engine Rate-of-Climb Speed - 106 KIAS at sea level 10. Trim Tabs - ADJUST 5° bank toward operative engine with approximately ½ ball slip indicated on the turn and bank indicator. 11. Cowl Flap - CLOSE (Inoperative Engine). 12. Inoperative Engine - SECURE as follows: a. Fuel Selector - OFF (Feel For Detent). b. Auxiliary Fuel Pump - OFF. c. Magneto Switches - OFF. d. Alternator - OFF. 13. As Soon As Practical - LAND. Cabin Heat System Review of maintenance records revealed that the cabin heat system was installed in December 2019 at an airframe total time of 5,878.3 hours. Records show that it was serviced and inspected in February 2020, April 2020, and January 2022. It had accrued 317.2 hours in service at the most recent servicing. - On February 1, 2022, about 1006 eastern standard time, a Cessna 310R airplane, N622QT, was destroyed when it was involved in an accident near Danville, Virginia. The commercial pilot was fatally injured. The airplane was operated by Sol Aerial Surveys as a Title 14 Code of Federal Regulations Part 91 aerial surveying flight. According to another company pilot, on the morning of the accident, he and the accident pilot arrived at the Danville Regional Airport (DAN), Danville, Virginia, conducted their flight planning together, and completed the preflight inspections of their respective airplanes. They then taxied their airplanes to runway 2 for engine run-up and surveying computer start-up. During the taxi and engine run-up, the accident airplane was heading 196º true (205° magnetic). The company pilot estimated that the accident pilot was on that heading for about 8-10 minutes while they completed these pre-departure tasks. The company pilot departed first, and the accident pilot departed several minutes later at 1003. A performance study was prepared based on automatic dependent surveillance-broadcast (ADS-B) data obtained from the Federal Aviation Administration (FAA). The study and ADSB-B data showed that that the airplane departed DAN and turned toward the southeast. Shortly after takeoff, the airplane’s climb rate decreased from 1,200 ft/minute to about 500 ft/minute, and the airplane’s acceleration stopped. The airplane reached an altitude of about 2,625 ft above mean sea level (msl) about 2 minutes into the flight and began a 10°-bank-angle left turn at an airspeed of 136 knots. About 10 seconds after turning left, the airplane returned to wings-level and then rolled right at a rate of about 3º/second while descending at a rate of more than 1,000 ft/minute. The last estimated bank angle was over 60° to the right at an altitude of 1,175 ft msl. The airplane impacted a wooded area about 4 nautical miles southeast of DAN. - The Commonwealth of Virginia Office of the Chief Medical Examiner, Western District, performed the pilot’s autopsy. According to the autopsy report, the cause of death was blunt force trauma of the head, torso, and extremities, and the manner of death was accident. The Virginia Department of Forensic Science (DFS) performed toxicological testing of postmortem pooled cavity blood from the pilot. Ethanol was detected at 0.012 g/dL. Carboxyhemoglobin, a marker of CO exposure, was elevated at 31%, as measured by spectrophotometry with confirmation by microdiffusion. The FAA Forensic Sciences Laboratory also performed toxicological testing of pooled cavity blood from the pilot. Ethanol was not detected at a reporting threshold of 0.01 g/dL. Carboxyhemoglobin testing was performed on five specimens using spectrophotometry. For three of these specimens, carboxyhemoglobin was not detected at a reporting threshold of 10%. The remaining two specimens were unsuitable for measuring carboxyhemoglobin. Postmortem ethanol production is made more likely by extensive traumatic injury and can cause an affected toxicological specimen to test positive. Carboxyhemoglobin is formed when CO binds to hemoglobin in blood, impairing the blood’s ability to deliver oxygen to body tissues (hypemic hypoxia). CO is an odorless, tasteless, colorless, nonirritating gas that can be produced during hydrocarbon combustion. Exposure to CO usually occurs by inhalation of smoke or exhaust fumes. Symptoms of low-level CO exposure are nonspecific and variable, and may include headache, nausea, and tiredness. Increasing levels of exposure may become impairing or incapacitating, causing more serious neurocognitive, cardiac, and/or vision problems, progressing to death above carboxyhemoglobin levels of about 50% (or lower if other serious medical conditions co-exist), although symptoms are not simply predictable from carboxyhemoglobin levels. Nonsmokers normally have carboxyhemoglobin levels of less than 1-3%, while heavy smokers may have levels as high as 10-15%. As with other causes of tissue hypoxia, CO poisoning may be insidious and difficult for an exposed person to recognize; there is no reliable physical sign of exposure. - According to the operator, the pilot had previously flown aerial surveying and had accrued 85 hours of flight experience in the same make and model of the accident airplane. The accident flight was his first solo aerial surveying flight for the company following several observation flights with the company’s owner. Interviews with friends and family of the pilot revealed that he was happy to have been hired by the operator, got along well with the company’s owner, and was pleased that the company’s airplanes were newer and better equipped than those at his previous surveying job. - After the accident, electronic CO detectors were installed in the operator’s fleet. Research was conducted by the operator at the investigator’s request to determine if the engine exhaust could penetrate the cockpit under the specific conditions that were present on the day of the accident. The goal of the research was to determine the ability of CO to enter the cockpit from the engine exhaust during taxi and engine run-up in similar wind conditions and relative wind. On the day of the of the accident, the reported wind was from 060° true at 7 kts, and the airplane’s engines were started on the ramp, where the airplane then taxied to the run-up area of runway 2 for run-up and surveying computer start-up. During this taxi and subsequent run-up, the accident airplane was heading 196º true (205° magnetic), and the relative wind to the airplane was a 44º left quartering tailwind, which would have blown the exhaust from the left engine toward the cockpit and heater air intake at the nose of the airplane. The airplane was on this heading for about 8-10 minutes according to the statement of another company pilot who taxied out in front of the accident airplane and conducted the run-up at the approach end of runway 2 while turned into the wind. During the test, the exemplar airplane (the same make/model as the accident airplane) was positioned so that the relative wind was also a quartering tailwind. The airplane was equipped with an electronic audible CO detector and the pilot video-recorded the test. The following is an excerpt from the pilot’s report: My startup and taxi time was "average". I taxied to runway 18 with the door cracked open and window open due to the heat that day. The heater was left off, including the fan. Neither were turned on. During the taxi, the electronic CO detector read "0" PPM the whole time. As I approached the run-up area, I closed the door and window. Once I got to the run-up area I angled, the airplane close to an east-northeast orientation to put the breeze off my right quartering tail based on the grass and other indicators. Almost immediately, I noticed the audible alarm on the CO detector going off. I looked over and could see the number on the CO detector rising through the 50-60 PPM range. . . it quickly rose above 100 PPM within the 17 second video. At the time, I was unsure what level would be harmful . . . I shut the video off so I could focus on clearing the cabin air. The number eventually climbed up to around 150-160 PPM before finally coming back down. There were very minor exhaust odors present during the high readings. Following this research, the operator noted that if the cabin heater had been on the day of the accident, when outside temperatures were 33° F, the heater fan would have drawn in air at the ventilation inlet on the front of the nose. This would have “pushed” the exhaust into the cabin. - The wreckage was highly fragmented along the 382-ft debris path oriented on a true heading of 246°. The accident site elevation was about 488 ft mean sea level. There was a strong fuel odor but no evidence of fire. The largest portion of the wreckage, consisting of the empennage, an engine, and the remnants of the cockpit was located about 214 ft beyond the severed treetops at the base of a 16-in-diameter pine tree that was broken about 15-20 ft above the ground. A second engine was located about 150 ft farther along the debris path. Neither the wings nor the fuselage was intact. The flap setting could not be determined. The landing gear were fractured off from their mounts and located in various parts of the debris field. The landing gear actuator indicated the nose and main landing gear were in the retracted position at the time of impact. The pitch trim actuator indicated the elevator trim tab trailing edge was about 10° tab up. Six propeller blades were recovered, all fractured from their mounts. All blades displayed impact damage, and some displayed leading-edge gouging, chordwise abrasion, twisting and aft bending. Postaccident wreckage examination was limited by a high degree of fragmentation. Examination of the wreckage revealed that no cockpit instruments were intact. The throttle control quadrant was impact-damaged with the left throttle near idle, the left propeller near feather, and the mixture set full rich for both left and right engines. Flight control continuity could not be confirmed for the elevators, rudder, and ailerons due to impact damage. The rudder trim actuator indicated that the rudder trim tab was about 14° right. The left fuel selector handle was found in the OFF position. The right fuel selector handle was found in the left main position. The left and right fuel selector valves were impact separated and had tumbled through the trees. The left fuel selector valve displayed a witness mark indicating it had been forced from the off position toward the auxiliary tank position. Both engines exhibited significant impact damage. Continuity of the crankshafts and camshafts on both engines was observed. Thumb compression was achieved for all but one cylinder on the right engine which was impact damaged. Examination of the cylinders using a lighted borescope revealed no anomalies to the pistons and valves. All magnetos sparked at all towers. All spark plugs which remained intact displayed normal coloration when compared to the Champion Check-A-Plug AV-27 chart. Oil filters were opened and found free of debris. Examination of both engines revealed no preimpact anomalies or malfunctions that would have precluded normal operation. Postaccident examination of the airplane’s heater assembly revealed that it was impact damaged and exhibited deformation of the outer casing, heat exchanger and combustor chamber sections as well as separation of some of the external accessories. The heater assembly did not exhibit any external fire or thermal damage. Detailed examination revealed that the welds and materials comprising the heater were intact and free of defects. A panel mounted engine data monitor was recovered and examined. The device broke apart during the accident sequence, and although data was recovered, it could not be determined whether this session correlated to the accident event. -
Analysis
The pilot was performing an aerial survey flight, and after completing a preflight inspection, he taxied toward the runway for engine run-up and surveying computer start-up. During taxi and the subsequent run-up, the airplane was positioned for about 8-10 minutes with a quartering tailwind. Track data revealed that shortly after takeoff, the airplane’s climb rate decreased, and its acceleration stopped. Shortly thereafter, the airplane began a 10°-bank-angle left turn at an airspeed of about 136 knots, followed by a rapidly descending right turn and impact with terrain. Postaccident examination of the wreckage revealed that the left fuel tank selector handle was in the OFF position, the left throttle was near idle, the left propeller control was near the feather position, and the rudder was trimmed to the right. These control positions were consistent with the left engine being partially secured, which would result in a lack of power and the loss of climb rate noted shortly after takeoff. Additionally, the right fuel tank selector handle was found in the left main fuel tank position. The examination of both engines revealed no evidence of any preimpact anomalies or malfunctions that would have precluded normal operation, and no reason for why the pilot might have partially secured the left engine. In the event of an engine failure during takeoff, the airplane manufacturer’s Pilot’s Operating Handbook (POH) assumes that the inoperative propeller is feathered and that 5° of bank toward the operating engine is used to balance the side force generated by a full rudder input. If these conditions do not exist, the airplane can quickly become uncontrollable at airspeeds much higher than the published single-engine minimum controllable airspeed (Vmc). The physical evidence, along with a performance analysis of the airplane’s flight track, showed that the left engine was not fully secured, the right engine fuel selector was set to the left tank, and the airplane banked 10° into the inoperative engine at an airspeed of about 136 kt shortly before the airplane entered a steep, descending right turn. This turn toward the inoperative engine would have dramatically increased the airplane’s minimum controllable airspeed above that assumed by the POH (80 knots), and the pilot's ability to maintain control of the airplane would have been significantly reduced. It is likely that during this left turn, the pilot allowed the airplane's airspeed to decrease below a speed for which the airplane would have been controllable, which resulted in a loss of control and led to the airplane's roll to the right and rapid descent toward the terrain. Postaccident toxicological testing performed by a state office of forensic science revealed that the pilot’s carboxyhemoglobin, a marker of carbon monoxide (CO) exposure, was elevated at 31%. Although the Federal Aviation Administration Forensic Sciences Laboratory toxicology results did not show elevated carboxyhemoglobin, these test results might have been misleadingly low if there was an actual postmortem decrease of carboxyhemoglobin in the tested blood. This may have occurred if the specimens were obtained from a collection site where blood intermixed with gastric acid. The carboxyhemoglobin percentage measured in the blood specimen tested by the state forensic science office was confirmed by a second distinct technique, and the probability is small that the elevated result was attributable to postmortem changes. Examination of the airplane’s combustion heater assembly revealed no defects that could have allowed the combustion biproducts to intermix with the ventilation air, and examination of the wreckage revealed no evidence of inflight or post-impact fire. A postaccident test with an exemplar airplane (the same make/model as the accident airplane) that was equipped with an electronic CO detector revealed that when taxiing and performing an engine run-up with a quartering tailwind, the exhaust from the left engine was able to penetrate the cockpit. Based on the observations from this test, it is possible that engine exhaust gasses containing CO could have entered the cockpit while the pilot was conducting his pre-takeoff tasks. Given that the airplane was equipped only with a disposable “spot” CO detector, the pilot would not have been alerted to increasing CO levels unless he had looked at the device and observed a color change. Given that the temperature on the day of the accident was 33° F, it is likely that the airplane’s heater was operating. It is possible that its fan could have drawn additional air containing engine exhaust gasses and CO into the cabin heater air intake, and then into the cockpit, which would have increased the pilot’s the level of CO exposure. No other source of abnormal CO was identified. Based on available operational and physical evidence, it is likely that the pilot was impaired due to CO exposure. It is possible that this impairment could have resulted in his perception of a left engine problem, and resulted in him partially securing it, as demonstrated by the postaccident positions of the engine controls. Ultimately, the turn into the partially secured engine resulted in a loss of control and impact with terrain.
Probable cause
The pilot’s impairment due to exposure to carbon monoxide as a result of undetected engine exhaust penetration into the cockpit, resulting in the pilot's failure to maintain a minimum controllable airspeed after partially securing an engine after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310
Amateur built
false
Engines
2 Reciprocating
Registration number
N622QT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
310R0828
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-07T23:22:38Z guid: 104587 uri: 104587 title: ERA22LA121 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104636/pdf description:
Unique identifier
104636
NTSB case number
ERA22LA121
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-01T14:30:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-03-04T09:41:55.928Z
Event type
Accident
Location
Crystal River, Florida
Airport
CRYSTAL RIVER-CAPT TOM DAVIS FLD (CGC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 1, 2022, at 1230 eastern standard time, a Piper PA46-350P, N35CM, was substantially damaged when it was involved in an accident in Crystal River, Florida. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during landing on the turf runway 18 at the Crystal River Airport (CGC), Crystal River, Florida, the airplane touched down near the beginning of the runway at a speed of about 70 knots. He applied normal braking, and the airplane drifted slightly right of centerline. He then applied “less right brake and more left rudder” and the airplane corrected back toward the runway centerline. After the speed reduced to “below 20 knots” the nosewheel suddenly collapsed. Tire marks on the runway near the end of the rollout veered toward the left. Examination of the accident site and airplane by a Federal Aviation Administration revealed that the airplane continued about 20 ft after the nose gear collapsed. The lower engine mount, to which the nose gear trunnion was attached, was substantially damaged. Remnants of grass were found along the circumference of the nose gear wheel, between the wheel rim and the tire. Airport personnel found a fractured bolt and fractured landing gear trunnion fitting on the runway. Examination of the fractures revealed that they were consistent with overload. The bolt exhibited features consistent with tension and bending. -
Analysis
After landing on the turf runway, the airplane drifted slightly to the right of the centerline and the pilot corrected with differential braking and left rudder, which brought the airplane back toward the centerline. When the speed reduced to less than 20 knots, the nose landing gear collapsed, and the lower engine mount was damaged. A landing gear trunnion bolt and fitting were found to have fractured consistent with overload, suggesting they fractured during the collapse rather than beforehand. Remnants of grass from the turf runway were found around the circumference of the right side of the nose landing gear wheel, between the wheel rim and the tire. This is consistent with a significant lateral load on the wheel from the right side, while the wheel was rotating (distributing grass around its circumference). Although it could not be determined when the lateral load occurred, the pilot reported correcting the airplane heading to the left during the landing roll, and tire marks showed the airplane veering left at the end of the landing roll. The lateral load on the nosewheel likely resulted in the overload failure of the trunnion bolt and fitting.
Probable cause
Collapse of the nose wheel landing gear assembly due to lateral loads encountered on the turf runway during rollout.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA 46-350P
Amateur built
false
Engines
1 Reciprocating
Registration number
N35CM
Operator
CRYSTAL MOTORSPORTS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4636708
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-04T09:41:55Z guid: 104636 uri: 104636 title: CEN22FA113 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104586/pdf description:
Unique identifier
104586
NTSB case number
CEN22FA113
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-01T15:40:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2022-02-04T02:55:06.882Z
Event type
Accident
Location
Heath, Ohio
Airport
NEWARK-HEATH (VTA)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 1, 2022, about 1340 eastern standard time, a Cessna 182T airplane, N716MC, was destroyed when it was involved in an accident near Heath, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. Flight track data retrieved from the pilot’s Foreflight account revealed that the airplane departed Zanesville Municipal Airport (ZZV), Zanesville, Ohio, at 1252. The airplane flew north about 22 nautical miles (nm) to Richard Downing Airport (I40), Coshocton, Ohio, where it appeared to complete a touch-and-go landing. The track then proceeded west about 27 nm toward Mt. Vernon, Ohio, where it made a few turns about 5 nm east of Knox County Airport (4I3). Finally, the airplane flew south about 21 nm to Newark-Heath Airport (VTA), Newark, Ohio. At 1338, the pilot completed a touch-and-go landing at VTA, then departed to the east. The airplane climbed to about 500 ft above ground level (agl), then descended to about 84 ft agl over a residential area. During the last 30 seconds of the flight, the airplane flew about 50 to 100 ft agl and about 145 knots (kts) groundspeed before the flight track ended. Figure 1 shows the approach and landing at VTA, then the subsequent takeoff and low-level flight until the impact with terrain. Figure 1. Google Earth overlay that depicts the accident flight path and points of interest. The labeled altitudes are ft above mean sea level with ft agl noted in parentheses. A witness at ZZV who interacted with the pilot before their respective flights stated that he seemed to be in a cheerful mood and in good health. The pilot told him that he planned to fly around locally for a little while to practice. They departed separately from ZZV. Later, the witness was on the ground at VTA, and observed the accident airplane approach runway 9 from the west. He stated that there was a direct crosswind from the south about 10 kts and the accident airplane approached with full flaps. The airplane made a hard landing, then he heard the engine advance to full power and reported that it sounded normal. The airplane climbed out slowly with full flaps and made a few “jerk like” small corrections in heading and altitude. A second witness at VTA watched the accident airplane land on runway 9, which was the opposite direction of the other departing traffic. He did not hear the accident pilot make any radio transmissions. The airplane approached with what appeared to be 30° flaps extended, and then made a “shaky landing” that appeared “hard enough to possibly damage the firewall.” The airplane departed and the “engine was making good power and sounded good.” The witness stated that the airplane appeared a bit “wobbly,” low, and that it was not climbing well. The wing flaps remained extended at least 30° until he could not see the airplane behind the hill to the east. A doorbell camera video along the accident route of flight, about 1 nm southwest of the accident site, showed the airplane flying at a low altitude with the wings relatively level. Another witness near the accident site observed the airplane flying west to east at a low altitude. He stated that the airplane was level with the flagpole at a nearby cemetery. The cemetery flagpole was located on the top of a hill about 230 yards from the beginning of the accident site. The top of the pole was estimated to be about 1,040 ft above mean sea level (msl). The flight track data showed that the airplane flew about 60 yards laterally from the flagpole about 1,026 ft msl (50 ft agl). - An autopsy of the pilot was performed by Office of the Coroner, Licking County Ohio, Newark, Ohio, which listed the cause of death as “blunt force injury to head, neck, and torso.” The FAA Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot. No drugs, carboxyhemoglobin, or ethanol were detected. Fexofenadine, and its metabolite azacyclonol, was detected. Fexofenadine (Allegra) is a non-prescription, non-sedating antihistamine used to treat seasonal allergies and is acceptable for pilots. This medication was not reported at the last physical exam. Warfarin was detected. Warfarin (Coumadin) is an oral anticoagulant used to treat blood clots or prevent new blood clots from forming especially around implanted devices such as artificial heart valves. Warfarin is conditionally acceptable for pilots and requires Special Issuance. This medication was not reported at the last physical exam. No medications were detected that would have posed a hazard to flight safety. - According to the pilot’s flight logbook, he logged 349.6 hours of total flight time before the accident. On September 28, 2020, he completed a prepurchase demonstration flight in the accident airplane. Since that date, the logbook entries were exclusive to the accident airplane and totaled 73.6 hours. A Federal Aviation Administration (FAA) inspector interviewed four flight instructors who had flown with the accident pilot between 2014 and October 2020. The pilot’s first flight instructor, who flew with the pilot during his initial private pilot training between 2014 and 2016, stated that he refused to endorse the pilot for solo flight due to concerns with his ability to remain focused on flying the airplane, his inability to land in any type of crosswind, and concerns that the pilot was unable to manage emergency or abnormal situations without assistance. The pilot’s second flight instructor reported that the pilot’s performance was “inconsistent,” that he was easily distracted from the task of flying the airplane, and that he would frequently “get behind the aircraft.” This instructor recommended the pilot for his private pilot practical test twice, with unsatisfactory outcomes. After the second practical test attempt, the pilot indicated to him that he was “going to stop flying and pursue other things.” The instructor was subsequently surprised to hear from the pilot in 2020 that he had received his private pilot certificate. The third flight instructor also described the pilot as inconsistent and stated that the pilot tended to fixate on instruments and drift off course and/or altitude. He stated that the pilot was consistently behind the aircraft and had difficulty with directional control. The fourth flight instructor, who flew with the pilot in the accident airplane, stated that he felt the pilot’s airmanship was “weak” and that he needed additional training. He also stated that he felt the pilot was “safe to operate the airplane in fair weather,” but was “behind the aircraft” and had issues with basic aircraft control. - The airplane impacted a wooded area in nose-low attitude. The initial tree impact was estimated to be about 50 ft high with corresponding airplane debris on the ground beginning near that point. Airplane components and tree branches were located on the ground and extended about 230 yards from the initial impact point toward the main wreckage. The right wing was found separated in the debris path about 70 ft from the initial tree impact. The right wing and other leading edge surfaces exhibited round indentations and impact damage consistent with tree contact. At least 30 tree branches were found on the ground that exhibited diagonal cuts and paint transfer consistent with propeller contact. Figure 2 shows a hole in the trees that corresponded to the downed branches and airplane wreckage debris. Figure 2. This photo was taken looking back toward the initial ground impact point (circled in yellow) and shows a hole in the trees above the debris field, circled in red. The hole in the trees corresponds with airplane debris and broken tree branches in the woods directly underneath. The airplane impacted the ground and continued across a road, where it collided with a metal guardrail before it descended an embankment and came to rest. A large portion of the left wing and the empennage separated from the airplane and remained next to the guardrail. The fuselage and engine were found beyond the embankment and among trees. The engine came to rest under a large tree that exhibited significant impact damage and associated cuts about 20 ft high. The front left seat separated from the fuselage seat rails and was located about 5 ft from the cockpit. The 3-point seatbelt remained buckled, and the webbing had been cut by first responders in multiple locations. The webbing exhibited stretching at the buckle, anchor point, and the inertia reel. Examination of the airframe revealed that all flight control cable ends remained attached to the respective controls. Flight control cable continuity was traced through multiple overload separations. The flap selector handle was found in the UP position. The flap actuator jackscrew corresponded to a fully retracted position. The engine displayed impact damage primarily to its bottom and left aft side. The No. 6 cylinder head separated from the cylinder barrel during impact. The No. 6 cylinder barrel remained attached to the crankcase. The cylinder barrel was damaged from the impact forces at the point where the cylinder head separated. A portion of the No. 6 cylinder head remained wedged with the cylinder barrel and No. 4 cylinder. The remainder of No. 6 cylinder was found beside the engine at the accident site. The three-bladed metal propeller remained attached to the crankshaft flange. One of the three blades separated from the propeller hub during impact. The second blade was missing the blade tip. All three blades displayed leading edge damage and S-shaped bends. The examination did not reveal any preimpact mechanical malfunctions or failure that would have precluded normal operation. -
Analysis
The pilot was completing a local flight to three nearby airports and was returning to the originating airport. According to witnesses, after a hard touch-and-go landing, the airplane flew east at low altitude with the flaps still extended. The recorded flight track data indicated that, after the landing, the airplane climbed to about 500 ft above ground level (agl), then descended to about 84 ft agl. A doorbell camera video about one nautical mile (nm) from the accident site showed the airplane flying at a low altitude (about 158 ft agl according to the flight track data) with the wings relatively level. Another witness near the accident site observed the airplane about level with a nearby flagpole at the top of a hill (about 50 ft agl). The airplane then made a gradual descent toward the ground. The airplane impacted a wooded area in a nose-low attitude. The 230-yard debris path comprised airplane components and tree branches. Many of the tree branches exhibited diagonal cuts and witness marks consistent with the engine producing power as the airplane descended through the trees. The airplane impacted the ground and continued across a road, where it collided with a metal guardrail before it descended an embankment and came to rest. Examination of the airframe and engine did not reveal any preimpact mechanical malfunctions or failure that would have precluded normal operation. The wing flaps were found retracted at the accident site. Four of the pilot’s flight instructors provided statements about his training history, piloting skills, and other concerns. Their statements were consistent in indicating that the pilot was easily distracted from the task of flying the airplane and tended to drift off course and altitude. The instructors indicated that the pilot was usually “behind the airplane” and had issues with basic airplane control. Based on the pilot’s training history and the accident circumstances, it is likely that the pilot was distracted and did not maintain a safe altitude, which resulted in an inadvertent collision with trees and terrain.
Probable cause
The pilot’s failure to maintain altitude after takeoff, which resulted in collision with trees and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182T
Amateur built
false
Engines
1 Reciprocating
Registration number
N716MC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18281717
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-04T02:55:06Z guid: 104586 uri: 104586 title: ERA22LA115 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104590/pdf description:
Unique identifier
104590
NTSB case number
ERA22LA115
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-02T08:55:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-02-17T00:00:52.322Z
Event type
Accident
Location
Ronkonkoma, New York
Airport
LONG ISLAND MAC ARTHUR (ISP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
The airplane was certificated under 14 CFR Part 23, effective February 4, 1991, including Amendments 23-1 through 23-42. Amendment 42 of 14 CFR Part 23.735, Brakes, effective February 4, 1991, specified that the, “Brakes must be able to prevent the wheels from rolling on a paved runway with takeoff power on the critical engine, but need not prevent movement of the airplane with wheels locked.” The airplane was equipped with a Pratt & Whitney Canada PT6A-67P engine. According to the Pilot’s Operating Handbook and EASA and FAA approved Airplane Flight Manual, the engine operating limits for takeoff are specified to be 1,200 shaft horsepower, 44.34 psi torque, 104% Ng, and 1,700 Np. A maximum transient Np value of 1,870 was allowed for 20 seconds. The PCL selects the required engine power (gas generator speed, specified as Ng) and in certain conditions it directly controls the propeller pitch. When the PCL is at the idle detent, Ng is at idle and the propeller is at minimum pitch. - On February 2, 2022, about 0655 eastern standard time, a Pilatus PC-12/47E, N357JK, was substantially damaged when it was involved in an accident at Long Island MacArthur Airport (ISP), Ronkonkoma, New York. The commercial pilot and a pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot stated that the ramp conditions where the airplane was parked for engine start consisted of spots of snow, slush, “and a spot of ice,” though he felt the ramp was safe. The pilot-rated passenger, who had accrued 252 hours in the airplane, performed the exterior preflight inspection for the anticipated positioning flight, reporting no airplane discrepancies. He then entered the airplane and closed the door, later reporting there were no PIREPs or NOTAMs for any adverse ramp condition(s). After the passenger joined the pilot in the cockpit, they used the manufacturer’s checklist to prepare for engine start. According to a summary of the cockpit voice recorder (CVR) recording, some under-the-breath comments similar in cadence to reading a checklist to oneself were heard, and portions of checklists were read out loud and challenged. There was no audible comment or challenge-and-response concerning the position of the power control lever (PCL) listed in the “Cockpit” checklist that immediately preceded the “Before Starting Engine” checklist. Although the PCL was specified to be in the idle position at engine start, and the pilot reported that it was in the idle position during the engine start, the data from the airplane’s flight data recorder (FDR) revealed that the PCL was not in the idle position for the entirety of recorded data; although the exact position could not be determined. The pilot applied the toe brakes and the parking brake while he engaged the engine starter switch and verified that the oil pressure was rising, and the compressor turbine (Ng) speed had increased to 13%. At 13%, based on the engine oil temperature and a note for a cold start in the “Engine Starting” checklist, he moved the condition lever (CL) to the flight idle position. He observed Ng increase and felt the airplane “lurching forward.” He pressed harder on the toe brakes, but the airplane continued forward while the engine, “spooled up.” FDR data indicated that the engine Ng, propeller speed (Np), and torque increased to maximum values of 95.1%, 1,870 rpm maximum for about 6 seconds, and 43.2 psi, respectively. While moving forward, the pilot attempted to secure the CL, but his thumb slipped off the cut-off guard. He looked down at the CL, then back outside, and noted the airplane was fast approaching a parked airplane, reaching a maximum groundspeed of about 26 knots based on FDR data. Surveillance video showed that the right wing of the Pilatus separated at the wing root after impacting the nose section of the parked, unoccupied airplane. The passenger assisted the pilot in securing the engine after impacting the airplane. - Postaccident examination of the cockpit by a Federal Aviation Administration (FAA) airworthiness inspector revealed that the parking brake was engaged, the PCL was in a forward position, the CL was in the cut-off position, and the manual override lever was in the off position. Postaccident operational testing of the left brake and parking brake revealed that both were operational with no discrepancies noted. Both main gear tires showed minor scuffing, but no flat-spotting. Because the right wing was separated, no testing of the right brake was performed. Postaccident examination of the ramp performed by an FAA airworthiness inspector about 1 hour after the accident revealed that it was wet with patches of snow and ice. Alternating skid marks consistent with the width of the main landing gear tires began about 50 ft from the reported parking spot and continued for 75 ft toward the nose of the impacted airplane. Inspection and examination of the engine controls, the throttle friction, the cut-off guard of the CL, and rigging checks of the engine controls were performed by the FAA airworthiness inspector using the appropriate sections of the airplane maintenance manual (AMM). No discrepancies were noted during the inspection of the engine controls, throttle friction device, or inspection and testing of the cut-off guard of the CL. A check of the engine control rigging revealed the maximum reverse stop at the center console was between 0.005 inch to 0.015 inch more than the clearance specified in the AMM, and the forward stop, also at the center console, was about 0.200 inch more than the value specified in the AMM. The rigging checks of the PCL and CL at the engine were within tolerances. The engine fuel control unit (FCU) was removed from the engine and shipped to the manufacturer’s facility for operational testing with NTSB oversight. According to a report from the FCU manufacturer, although multiple test points in the start and acceleration schedule were out of acceptance test procedure limits during testing as received, the reported out-of-limit tests points did not preclude normal operation of the FCU and did not contribute to the reported engine acceleration. According to the maintenance records, the most recent inspections were performed on January 20, 2022. An adjustment of the overspeed governor and inspection of the FCU linkage were performed during this time. The airplane was approved for return to service, and there was no maintenance performed to the airframe or engine between the numerous inspections and the accident date, accruing 16 hours over 10 flights. Recorded data from the FDR for the previous uneventful engine start, on January 30, 2022, performed by the pilot of the accident flight, revealed that with the PCL positioned to idle, the Ng, Np, and torque values increased to maximum values of 66.7%, 1,036 rpm, and 7.59 psi, respectively. Engine start testing was performed of an exemplar airplane, witnessed and video recorded by personnel from the FAA. During an engine start with the PCL in the idle position (correct per checklist) and the CL moved to the ground idle position at the appropriate percent Ng, the Np increased to about 963 rpm and with no brakes applied the airplane was “barely starting to move a little bit.” Additional testing was performed with the PCL at idle and the CL moved to the flight idle position, and with no brakes applied, the airplane moved forward slightly. -
Analysis
The pilot and a pilot-rated passenger were starting the engine before a positioning flight. The airplane’s cockpit voice recorder captured some checklist usage; however, there was no comment for the position of the power control lever (PCL) in the “Cockpit” checklist. Although the checklist specified and the pilot reported that the PCL was in the idle position at engine start, based on the flight data recorder (FDR) data, it was not in the idle position at any time during the engine start or accident sequence. After the engine was started with the parking brake engaged and the pilot’s application of normal toe brakes, the airplane accelerated on the ramp to a maximum speed of 26 knots and briefly attained a maximum propeller speed of 1,870 rpm, which was likely due to the cold engine oil temperature, but well within rpm and time limits. The pilot was unable to stop the airplane on the ramp, which likely contained ice, or to move the condition lever (CL) to stop the engine, and the airplane impacted a parked, unoccupied airplane, resulting in substantial damage. Although cockpit rigging checks of the PCL and CL showed out-of-tolerance conditions, rigging checks at the engine for those controls and for the cut-off guard of the CL in the cockpit revealed no evidence of preimpact failure or malfunction that would have precluded a normal engine start. There were no discrepancies with the fuel control unit that would have caused the engine acceleration issue at engine start, and there were no discrepancies with the parking brake or the left brake. Although testing of the right brake was not performed due to separation of the right wing, there was no evidence of preimpact failure or malfunction of the brakes or parking brake that contributed to the collision. While there was no flat-spotting of either main landing gear tire, alternating skid marks on the ramp were likely due to the ice on the ramp. Recorded data from a previous, uneventful engine start performed by the accident pilot with the PCL in the idle position revealed normal engine parameters. Testing of an exemplar airplane with the PCL in the correct position at engine start (idle) and the CL in either ground or flight idle positions during engine start revealed little forward movement with no brakes applied. The PCL was found in a forward position following the accident. Although the exact position of the PCL at engine start could not be determined from the FDR information, based on the maximum engine and propeller parameters recorded by the FDR, and the speed the airplane reached before the collision, it is likely that the PCL was nearly fully advanced during the engine start. Had the pilot performed a flow check then reviewed the checklists for any missed items or engaged the passenger to perform challenge-and-response to the entire checklist, the incorrect position of the PCL could have been detected and corrected before engine start. Though the pilot reported being unable to secure the CL while accelerating and approaching the parked airplane, there were no reported discrepancies with the cut-off guard, or of the CL during postaccident operational testing. Therefore, the pilot’s unsuccessful attempt to secure the CL were likely due to errors made while multitasking when presented with an unexpected situation (airplane acceleration during engine start and being unable to stop the airplane) while fast approaching a parked airplane.
Probable cause
The pilot’s failure to properly position the power control lever before starting the engine as required per the checklist. Contributing to the accident were the ice on the ramp and the pilot’s failure to secure the engine using the condition lever.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PILATUS AIRCRAFT LTD
Model
PC-12/47E
Amateur built
false
Engines
1 Turbo prop
Registration number
N357JK
Operator
ExcelAire, LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
1451
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-17T00:00:52Z guid: 104590 uri: 104590 title: WPR22LA093 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104616/pdf description:
Unique identifier
104616
NTSB case number
WPR22LA093
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-07T18:00:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2022-03-08T08:55:37.211Z
Event type
Accident
Location
Chemehuevi Valley, California
Airport
CHEMEHUEVI VALLEY (49X)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 7, 2022, about 1600 Pacific standard time, a Cessna 152, N6496L, was substantially damaged when it was involved in an accident at Chemehuevi Valley Airport, Chemehuevi Valley, California. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations instructional flight. The flight was the first time the student had flown solo, having just received an endorsement from his flight instructor earlier in the day. He stated that during the first solo landing, the airplane experienced a pronounced nose wheel shimmy after touchdown. He exited the runway and communicated the event to his flight instructor, who told him it was likely a result of excessive braking after touchdown. He then departed and performed a series of uneventful takeoffs and landings while remaining in the traffic pattern. He stated that during his fifth takeoff, which was part of a touch-and-go landing, after reaching rotation speed, he pulled back on the yoke, but the airplane did not rotate. He verified the flight instruments and tried again, and although the nose pitched up slightly, the airplane did not rotate. He released back pressure on the yoke and realized that during the takeoff attempt, the airplane had veered to the left of the runway. The airplane departed the runway and collided with a small tree. The airplane damage was generally limited to the left wing, which had folded down at the root, and the nosewheel, which remained partially attached to the firewall but had bent aft. Examination did not reveal any anomalies with the pitch control system. The elevator trim was set to the takeoff position, and the flaps were in the fully retracted (zero flaps) position. The left nosewheel steering control rod was bent, and the eyebolts for both steering rods had broken away from the nosewheel trunnion. The shimmy damper remained attached to its steering arm and had also broken away from the trunnion. The separation surfaces of the control rods and shimmy damper exhibited damage consistent with overload. The right rudder cable was continuous from the foot pedal assembly to the control surface, and the left cable had separated around the aft pulley in the tailcone. Examination of both cables revealed significant wear and wire fractures at the points where the cables passed around the aft pulleys. Both pulleys were free and could be spun easily by hand. The cables were nominally 1/8-inch diameter, 7 by 19 wire construction, grade 304 stainless steel, which according to Textron Aviation had a breaking strength of 1,760 pounds. The damaged sections of both cables were sent to the National Transportation Safety Board Materials Laboratory for analysis. Examination of the right rudder cable revealed that its diameter, which was nominally 0.132 inches through most of its length, had worn down to between 0.105 inch to 0.117 inch in the region that passed over the aft pulley. Multiple worn and broken wires were identified within this region. Examination of the separated portions of left rudder cable revealed that it had fully fractured in the region around the aft pulley. Approximately 52% of the wires exhibited wear with about 43% of the wires exhibiting material loss through the full diameter of the wire due to wear. The balance of the wires fractured in overstress across the full wire diameter. A visual inspection of the right and left aft pulleys showed that the grooves in the pulleys exhibited deposits and remnants of dried or degraded grease. No fresh grease was present. The airplane’s most recent annual inspection was completed 3 months before the accident. -
Analysis
During the takeoff roll, after reaching rotation speed, the student pilot pulled back on the yoke but the airplane did not rotate. He verified the flight instruments and tried again, and although the nose pitched up slightly the airplane did not rotate. He released back pressure on the yoke and realized that the airplane had veered to the left of the runway. The airplane departed the runway and collided with a small tree. The flight was the first time the pilot had flown solo, having just received an endorsement from his flight instructor earlier in the day. Postaccident examination did not reveal any anomalies with the pitch control system, and both the flaps and elevator trim were set appropriately for takeoff. The rudder cables exhibited significant preexisting wear in the area of the aft rudder pulleys, and the left cable had separated in that area. Metallurgical examination determined that about half of the left cable wire strands had failed before the accident due to wear, but the cable was likely still strong enough to operate the rudder. Therefore, the separation of the left rudder cable likely occurred at impact when the nose wheel, which was connected to the rudder cables, struck terrain, and the remaining intact wire strands of the weakened rudder cable failed in overload. Further, it is unlikely that the deteriorated rudder cables contributed to the accident as the pitch control issues described by the pilot did not indicate a rudder control problem. The extent of wear and the caked and old grease in the pulleys indicated the cables had not been examined or serviced recently, even though the annual inspection was performed 3 months earlier.
Probable cause
The student pilot’s loss of directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N6496L
Operator
Mach 6
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15284420
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-08T08:55:37Z guid: 104616 uri: 104616 title: RRD22FR006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104619/pdf description:
Unique identifier
104619
NTSB case number
RRD22FR006
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-09T12:57:00Z
Publication date
2023-06-20T04:00:00Z
Report type
Final
Last updated
2023-06-09T04:00:00Z
Event type
Accident
Location
Denver, Colorado
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the February 9, 2022, BNSF Railway remote control operator helper fatality was being struck by remote-control locomotive BNSF 1961 after falling from the locomotive’s front platform into the tracks when slack action in the train consist caused a sudden deceleration of the locomotive.
Has safety recommendations
false

Vehicle 1

Railroad name
BNSF
Train name
YDEN1152-09i
Train type
FRA regulated freight
Findings
creator: NTSB last-modified: 2023-06-09T04:00:00Z guid: 104619 uri: 104619 title: ERA22LA117 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104620/pdf description:
Unique identifier
104620
NTSB case number
ERA22LA117
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-09T18:28:00Z
Publication date
2024-02-21T05:00:00Z
Report type
Final
Last updated
2022-02-14T23:08:12.091Z
Event type
Accident
Location
Bel Air, Maryland
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On February 9, 2022, at 1628 eastern standard time, a McDonald Douglas MD-369D helicopter, N9159F, was substantially damaged when it was involved in an accident near Bel Air, Maryland. The commercial pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The pilot stated that while conducting powerline inspection work earlier in the day, line personnel reported that the helicopter was making a strange "whistle" noise. The pilot inspected the helicopter and no anomalies were noted or observed. The pilot continued with normal operations, but the noise continued and one of the operator’s superintendents took a video, where a “whistle”-like sound could be heard. The pilot landed and ceased all human external cargo operations. He then reviewed the video, re-examined the helicopter, and spoke with company maintenance personnel. Though no obvious mechanical issues were observed, the pilot “parked” the helicopter for the remainder of the workday. At the end of the workday, the pilot again inspected the aircraft and found no mechanical reason not to reposition the helicopter back to its normal base of operations. He and another company helicopter departed as a flight of two. Several minutes into the flight, the pilot said the ENGINE CHIP light illuminated. He told the other pilot that even though the engine seemed to be operating normally, he would need to land as soon as practicable. Shortly after, the engine began to make a “grinding” noise along with an odor of engine oil, which eventually became smoke in the aft section of the passenger compartment. With the presence of smoke and the potential for an inflight fire, the pilot initiated an emergency descent-to-land to a suitable landing area. During the descent the engine noise and smoke in the aft section of the cabin intensified and began moving to the forward section of the cockpit. Descending through the landing flare, as the pilot leveled the helicopter to land, the engine stopped producing power and smoke in the cockpit reduced his visual reference to the ground. The pilot attempted to slow the rate of descent and impacted the ground in a near-level attitude. During the ground run the front portion of the skids dug into the ground, causing the helicopter to pitch forward. The pilot applied aft cyclic to keep the helicopter level. During the landing sequence, the main rotor blades struck the tail boom, which resulted in the horizontal and vertical stabilizers and the tail rotor assembly separating from the helicopter. Residual oil was observed on the interior and exterior surfaces of the engine access doors and on the interior of the engine compartment. AIRFRAME AND ENGINE EXAMINATION The helicopter was recovered by the operator and taken to their facility in Gettysburg, Pennsylvania. Before the engine was removed, an external examination of the lubrication system between the airframe and the engine was conducted. Neither the aircraft-mounted oil reservoir nor the oil cooler were damaged, and no residual oil was noted within the cabin area (where the cooler and reservoir were located). The engine was then removed from the airframe and shipped to Keystone Turbine Services, Coatesville, Pennsylvania, where a full engine examination was conducted under the supervision of the NTSB. Examination of the engine revealed that each of the external oil lines were secure except for the oil line which supplies pressure oil to the turbine sumps. The line connected to a horizontal fire shield and a T-fitting near the Nos. 6 and 7 bearing sump. The line was fractured at the horizontal fire shield and misaligned. Also, the clamp that secured the line to the turbine module was fractured. The scavenge oil filter was clean and full of oil. A small amount of ferrous debris was observed on the filter. The pending bypass button was not extended. Both the upper and lower engine magnetic chip detector plugs were removed, and ferrous debris was observed on both. The gas producer turbine rotor (N1) was seized but the power turbine (N2) turned and was connected to the powertrain. No damage was noted on the first stage compressor blades or compressor inlet. The fourth stage turbine wheel was normal in appearance when viewed from the exhaust collector. The accessory gearbox was intact except for one fractured compressor mount pad. As the compressor was removed, the mount was found liberated from the gearbox housing. The gearbox housing and cover were split apart, and all the internal gears and bearings were intact, except for the No. 2 ½ bearing. The No. 2 ½ bearing was missing 6 rollers, consistent with having fallen out during the compressor removal, and were recovered from the bottom of the engine stand. The rollers were undamaged. The compressor bore on the gearbox cover displayed a wear step between the 1:00 to 12:00 position. The combustion section was not damaged. The inner surface of the outer combustion case barrel was missing material and was cracked. Several pieces of barrel material were recovered from the turbine inlet. The combustion liner was covered in carbon, but no mechanical damage was observed. Several areas within the turbine module displayed evidence of oil starvation: • No. 8 bearing cavity • No. 8 bearing sump oil scavenge line (was also clogged with debris/dry residue) • No. 8 bearing sump oil supply tubes • No. 6/7 bearing cavity • No. 6/7 bearing scavenge orifice • No. 6/7 bearing oil supply tube • No. 6/7 bearing external sump can The No. 6 bearing rollers were disintegrated, which precluded inspection of the No. 7 bearing. The No. 8 bearing balls were also disintegrated and the remaining components (inner race, outer race, and separator) were removed. The bearing components displayed thermal signatures consistent with overtemperature operation. The gas producer (GP) rotor tie bolt nut was loose but remained in position within the locking feature; the GP rotor was intact. The trailing edge blade tips of the first stage turbine wheel displayed mechanical damage and the upstream face of the wheel was circumferentially gouged and smeared. The energy absorbing ring location tabs and corresponding slots in the GP support displayed heavy wear. The No. 5 bearing turned freely and smoothly and displayed some brown discoloration. The N2 rotor was removed and all airfoils were intact. The upstream face of the third stage turbine wheel was coated in a gray carbon-like substance. The N2 shaft was intact with some discoloration and carbon noted on the exterior surface. The N1 shaft was intact and exhibited some slight bulging at the end of the shaft. The engine compressor turbine assembly, gearbox housing, oil pump, oil supply line with fittings and clamp assembly, N1 coupling, GP turbine assembly, GP turbine support (which included a sump nut, retaining ring and plate, and the No. 8 oil supply jet), No. 8 bearing, No. 8 rotating and stationary seal, No. 8 bearing spanner nut, and the outer combustion chamber, were sent to the NTSB Materials Laboratory for examination. Examination of these components by the NTSB Materials Laboratory determined numerous instances of high heat damage and fracture due to high-cycle fatigue. The gearbox housing support lug located on the upper left side of the gearbox exhibited fracture surfaces consistent with high-cycle fatigue. The oil pump, which was installed on the interior of the gearbox, was intact. There were no fretting contact marks noted on the pump mating to blended area on gearbox housing. Pitting consistent with cavitation damage were noted on gear teeth in the pressure body. The oil supply line that was found fractured during the engine exam, and its associated support clamp, also exhibited fracture surfaces consistent with high-cycle fatigue. This oil line supplied oil to the Nos. 6 and 7 bearings in the turbine section. The fracture of this line most likely led to the rapid deterioration of the bearings from oil starvation. The GP support and its related components revealed the retaining plate shear pin was fractured. The fracture surfaces showed curving crack arrest lines and dark tinting consistent with fatigue. The retaining plate was installed on the aft side of the GP support hub and had multiple recesses machined into the outer diameter, including those for accommodating the shear pin and the No. 8 oil supply jet. A mark was observed on the clockwise side of the recess for the shear pin corresponding to contact with the aft piece of the shear pin that was not recovered. A separate mark was observed near the clockwise end of the recess for the No. 8 oil jet, and a corresponding contact mark was observed on the lower inboard side of the No. 8 oil supply jet body. The marks on the retaining plate recesses corresponded to contact with the shear pin and the oil jet, respectively, as the retaining plate rotated counterclockwise relative to the GP support hub. On the forward side of the retaining plate, damage from fretting contact with the No. 8 bearing outer race was observed near the retaining lug on the forward face next to the inside diameter. The surfaces of the retaining lug on both the clockwise and counterclockwise sides showed damage from fretting contact with the No. 8 bearing outer race. The contact damage was more extensive on the lower (clockwise) side of the lug, consistent with the bearing outer race rotating counterclockwise relative to the retaining plate. (The GP turbine and No. 8 bearing inner race normally rotate clockwise). Fretting contact marks were observed on the sump nut face corresponding to contact with the outer diameter of the retaining plate. A wear contact mark was observed on one of the castellation surfaces on locking flange on the aft side of the sump nut. The wear mark corresponded to contact with the retaining ring with the sump nut flange approximately flush to the aft side of the GP hub. The retaining ring for the sump nut is installed in a groove at the aft side of the castellated GP support hub. The aft side of the GP support hub was deformed radially outward at five of the castellations. As a result of the deformation, the retaining ring did not fully seat in the groove around the diameter of the GP support hub. However, the deformation did not appear to affect full engagement of the retaining ring with the sump nut lock flange. The e-ring seal was not located, and there was no documentation confirming the presence or absence of the e-ring seal in any photographic documentation or notes taken at the time of the engine teardown. The No. 8 bearing inner race, cage, and outer race were intact, and all rolling elements were missing. The No. 8 bearing outer race and cage were held within the fractured aft piece of the stationary seal. The notch on the aft side of the No. 8 bearing outer race and the corresponding lug on the forward face of the retaining plate were intact but marks consistent with heavy contact were observed. The shear pin restraining rotation of the forward end of the stationary seal was intact in the GP support. The components of the No. 8 bearing were substantially darkened consistent with high heat and loss of lubrication. The stationary seal for the No. 8 bearing was tinted consistent with high heat exposure and was fractured at the forward end of the bearing cup adjacent to the shoulder for the bearing outer race. Flat oxidized areas with curving boundaries were observed consistent with fatigue. The fatigue initiated from multiple origins at the inner diameter of the cup wall around the circumference. The planes associated with each origin were slightly angled relative to the circumferential plane consistent with torsional loading combined with flexure or tension loads. The relative orientation of the angle was consistent with torsion loading associated with the aft end of the seal loaded counterclockwise relative to the forward end, which is consistent with the rotation observed associated with the retaining plate. Ratchet marks were rubbed from contact with the mating side of the fracture, consistent with counterclockwise rotation of the aft side of the fracture relative to the forward side following fracture. The fracture surface on the No. 8 stationary seal was further examined using the scanning electron microscope (SEM). The fracture surface showed substantial damage from post-fracture rubbing contact, and fatigue striations were also observed. The shoulder on the No. 8 stationary seal adjacent to the fracture surface showed heavy fretting contact damage on the aft face adjacent to the inside diameter of the shoulder, consistent with contact with the No. 8 bearing outer race. Fretting damage was also observed on the outside diameter of the stationary seal where it contacted the GP support hub. According to information provided by representatives for the engine manufacturer, the No. 8 stationary seal should have an interference fit in the GP support hub within approximately ¼-inch of the shoulder against which the bearing cup portion of the seal rests, and the stationary seal has two part-number options available to achieve the proper interference fit. The “-1” part has an outside diameter that is slightly larger than the “-2” part. The inside diameter of the GP support hub was measured, and the measured value could be within the specified maximum inside diameter after accounting for the range of accuracy of the measuring device. The outside diameter of the No. 8 stationary seal was measured on the forward piece in the interference fit region using calipers. Several measurements were taken including areas that appeared to have original machining markings, and none would provide an interference fit with the as-measured or the as-specified inside diameter of the corresponding area on the GP support. It was undersized by 0.008 inch or more, depending on which part number had been installed. A part number for the No. 8 stationary seal could not be obtained due to heat and impact damage. Examination of the No. 8 rotating seal revealed heavy circumferential rubbing damage and high heat damage. White deposits were observed in the rotating seal ridges. The flange in the middle of the rotating seal was fractured around the circumference, and the remaining portion was deformed aft. The No. 8 spanner nut lock flange was deformed in one location and had a semicircular section removed from a second area. The size of the semicircular cutout was consistent with removal of a deformed flange segment from a prior installation. Pieces of the interior wall of the outer combustion case were re-assembled and two of the pieces were darkened relative to the mating piece, consistent with post-fracture heat exposure. Examination of the fractured pieces showed substantial rub damage with lips on either side of the surface consistent with vibratory contact damage. After an initial optical examination using a stereo microscope, the fracture surfaces on the two pieces without heat damage were further examined using the SEM. Although most of the surfaces were obliterated by rub damage, striations consistent with fatigue fracture were observed. The compressor assembly was intact and rotated freely. Some impact marks were observed on the aft end face of the impeller stub shaft. MAINTENANCE RECORDS According to overhaul records, the turbine section was last overhauled on July 2, 2020, when the GP turbine wheels were replaced due to service time limits. A review of the engine manufacturer’s overhaul maintenance manual (OHM), section 72-50-00 L, revealed the following inspections were required when the turbine module was removed to address life expired 1st or 2nd stage turbine wheels: (1) Visually inspect the No. 1 and No. 2 turbine nozzle assembly for any damage or discrepancies. (2) Inspect the gas producer tie bolt, 2nd-stage splined adapter and compressor to turbine coupling shaft. Replace if necessary. (3) Inspect all oil nozzles and passages for carbon formation and/or obstructions. Clean as necessary. During assembly, make sure oil will pass through all designated nozzles and that they are targeted appropriately. (4) Inspect the power turbine rotating labyrinth 9--12 and 13--18 seals. (5) Inspect 3rd-- and 4th--stage turbine wheels for obvious cracks or damage. (6) Visually inspect the power turbine inner shaft I.D. for excessive carbon buildup. Clean any excessive carbon from the power turbine inner and outer shaft. The required inspections necessitate disassembly, inspection, and reassembly for the turbine module components, including the GP support bore diameter and the condition of the No. 8 stationary seal; however, there was no indication in the overhaul records that the No. 8 stationary seal had been inspected, removed, or replaced. A few months after this overhaul, in September 2020, the turbine module was removed from the engine by the operator and sent to a repair facility due to a N2 lockup. The repair facility ended up removing the GP support and sending the unit to another facility where the 4th stage wheel was replaced. According to the engine manufacturer, the repair facility that received the GP support should have been following the same OHM inspection criteria as stated above, which included inspection of the No. 8 stationary seal at the time the 4th stage wheel was replaced. There was no entry in the maintenance record that the No. 8 stationary was repaired/replaced at the time the GP support/4th stage wheel was replaced. -
Analysis
The pilot reported that he had heard a whistling sound with the engine while conducting powerline operations and landed out of precaution. He examined the engine and consulted with maintenance personnel, but no mechanical anomalies were found. The helicopter was grounded for the workday; however, at the end of the day, a decision was made to try and return the helicopter back to its base of operations. During the flight, the engine chip light illuminated followed by the smell of engine oil and a grinding noise. The pilot attempted a precautionary landing to a field, but smoke filled the cabin, reducing his visibility while in the landing flare. The pilot attempted to slow the rate of descent and impacted the ground in a near-level attitude. During the ground run the front portion of the skids dug into the ground, causing the helicopter to pitch forward. The pilot applied aft cyclic to keep the helicopter level. During the landing sequence the main rotor blades struck the tail boom, which resulted in the horizontal and vertical stabilizers and the tail rotor assembly separating from the helicopter. Postaccident examination of airframe and engine revealed residual oil on the interior and exterior of the engine access doors and on the interior of the engine compartment. The oil supply line that feeds oil to the Nos. 6 and 7 bearings was fractured along with its support bracket. Numerous other components including the gearbox housing, N1 coupling, gas producer (GP) turbine support assembly (which included a sump nut, retaining ring and plate, the No. 8 oil supply jet, and a fractured shear pin), No. 8 bearing, No. 8 rotating seal, No. 8 stationary seal, and the outer combustion chamber, had also fractured and/or sustained high heat damage. Evidence of fretting damage was also observed on multiple components. The National Transportation Safety Board (NTSB) Materials Laboratory analyzed these components and determined that the engine most likely failed due to bearing failures in the turbine section resulting from the high-cycle fatigue fracture of the oil supply line that fed oil to the Nos. 6 and 7 bearings. The oil line failure led to rapid deterioration of the bearings from oil starvation, resulting in misalignment of rotating components and interference with stationary components within the engine, producing the grinding noise noted by the pilot. The oil line fracture was also likely associated with the smell of oil followed by the smoke in the cockpit reported by the pilot. Further examination of the engine revealed that the engine failure likely started with the No. 8 bearing stationary seal. The outside diameter of the seal was undersized, so it did not have the specified interference fit with the GP support hub. The improper fit likely led to insufficient support for the No. 8 bearing and excessive flexing of the No. 8 stationary seal cup wall. As a result, the stationary seal developed fatigue cracks and eventually fractured. The lack of interference fit with the No. 8 stationary seal likely affected the effectiveness of the seal between the stationary and rotating seals, which could have allowed oil to escape forward past the seal and into the gas path. The fracture of the No. 8 stationary seal reduced the support for the rotating turbine components at the No. 8 bearing, which likely led to increased vibrations in the engine. Fractures in the outer combustion chamber, oil line clamp, and gearbox case housing all had indications of high-cycle fatigue fracture from vibration loading. These failures likely resulted from excessive vibrations associated with the reduction in support for the turbine section rotating components. The fractured oil line support clamp failed followed by the oil supply line. According to overhaul records, the turbine section was last overhauled in July 2020, when the GP turbine wheels were replaced due to service time limits. A review of the engine manufacturer’s overhaul maintenance manual (OHM) revealed the condition of the No. 8 stationary seal should have been inspected; however, there was no indication in the overhaul records that the No. 8 stationary seal had been inspected, removed, or replaced. The turbine module was removed by the operator a few months after the overhaul due to a N2 lockup and sent to a repair facility. The repair facility ended up removing the GP support and sending the unit to another facility where the 4th stage wheel was replaced. According to the engine manufacturer, the repair facility should have been following the same OHM inspection criteria that included inspection of the No. 8 stationary seal. According to the repair facility, they had no record that the No. 8 stationary was repaired/replaced at the time the GP support/4th stage wheel was replaced.
Probable cause
A loss of engine power due to bearing failures in the turbine section resulting from a fatigue fracture of the oil supply line that fed oil to the Nos. 6 and 7 bearings. The oil line failure led to rapid deterioration of the bearings from oil starvation. Contributing to the power loss was the installation of a No. 8 stationary seal with an undersized outside diameter, which resulted in a reduction of support for the turbine section rotating components and resulted in high vibration loads in the engine, which ultimately caused the oil supply line to fatigue and fail. Also contributing was the improper or inadequate inspections of the No. 8 stationary seal by maintenance personnel.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
369D
Amateur built
false
Engines
1 Turbo shaft
Registration number
N9159F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
1090605D
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-14T23:08:12Z guid: 104620 uri: 104620 title: WPR22FA094 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104624/pdf description:
Unique identifier
104624
NTSB case number
WPR22FA094
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-10T13:05:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-02-14T10:44:31.48Z
Event type
Accident
Location
Glendale, Arizona
Airport
LUKE AFB (LUF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
Due to the accident and other fuel anomalies experienced in some of their other F-1 airplanes, the operator accomplished a one-time inspection of their F-1 fleet’s fuel tanks and discovered that 5 airplanes (out of a fleet size of about 8 aircraft) at the LUF location were found with varies type of Foreign Object Debris (FOD). The main source of FOD in the tanks was the fuel tank sealant remnants. Fuel system anomalies, including false full tank fuel indications during refueling and issues affecting the fuel transfer valves, were experienced consistent with the FOD present in the fuel tanks. Once the FOD was removed from the fuel tanks, few additional anomalies related to the airplane’s fuel systems were experienced. - The F-1 Mirage was a French fighter and attack aircraft that was imported into the United States and registered under the experimental category. It is a single-engine, swept-wing, supersonic airplane capable of Mach 2.1. The airplane had a maximum takeoff weight of over 35,000 lbs. The airplane’s fuel system is comprised of a left and right fuel system. Normally, the left and right fuel systems are isolated from each other but can be connected to each other through a crossfeed valve. Refueling is normally carried out by pressurized single point refueling. The total quantity of usable fuel was about 4,100 liters. This total does not include the use of the optional external centerline fuel tank, which increased the fuel capacity by about 1,180 liters. The airplane was equipped with 9 internal fuel tanks (including the 2 feeder tanks), 2 internal wing tanks, and 2 negative-g flight accumulators. Engine air pressure moves the fuel to the feeder tanks and from there it flows directly to the engine by 2 low pressure pumps. The F-1 refueling checklist indicated for a clean airplane the following fuel capacity (in liters): The airplane fuel gauges consisted of 2 vertical tapes that indicated the fuel quantity on the left and right side. The wing tanks and optional external tanks are not gauged. The fuel tapes only indicate about a maximum of about 2,000 liters of fuel on each side and, therefore, the tape indications would only start to decrease when the airplane had less than about 4,000 liters of total fuel. The fuel transfer sequence is designed so that the optional external fuel tanks are consumed first, then the wing tanks, and then the gauged internal fuel tanks. Usually, once the airplane’s external centerline and wing tanks are empty, the tape indications should reflect what the fuel remaining indicator (a 4-figure counter measured in liters) indicated. With more than 2,000 liters of fuel in each tank, the tapes would indicate near the full indication. In addition, the fuel remaining indicator (totalizer) would be manually preset to the total quantity of fuel onboard before flight and would decrease according to how much fuel the airplane used. The accident airplane was refueled the day before the accident. During the start of the refueling the nozzle pressure was kept at 20 psi to ensure that the airplane took fuel and did not overpressure and vent fuel. About three minutes into the refueling, the fuel truck driver observed a significant amount of fuel venting from the airplane and was instructed to stop refueling by the operator’s maintenance personnel. The driver said it was the most venting he had seen during his one year of refueling the F-1. After having stopped for a couple of minutes, the operator’s maintenance personnel checked the airplane and placed the collection container back to collect fuel that vented overboard and the refueling was resumed. Subsequently, about 7 minutes later, a total of about 456 gallons (about 1,726 liters) was added to the airplane and then the refueling driver observed a spike in back pressure that was a characteristic of the jet being fully loaded with fuel and stopped refueling. In addition, the operator’s refueling personnel monitoring the refueling thought the refueling was complete as well. However, the fuel added was not to the full fuel load amount that was normally serviced. Given, that the airplane’s shutdown fuel from the previous flight was 2,320 liters and the fuel serviced was 1,726 liters, the airplane’s fuel load for the accident flight after refueling was about 4,046 liters, which was less the normal full fuel load of about 5,280 liters with the external center fuel tank that was installed. Additionally, an engine run of about 10 minutes for maintenance took place on the airplane before takeoff and no fuel was added afterward. Therefore, the fuel load for takeoff was slightly lower than 4,046 liters. Maintenance personnel and the pilot then reviewed the aircraft forms, which indicated the amount of fuel serviced, but did not detect the shorted amount of fuel added. Additionally, during the ground refueling process, the refueling lights flash on and then go out when the corresponding tanks are full. The last step of the checklist was to manually set the fuel remaining quantity indicator (totalizer) to display the amount of fuel in the airplane. The fuel remaining quantity indicator was as if the airplane was fully fueled with 5,280 liters of fuel. On the airplane’s warning and caution panel, the FUEL PRES red light would illuminate when the engine inlet fuel pressure was < 700 mb (10.15 psi). The LOW FUEL red light would illuminate when either feeder fuel tank was < 250 liters. A red warning light illumination called for immediate action by the pilot. The emergency procedure for a FUEL PRES red warning light, which indicated that the dry engine fuel pressure was less than 700 mb while airborne, was to shut down use of AB and reduce rpm, check LP pumps on, check left and right LP caution lights out, and land as soon as possible while monitoring the fuel totalizer and both fuel gauges for indications of a fuel leak. The emergency procedure for LOW FUEL warning light was to select the emergency transfer switch forward or aft as required, which connected the left and right forward or aft tanks (depending on selection) and allowed transfer of both tanks to the same feed tank. If the quantity of both feed tanks was below 250 liters and transfer sequence was normal, with or without tank 3 illuminated, the procedures were: - RPM reduce. - Descend to below 20,000 ft, heading to nearest field. - RPM – set 8,000 for 30 seconds (maximum) and check the feed tank quantity. - If the feed tank transfer does not increase – use emergency transfer. - If the feed tank quantity increases – if necessary, continue flight at no higher than current altitude (< 20,000 ft). - Land as soon as possible. The operator performed a daily inspection on the accident airplane before its flight. Additionally, the airplane’s last 100-hour inspection was accomplished on November 2, 2021, at an airframe total time of 6,333.3 hours. - LUF is a United States Air Force owned, towered airport, with a reported field elevation of 1,083 ft. The airport was equipped with two concrete runways, runway 03L/21R (10,000 ft long by 150 ft wide) and runway 03R/21L (9,912 ft long by 150 ft wide). - The airplane was equipped with an Enertec PE6010-5A flight data recorder (FDR). The tape-based recorder was developed for use in early Dassault Mirage F-1 aircraft. The recording medium is a 1/2-inch magnetic tape, 63 meters in length, capable of storing up to 16 hours of flight data. The National Transportation Safety Board (NTSB)was unaware of any 1/2-inch tape-based recorders in commercial service in the United States and does not maintain equipment for the readout of 1/2 inch magnetic tape. The Bureau of Enquiry and Analysis for state owned aircraft (BEA-E) in France reported that they have some experience with the Enertec recorder, and that a specific readout bench is required to recover data from it. The BEA-E also reported that the recorder requires regular maintenance, and unless the tape is regularly changed recovery is unlikely. It was determined that due to the age of the recorder and the lack of documented continued airworthiness maintenance on the recorder, the likelihood of recovering valid data was low. Because of the low probability of recovery, it was determined that no further attempts to recover the FDR data would be made. - On February 10, 2022, about 1105 mountain standard time, an experimental Dassault Aviation Mirage F-1 CR Turbo-jet, N633AX, was destroyed when it was involved in an accident near Luke Air Force Base, (LUF), Glendale, Arizona. The pilot sustained minor injuries. The airplane was operated as a public-use aircraft in support of the United States Air Force’s simulated combat flight training. According to the accident pilot, he flew in the number two position in a flight of two aggressor jets. The formation took off and proceeded to the MOA, where the two airplanes split up into separate areas. Near the completion of the area work, the pilot reported a discrepancy between the two fuel quantity indications in the cockpit. Shortly thereafter, he recovered before the lead airplane since his airplane reached its briefed minimum fuel status first. While exiting the MOA, and en route on the recovery, the pilot reported a loss of fuel pressure and shortly afterward the engine flamed out. The pilot attempted to restart the engine but was unsuccessful. When the pilot determined that he could not make it back to the runway at LUF, he executed a left turn to an uninhabited area and successfully ejected from the airplane. Subsequently, the airplane struck desert terrain about 16 miles northwest of LUF. Postaccident interviews revealed that the airplane was not fueled with the correct amount of fuel for the flight by maintenance personnel before the flight. Although the refueling forms accurately reflected the shorted amount of fuel, the error was not detected by maintenance personnel or the pilot before the airplane took off. During the flight, the pilot failed to notice that his fuel load was incorrect. A high throttle setting (with frequent afterburner use) basic fighter maneuver flight engagement for the pilot, made him rely on the fuel remaining totalizer, without appropriately referencing the individual fuel quantity tapes. The fuel remaining totalizer that the pilot relied on had been manually set to the expected full fuel load, not to the actual fuel load. Subsequently, the low fuel light illuminated in the MOA and during the return to LUF, the fuel quantity tapes indicated zero, while the fuel totalizer read about 1,300 liters. Shortly afterwards, the engine flamed out consistent with fuel exhaustion. - The operator coordinated to have toxicological testing accomplished on the pilot and the results were negative. - Airborne Tactical Advantage Company (ATAC) operated the airplane and, according to their web site, is the world’s largest outsourced civilian tactical airborne training organization. ATAC is a business unit of Textron Systems that operates a variety of ex-military aircraft consisting of the F-1 Mirage, the F-21 KIFR, the L-39 Albatros, and the MK-58 Hawker Hunter. The accident airplane was part of their operating location at LUF. ATAC accomplished both the maintenance of its aircraft and provided initial and recurrent ground and flight training to its F-1 pilots. Additionally, the organization had a safety department that was managed by their Vice President of Safety. Their safety department had a safety representative stationed at LUF. The F-1 lead pilot of the formation stated that his F-1 ground school training was challenging and he was surprised by the length and depth of the ground school. Additionally, the accident pilot stated that the F-1 instructors do a good job in systems knowledge and instruction in the jet. - The pilot held an airline pilot certificate with a flight instructor airplane single-engine and multi-engine land and airplane instrument ratings. He also held an experimental aircraft authorization for the DA-F1. The pilot was issued a Federal Aviation Administration (FAA) first-class medical certificate on July 20, 2021, without limitations. The pilot reported about 4,859 total hours of flight experience and about 240 hours in the F-1 aircraft. He was a former military fighter pilot in the F-16 and F-18 aircraft and an airline pilot. According to the pilot of the lead aircraft and maintenance personnel that launched the airplane, the accident pilot appeared to be in a normal good mood the day of the accident. The accident pilot stated that he had normal sleep the 3 days before the accident and had no personal issues to report. - The canopy, ejection seat, harness, and parachute were examined by the NTSB investigator-in- charge, the FAA, and a representative of the operator. Examination revealed that the ejection equipment functioned normally. - Examination of the accident site revealed that the jet airplane impacted flat desert terrain in an unoccupied area between residential areas. All major components of the airplane were found at the main wreckage site. The wreckage site was at an elevation of about 1,622 ft msl. There was no postimpact fire. There was a large ground disturbance that led to the area where most of the major sections of the airplane were located. The initial point of impact was orientated on a heading of about 060° magnetic. The aft portion of the fuselage (the largest portion of fuselage that remained relatively intact) came to rest inverted. Small fragments of aircraft debris were scattered about several hundred ft from the accident site. The large portions of the remaining forward section of the fuselage and wings were found nearby. The ejection seat and parachute were found about a half mile from the main accident site. A postaccident examination of the airplane wreckage revealed that the airplane’s fuel tanks had some loose excess sealant globules inside the main feeder fuel tanks; a loose screw was also found. No additional evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation of the airplane were observed. -
Analysis
A turbo-jet airplane was being operated as a public-use aircraft in support of the United States Air Force’s simulated combat flight training at the time of the accident. The airplane took off and proceeded to the Military Operating Area (MOA) and, near the completion of the flight the pilot reported a discrepancy between the two fuel quantity indications in the cockpit. Shortly thereafter, the pilot headed back to the airport once the airplane reached its briefed minimum fuel status. While en route to the airport, the pilot reported a loss of fuel pressure and shortly afterward the engine flamed out. The pilot attempted to restart the engine but was unsuccessful. When the pilot determined that he could not make the runway at his destination, he turned toward an uninhabited area and successfully ejected from the airplane. Subsequently, the airplane impacted terrain. Postaccident interviews revealed that the airplane was not fueled with the correct amount of fuel for the flight by maintenance personnel before the flight. Although the refueling forms accurately reflected the shorted amount of fuel, the error was not detected by maintenance personnel or the pilot before the airplane took off. During the flight, the pilot failed to notice that his fuel load was incorrect. The pilot relied on a fuel remaining totalizer that had been manually set to the expected full fuel load, not to the actual fuel load, and did not appropriately reference the individual fuel quantity tapes. Postaccident examination of the airplane wreckage revealed that the airplane’s fuel tanks had loose sealant globules inside the main feeder fuel tanks and an additional piece of Foreign Object Debris (FOD) present. Additionally, the operator discovered that several of their F-1 airplanes were found with varies type of FOD in the fuel tanks, including loose pieces of fuel tank sealant, which led to fuel anomalies including issues that caused false full tank fuel indications during refueling. Once the FOD was removed, the airplanes’ fuel system anomalies that were experienced were virtually eliminated. It is possible that the FOD caused anomalies during refueling of the accident airplane and presented a false full tank indication, which contributed to the airplane not being serviced to the correct fuel load.
Probable cause
A loss of engine power due to fuel exhaustion as result of the failure of maintenance personnel to ensure the airplane was serviced with the correct amount of fuel, the failure of maintenance personnel and the pilot to adequately check the airplane’s paperwork to ensure the correct amount of fuel was present for the flight, and the failure of the pilot to adequately monitor the airplane’s fuel status during the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DASSAULT AVIATION
Model
MIRAGE F1 CR
Amateur built
false
Engines
1 Turbo jet
Registration number
N633AX
Operator
AIRBORNE TACTICAL ADVANTAGE COMPANY LLC
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft - federal
Commercial sightseeing flight
false
Serial number
653
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-14T10:44:31Z guid: 104624 uri: 104624 title: CEN22LA117 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104629/pdf description:
Unique identifier
104629
NTSB case number
CEN22LA117
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-10T22:06:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-02-23T20:34:16.479Z
Event type
Accident
Location
Lincoln, Nebraska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 10, 2022, at 2006 central standard time, a Cirrus SR22T, N317KJ, sustained substantial damage when it was involved in an accident near Lincoln, Nebraska. The pilot and a passenger were uninjured. The airplane was operated as a Code of Federal Regulations Part 91 personal flight. The pilot did not report any anomalies with the engine start, run-up, or takeoff. He reported the that the flight was initially uneventful, and the airplane was operating with all the gauges indicating within the proper operating limits. At 10,000 ft mean sea level (msl) and about 60 nm east of Lincoln Airport, Lincoln, Nebraska, there was a brief “stutter” of the engine, and the engine began to run rough. He contacted Omaha approach control and told them the engine was running rough and would like to divert to Plattsmouth Municipal Airport/Douglas V Duey Field (PMV), Plattsmouth, Nebraska, located about 39 nm and 080o from LNK. The pilot said he a received clearance to fly direct to PMV and to descend and maintain 4,000 ft msl. About 40 nm miles from LNK and 8,000 ft msl, the pilot said he told Omaha approach control that the engine smoothed out, and he would like to continue the flight to LNK at 6,000 ft msl. The pilot said as the flight continued to LNK, the engine’s No. 3 cylinder head temperature indicated 0oF. About 15 nm east of LNK, the engine began to run rough again, and the pilot asked Omaha approach control if he could begin a slow descent toward LNK. He was cleared to descend and maintain 3,000 ft msl. About 12 nm from LNK, he was issued cleared for a visual approach to runway 17 and subsequently a clearance to land. As he continued the descent to 2,500 ft msl, the engine began to run rough, the oil pressure rapidly decreased, and the indicated airspeed decreased. About 6 nm from LNK, he told LNK air traffic control that he would be unable to make it to the runway and was going to look for a field to land on. He located a field, deployed the airframe parachute, and the airplane landed in the field and sustained substantial damage to the fuselage. Recorded avionics data showed that about 1930, the airplane was about 100 nm from LNK and about 7 nm northeast of Schenck Field Airport, Clarinda, Iowa, at an altitude of about 10,000 ft when the No. 3 cylinder head temperature decreased to and remained about 210oF while the remaining cylinder head temperatures were about 300oF. The No. 3 cylinder had a corresponding decrease in exhaust gas temperature to about 600oF while the remaining cylinder exhaust gas temperatures remained about 1,300oF. These temperature indications remained constant to about 2007:30, at which time the temperatures further decreased to the end of recorded data at 2009:55. The continuous decrease in engine temperature corresponded to decreases in indicated airspeed and engine speed. Postaccident examination of the engine revealed that the No. 3 cylinder, opposite to the No. 4 cylinder, was attached and secured to its crankpin. The cylinder exhibited debris related impact damage to an estimated 45o of the piston skirt bottom and nearest crank cheek. The No. 4 cylinder connecting rod was detached from its crankpin at the connecting rod end. The end of the connecting rod was deformed and its connecting rod bolts and connecting rod cap were not intact. The No. 4 cylinder crankpin exhibited partial gouging along its circumference and radial impact related deformation. The No. 5 piston and its connecting rod were intact and secure. The crankpin end of the No. 5 piston connecting rod was not connected to its crankpin, and the connecting rod end was hammered into a rounded shape. The connecting rod cap was not intact. The No. 5 cylinder crankpin did not exhibit scoring and did not possess gouging like that of the No. 4 cylinder crankpin. The deformed end of a connecting rod with both connecting rod bolts in place was recovered loose in the engine. The engine oil sump contained metallic debris, which was consistent with internal engine component failure, and engine oil. The airplane engine logbook showed that on June 30, 2021, at a Hobbs time of 887.7 and a flight time of 790.0 hours, the No. 5 cylinder, part number 658595A1, serial number AC18FB740, was removed and replaced with a new cylinder, part number 658815A3, serial number AC21CA785. The engine logbook did not have entries for any subsequent engine cylinder removals. -
Analysis
The pilot reported that the engine start, taxi, and run-up were normal. The night flight proceeded uneventfully until about 60 nm from the destination airport when the engine briefly stuttered and started to run rough. The pilot stated that he told air traffic control that the engine was running rough and requested to divert to an airport located about 39 nautical miles (nm) east of the destination airport. About 40 nm from the destination airport, the pilot told air traffic that the engine smoothed out and he wanted to continue the flight to the destination airport. About 6 nm from the destination airport, the pilot told air traffic that he would be unable to make it to the runway due to engine power loss and was going to look for a field where he could land. He located a field and deployed the airframe parachute. The airplane landed, under parachute, in the field and sustained substantial damage to the fuselage. Recorded avionics data for the flight showed that the abnormal engine indications began about 100 nm from the destination airport and continued to the end of the flight. The pilot continued the flight and passed two airports where a safe precautionary landing could have been performed while operating in night light conditions, which increased the risk of finding a safe area to perform an off-airport landing. Postaccident examination of the engine revealed a catastrophic engine failure. The No. 4 and 5 cylinders were not connected to their respective crankpins. The No. 5 cylinder crankpin surface lacked the deformation and scoring found on the No. 4 cylinder crankpin, suggesting that the No. 5 piston connecting rod separated from its crankpin and that material from the No. 5 cylinder induced foreign object damage and subsequent failure to the remaining portions of the engine.
Probable cause
The pilot’s decision to continue the flight with abnormal engine indications and the subsequent failure of the No. 5 cylinder connecting rod for unknown reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22T
Amateur built
false
Engines
1 Reciprocating
Registration number
N317KJ
Operator
Pilot
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1881
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-23T20:34:16Z guid: 104629 uri: 104629 title: CEN22LA118 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104631/pdf description:
Unique identifier
104631
NTSB case number
CEN22LA118
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-11T22:06:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-03-01T22:22:50.465Z
Event type
Accident
Location
Katy, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On February 11, 2022, about 2006 central standard time, a Mooney M20J airplane, N201VZ, was substantially damaged when it was involved in an accident near Katy, Texas. The pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of archived Federal Aviation Administration (FAA) automatic dependent surveillance - broadcast (ADS-B) data revealed that the airplane departed Castroville Municipal Airport (CVB), Castroville, Texas about 1827 destined for West Houston Airport (IWS), Katy, Texas. After overflying IWS at about 1,075 ft GPS altitude, the airplane turned left onto a downwind flight pattern leg for landing on runway 15. About 650 ft GPS altitude the airplane turned final and descended at which point the ADS-B data ended. The responding FAA inspector documented the accident site, which revealed that the airplane had collided with a tree, impacted terrain, and came to rest about 500 ft short of the runway. The airplane sustained substantial damage to the left wing and empennage. Due to injuries sustained in the accident, neither the pilot nor the passenger could recall the events of the accident flight. A postaccident examination of the engine and airframe revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Additionally, data recovered from multiple devices that contained non-volatile memory revealed no anomalies with recorded engine parameters and that all flight parameters were consistent with controlled flight. Historical sunrise and sunset times for the Houston, Texas area for the day of the accident listed the sunrise as 0704, the sunset as 1807 and the end of civil twilight as 1831. -
Analysis
The airplane was approaching the destination airport in dark night conditions when it collided with trees, impacted terrain, and came to rest about 500 ft before the runway threshold. The airplane sustained substantial damage to the left wing and empennage. Neither occupant could remember the events of the accident flight. A postaccident examination of the engine and airframe revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Additionally, data recovered from multiple devices that contained non-volatile memory revealed no anomalies with recorded engine parameters and that all flight parameters were consistent with controlled flight.
Probable cause
The pilot’s failure to maintain a proper glidepath while on the final approach segment of the traffic pattern in dark night conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20J
Amateur built
false
Engines
1 Reciprocating
Registration number
N201VZ
Operator
AVIATION PARTNERS SA LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-0243
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-01T22:22:50Z guid: 104631 uri: 104631 title: CEN22FA119 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104632/pdf description:
Unique identifier
104632
NTSB case number
CEN22FA119
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-13T12:20:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-02-14T01:16:41.061Z
Event type
Accident
Location
Olathe, Kansas
Airport
JOHNSON COUNTY EXEC (OJC)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The “Pilot’s Operating Handbook and [Federal Aviation Administration] Approved Airplane Flight Manual” for the airplane showed the airplane’s stall speed when lightly loaded, flaps at 36°, and landing gear extended, was 64 knots indicated airspeed (IAS). This was the lowest published stall speed for any configuration or weight. With flaps at 0° and the landing gear retracted, the stall speed was depicted as 74 knots IAS. There was no chart depicting stall speeds for flaps at 10° and landing gear extended. - On February 13, 2022, at 1020 central standard time, a Piper PA-46-500TP, N2445F, was destroyed when it was involved in an accident at the Johnson County Executive Airport (OJC), Olathe, Kansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane had recently undergone an annual inspection, and the pilot planned to fly the airplane back to his home base of operations. An instrument flight rules (IFR) flight plan had been filed for the flight from OJC to the Albuquerque International Sunport Airport (ABQ), Albuquerque, New Mexico. Communication data indicated that the pilot contacted the OJC controller and the OJC controller issued an IFR clearance for the flight to ABQ. Once the airplane had taxied to the runway, the OJC controller issued a takeoff clearance with instructions to fly a heading of 340° to an altitude of 5,000 ft msl. About one minute later, the pilot informed the tower controller that he urgently needed to return, and the tower controller cleared the airplane to land. The pilot did not provide a reason for the return, and no further transmissions were received from the accident airplane. Flight track data for the accident flight showed that the airplane began the takeoff roll on runway 36 at OJC at 1019:42. The airplane accelerated and reached a peak ground speed of 81 kts about 2,075 ft down the 4,097 ft long runway. Once airborne, the airplane drifted slightly to the right and slowed before it turned back toward the left. The airplane’s groundspeed continued to decrease throughout the remainder of the data. The final three data points showed the airplane’s groundspeed as 49 kts, 47 kts, and 45 kts respectively. The final recorded position was about 100 ft southeast of the initial impact point. Figure 1. Overview of accident flight track with time, altitude, ground speed, and heading information. Figure 2. Final segment of accident flight track in profile view looking from southwest to northeast. - The pilot reported on his application for his most recent medical certificate that he had 354 hours total flight experience with 66 hours in the six months preceding the examination. No further pilot flight records were made available during the investigation. - The airplane impacted the ground on the extended runway centerline about 400 ft past the departure end of runway 36. The airplane came to rest upright with its fuselage oriented in a southeasterly direction. A postimpact fire that burned the wings and forward fuselage aft to the rear spar carry-through structure. The fuselage aft of the cabin, including the empennage, was intact. There was a fan shaped burn area on the ground that extended from the aircraft wreckage in a southerly direction. Figure 3. The aircraft wreckage at the accident site looking south. Postaccident examinations of the airframe did not indicate any preimpact structural failures of the airplane. Flight control continuity was verified from the control surfaces into the cabin area. Impact and fire damage precluded comprehensive determination of the integrity of the cockpit flight controls; however, no preimpact anomalies were noted. The flap jackscrew extension found at the accident site corresponded to about 10° flap extension. The landing gear was in the extended position. Examination of the engine showed that the engine exhaust duct had visible angular deformation, consistent with torsional loading. Several internal engine components had rub marks and damage that were consistent with engine rotation during the impact sequence. The propeller shaft was fractured consistent with torsional overload. Further testing and examination of the propeller governor, overspeed governor, torque limiter, fuel-oil heat exchanger, fuel pump and fuel control were conducted and did not reveal any preimpact anomalies. Examination of the propeller revealed that all five of the propeller blades were broken off at the root with the blade roots still present in the propeller hub. Internal impact damage suggested that the propeller blade angle was between 26-34°, corresponding to a cruise power setting. -
Analysis
The airplane had recently undergone an annual inspection, and the pilot planned to fly the airplane back to his home base. After receiving clearance from air traffic control, the pilot proceeded to take off. The airplane accelerated and reached a peak groundspeed of 81 kts about 2,075 ft down the 4,097-ft runway. Once airborne, the airplane drifted slightly to the right and the pilot radioed an urgent need to return to the airport. The controller cleared the airplane to land and no further transmissions were received from the accident airplane. The airplane’s flight path showed that it slowed before turning back toward the left and the airplane’s speed continued to decrease throughout the remainder of the data. The final data point recorded the airplane at a groundspeed of 45 kts. The groundspeed would equate to 60 kts airspeed when considering the 15-kt headwind. The stall speed chart for the airplane listed the minimum stall speed for any configuration as 64 kts. Postaccident examinations of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. External and internal engine damage indicated that the engine was producing power at the time of impact, but the amount of power output could not be determined. Based on the available information, the pilot perceived an urgent need to return the airplane to the airport; however, due to the amount of damage from the impact and postimpact fire, the reason that the pilot was returning to the airport could not be determined. Stall speed information for the airplane, the recorded winds, and flight track data, indicated that the airplane encountered an aerodynamic stall before impacting the ground near the departure end of the runway. Since the airplane stalled and impacted the ground before reaching the perimeter of the airport, the pilot may not have had sufficient altitude to execute a forced landing to the empty field off the departure end of the runway.
Probable cause
The unknown emergency that warranted a return to the airport and the airspeed decay which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA46-500TP
Amateur built
false
Engines
1 Turbo prop
Registration number
N2445F
Operator
Quadrant Investments 1, LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4697480
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-14T01:16:41Z guid: 104632 uri: 104632 title: ERA22LA120 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104634/pdf description:
Unique identifier
104634
NTSB case number
ERA22LA120
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-13T16:02:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-02-17T18:20:36.059Z
Event type
Accident
Location
Beaufort, North Carolina
Airport
MICHAEL J SMITH FLD (MRH)
Weather conditions
Instrument Meteorological Conditions
Injuries
8 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation   The FAA's Pilot's Handbook of Aeronautical Knowledge contained the following guidance:   Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the airplane. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the airplane, there are many situations where combinations of normal motions and forces can create convincing illusions that are difficult to overcome.   The FAA’s Airplane Flying Handbook (FAA-H-8083-3) described hazards associated with flying when visual references, such as the ground or horizon, are obscured.   The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.   The FAA’s publication "Spatial Disorientation Visual Illusions" (OK-11-1550), stated in part the following:   False visual reference illusions may cause you to orient your aircraft in relation to a false horizon; these illusions are caused by flying over a banked cloud, night flying over featureless terrain with ground lights that are indistinguishable from a dark sky with stars, or night flying over a featureless terrain with a clearly defined pattern of ground lights and a dark starless sky.   The publication provided further guidance on the prevention of spatial disorientation. One of the preventive measures was "when flying at night or in reduced visibility, use and rely on your flight instruments." The publication also stated the following:     If you experience a visual illusion during flight (most pilots do at one time or another), have confidence in your instruments and ignore all conflicting signals your body gives you. Accidents usually happen as a result of a pilot's indecision to rely on the instruments.   The FAA publication “Medical Facts for Pilots” (AM-400-03/1) described several vestibular illusions associated with the operation of aircraft in low-visibility conditions. The somatogravic illusion, which involves the semicircular canals of the vestibular system, was generally placed into the "graveyard spiral" Category. According to the publication text, the graveyard spiral “…is associated with a return to level flight following an intentional or unintentional prolonged bank turn. For example, a pilot who enters a banking turn to the left will initially have a sensation of a turn in the same direction. If the left turn continues (~20 seconds or more), the pilot will experience the sensation that the airplane is no longer turning to the left. At this point, if the pilot attempts to level the wings this action will produce a sensation that the airplane is turning and banking in the opposite direction (to the right). If the pilot believes the illusion of a right turn (which can be very compelling), he/she will reenter the original left turn in an attempt to counteract the sensation of a right turn. Unfortunately, while this is happening, the airplane is still turning to the left and losing altitude.” - The airplane was equipped with an automatic flight control system. According to the airplane flight manual, “Autopilot disengagement is defined as either normal or abnormal. A normal disengagement is initiated manually by pressing the AP DISC push-button on the control wheel or by the AP push button on the [flight controller] or by activating the manual trim system. A normal disconnect will cause the AP indication on the PFD to flash red/white and the aural “Cavalry Charge” warning tone to be activated. After 2.5 seconds the AP indicator and audio are removed. Any disengagement due to a monitor trip or failure is considered abnormal. An abnormal disconnect will cause the AP indication on the PFD to flash red/white and the aural warning tone to be activated until acknowledged via the AP DISC push-button.” In addition, it stated “Activation of the stick shaker disengages the autopilot if engaged, in order to give full authority to a possible stick pusher activation. The autopilot can be manually reconnected after the angle of attack is reduced and the stick shaker has ceased operation.” Also, the airplane flight manual indicated that the wings level stall speed at the maximum takeoff weight with flight idle power was 95 knots with 0° of flaps in non-icing conditions. - The airplane was equipped with an L-3 Lightweight Data Recorder (LDR), which provided both a flight data recorder (FDR) and cockpit voice recorder (CVR) function. The recorder was recovered and 2 hours of voice data were successfully downloaded, along with 36 flights worth of parametric data from the airplane. - On February 13, 2022, about 1402 eastern standard time, a Pilatus PC-12, N79NX, was destroyed when it was involved in an accident near Beaufort, North Carolina. The commercial pilot, and 7 passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Earlier on the day of the accident, the airplane departed Pitt-Greenville Airport (PGV), Greenville, North Carolina, about 1235, and landed at Hyde County Airport (7W6), Engelhard, North Carolina, at 1255. According to data recovered from the airplane’s combination flight data and cockpit voice recorder, before departing on the accident flight, when the passengers were boarding the airplane, the pilot was instructing the student pilot-rated passenger, who was seated in the right front seat of the airplane, on how to enter the flight plan information into the avionics. At one point, the passenger was told to enter W95 (Ocracoke Island Airport, Ocracoke, North Carolina) into the flight plan; however, he seemed unsure if he entered the information correctly. The pilot responded and stated that “we’ll get it later.” The passenger proceeded to insert Michael J. Smith Field Airport (MRH), Beaufort, North Carolina, into the flight plan, and then activate it. The data recorder data showed that the engine was started at 1329, and after taxi, the engine power was advanced for takeoff at 1334. The autopilot was engaged shortly after takeoff and the airplane climbed and leveled at the selected target altitude of 3,500 ft. The airspeed then stabilized around 220 knots from about 1337 to about 1343. Figure 1 depicts the airplane’s flight track for the entirety of the accident flight overlayed onto a visual flight rules sectional chart. Figure 1. View of the airplane’s flight track (red) overlayed onto a visual flight rules sectional chart. The airplane’s position at various 5 minute time increments is also labeled. After departure, the pilot and passenger spent several minutes amending and activating a flight plan into the airplane’s integrated flight management system before the pilot contacted air traffic control and reported they were going to level off at 3,500 ft mean sea level (msl). He requested VFR flight following as well as an IFR clearance to MRH. At 1338, the controller advised the pilot that a nearby restricted airspace was active, and the pilot confirmed that they would remain clear of the airspace and fly to the east. After that, while still attempting to program the autopilot flight plan, he stated, “I don’t know what I need to do. Just I almost [want] to take it all out and start from scratch.” According to air traffic control data, at 1341, the controller called the pilot and indicated that they were about to enter the restricted airspace. After multiple calls with no response from the accident pilot, the controller instructed the military aircraft that were operating in the restricted airspace to remain above 4,000 ft msl. Although the pilot never responded to the controller, the cockpit voice recorder indicated that the pilot and passenger continued to try and program the flight plan into the flight management system. The pilot expressed concern to the passenger about entering the restricted area, and at one point the pilot stated, “what in the [expletive] am I doing?” From 1341 to 1347, the pilot continued his attempts to program the flight plan into the integrated flight management system. At 1342:55 the selected altitude decreased to 3,000 ft and pitch control mode changed from altitude hold to vertical speed. The airplane began to descend, and the airspeed accelerated to 240 knots by 1343:42. Upon reaching 240 knots an overspeed warning was recorded. The “speed” (overspeed) alert sounded twice from the crew alerting system (CAS) and the pilot continued to enter waypoints into the integrated flight management system. After the first “speed” alert, the cockpit area microphone recorded a sound similar to a reduction in engine power, which correlated with the flight data recorder data that indicated the engine torque was reduced, and the airplane leveled at 3,000 ft. The torque setting remained unchanged until 1355. With the reduced torque setting, the airspeed stabilized at 147 knots. At 1346, the pilot stated, “I have – I have [got to] get a fricken flight plan in this thing.” At 1347, the pilot verbalized the weather conditions at the destination airport. At 1348, the pilot called the controller and requested the RNAV approach to runway 26 but was denied the request because of the active restricted airspace. The controller then queried the pilot as to why he did not respond to the earlier radio calls, and the pilot responded that he “was trying to get out” and was unable to receive the radio transmissions. The controller offered an approach to runway 8 or runway 3, and the pilot chose runway 8. After that, the pilot talked about programing the avionics, and even mentioned “I’ve got to get my iPad out…. this is not good this way – I’m way behind the eight ball – [expletive] I hate it – I hate it when that happens.” The pilot asked the passenger to “bring up” runway 08 [instrument approach procedure], the passenger responded “here I got you” and “there you go,” to which the pilot stated, “I [do not have] my dang gone glasses either – there we go the lights help.” At 1352, the controller reported that the restricted airspace was not active anymore and asked if the pilot wanted the RNAV approach to runway 26 instead. The pilot responded that he would appreciate that, and the controller cleared the pilot direct to CIGOR, the initial approach fix for the RNAV 26 approach. The pilot spent the next 3 minutes attempting to program the route of flight into the flight management system, and mentioned, “I can’t get [nothing] on this thing that I want.” On one occasion, the pilot asked the controller to clarify the name of the fix that they had been cleared to fly to in order to begin the approach (CIGOR or CIBAG), and on another occasion he asked the same question of the passenger. The passenger mentioned that he thought the correct waypoint was CIGOR. At 1355, the controller called the pilot and asked to verify if they were proceeding direct to CIGOR because the airplane was still on a southwesterly track. The pilot responded “roger” and the controller said the pilot could proceed direct to CIGOR, to cross the waypoint at or above 1,900 ft msl, and was cleared for the runway 26 RNAV approach. The pilot read back the instructions correctly and then the passenger stated to the pilot, “should we get [them] to spell CIGOR and just insert it.” The pilot continued to program, delete, and activate waypoints. At 1356:14, the vertical speed mode was engaged again, and the airplane descended to a new selected altitude of 1,800 ft, at 1357:33. During the descent, the engine torque was reduced slightly from its previous setting. After capturing the altitude, airspeed began to decrease at a rate of about 1 knot per second and pitch began a gradual increase of about 0.1 degree per second. Engine torque was reduced again during the slow decay of airspeed while the airplane’s pitch and angle of attack slowly increased. At 1358, the controller contacted the pilot and issued a heading to CIGOR, but then indicated that he had observed that the airplane was “correcting now.” At 1358:46, the controller called the pilot and issued the local altimeter setting (the airplane was flying at 1,700 ft msl, but the pilot had been instructed to maintain 1,900 ft msl). The pilot read back the altimeter setting correctly, which was the last transmission from the pilot. At 1358:56, the airplane’s barometric altimeter setting changed from 29.98 inHg to 29.96 inHg. At that time, the pitch increased to 10° nose up, while the airspeed had decayed to 109 knots. At 1359:12, the “stall” alert sounded from the CAS, the stick shaker activated, and the autopilot automatically disengaged. The airspeed reached a low of 93 knots and the autopilot remained disconnected for the rest of the recording. At 1359:13, the engine torque increased, which was also correlated with a sound consistent with the engine power increasing. The autopilot disconnect warning sounded continuously at 1359:15 and over the next 2 minutes until the end of the recording. During this time the pilot also continued to make comments about the airplane’s navigation system including, “what are we doin’,” “it’ll navigate,” and “activate vectors.” At 1359:40, the passenger stated, “we’re sideways.” Following the stick shaker activation, at 1359:50, the engine power was increased to nearly full power, the stall alert sounded 8 times, the airspeed decayed to 83 knots and the pitch increased to 31.7° when the stick shaker and pusher activated again. At 1401:21, the sink rate alert sounded, and the terrain avoidance warning system announced “pull up” and “speed” before the recording ended at 1401:29. In the final moments of flight, the airplane rolled to a bank of more than 90° to the right and pitched more than 50° nose down. Figure 2 depicts the airplane’s horizontal and vertical flight track during the final 2 ½ minutes of the flight. Figure 2. View of altitude variation during the final 2 ½ minutes of the flight. At 1401, the controller attempted to contact the pilot to inquire about the airplane’s altitude (the airplane was at 4,700 ft msl and climbing quickly). There was no response. Radar contact with the airplane was lost about 1402 and an ALNOT was issued by air traffic control at 1429. - The commercial pilot held a held a second-class medical certificate with a special issuance for mantle cell lymphoma (in remission). At his most recent FAA medical certification examination on June 28, 2021, he reported taking acyclovir daily and infusions of rituximab every 8 weeks for the lymphoma and reported no side effects from these medications. No autopsy report or toxicology testing results were available. Review of the pilot’s medical records showed that the pilot was diagnosed with mantle cell lymphoma in November 2019 and received a stem cell transplant in April 2020. His most recent visit to the oncologist for follow-up and rituximab infusion was on December 10, 2021, and he was reported to overall be doing well. The pilot had an acute injury to his back in August 2021 and over the next three months received three steroid injections for a bulging disc. In August 2021, he reported to his oncologist that he had taken oxycodone for the pain. In addition to the steroid injections, his primary care doctor had prescribed non-steroidal anti-inflammatory medications for his ongoing back pain. The pilot tested positive for COVID-19 in January 2022 and reported receiving a monoclonal antibody infusion and a five-day course of hydroxychloroquine and ivermectin in early February 2022. The passenger held a held a third-class medical certificate without limitations. At his most recent and only exam July 6, 2021, he reported taking no medications and no medical conditions. No autopsy report or toxicology testing results were available. - The weather reported at the departure airport (7W6) around the time of departure indicated that there was a wind from 360° at 10 knots, gusting to 15 knots, visibility 10 miles, ceiling overcast at 2,100 ft above ground level (agl), a temperature of 6° C, a dewpoint temperature of 3° C, and an altimeter setting of 29.93 inches of mercury. The weather reported at the destination airport, MRH, at 1258 included wind from 020° at 10 knots with gusts to 20 knots, visibility 7 statute miles, light rain, ceiling overcast at 1,000 feet agl, a temperature of 8° C and a dew point temperature of 6°C, with an altimeter setting of 29.96 inches of mercury. At 1358, the automated weather reported at MRH included a wind from 020° at 13 knots with gusts to 18 knots, visibility 10 statute miles or greater, light rain, ceiling overcast at 900 feet agl, a temperature of 7° C and a dew point temperature of 6°C, and an altimeter setting of 29.93 inches of mercury. The weather report remarks included that the ceiling was variable between 600 and 1,200 feet agl, that there had been 0.02 inches of liquid-equivalent precipitation since 1258, and that there was a trace amount of ice accretion since 1258. Infrared cloud-top temperatures over the accident site were about -29°C, which corresponded to cloud top heights of about 25,000 ft. A text AIRMET SIERRA for IFR conditions, identifying ceilings below 1,000 feet, visibility below 3 statute miles in precipitation and mist, was issued at 1319 and was valid for the accident site at the accident time. A review of preflight weather briefing information revealed that the pilot did not obtain preflight information from Leidos Flight Services. An account with ForeFlight associated with the airplane viewed airport information on February 12-13, 2022. The airports viewed on February 12, 2022, were: o Morgantown Municipal Airport (MGW), Morgantown, West Virginia o Wilmington International Airport (ILM), Wilmington, North Carolina The airports viewed on February 13, 2022, were: o Hyde County Airport (7W6), Engelhard, North Carolina. Viewed at 0901. o Michael J Smith Field Airport (MRH), Beaufort, North Carolina. View at 0902. o Duluth International Airport (DLH), Duluth, Minnesota. Viewed at 0934. o Manchester Boston Regional Airport (MHT), Manchester, New Hampshire. Viewed at 0934. The Airports page in ForeFlight included airport information, METARs, TAF/MOS and other forecasts. However, ForeFlight did not have any logs about what information was viewed on the airports page. No other information about the pilot’s preflight weather briefing was located. - According to Federal Aviation Administration (FAA) airman records, the pilot held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, and instrument airplane. In addition, he held a ground instructor certificate and held a mechanic certificate with airframe and powerplant ratings. His most recent second-class medical certificate was issued June 28, 2021. At that time, he reported 3,000 total hours of flight experience. According to FAA airman records, the passenger (who was seated in the right cockpit seat) held a student pilot certificate. His most recent third-class medical certificate was issued on July 6, 2021, and at that time he reported 20 hours of flight experience. - The airplane impacted the Atlantic Ocean and was located by the US Coast Guard 3 miles offshore in about 60 ft of water about 5 hours after the accident. Portions of the wreckage were recovered. Examination of the recovered wreckage revealed that the forward and aft sections of the main wing spar were separated, and that the fracture surfaces exhibited overload. The left and right main landing gear were recovered. A section of the left wing and left inboard flap actuator was recovered, along with a section of the left winglet. The 7.5 ft inboard section of the right-wing flap and a majority of the right winglet were located. Aileron control continuity could not be confirmed because a majority of the aileron flight control system was not recovered. The vertical stabilizer remained attached to the empennage. The pitch trim actuator extension was measured and corresponded to slightly nose up trim. The rudder was separated from the vertical stabilizer but remained intact. The rudder trim tab remained attached to the rudder. The rudder trim actuator extension and corresponded to a trim setting slightly in the nose right direction. The elevator flight control cables remained attached to the control rods. Elevator and rudder flight control continuity was confirmed from the flight control surfaces to the forward cabin area of the fuselage through multiple overstress breaks and cuts by recovery personnel. The clamps that attached the stick pusher servo to the elevator control cables were intact and exhibited no signs of slippage. There was no evidence of fire on any section of the airplane. The emergency locator transmitter (ELT) was removed from the empennage by divers who turned the ELT to the off position. The engine was impact separated from the airframe. The accessory gear box and reduction gear box were not recovered. The power turbine housing and sections of the power turbine vanes exhibited rotational scoring. In addition, the power turbine vanes were bent the opposite direction of normal rotation. The fuel filter was removed, and no debris was noted in the screen. The P3 filter was removed from the engine. Water and corrosion were noted in the filter. The oil filter was removed and examined. Oil was noted in the screen, and no debris was noted. The propeller governor and overspeed governor were not recovered. The propeller hub was not recovered. Three propeller blades were recovered with the wreckage, the two others were not. The three propeller blades were separated at the hub and about midspan of the blade. -
Analysis
Before departing on the flight, the pilot of the turbo-propeller-equipped, single-engine airplane and student pilot-rated passenger seated in the right front seat of the airplane attempted to enter a flight plan into the airplane’s integrated flight management system. They ultimately did not complete this task prior to takeoff with the pilot remarking, “we’ll get to it later.” The pilot subsequently departed and climbed into instrument meteorological conditions (IMC) without an instrument flight rules (IFR) flight plan. After entering IMC, he contacted air traffic control and asked for visual flight rules (VFR) flight following services and an IFR clearance to the destination airport. From shortly after when the airplane leveled after takeoff through the final seconds of the flight, the pilot attempted to program, delete, reprogram, and activate a flight plan into the airplane’s flight management system as evidenced by his comments recorded on the airplane’s cockpit voice recorder (CVR). After departing, the pilot also attempted to navigate around restricted airspace that the airplane had flown into. The CVR audio showed that during the final 10 minutes of the flight, the pilot was unsure of the spelling of the fix he should have been navigating to in order to begin the instrument approach at the destination airport, and more generally expressed frustration and confusion while attempting to program the integrated flight management system. As the pilot continued to fixate on programming the airplane’s flight management system and change the altimeter setting, the airplane’s pitch attitude increased to 10° nose up, while the airspeed had decayed to 109 knots. As a result of his inattention to this airspeed decay, the stall warning system activated and the autopilot disconnected. During this time the airplane began climbing and turning to the right and then to the left before entering a steep descending right turn that continued until the airplane impacted the ocean. For the final 2 and 1/2 minutes of the flight, the pilot was provided with stall warnings, stick shaker activations, autopilot disconnect warnings, and terrain avoidance warning system alerts. The airplane impacted the ocean about 3 miles from the coast. Examination of the recovered sections of the airplane did not reveal evidence of any mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. The instrument meteorological conditions present in the area at the time of the accident were conducive to the development of spatial disorientation. The airplane’s erratic flight track in the final 2 minutes of flight, culminating in the final rapidly descending right turn, were consistent with the known effects of spatial disorientation. It is likely that the pilot’s inadequate preflight planning, and his subsequent distraction while he unsuccessfully attempted to program the airplane’s flight management system during the flight resulted in his failure to adequately monitor the airplane’s speed. This led to the activation of the airplane’s stall protection and warning systems as the airplane approached and entered an aerodynamic stall. The resulting sudden deactivation of the autopilot, combined with his inattention to the airplane’s flight attitude and speed, likely surprised the pilot. Ultimately, the pilot failed to regain control of the airplane following the aerodynamic stall, likely due to spatial disorientation. The pilot had a history of mantle cell lymphoma that was in remission and his maintenance treatment with a rituximab infusion was over 60 days prior to the accident. The pilot also had a history of back pain and had received steroid injections and nonsteroidal anti-inflammatory drugs. By self-report, he had taken oxycodone for pain management; it is unknown how frequently he used this medication or if he had used the medication on the day of the accident. While oxycodone can result in fatigue and dizziness, and may interfere with reaction time, given the information from the CVR, it could not be determined if the pilot had these side effects. A few weeks prior to the accident, the pilot reported having COVID-19 and receiving a 5-day treatment course of hydroxychloroquine and ivermectin. While there are some impairing side effects associated with the use of those medications, enough time had elapsed that no adverse effects would be expected. There is an increased risk of a sudden incapacitating cardiovascular event such as a dysrhythmia, stroke, or pulmonary embolism in people who have recovered from their COVID-19 infection. The risk is slight for those not hospitalized for the infection. The pilot did not have an underlying cardiovascular disease that would pose an increased risk for a sudden incapacitating event and the CVR did not provide evidence of a sudden incapacitating event occurring. Thus, it could not be determined if the pilot’s medical conditions of mantle cell lymphoma, back pain, and recent history of COVID-19 and the medications used to treat these conditions, including rituximab, oxycodone, hydroxychloroquine, and ivermectin, were contributing factors to this accident.
Probable cause
The pilot’s inadequate preflight planning, inadequate inflight monitoring of the airplane’s flight parameters, and his failure to regain control of the airplane following entry into an inadvertent aerodynamic stall. The pilot’s likely spatial disorientation following the aerodynamic stall also contributed to the outcome.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PILATUS AIRCRAFT LTD
Model
PC-12/47E
Amateur built
false
Engines
1 Turbo prop
Registration number
N79NX
Operator
EDP MANAGEMENT GROUP LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1709
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-17T18:20:36Z guid: 104634 uri: 104634 title: CEN22LA121 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104640/pdf description:
Unique identifier
104640
NTSB case number
CEN22LA121
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-14T18:40:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-02-15T21:41:19.383Z
Event type
Accident
Location
Furlow, Arkansas
Airport
Country Air Estates (1AR9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On February 14, 2022, about 1640 central standard time, a Piper PA-22-150, N7337D, was substantially damaged when it was involved in an accident near Furlow, Arkansas. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot recalled that the left and right fuel tanks contained about 4 gallons and 7 gallons of fuel, respectively, before takeoff. He reported the takeoff and initial climb into the traffic pattern were uneventful. When the airplane was on the downwind leg, abeam the approach end of the runway, the engine began to run rough. The pilot immediately changed the fuel selector from the right tank to the left tank, verified that the carburetor heat was on, and turned the airplane toward the runway. The engine subsequently lost power completely. The airplane was not able to glide to the runway, and the pilot executed a forced landing into a wooded area, which resulted in damage to the fuselage, both wings, and the empennage. A postaccident airframe examination revealed that the left fuel tank was intact, and the right fuel tank appeared to be compromised. First responders noted a significant odor consistent with fuel while on scene. A postrecovery engine examination revealed that the carburetor bowl contained minimal fuel, the accelerator pump appeared functional but did not contain any fuel, and the fuel inlet screen was clean. No other anomalies with respect to the engine were observed. The pilot noted that on two occasions before the most recent annual inspection, the engine ran “very badly” for about 30 seconds and then immediately cleared up. The accident occurred during the pilot’s first flight in the airplane following the inspection. The inspection determined the muffler baffles were loose, and a new muffler was installed. An examination of the recently installed muffler did not reveal any anomalies. -
Analysis
The pilot reported the takeoff and initial climb into the traffic pattern were uneventful. However, the engine began to run rough while on the downwind leg of the traffic pattern. The pilot immediately changed the fuel selector from the right tank to the left tank, verified that the carburetor heat was on, and turned the airplane toward the runway. The pilot’s efforts to restore engine power were not successful. The airplane was not able to glide to the runway, and the pilot executed a forced landing into a wooded area. Postaccident examination revealed that the left fuel tank was intact and the right fuel tank appeared to be compromised. A distinct fuel odor was present at the accident site and fuel was observed leaking from the left tank. The engine carburetor bowl contained minimal fuel, and the carburetor accelerator pump did not contain any fuel. No other anomalies with respect to the engine were observed. The pilot recalled that the left and right fuel tanks contained about 4 gallons and 7 gallons, respectively, before takeoff. While it is possible that the pilot’s decision to change to the tank containing less fuel resulted in unporting of the fuel tank inlet and the subsequent loss of engine power, the investigation was unable to determine the reason for the loss of power or the initial engine roughness.
Probable cause
A loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA22
Amateur built
false
Engines
1 Reciprocating
Registration number
N7337D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
22-5126
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-15T21:41:19Z guid: 104640 uri: 104640 title: ERA22LA123 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104644/pdf description:
Unique identifier
104644
NTSB case number
ERA22LA123
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-15T11:55:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2022-02-25T00:27:18.41Z
Event type
Accident
Location
Culebra, Puerto Rico
Airport
BENJAMIN RIVERA NORIEGA (CPX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 15, 2022, about 0955 Atlantic standard time, a Britten-Norman BN-2A-9 airplane, N821RR, was substantially damaged when it was involved in an accident at Benjamin Rivera Noriega Airport (CPX), near Isla de Culebra, Puerto Rico. The pilot receiving instruction, flight instructor, and pilot-rated passenger were not injured. The airplane was operated by Air Flamenco conducted as a Title 14 Code of Federal Regulations Part 91 instructional flight.   According to the pilot, he had recently retired from flying large transport-category airplanes. He was recently hired by Air Flamenco and had received some ground school training on the BN-2A-9, the company mission, routes, and destinations. The accident occurred on the first landing of his first flight, and it was his first ever landing at the accident airport. The pilot stated that he entered a left downwind for landing on runway 13, and the estimated wind conditions were 090° at 15 to 16 knots. The instructor advised him that his aiming point should be the grass area that preceded the landing threshold. The approach was flown about 80 knots and about 100 ft above the normal flightpath. The pilot reported that the wind was not a factor. After touchdown the airplane “leaned to the right” and veered off the right side of the runway.   In an interview with a Federal Aviation Administration (FAA) aviation safety inspector, the flight instructor confirmed this was the first flight with the pilot. Air Flamenco considered CPX a “special airport” because of the short runway and challenging runway environment and company pilots who flew there participated in a “special” training program. Typically, pilots would have completed the other phases of flight training and additional training specific to CPX before landing at CPX for the first time.   The instructor described a stabilized approach at 70 knots. He said the pilot made a three-point, flat landing (all three of the airplane’s landing gear contacting the runway at the same time), and the airplane turned right almost immediately. When asked, the instructor said it was not a hard landing. In the company flight log for the accident flight, he reported the airplane “experienced strong wind conditions sliding the aircraft off of the runway.” In another company incident report, the instructor stated that because it’s free castering, the nosewheel turned 90° to the right at touchdown, causing the aircraft to drift right of the runway and “making it very hard to regain directional control.”   The commercial pilot seated in the back stated it was not a hard landing, but it was “harder than anything he had experienced before at that airport.”   The FAA inspector who responded to the accident site photographed witness marks on the runway, in the grass apron along the wreckage path, and the wreckage itself. The inspector described and his photographs illustrated witness marks consistent with propeller strikes and orange paint transfer marks on the runway. The right propeller blades displayed tip curling and the orange-painted wingtip displayed impact damage, scraping, and asphalt transfer. The distance between the scars on the runway were consistent with the distance between the propeller spinner and the wingtip. The right main landing gear was mounted to the aft portion of the right engine. The right wing was twisted downward and the aft portion of the right wing was deformed upward at the wing root, which resulted in substantial damage to the right wing. After the accident, there was some discussion between the flight crew and company mechanics about the nosewheel free-castering system. Postaccident examination of the airplane at the airport by the FAA revealed no evidence of preimpact mechanical anomalies with the nosewheel that would have prevented normal operation.  A detailed examination of the wing revealed the right half of the wing was deformed aft and the leading edge was twisted down. The right wing lower spar cap was deformed upward. The forward spar cap was bent aft. The rear spar upper and lower spar caps were deformed upward significantly. The rear spar upper and lower caps were deformed down and aft. The right wing front and rear spars, ribs, and stringers were damaged. There were abrasions present on the lower portion of the right wing tip, and yellow paint transfers were observed on the runway surface. There was no appreciable corrosion noted in any of the interior or exterior areas of the wing examined, or on the fuselage structure. All the fracture surfaces examined had a dull, grainy appearance consistent with overstress separation The approach into CPX involves some maneuvering prior to touchdown due to terrain west of the airport. The initial approach begins at 800 ft mean sea level (msl) and 80 kts over Flamenco Lagoon northwest of the airport on a heading aligned about 40° right of runway heading. While over Flamenco Lagoon, the instructions call for flaps at 56°, completion of the before landing checklist, and maintaining a positive rate of descent. The approach continues the same heading to a descent to 400 feet msl to a saddle in the terrain located about 2,000 ft northwest of the runway 13 threshold. The approach necessitates a continued descent to the runway from the saddle while making a left 40° turn to align with the runway. Just before touchdown the airplane must roll right from the left turn to a wings level attitude. The recommended speed remains 80 knots for the final approach and the instructions warn not to overshoot the runway. The note in the training materials states “If you do not land in the first 1,300 feet of RWY 13 or you are above 80 kts, a go-around procedure must be executed. Turbulence may be experienced when the wind is from the north.” Britten-Norman Aircraft Limited provided information on the certification landing loads for the airplane. They stated that the rear spar web would be expected to fracture first followed by bending of the upper and lower spar caps near the location noted on the accident airplane under a hard landing condition that exceeded the design limit load by about 20% to 50%. They noted that typical hard landing events that do not exceed the design limits would result in damage to the lower part of the nacelle where the lower main landing gear mount point is located and the upper wing skin above the main landing gear. -
Analysis
The pilot was receiving flight training as a new hire, and the accident occurred during his first flight in the airplane and the first landing. The pilot stated the approach was flown at the upper end of the allowable approach speed, and about 100 ft above the normal glidepath. During the landing, all three of the airplane’s landing gear touched down at the same time, the airplane immediately veered right, and continued off the right side of the runway. The airplane sustained substantial damage to the right-wing structure. The flight instructor chose an airport with a challenging approach that required a special training program prior to the first landing. The approach procedure requires a left 40° turn then rolling wings level just before touchdown. It is likely that the airplane’s descent rate during landing exceeded the airplane’s capability, which resulted in a hard landing and failure of the right-wing structure.
Probable cause
The flight crew’s failure to arrest the descent rate during the non-standard approach, which resulted in a hard landing and failure of the right-wing structure. Contributing was the flight instructor’s selection of a challenging approach for initial training.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BRITTEN-NORMAN
Model
BN-2A-9
Amateur built
false
Engines
2 Reciprocating
Registration number
N821RR
Operator
AIR CHARTER INC DBA
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
338
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-25T00:27:18Z guid: 104644 uri: 104644 title: DCA22FA082 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104654/pdf description:
Unique identifier
104654
NTSB case number
DCA22FA082
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-16T11:58:00Z
Publication date
2024-02-07T05:00:00Z
Report type
Final
Last updated
2022-03-03T00:00:24.528Z
Event type
Accident
Location
Jolon, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
Flight Test Video Review Joby performed a detailed frame-by-frame analysis of the cockpit-mounted GoPro 360 view camera to document the station 3 propeller condition prior to and during the accident sequence. The blade pitch angles were estimated by comparison to the station 2 blade pitch angles and a CAD model of the blades at various pitch angles. Joby indicated that, seconds before the first propeller blade separated from station 3, it appeared normal and was operating with blade pitch angles within their normal range. The aircraft was established in a descent, then accelerated to a commanded 181 KIAS test point prior to the accident condition. About 0.07 seconds prior to the first propeller blade separating from propulsion station 3, the failure blade (blade 4) was located near the 2 o’clock position (as viewed from behind looking forward, rotation direction counter-clockwise). Joby indicated that the blade’s pitch angle appeared greater than the other blades. When the blade was near the 10 o’clock position, its pitch angle was estimated to have exceeded the commanded pitch angle and appeared to be near or beyond the physical pitch stop. The outer one-third of the trailing edge of the blade appeared to be disbonded. The following propeller blade (blade 5) also exhibited evidence of a core disbond. Blade 4 failed near the root when it was near the 7 o’clock position; its trailing edge root skins appeared to be ruptured and the blade pitched and deflected in a way consistent with a failure of the blade spar near the root. At this time, blade 5 was near the 10 o’clock position and its pitch angle was estimated to have exceeded the commanded pitch angle and appeared to be near or beyond its physical pitch stop. Shortly after blade 4 separated, the video showed it approaching the station 4 propeller; subsequently, the station 4 EPU began to separate from the aircraft. Following the separation of blade 4 from station 3, three additional propeller blades separated from the station 3 propeller within a couple of seconds, and the fifth blade separated during the aircraft’s descent to the ground. Flight Test Data Review Examination of the HRR data for the accident time period revealed that the variable pitch actuator for station 3 was commanding a typical cruise pitch when the blade release occurred, whereas video evidence indicated a steeper pitch on some blades immediately before the initial blade release. All propellers were at different operating speeds at the time of the incident – an intended behavior of the control system – and the station 3 propeller speed was recorded near a predicted propeller natural frequency (resonance) crossing mode. Accelerometer data for station 3 showed a rapid growth in vibration after reaching the accident flight condition before the initial blade release. Tilt actuator position values for station 3 also showed an oscillation at this time. Further examination of prior flight test data by Joby revealed that there was consistent asymmetric behavior between station 2 and station 3, despite identical mirrored designs. In cruise mode, the tilt actuators on station 3 showed increased activity in all flight conditions compared to station 2, which experienced steady loading after achieving zero tilt angle. Tilt linkage loads were also higher in station 3, which analysis by Joby determined could be an indication of anomalous behavior in the tilt mechanism. The resonant response to this propeller mode crossing in station 3 was also consistently stronger than in station 2, indicative of a coupled interaction with the anomalous tilt mechanism. While prior flights excited the propeller mode in transition flight, the strong excitation in cruise was not predicted; post-accident analysis revealed this strong excitation was due to aerodynamic interactions that only become significant above the design never-exceed airspeed. Aircraft Component Examination The recovered station 3 propeller blade segments were examined. Each of the blades was conclusively identified using distinct markings from the video. The initial failure blade spar was separated from the blade skins and was fractured about 50 mm outboard of the end of the titanium root fitting. This location corresponded to two closely spaced spar ply drops which created a stress concentration. The unidirectional fibers at the fracture location had a splayed, broomstraw appearance consistent with a bending failure. The top and bottom blade skins remained connected together at the tip, but the leading edge and trailing edge joints were disbonded. Only the 50 mm of spar stub remained attached to the hub. The fractured root areas of the initial separation blade skins were recovered separately, with some sections not identified. The separated leading edge “taco” had a kink consistent with impact with the station 4 propeller blade. There were abrasion marks on the inside of the blade skins at the leading edge consistent with the spar being pulled out during the separation. There were irregularities noted in portions of the adhesive bond area on the upper skin that were consistent with amine blush. There were impact marks near the trailing edge of the root rib consistent with contact between the root rib and the motor resulting from chordwise blade flexure with the blades at a steep pitch. The tip of the station 3 initial failure blade was not identified. Examination of the other station 3 propeller blade fragments revealed that all had impact marks near the trailing edge of the root rib consistent with contact between the root rib and propulsion motor elements at steep pitch. The second blade to depart fractured from the hub near the outboard end of the titanium fitting and was fractured near the 2/3 span location. The video showed this blade impacted the right wingtip after departure. The skins of the third and fourth blades to depart were separated from their spars, and the spars were fractured near the outboard end of the titanium fittings. The fifth blade to depart fractured from the hub near the outboard end of the titanium fitting and was mostly intact. Station 4 (located on the right wing outboard) was found separate from the aircraft with the propeller intact except for a single propeller blade, which was not attached. Examination of the non-attached blade found that it exhibited significant mid-span leading edge damage consistent with the impact of another blade. The spar was intact in this blade and was broken similar to other failed blades. A propeller blade from station 6 separated from the propeller before the station separated from the aircraft. The initial separation blade has not been identified. Two blades have significant damage but are not believed to be the initial separation blades based on video evidence. The three remaining blades have no obvious impact marks that would be consistent with collision with flying debris, unlike the damage seen on the separated Station 4 blade. Stations 1 and 5 were found with intact propellers and cowlings near station 4. Stations 1 and 5 had no identified propulsion unit or propeller damage that could be attributed to impact with the terrain. Station 2 suffered a propeller rupture just prior to impact. The propulsion unit and tilt mechanism separated from the main aircraft immediately prior to impact and was located near the main crash site. The tilt mechanism was in nominal condition and was found in the cruise configuration. Joby Aviation reported that computed tomography non-destructive testing scans from most of the propeller blades on the aircraft had been conducted prior to the accident. Ultrasonic testing (UT) inspections had also been conducted on all propeller blades on the day prior to the accident flight. The station 3 initial failure blade was found to be a typical blade prior to the accident in comparison to past inspections. Previous CT scans showed a small anomaly on the inner surfaces of the spar likely affecting a single ply, but scan comparisons of this anomaly over time revealed that this feature would not have met the criteria to remove the blade from service and was not likely a factor in the accident. There was no evidence of a skin-to-spar disbond on the initial failure blade. The recovered station 3 propulsion unit – including the propulsion motor, propeller pitching system, and propeller hub – were disassembled and examined on February 24, 2022, by Joby and observed by NTSB and FAA representatives. The unit sustained significant mechanical damage to its propeller pitch system components and was fire-damaged. Elements of the blade pitching system were forced into the propeller hub by the impact; the portion of the system responsible for maintaining uniform blade pitch was crushed, with elements sheared off, and all components of the system were damaged. Although all five propeller blades had separated prior to impact, all five stub spars and their associated fittings remained installed in the hub. All blade retention hardware was intact. The blade pitch linkage was all present and similarly damaged by the impact. Two of the propeller hub-to-rotor fasteners were broken consistent with the inverted nose-low impact attitude. Some damage was found to the station 3 blade pitch stops. Damage to the stops was most observable on blade 1. Evidence of mechanical interference on Station 3 between blade 2 and 3 linkage prior to post-crash fire could represent abnormal propeller operation prior to impact. The interference was between the pitch arm on the blade root and the fastener connecting the pitch link to the pitch arm on the adjacent blade. The propeller variable pitch actuator was found damaged and compressed consistent with impact. The corners of the hexagon-shaped thread locking washer under the retaining nut for the bearing between the rotating propeller and fixed actuator were mostly bent forward, away from the bearing and opposite of the direction expected from impact. The outer bearing grease seal showed signs of wear, heat, and deformation. Joby indicated that these two observations were consistent with damage that could occur if the bearing and associated pitching system components were operating at or beyond the designed operational angular travel. - The accident aircraft was the first of two second-generation, pre-production prototype flight test aircraft produced by Joby Aviation. The aircraft was all-electric, fly-by-wire, and capable of vertical takeoff and landing. Provisions for five occupants (a pilot and four passengers), were provided, though it could be piloted remotely. The design's maximum gross takeoff weight was 4,200 pounds. The aircraft was operated with a civil Optionally Piloted UAS Experimental Airworthiness Certificate. The Certificate of Authorization (COA) assigned to the aircraft dated May 5, 2021, was not applicable for the accident flight which occurred in special use airspace. Figure 1. Depiction of a JAS4-2 aircraft (Source: Joby Aviation) The aircraft was configured with six tilting propellers directly driven by six dual-powered electric motors supplied by power from four battery packs. The six electric propulsion unit (EPU) stations are identified numerically based on location as station 1-outboard left wing, station 2-inboard left wing, station 3-inboard right wing, station 4- outboard right wing, station 5-left tail, and station 6-right tail. Each of the six variable pitch propeller assemblies were equipped with five blades and actuated by a single variable pitch actuator driving a mechanical pitch change mechanism. - Debris at the main wreckage site was largely located in an area about 100 feet in diameter. Battery pack structures failed during the impact and battery cells were found spread in the wreckage. Two main fires occurred at the primary impact site and were largely confined to battery cells that were damaged during the impact. Both fires affected an area about 10 feet in diameter and were contained with handheld fire extinguishers. - Several devices onboard the aircraft were capable of recording data or video. The following items were recovered from the wreckage with recoverable information. o 3x High-Resolution Recorders (HRRs) data. o Only one of these included a full data set for the accident. o GoPro 360 video from the onboard pilot eyepoint. o Right door-mounted GoPro video looking out the right wing and slightly aft. Information was unable to be recovered from the data acquisition system (DAQ) and GoPro forward-pointing nose camera. Additionally, the following data and video were captured off aircraft: o Ground control station recordings of the nose and tail First Person Video (FPV) cameras o Ground control station antenna video o Chase aircraft video o Ground control station video The majority of the recorded parametric data came from the Joby Aero Inc. high-resolution recorder (HRR), a custom unit that captured various on-vehicle information, including control system messages. There were multiple HRRs on the aircraft to ensure consistent recording of data between redundant aircraft systems. One HRR, which recorded the data relevant to this incident, was the source for all data used in this report. Joby also employed a commercial off-the-shelf data acquisition system (DAQ) to record additional flight test data. This dataset would have included vibration and strain gauge information. This unit was not designed to be crash-resistant and did not survive the accident. No data was recovered from this device. Valuable information was recorded by a cockpit-mounted GoPro 360-degree video camera. This unit was not crash-resistant. The unit’s files were corrupted in the accident but were recovered by the NTSB flight recorders laboratory. Much of the analysis of the accident sequence – specifically, the behavior of the blades and subsequent blade pitch angles on station 3 – was constructed from this recording. Additional video sources on the aircraft include a camera looking outboard in the right door and a forward looking "stinger" camera mounted on a shaft extending behind the tail and looking forward. - On February 16, 2022, a Joby Aero Inc. JAS4-2 experimental aircraft, N542AJ, was engaged in a planned speed and altitude envelope expansion flight test, beyond expected operating conditions. The aircraft was remotely piloted from the ground and observed from a chase aircraft. The aircraft was performing a developmental flight test, operating under the provisions of 14 Code of Federal Regulations part 91, utilizing an experimental category special airworthiness certificate. The flight began about 09:42 PST with a normal vertical takeoff, transition to wing-borne flight, and climb up to 11,000 feet mean sea level (MSL). After successfully completing one test condition, the remote pilot-in-command (PIC) began descending and increasing the speed of the aircraft in preparation for the next test condition. After reaching a maximum dive speed of 181 knots indicated airspeed (KIAS) at an altitude of approximately 8,900 feet, the propeller on propulsion station 3 (located on the right wing inboard) experienced oscillations in rpm and motor vibrations. Based on a review of video evidence and recorded flight data, about 09:58, the station 3 propeller stabilized at a resonant condition with previously unidentified destructive effects which quickly culminated in a propeller blade release from propulsion station 3. The blade spar failed near the root outside the hub and the blade traveled outboard and impacted the propeller on propulsion station 4, resulting in the separation of a blade from this propeller and the separation of this station from the aircraft. The station 3 propeller continued to rotate with significant imbalance. Shortly thereafter station 6 (right tail propeller) experienced a single blade separation and the separation from the aircraft. Cascading effects (loss of other propeller stations from the aircraft) resulted in the aircraft subsequently breaking up in flight. The aircraft departed controlled flight, rapidly rolling to the left, entered an inverted dive, and crashed in an uninhabited area near Jolon, California. There were no injuries, and the aircraft was destroyed. - The aircraft’s main wreckage consisted of the main body of the aircraft, wings, station 3 motor, and most of the tail. The main fuselage of the aircraft impacted the ground about 0.5 nautical miles (nm) south-southeast of the initial in-flight failure event. The separated stations 1, 4, and 5 EPUs (including attached propellers), separated propeller blades and fragments from stations 2, 3, and 6, various nacelle cowlings, skin sections from the right tail, and other lightweight debris were scattered in a debris field up to 4 nm south-southeast of the main wreckage. The station 6 EPU separated from the aircraft with no propeller blades attached and impacted the ground about 0.8 nm southeast of the main wreckage. The station 2 EPU and separated propeller blades were located between the main wreckage and an area about 0.1 nm northeast. -
Analysis
On February 16, 2022, Joby Aero Inc. was conducting planned, remotely piloted, airspeed and altitude envelope expansion flight tests on aircraft JAS4-2, the first of their two second-generation, pre-production prototype flight test aircraft. The envelope expansion flight test conditions were beyond the expected operating conditions of the aircraft. During the second test flight, and after reaching a maximum dive speed of 181 knots indicated airspeed (KIAS) at an altitude of approximately 8,900 feet, a propeller blade on propulsion station 3 (located on the right wing inboard) experienced a bending failure near the root of the blade which culminated in the release of the propeller blade. The released blade impacted the propeller on propulsion station 4 (located on the right wing outboard), which subsequently resulted in a release of the impacted blade. Cascading effects resulted from the initial inflight blade failures including the separation of multiple propulsion motor/propeller assemblies and loss of remote pilot control of the aircraft. The aircraft departed controlled flight after the initial inflight blade failure and impacted the ground about 0.5 nautical miles (nm) south-southeast away. Examination of the High-Resolution Recorder data for the accident time period revealed that the variable pitch actuator for station 3 was commanding a typical cruise pitch when the blade release occurred, whereas video evidence indicated a steeper pitch on some blades immediately before the initial blade release. Accelerometer data for station 3 showed a rapid growth in vibration after reaching the accident flights test condition before the initial blade release. Tilt actuator position values for station 3 also showed an oscillation at this time. Examination of prior flight test data by Joby revealed consistent asymmetric behavior between station 2 and station 3, despite identical mirrored designs. In cruise mode, the tilt actuators on station 3 showed increased activity in all flight conditions compared to station 2. Tilt actuator linkage loads were also higher in station 3, which can be an indication of anomalous behavior in the tilt mechanism. The resonant response to this propeller mode crossing in station 3 was also consistently stronger than in station 2, indicative of a coupled interaction with the anomalous tilt mechanism. While prior flights excited the propeller mode in transition flight, the strong excitation in cruise was not predicted; post-accident analysis revealed this strong excitation was due to aerodynamic interactions that only became significant when the airspeeds were beyond the expected operating conditions of the aircraft. The dive speed of 181 KIAS reached during the speed and altitude envelope expansion flight test in conjunction with an anomalous propeller tilt system condition at propulsion station 3, likely resulted in unanticipated aerodynamic interactions that excited a propeller mode, leading to a non-uniform blade pitch increase beyond its design limitations. This likely caused a load exceedance which resulted in the initial blade failure. Aircraft control was lost as a result of cascading effects following the initial propeller blade separation.
Probable cause
The separation of a propeller blade during expansion flight testing that resulted in cascading effects to include the separation of multiple propulsion motor/propeller assemblies and the loss of remote pilot control of the aircraft. Contributing to the accident was the tilt rotor actuator linkage for propulsion station 3 that allowed some propeller blades to be at a steeper angle than commanded.
Has safety recommendations
false

Vehicle 1

Aircraft category
Unmanned
Make
JOBY AERO INC
Model
JAS4-2
Amateur built
false
Engines
6 Electric
Registration number
N542AJ
Operator
JOBY AERO INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
JAS4-201
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-03T00:00:24Z guid: 104654 uri: 104654 title: WPR22FA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104646/pdf description:
Unique identifier
104646
NTSB case number
WPR22FA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-16T23:30:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-02-18T21:26:28.916Z
Event type
Accident
Location
Coalinga, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 16, 2022, about 2130 Pacific standard time, a Bell UH-1H helicopter, N72297, was substantially damaged when it was involved in an accident near Coalinga, California. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot had planned to conduct spray operations over five separate jobsites during night conditions. A ground crew supervisor and two others were supporting the operation. The ground crew operated out of two support trucks that were equipped with a radio for communicating with the pilot and had a landing pad mounted above the tanks containing fuel and chemicals. The pilot arrived at work at 1630 and subsequently departed for the first of the five planned flights. See figure 1. Figure 1. Google Earth image of the five job sites, the accident site, and the airstrip. Note: The white arrows denote the direction of travel. The red line indicates the location of large power distribution lines. The two insets show the proximity of the power distribution lines to the fourth job site and the accident site. The pilot arrived at the first job location about 1800. While at that job site, the pilot told the ground crew that the GPS was acting up. He completed operations at the first job site and then traveled about 5 miles north to the second job site. After completing operations there, the pilot traveled about 29 miles west to the third job site. He began operations at that job site but canceled the job about 2130due to increased wind, which caused difficulty lining up the helicopter to the support truck. One ground crewmember reported that the pilot became confused about the number of loads remaining at the third job site and had to be told twice about the number of loads remaining. The ground crew foreman (who was not part of the ground crew at the job sites) explained that the pilot was usually very aware of the loads left to be applied and that it was odd that a ground crewmember would have to tell the pilot that information. In addition, the ground crew supervisor reported that, while at the third job site, the pilot stated that he was cold and that the heater on the helicopter was acting up. The pilot departed and traveled west about 1 mile, overflew the fourth job site, canceled it, and directed the ground crew to go to the fifth job site. The pilot then departed the area without announcing his intentions. One ground crewmember saw the helicopter “lift off, making a passenger-side [left] turn toward the south, over the [power distribution] wires and leveling out.” The last communication with the pilot occurred about 2138 and involved the pilot questioning a ground crewmember about how he determined the wind speed at the fifth job site. About 2200, when the helicopter had not arrived at the fifth job site and the pilot did not respond to radio calls, the ground crew supervisor alerted his employer and then called 911. None of the ground crewmembers supporting the operation reported hearing a mayday call over the radio. The helicopter was found in an orchard about 0300 the next day. The wreckage was located about 9 miles southeast of the fourth job site and about 3 miles northwest of Harris Ranch Airport (3O8) Coalinga, California. According to another pilot, the accident pilot was known to land at the airport when taking breaks. The ground crew supervisor stated that it would not have been normal for the pilot to take off to the store without telling the ground crew, and for the pilot to take a load of pesticides to Harris ranch. One ground crewmember stated that the pilot did not indicate that he needed a break. A set of power distribution lines was located about 120 ft east of the accident site. The power distribution line towers were about 100 ft tall and ran generally north and south parallel to an interstate highway and alongside the fourth job site and 3O8. The power distribution lines and the towers near the accident site showed no evidence of damage. - The Fresno County Sheriff–Coroner’s Office, Fresno, California, performed an autopsy on the pilot. His cause of death was head injury due to blunt impact. The pilot’s postmortem COVID-19 test was negative, and a blood sample sent to the Federal Aviation Administration (FAA) was negative for carbon monoxide. The autopsy report stated that the pilot was dressed in (among other things) two jackets, and long johns. Toxicology testing performed by the FAA Forensic Sciences Laboratory identified ethanol in the pilot’s femoral blood but not in his urine and found acetaminophen in the pilot’s subclavian blood and urine. Acetaminophen is an over-the-counter analgesic and fever reducer commonly marketed with the name Tylenol. It is generally not considered impairing. A pack of Plaquenil (hydroxychloroquine) and a bottle of ibuprofen were found at the accident site. - A witness to the meteorological conditions on the night of the accident (one of the operator’s fixed-wing pilots who searched for and located the missing helicopter) reported that the moon was full and that visibility was unlimited. According to the US Naval Observatory, on the day of the accident, the sun set at 1742, and moonrise occurred at 1651. The moon phase was full with 100% of the moon’s disk illuminated. - Multiple people reported that the pilot thought that he had contracted COVID19. A family member reported that, 2 days before the accident flight, the pilot asked questions about the symptoms of COVID-19 and went to sleep immediately after dinner. Both the pilot’s wife and an employee of his business reported that, on the day before the accident, the pilot told them that he tested positive for COVID-19. One ground crewmember reported that, when he communicated with the pilot on the night of the accident, the pilot would already be talking as he keyed the microphone and that he would release the microphone before he stopped talking. A pilot who was trained to operate the accident helicopter by the accident pilot reported that the accident pilot “insisted” that ferry flights be flown at 500 ft above ground level. This pilot also stated that, because of the power lines, the accident pilot would not have considered flying the helicopter lower than that altitude on the night of the accident. - The helicopter came to rest on its left side in an orchard, as shown in figure 2. The orchard was at an elevation of about 385 ft mean sea level and consisted of 12-ft trees spaced about 15 ft apart. An area of disturbed ground and felled trees extended back from the helicopter about 120 ft on a magnetic bearing of 170°. The fuselage had rotated about 180°. Figure 2. Aerial view of the accident site and the power distribution lines (left side). All major components of the helicopter were observed near the accident location. The forward area of the fuselage exhibited damage consistent with a nose-low, left-bank impact. Flight control continuity was established for all flight controls to the hydraulic servos for the respective systems and from the hydraulic servos to the respective flight control surfaces. Both rotor systems exhibited damage consistent with rotation at impact. The helicopter was equipped with forward-facing LED supplemental lights. Examination of the pilot’s collective control revealed that both supplemental light switches were in the ON position. According to a pilot employed by the operator, the helicopter’s supplemental lights were used for night spraying, and the pilot would not normally use the lights for ferry flights because the lights were oriented upward and the beam would be too high for straight-and-level flight. Examination of the engine revealed that it remained secured to the engine mounts and that a section of the firewall had separated and become wrapped around the power output shaft. Tree debris and airframe wire were found between the compressor inlet guide vanes, consistent with ingestion at impact. A teardown of the engine axial compressor section at the engine manufacturer’s facility revealed that all blades exhibited hard-body impact damage and trailing-edge tip bending opposite the direction of rotation. Postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The annunciator panel, master caution, rpm warning, and fire warning lights were recovered from the instrument panel. No light filaments appeared to be stretched. -
Analysis
The pilot departed the operator’s ramp for five nighttime aerial application operations. He was supported by three ground crewmembers, who described normal interactions with the pilot during the landings to the truck. About 2.5 hours later, while at the third job site, the pilot indicated that the wind had increased and that he was having difficulty lining up the helicopter with the support truck (for landing). The pilot also reported that the helicopter’s heater was not working and that he was cold, even though he was dressed for the outside conditions. The pilot also exhibited confusion and difficulty with communicating with the ground crew. The pilot subsequently canceled the third and fourth jobs, directed the ground crew to the fifth job site, and then departed the fourth jobsite with chemicals still in the helicopter’s tanks and without stating his intentions—two actions that were reportedly not typical for the pilot. The helicopter was last seen heading south above a large set of power lines that were about 100 ft high and close to the fourth job site. The last location of the helicopter was also near an airstrip that the pilot commonly used when taking breaks. The helicopter impacted terrain in a nose-low left bank. Postaccident examination of the recovered airframe and engine revealed no evidence of any mechanical anomalies that would have precluded normal operation. Before the accident, the pilot had told two family members that he had tested positive for COVID-19. Hydroxychloroquine and ibuprofen were found in the debris field, and acetaminophen was found in one of the pilot’s specimens. His postmortem COVID-19 test was negative. A low level of ethanol was detected in a single specimen from the pilot but not in two others, which indicated that the source was not from ingestion and thus was not a factor in the accident. Given the evidence of the pilot’s conversations about COVID-19, the medicines found at the accident site, and the reported change in the pilot’s normal behavior pattern as the night progressed suggested that the pilot might have reported to work ill and was experiencing worsening symptoms or fatigue. The location of the accident is consistent with the pilot deciding to fly to the airstrip with the intentions of taking a break. The full moon and clear night would have provided ample illumination for a transition to the airstrip, which was parallel with the power distribution lines in the area. Even though the pilot was likely operating the helicopter at 500 ft above ground level, the altitude that the pilot used for ferry flights, the pilot likely lost situational awareness and descended the helicopter into the terrain while enroute to the airstrip.
Probable cause
The pilot’s loss of situational awareness for reasons that could not be determined given the available evidence, which led to controlled flight into terrain. Contributing to the accident was the pilot’s decision to operate the helicopter while ill and fatigued.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
UH-1H
Amateur built
false
Engines
1 Turbo shaft
Registration number
N72297
Operator
AMERICAN AG AVIATION INC DBA
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
67-17147
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-18T21:26:28Z guid: 104646 uri: 104646 title: CEN22LA123 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104664/pdf description:
Unique identifier
104664
NTSB case number
CEN22LA123
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-17T16:48:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-02-19T00:36:31.511Z
Event type
Accident
Location
Spring, Texas
Airport
DAVID WAYNE HOOKS MEML (DWH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On February 17, 2022, about 1448 central standard time, a Pitt S-1T, N731FL, was substantially damaged when it was involved in an accident at David Wayne Hooks Memorial Airport (DWH), Spring, Texas. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after departure from DWH, he noticed that engine power was not responding to throttle movements. The pilot turned back toward DWH and entered a left downwind leg to runway 35L. During the base turn and after turning off the engine ignition switch, the pilot executed a forced landing. Due to a higher-than-anticipated headwind, the pilot misjudged the flight profile, and the airplane landed before reaching runway 35L. The airplane impacted instrument landing system structures, which substantially damaged both wings, the fuselage, and the empennage. Postaccident examination revealed that the throttle cable was disconnected from the throttle lever arm at the fuel injector/control, and a loose washer was found at the bottom of the engine cowling. Proper installation of the throttle lever included a bolt, two washers, a castellated nut, and a cotter pin. The bolt, castellated nut, and cotter pin were not located. During the airplane’s last annual inspection, the engine fuel nozzles, fuel injector, and flow divider were removed for overhaul and were then reinstalled. During this maintenance, the throttle cable would have been disconnected, and it should have been reconnected once the maintenance was completed. After the annual inspection, no maintenance actions were recorded or reported that would have required the throttle cable to be disconnected. -
Analysis
The pilot reported that, during the initial climbout, the engine did not respond to his throttle movements. The pilot turned the airplane back toward the airport and entered the downwind leg. While on the base leg, the pilot turned off the engine ignition switch and performed a forced landing. Due to a higher-than-anticipated headwind, the pilot misjudged the flight profile, and the airplane touched down short of the runway and impacted instrument landing system structures, which damaged both wings, the fuselage, and the empennage. Postaccident examination revealed the throttle cable was disconnected from the throttle lever arm at the fuel injector/control. A loose washer was found at the bottom of the engine cowling, and the castellated nut and cotter pin required for proper installation of the throttle linkage were not located. During the last annual inspection, the throttle cable had been disconnected to perform maintenance actions. The linkage hardware was likely not secured properly after that maintenance was performed, which resulted in the separation and subsequently the engine did not to respond to the pilot’s inputs during initial climb.
Probable cause
The failure of maintenance personnel to properly connect the throttle cable, which led to the pilot’s inability to control engine power during the initial climb. Contributing to the accident was the pilot’s misjudgment of the headwind during the forced landing, which resulted in the airplane’s touchdown short of the runway and its impact with airport structures.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PITTS
Model
S-1T
Amateur built
false
Engines
1 Reciprocating
Registration number
N731FL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1061
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-19T00:36:31Z guid: 104664 uri: 104664 title: ERA22LA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104679/pdf description:
Unique identifier
104679
NTSB case number
ERA22LA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-19T15:10:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-02-22T23:12:33.709Z
Event type
Accident
Location
Miami Beach, Florida
Airport
NONE (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On February 19, 2022, at 1310 eastern standard time, a Robinson Helicopter R44, N544SB, was substantially damaged when it was involved in an accident near Miami Beach, Florida. The pilot and two passengers sustained serious injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, about an hour before the accident, he had departed a helipad in Marathon, Florida, and was returning along the coastline to North Perry Airport (HWO), Hollywood, Florida. As he flew overwater parallel to the South Miami Beach area, he experienced a sudden and violent left to right shaking and vibration, which was followed by a loss of engine power and a low rotor rpm warning light and horn. The pilot attempted to increase engine power; but realized that the engine had lost power and initiated an autorotation. He maneuvered the helicopter toward an area of shallow water between two groups of people and the helicopter impacted water about 10 seconds after the vibration began. The pilot assisted his passengers in evacuating the helicopter, and they received additional assistance from beachgoers to reach the shore. The pilot recalled that he was flying about 420 ft to 450 ft above ground level at an airspeed about 85-95 knots when the loss of engine power occurred. Before the loss of power, the helicopter had been functioning normally without issue. A Federal Aviation Administration inspector examined the helicopter at the accident site and recovery facility. The fuselage, tail boom, and tail rotor sustained substantial damage. One main rotor blade remained intact with little damage and the other had fractured about mid-span. The National Transportation Safety Board examined the helicopter at the recovery facility. Examination of the helicopter’s flight controls found no anomalies that would have prevented normal control or would have contributed to the vibration. The engine and its accessories displayed significant saltwater corrosion consistent with the engine being submerged in the ocean post-accident. Examination of the engine revealed no evidence of a catastrophic failure of the engine core or its accessories. All cylinders were removed from the engine case and dissembled in order to examine the individual exhaust and intake valves, springs, and pistons. No anomalies were found within the cylinders, with exception of varying amounts of corrosion to the valves, cylinder walls, and pistons. The level of corrosion was consistent with the engine being submerged in saltwater. According to maintenance records, four cylinders were replaced in the year preceding the accident. From March 1, 2021, through December 11, 2021, the Nos. 2, 4, and 6 cylinders (and a second time, the No. 2 cylinder) were removed, overhauled, and reinstalled. According to the maintenance endorsements and interviews with the mechanic who performed the work, the cylinder replacements were due to low compression and stuck piston valve issues. The pilot reported that he experienced a similar engine malfunction and vibration sensation while in hover flight months before the accident flight. He could not recall exactly when the event occurred; however, he believed it was around the time of one of the cylinder replacements. During this past event, he was able to perform an autorotation from a hover and landed without incident. After the event, a burnt intake valve was discovered. He recalled that a total of 4 intake valves were discovered burnt over the year before the accident. The most recent 100-hour inspection occurred on August 1, 2021, at hour meter time of 1,509.5. The most recent annual inspection was completed on March 1, 2021.The hour meter at the time of the accident was 1,646.6. According to the Robinson Helicopter R44 maintenance manual, Chapter 2, inspection intervals are required at 100 hours’ time in service or 12 calendar months; whichever occurs first. The Textron Lycoming Service Instruction, No. 1425A, dated January 19th, 1988, Suggested Maintenance Procedures to Reduce the Possibility of Valve Sticking, stated in part: Operating in high ambient temperatures, slow flight with reduced cooling, or high lead content of fuel, can promote deposit build-up reducing valve guide clearance and result in valve sticking. If any of the conditions are present or hesitation is observed, the service instruction recommended inspection and cleaning of the valves. Exposing the engine to sudden cool down, as in a rapid descent with the power reduced, or shutting the engine down before it has sufficiently cooled down can also induce valve sticking. -
Analysis
The helicopter pilot was flying about 450 ft above ground level over water paralleling a coastline. The engine suddenly developed a violent shaking and vibration, and engine power was lost. The pilot entered an autorotation, flew toward shallow water, and impacted the water hard about 10 seconds after the onset of the vibration. Examination of the engine revealed no evidence of preimpact mechanical malfunction; however, the examination and teardown were significantly limited due to corrosion as a result of postaccident saltwater immersion. Engine manufacturer guidance indicated that the helicopter was at an increased risk of stuck valves due to being operated in a region with high ambient temperatures, in addition to operating at lower altitudes and slower airspeeds. Within the year preceding the accident, a total of four engine cylinders had been overhauled and replaced due to stuck valves and low compression. The postaccident examination found no evidence of a stuck intake or exhaust valve. Given the engine’s repeated history of stuck valves and low compression, combined with the pilot’s reported sensations felt during the loss of power, and the lack of any evidence of catastrophic engine failure, it is likely the engine again experienced a stuck valve, which resulted in the loss of engine power and a forced landing in water. At the time of the accident, the helicopter was 37 flight hours past its manufacturer-required 100-hour inspection interval. Had the inspection intervals been followed, it is possible evidence of valve sticking may have been identified, as it had been several instances within the year before the accident.
Probable cause
A loss of engine power due to a stuck valve, which resulted in an autorotation and a hard landing in water.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N544SB
Operator
HD AVIATION SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1759
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-22T23:12:33Z guid: 104679 uri: 104679 title: WPR22FA101 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104671/pdf description:
Unique identifier
104671
NTSB case number
WPR22FA101
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-19T20:34:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-03-09T04:25:58.361Z
Event type
Accident
Location
Newport Beach, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
Flight Training HBPD provided annual recurrency training to their flight crews at either their facility in Huntington Beach, or at the factory facilities of MD Helicopters. The recurrency training for the pilot was completed 17 days before the accident. However, because HBPD was in the process of transitioning its fleet to the conventional tailrotor 500 series, “difference training” was performed, in an MD530F at MD in Mesa, Arizona. The “Normal Operations” segment of the MD syllabus included a section devoted to “Low Speed Maneuvering”. According to MD, this part of the syllabus includes “loss of tail rotor effectiveness (LTE)” training in tail rotor helicopters and “unanticipated right yaw” training in NOTAR helicopters. According to MD, the 500N series helicopter is more susceptible to encountering unanticipated right yaw at higher speeds than the 530F helicopter, but with appropriate control inputs, a prompt recovery can be achieved. The pilot’s training records indicated that he last performed “Low Speed Maneuvering” during the “difference training” in the 530F in 2022, but the last time he performed this training in the 500N series was in 2015. According to MD training staff, guarding against unanticipated right yaw is intrinsic to the basic operation of the helicopter, and is addressed routinely throughout training. The syllabus included night “Emergency/Malfunction” with unusual attitude recovery. Training records indicated that the pilot last completed this training in May 2018. In addition to annual training with MD, HBPD provided monthly group training for all pilots. This included both ground and flight training performed by either the chief pilot or safety officer. All checkrides were performed by members of the MD factory flight training department, either at the MD or HBPD facilities. At the time of the accident, the “Low Speed Maneuvering” section of the MD600N (the other helicopter in the MD range that used the NOTAR system) Rotorcraft Flight Manual RFM gave specific guidance regarding unanticipated right yaw: An unanticipated right yaw can occur when operating at low altitude (AGL) and low airspeed where a pilot, focusing his attention on surface objects, may be distracted from the aerodynamic conditions affecting the helicopter's attitude. If no directional or cyclic control inputs are made, a nose down pitch and a right roll may follow the right yaw. Maneuvering at speeds less than 60 knots with left sideslips (flying out of trim with too much right pedal) or with winds from the left can cause a right yaw and an increase in left pedal force. Typical maneuvers where this can occur are uncoordinated turns to the right utilizing too much right pedal and right turns to a downwind condition. If this condition is encountered, application of left pedal along with necessary cyclic inputs will stop the right yaw and return the helicopter to the desired attitude. The pedal force required to stop the right yaw will increase as the degree of left sideslip increases. Although the MD500N RFM addressed emergency procedures during an anti-torque system failure, it did not make any specific reference to unanticipated right yaw as found in the 600N RFM. Unanticipated Right Yaw Federal Aviation Administration Advisory Circular 90-95 addressed the subject of unanticipated right yaw in helicopters. The circular stated that any maneuver which requires the pilot to operate in a high-power, low-airspeed regime with a left crosswind or tailwind creates an environment where unanticipated right yaw may occur, with a greater susceptibility for a loss of tailrotor effectiveness in right turns. Flight operations at low altitude and low airspeed in which the pilot is distracted from the dynamic conditions affecting control of the helicopter are particularly susceptible to this phenomenon. The right yaw is usually correctable, but if the response is incorrect or slow, the yaw rate may rapidly increase to a point where recovery is not possible. - The helicopter was owned by the City of Huntington Beach and was providing law enforcement air support under a contract service agreement for the City of Newport Beach. The helicopter was designated as a 500N, but marketed as the 520N. It was a no tail rotor (NOTAR) design, which utilized a variable thruster and ducted fan system for anti-torque control rather than a traditional tail rotor. It was configured with dual flight controls with the right (TFO side) foot pedals removed. It had been equipped for law enforcement and included an external “Nightsun” searchlight, and a “WESCAM MX-10” gimbled imaging system, processed by an AeroComputers digital mapping system. - Both automatic dependent surveillance – broadcast (ADS-B) and GPS data recorded by the onboard imaging system were used by specialists from the NTSB Office of Research and Engineering to determine the helicopter’s heading and yaw rate towards the end of the flight. This data, along with winds aloft information was used to extrapolate the helicopter’s flight trajectory and heading for the last two minutes of flight. The results indicated that, after performing two orbits, the helicopter slowed to a ground speed of between 15-23 kts as it moved east, which correlated to a calibrated speed of between 3-12 kts. During the next 5 seconds, the helicopter was pointing perpendicular to the direction of travel, on a heading of about 180°. The helicopter then held its position over the ground and started to move west while still pointing south, and two seconds later, it began to spin to the right as the imaging system’s camera pitched up. The spin progressed at a rate of about 130° per second, and ground-based security video footage indicated that the rate remained about the same until the helicopter impacted the water. (See Figure 2.) Figure 2 - ADS-B flight path in Northing and Easting with time (top left), heading (top right), groundspeed (bottom left) and calibrated airspeed (bottom right) for each point. The X and Y axes reflect the distance from the last ADS-B data point, which was in the water. Wind direction and magnitude is also noted on calibrated airspeed plot. The data indicated that the helicopter approached the area for the first orbit at an altitude about 850 ft agl. It descended to 350 ft agl after completing the first orbit; its altitude varied between 450 ft and 300 ft for the final two orbits until the diversion. (see Figure 3.) The radius of the final two orbits was about 650 ft. Figure 3 - Altitude (msl), calibrated airspeed, and groundspeed of the end of flight. - On February 19, 2022, about 1834 Pacific standard time, a McDonnell Douglas Helicopter 500N (520N), N521HB, was substantially damaged when it was involved in an accident in Newport Beach, California. The pilot sustained minor injuries and the TFO was fatally injured. The helicopter was operated as a public aircraft flight by the Huntington Beach Police Department (HBPD). The helicopter departed its home base, Huntington Beach Police Department Heliport (CL65), at 1800, and for the next 30 minutes flew a routine patrol along the coast of Huntington Beach, inland to Costa Mesa, and then south to Newport Beach. The pilot reported that as they were about to depart the Newport Beach area, they received a transmission over the primary police radio channel that there was a fight taking place just south of their location. The pilot stated that he redirected the helicopter toward the area and began a right orbit between 500-600 ft above ground level (agl) while the TFO (who was seated in the right seat) turned on the infrared camera and began searching the ground. The TFO spotted a group fighting, and the pilot began to maneuver the helicopter in a tighter orbit while the TFO relayed his observations over the police radio channel. Ground patrol officers arrived on the scene, and the pilot continued the orbits about 500 ft above ground level, while simultaneously viewing the activity through his monitor, and maneuvering the helicopter so the TFO could continue to observe the altercation. The pilot stated that he watched as ground patrol officers got out of their car and approached the group, who by this time had mostly dispersed. He was concerned that one person was about to start fighting with an officer, and he slowed the helicopter to about 50 knots (kts) indicated airspeed to keep the camera aimed at the scene longer, so that they would not lose sight of it behind a building. The pilot stated that, suddenly, the helicopter yawed aggressively to the right, and he immediately applied full left foot pedal and forward cyclic to arrest the rotation, but there was no response. He then applied right pedal to see if the pedals had malfunctioned, and observing no change, he reverted to full left pedal. He continued to apply corrective control inputs, but the helicopter did not respond and began to progress into a spinning descent. (see Figure 1.) The TFO transmitted over the police radio channel, “We’re having some mechanical issues right now”, followed by, “we’re going down, we’re going down”. Figure 1 – Final flight path segment The pilot stated that the rotation became more aggressive, and he began to modulate the throttle, collective, and cyclic controls to try to arrest the rotation rate. He stated that his efforts appeared to be partially effective, as the helicopter appeared to respond; however, because it was dark, he had no horizon or accurate external visual reference as the ground approached. The engine continued to operate, and he chose not to perform an autorotation because the area was heavily populated. He then had a sense that impact was imminent, so he pulled the collective control in an effort to bleed off airspeed. The helicopter hit the water hard on the TFO’s side in a downward right rotation. The pilot recalled a sudden smash and saw water and glass coming toward him as the canopy shattered. He felt the rotor blades hitting the water, everything then stopped, and within a few seconds he was submerged. The spinning sequence was captured by security cameras and multiple witness cell phone cameras. Review of the footage indicated that the sound of the helicopter’s engine and rotor system was present until water impact, and the helicopter was not emitting any smoke. As the helicopter descended, its pitch attitude violently oscillated between about 30° nose down and almost full nose down as the gyrations progressed. None of the cameras captured the transition from the orbit maneuver to the spin, but one security camera captured the helicopter on its final orbit. The helicopter moved behind a building and out of view and was already spinning when it came back into view. The sound of the engine and rotor system could be heard throughout, with no sounds indicative of a mechanical failure. - An autopsy examination was conducted on the TFO by the Orange County Sheriff-Coroner. The cause of death was reported as drowning, and no significant injuries were noted. The autopsy indicated chest abrasions consistent with resuscitative efforts, along with rib and sternum fractures. Toxicology testing did not identify the presence of any screened drug substances or ingested alcohol. - A High-Resolution Rapid Refresh (HRRR) model sounding was created for 1800 and 1900 for the accident location at varying altitudes. The 1800 data indicated that at an elevation of 313 ft msl, wind was from 281° at 14 kts, and at 1900 286° at 11 kts. Sunset occurred at 1740, with dusk at 1805. The moon was below the horizon and rose at 2054. - The pilot was hired by HBPD in 2005. His initial duties included that as a TFO, and over the next few years he began flight training, eventually attaining a commercial pilot certificate. At the time of the accident, he was the second most experienced pilot at HPBD, with about 3,700 flight hours of flight experience as pilot-in-command of the MD500N. He typically flew between 12 to 20 hours per month, with half of his flights performed at night. The day of the accident was the pilot’s first day of a three-day shift; he had spent the preceding days off in Spokane, Washington. He started his day by waking up at 0400, having gone to bed about 2100 the night before. He then flew down to Long Beach, California, via connecting commercial flights, arriving at 1230. He reported for work at 1500, and his duty was to end at 0330. He reported that he was able to get some sleep on the commercial flights. HBPD did not have any policies in place for crew rest requirements prior to reporting for duty. - The pilot and TFO were wearing flight suits, a dual-visor helmet system, a combination inflatable life preserver/tactical vest, and an emergency breathing system that consisted of a supplemental rescue air bottle mounted to the vest. Both helmets were equipped with night vision goggles, which were not being used and were in the “up” position for the flight. The pilot stated that, after impact, he continued to hold on to the collective as a reference point, then cleared the mouthpiece from the air bottle, and after clearing it, started to use it to breathe. He continued to hold the collective with one hand, and reached down and released his seat harness. His eyes were closed, and he was able to move by feel. He did not recall opening the door and was able to egress by pushing himself off the collective away from the helicopter. He exited the helicopter and remained motionless while waiting to rise, but realized he was still attached to the helicopter by his helmet cord. He disconnected the cord, and slowly started to ascend. He reached the surface and could see the tail boom, and he started calling out for the TFO. He could see bubbles surfacing, but did not get a response. Witnesses began to arrive, and they pulled him away and toward a boat. He told them that he was ok, and that they should focus their efforts on finding the TFO. A witness, who initially assisted the pilot, dived back in to search for the TFO. He used the pilot’s air bottle and reported that the water visibility was about 20 inches. He found a door handle and rotated it 90° and the door opened. When he entered, he felt initially what he thought was the TFO, but it was a tactical bag. He came back to the surface and the pilot called out that he was on the wrong side of the helicopter, so he dived again to the other side but was not able to find the door. First responders began to arrive on the scene, and multiple members of the fire department and local law enforcement dived in to attempt to find the TFO. After a few minutes, the helicopter was pulled closer to the shore by a truck, revealing the cabin. A diver stated that the forward left door was closed, and its window was gone, and he could see that the TFO was halfway out of the window. He appeared uninjured, his seat harness was unbuckled, and his helmet cord was already disconnected. They attempted to pull him out, but it became apparent that his leg was stuck. They pushed him back in and tried again, and this time he came out easily. The TFO was still wearing his helmet and vest. The inflatable section of the vest had not been deployed, and its trigger handle had not been pulled. The protective cover of his air bottle mouthpiece had been removed; the air valve was open, and the bottle was empty. Examination revealed that both the pilot and TFO’s seat belt buckles were unlatched, and their belt harnesses remained attached to the respective airframe anchor points. Both seat bases and seat pans were intact, attached to the airframe, and did not exhibit any evidence of crush damage or stroking. Additionally, the entire forward canopy and lower windows had shattered, leaving openings in the frame. Egress Training Both the pilot and TFO had completed “Dunker Training” using a shallow water egress trainer system (SWET) on January 27, 2020. The training used equipment in the shallow end of a swimming pool and taught basic underwater escape procedures dealing with seat belts, brace positions, reference points, and exits. The training included use of the emergency breathing device. The training was performed using a SWET roll cage system, rather than a simulation helicopter structure. According to the training syllabus, the course covered the content required for compliance with Army Regulation 95–1 (Flight Regulations). - Flight Testing A series of flight demonstrations were performed by members of the MD training department with the NTSB investigation group in a factory 520N helicopter, to demonstrate the handling characteristics as the helicopter approached and entered unanticipated right yaw. The tests were conducted at varying speeds and attitudes. It was found that once the yaw had begun, the rate could be arrested with prompt application of the left foot pedal followed by forward cyclic. If aft cyclic was applied, the yaw rate would rapidly increase. An effective recovery was dependent on the pilot's ability to use external visual references to coordinate corrective control inputs. Y-SAS The helicopter was equipped with a yaw stability augmentation system (Y-SAS), designed to provide the pilot with increased directional stability and thus reduce workload. It enhanced handling qualities by providing control inputs to an active vertical stabilizer. The system had control authority over the right vertical stabilizer, which had a total range of travel of approximately 15°. The left vertical stabilizer was also active but controlled by direct pilot input through the antitorque pedals, with a control surface range of about 29°. The system used information from a yaw rate gyro and a lateral accelerometer to position the right stabilizer. A Y-SAS control box/computer received signals from the rate gyro and accelerometer and used this information to send command signals to the Y-SAS actuator located in the right horizontal stabilizer, which then moved the right vertical fin. According to MD, at slow airspeed when the helicopter is in a slipped condition with a large amount of right pedal, the dominant yaw control effect will not be from the vertical stabilizer, but rather as a result of the thruster being mostly open to the right. During the helicopter examination, the Y-SAS actuator was found extended to almost the full right travel limit of the stabilizer. In 1991, McDonnell Douglas performed a series of flight tests to ascertain the flying qualities of the NOTAR-equipped helicopter. Testing included determining the helicopter’s controllability throughout the flight envelope during Y-SAS hard-over and oscillatory conditions. Testing revealed that, in hard-over conditions, pedal margins and controllability still allowed for full helicopter maneuverability, did not degrade the basic handling qualities, and overall, the handling qualities during the simulated failure events were considered “benign.” It was found that hard-over failures at speeds less than 40 kts had little to no noticeable effect. The primary components of the Y-SAS system were examined at the manufacturer’s facility under the immediate oversight of the investigation team. Both the yaw damper computer and rate gyro were externally undamaged, but disassembly revealed evidence of saltwater intrusion and corrosion, presumed to be because of the immersion following the accident. Acceptance test procedures were performed on both units, with sporadic failures observed. The linear actuator appeared similarly undamaged, although corrosion deposits were present coming out of its case seals. The actuator began to vibrate (“chatter”) when power was applied, and it would not respond to control inputs during a functional test. Disassembly revealed the motor and drive assembly, although corroded, appeared generally undamaged. The internal circuit board was coated in white- and rust-colored deposits, but all components appeared intact. Of note, an inductor through which electrical power was supplied to the unit’s microprocessor had a longitudinal crack, which was emitting brown deposits. The deposits on the top of the inductor were clean and bright, and not coated in the white and rust deposits as found on the other circuit board components. - The helicopter came to rest on the seabed, submerged in saltwater about 45 ft from a beach within Newport Bay. The fuselage was largely intact, with the landing skids and tailboom still attached. The stinger remained attached to the tail and had been displaced to the left. The cabin was intact, and the windscreen on both the pilot and copilot sides had broken out, leaving only the frame. The main rotor drive assembly was still attached to the mast. Two rotor blades had separated from the rotor head and were recovered in the vicinity of the initial water impact, and the remaining three blades remained attached to the rotor head. The blades all exhibited varying degrees of aft bending, trailing edge buckling, and split skins at their trailing edges. Examination of the flight control systems did not reveal any failures that would have precluded normal operation. The cyclic and collective controls were continuous from both the pilot and copilot's controls to the swash plate assembly. The anti-torque blade drive system was still connected to the main transmission, and control continuity was confirmed from the pilot's anti-torque pedals through to the rotating cone and left vertical stabilizer bell crank. Pitch change of the anti-torque fan blades corresponded to movement of the foot pedals. The interior of the ducted tail boom was clear of debris and no damage was observed. The rotating diffuser cone sustained slight bending damage consistent with impact, but was intact. The stationary thruster was attached, and all thruster vanes were in place. The duct control assembly was intact and functional, and the anti-torque system appeared to have been correctly rigged. The horizontal and vertical stabilizer assembly mounts had broken from the tail boom and the assembly remained connected by electrical cables and control linkages. First responders pulled the helicopter with a rope by the tail immediately following the accident to assist crew recovery. -
Analysis
The pilot and tactical flight officer (TFO) onboard the law-enforcement helicopter were performing right turns around a ground altercation over an ocean peninsula at night when the helicopter began to spin rapidly to the right. The pilot applied corrective control inputs but was unable to arrest the rotation, and the helicopter descended into the water. The pilot sustained minor injuries and the TFO was fatally injured. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Although the pilot reported that the helicopter was traveling at a speed of about 50 knots before the spins began, review of flight track data and onboard imaging revealed that, after factoring relative wind, the helicopter had essentially transitioned to a hover shortly before the event started and was flying almost perpendicular to the direction of travel for about 30 seconds before entering the rotation. This discrepancy was likely because the pilot was fixated on the scene below as it became obscured by buildings, and he was concerned about the safety of ground patrol officers who had just arrived. The nature of law enforcement flights can result in pilots needing to perform tight- radius, uncoordinated turns in a high-power and low-airspeed regime. Such conditions create an environment where unanticipated right yaw may occur, with a greater susceptibility for a loss of tail rotor effectiveness (LTE) in right turns. Flight operations at low altitude and low airspeed in which the pilot loses situational awareness from the dynamic conditions affecting control of the helicopter are particularly susceptible to this phenomenon. Additionally, the helicopter was equipped with a ducted fan anti-torque system, rather than a conventional tail rotor, which was more susceptible to encountering unanticipated right yaw at higher speeds. While the right yaw is usually correctable, the response must be appropriate and rapid, otherwise the condition may quickly increase to a point where recovery is not possible. Additionally, for the accident helicopter model, if aft cyclic was applied during the early recovery phase, the yaw rate can rapidly increase. An effective recovery is also dependent on the pilot's ability to use external visual references to coordinate corrective control inputs. Due to the night conditions and the helicopter’s proximity to open water, the pilot likely did not have a horizon or accurate external visual reference at the time the helicopter encountered the unanticipated right yaw. Although the pilot stated that he immediately applied forward cyclic and full left foot pedal in accordance with the approved recovery technique, the helicopter’s imaging system camera pitched up rapidly at the onset of the spin, indicating that the helicopter likely was in an immediate nose-down attitude. Under these circumstances, with the ground immediately filling the windshield, it is possible that the pilot initially instinctively pulled aft on the cyclic, thereby exacerbating the early stages of the spin. Once the spin had progressed, recovery would have been difficult. Both crew members had recently undergone water egress training, and the pilot was able to use it effectively to exit the helicopter after it sunk following the accident. Evidence suggests that the TFO survived the impact essentially uninjured and began the process of self-extracting. He was positioned on the lower right side of the helicopter, which was on the seabed, and would have needed to crawl through the cabin to climb out of another door or window. He had begun the process of extracting himself, but eventually drowned and was found partially out of the left door window. The pilot had a significant amount of flight experience in the helicopter, much of it at night, and had recently received training in the tail rotor-equipped version about two weeks before the accident. That training included a section on LTE, but training records indicated that the last time he had received unanticipated right yaw training specific to the accident helicopter type was about seven years before the accident. The recovery techniques for the two situations are similar, however, and the phenomenon and its recovery are well understood, especially for a pilot with his experience. The helicopter was equipped with a yaw stability augmentation system designed to reduce pilot workload by continuously adjusting the vertical control surface on the tailcone to correct out-of-trim flight. Postaccident examination revealed that the actuator for the control surface was at its full deflection, likely because of the system attempting to correct the extreme yaw encountered during the spinning descent. Detailed examination of the augmentation system did not reveal any anomalies, and although an electrical inductor within the actuator appeared to have burnt out, its damage signatures appeared to be fresh and were possibly a result of investigative testing after the unit had been damaged by corrosion following saltwater immersion. The augmentation system’s control authority was negligible at the speeds the helicopter was traveling before the spin began; therefore, an uncommanded control surface hard-over would not have contributed to the spin entry or inhibited the pilot’s ability to recover from it. The pilot started the day earlier than usual at 0400, having spent the preceding few days on leave out of state. He reported for duty after taking a connecting commercial flight to get home, almost 12 hours after waking up. The accident then occurred about 3.5 hours later, with his duty day due to finish 23 hours after he woke up. Although he took a nap on the earlier flights, the short nature of the flights meant that his sleep would have been interrupted and insufficient to have overcome the accrued sleep debt. The police department did not have policies for crew rest requirements before reporting for duty, and it is likely that the pilot was beginning to show signs of fatigue during the flight.
Probable cause
The helicopter’s encounter with unanticipated right yaw during a low-altitude, low-airspeed, tight-radius orbit. Contributing to the accident was the pilot’s distraction during the orbit, which resulted in the loss of control, his fatigue due to his early wake time and time since awakening, and the lack of external cues that hindered his ability to perform a recovery.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MCDONNELL DOUGLAS
Model
500N
Amateur built
false
Engines
1 Turbo shaft
Registration number
N521HB
Operator
CITY OF HUNTINGTON BEACH
Second pilot present
true
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
LN084
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-09T04:25:58Z guid: 104671 uri: 104671 title: CEN22LA128 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104674/pdf description:
Unique identifier
104674
NTSB case number
CEN22LA128
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-20T13:15:00Z
Publication date
2023-06-14T04:00:00Z
Report type
Final
Last updated
2022-02-22T22:48:23.365Z
Event type
Accident
Location
Livingston, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 20, 2022, about 1115 central daylight time, a Ryan L-17B airplane, N5042K, was substantially damaged when it was involved in an accident near Livingston, Illinois. The pilot receiving instruction, the flight instructor, and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot receiving instruction reported that the purpose of the flight was to practice various flight maneuvers. The airplane departed about 0943, and the training was successfully performed. About halfway back to the departure airport, the pilot noticed that the engine was “running rough.” The pilot proceeded to lean the airplane’s fuel mixture to correct the problem, and he then noticed that the fuel flow gauge was “pegged.” The pilot continued to lean the mixture and adjusted the throttle, but the airplane did not respond to these inputs. The airplane began to lose altitude, and the pilot receiving instruction performed a forced landing to a flat muddy field. During the landing rollout, the nosewheel turned left in the mud, the airplane spun around, both wings and the propeller impacted the ground, and the airplane came to rest upright. The airplane sustained substantial damage to both wings. The flight instructor, who was also a mechanic, reported that, when the engine was running roughly, he tried to lean the mixture with no engine response. He also reported that the fuel flow gauge needle had advanced into the manifold pressure side of the gauge and that the throttle had no response. The flight instructor assumed that the fuel control unit had a mechanical issue. Postaccident examination of the airplane found no mechanical anomalies with the airframe and engine. Fuel injection system testing was conducted. During the fuel pump testing, the fuel pressure was 4.5 pounds per square inch (psi); the standard is between 9 and 11 psi. The fuel control valve was found leaking through the screw to the metering insert. The fuel flow level would not stay set during the testing. The fuel control valve was disassembled, and the shafts and metering valve were found to have internal damage. The manifold valve was found leaking fuel to the air side of the diaphragm. The interior of the fuel pump had a dark deposit. The fuel pump was provided to the NTSB’s Materials Laboratory, which found that the deposit was firmly adhered to the surface and could not be removed. The deposit was viewed under magnification and found to be consistent with corrosion/oxidation of the surface material. Continental Motors released Service Bulletin SB-04A, Fuel Injection System Contamination (issued in March 2008 and revised in July 2016). This document provided guidance for maintenance personnel to prevent contamination of fuel injection systems during installation and maintenance work. This document states in part the following: o All caution must be exercised during reassembly of the fuel system to NOT allow any contaminants to enter the components, lines and fittings during installation. o All surfaces surrounding the area where components are to be installed must be clean and free of all forms of contaminant before and during installation. o All hose assemblies must be flushed and verified to be free of contamination prior to installation. o All fuel system component and lines must be capped and remain capped until flushed and ready for installation. o The engine, tools and environment must be clean to minimize any potential for fuel system contamination. o All fuel system components, regardless of their source, must be purged at time of installation. SB-04A concluded with a warning that stated, “Fuel system contamination may lead to fuel system component damage, erratic engine operation, loss of power, or engine shutdown.” A review of maintenance records showed that the engine and its fuel system were overhauled in November 2017 and that the engine was installed in the accident airplane that same month. The maintenance records showed no further work for the engine fuel system. The maintenance records also did not indicate compliance with Continental Motors Service Bulletin SB-04A during the overhaul work performed in November 2017. The Federal Aviation Administration does not mandate compliance with service bulletins for 14 CFR Part 91 operations. -
Analysis
The pilot receiving instruction reported that the purpose of the instructional flight was to practice various flight maneuvers, which were successfully performed. About halfway back to the departure airport, the pilot noticed the engine was “running rough.” The pilot proceeded to lean the airplane’s fuel mixture to correct the problem and noticed that the fuel flow gauge was “pegged.” The pilot continued to lean the mixture and adjusted the throttle, but no response was received from his inputs. The airplane began to lose altitude, and the pilot receiving instruction performed a forced landing to a flat muddy field. During the landing rollout, the nosewheel turned left in the mud, the airplane spun around, both wings and the propeller impacted the ground, and the airplane came to rest upright. The airplane sustained substantial damage to both wings. The flight instructor, who was also a mechanic, reported that, when the engine was running roughly, he tried to lean the mixture with no response. The flight instructor also reported that the fuel flow gauge needle had advanced into the manifold pressure side of the gauge and that the throttle had no response. The flight instructor assumed that the fuel control unit had a mechanical issue. Postaccident examination of the airplane found no anomalies that would have precluded normal operation. Testing of the fuel injection system found internal damage to the fuel control valve. The internal damage was likely consistent with fuel injection system contamination. In addition, the interior of the fuel pump had a dark deposit that was firmly adhered to the surface and could not be removed. When viewed under magnification, the deposit was found to be consistent with corrosion of the surface material. Thus, corrosion was likely present in the contamination. The engine manufacturer’s guidance stated that fuel injection system contamination may lead to “component damage, erratic engine operation, loss of power, or engine shutdown.” Although the source of the contamination could not be determined based on the available evidence, the contamination likely caused the fuel control system to fail, which led to the total loss of engine power during the accident flight.
Probable cause
A total loss of engine power due to fuel injection system contamination from an unknown source.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RYAN
Model
L17
Amateur built
false
Engines
1 Reciprocating
Registration number
N5042K
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
NAV-4-1654
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-02-22T22:48:23Z guid: 104674 uri: 104674 title: ERA22LA134 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104693/pdf description:
Unique identifier
104693
NTSB case number
ERA22LA134
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-20T16:45:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-15T03:49:36.493Z
Event type
Accident
Location
Sarasota, Florida
Airport
SARASOTA/BRADENTON INTL (SRQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On February 20, 2022, an experimental amateur-built Spangenberg AR-1KC gyrocopter, N65PC, was substantially damaged when it was involved in an accident at Sarasota Bradenton International Airport (SRQ), Sarasota, Florida. The pilot sustained minor injuries. The gyrocopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, during the takeoff roll as the rotors reached 180 rpm, she released the pre-rotator and increased speed for a normal takeoff. Just before becoming airborne, the gyrocopter and the control stick “began to shudder.” The pilot also stated that she immediately aborted the takeoff and pulled back engine power. According to the pilot, she had the control stick “back too far for the conditions at that moment,” which caused a nose-high attitude and a rotor blade to “hit the very top of the tail on two screw heads that held the top of the rudder in place.” The gyrocopter departed the left side of the runway and landed hard, which resulted in substantial damage to the rudder. The pilot reported that she and her flight instructor examined the flight controls after the accident and found no mechanical problems that would have contributed to the accident. The nose wheel separated from the gyrocopter at the weld point where it attached to the airframe. Metallurgical examination of the fracture surfaces revealed that they failed due to ductile overstress shear fracture from impact. No evidence of fatigue was observed. -
Analysis
The pilot stated that, during the takeoff roll, she felt a “shudder” just before the gyrocopter became airborne. She immediately aborted the takeoff and reduced power with the aft cyclic still applied. The gyrocopter entered a steep nose-high attitude, and a main rotor blade struck the top of the vertical stabilizer. The gyrocopter departed the left side of the runway and landed hard, which resulted in substantial damage to the rudder. Also, the nosewheel fractured and separated from the airframe. Postaccident examination of the flight controls and the fractured nosewheel revealed no preimpact mechanical anomalies that would have precluded normal operation.
Probable cause
The pilot’s improper control input during an aborted takeoff procedure, which resulted in a main rotor blade contacting the vertical stabilizer, a loss of control, and subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
SPANGENBERG
Model
AR-1KC
Amateur built
true
Engines
1 Reciprocating
Registration number
N65PC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0038
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-15T03:49:36Z guid: 104693 uri: 104693 title: CEN22LA132 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104688/pdf description:
Unique identifier
104688
NTSB case number
CEN22LA132
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-20T17:30:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-03-11T01:33:35.569Z
Event type
Accident
Location
Crete, Nebraska
Airport
Crete Municipal (KCEK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 20, 2022, about 1530 central daylight time, a Mooney M20C airplane, N6750U, was substantially damaged when it was involved in an accident near Crete, Nebraska. The pilot and passenger were not injured. The airplane was operated under the provision of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot stated that the airplane’s preflight was normal and, as he started the takeoff roll, he perceived that the airplane made a “hard left turn” before the airplane rotated for takeoff. The pilot added backpressure to the control yoke and the airplane became airborne in a “nose high attitude.” He stated that the airplane lifted off for a short duration, stalled, and settled back to the runway, dragging the tail. The airplane became airborne again and veered to the left before stalling once again. The airplane then touched down off the runway in a bean field. The airplane sustained substantial damage to the wings. A video provided by the airport recorded the takeoff and showed that, during the takeoff roll, the airplane’s nose rotated for takeoff and the airplane did not appear the gain any altitude as it continued down the runway. Still in a nose-high attitude, the airplane lifted off and then began to drift to the left before it settled back to the ground into the bean field. During the accident sequence, the airport’s windsock displayed a slight left crosswind. The pilot reported that there may have been some landing gear wear points or a problem with the nose gear alignment that contributed to the accident; however, postaccident examination of the airplane did not reveal any anomalies that would have precluded normal operations. -
Analysis
During the takeoff roll, the pilot felt the airplane veer left, so he applied backpressure to the control yoke. The pilot reported that the airplane became airborne, settled back to the runway, became airborne again, then veered to the left and settled into a bean field off the side of the runway. The airplane sustained substantial damage to the wings. An airport surveillance video of the accident showed that, during the takeoff roll, the airplane’s nose rotated for takeoff and the airplane did not appear to gain any altitude as it continued down the runway. Still in a nose-high attitude, the airplane lifted off and then began to drift to the left before it settled back to the ground into the bean field. A visual examination of the airplane did not reveal any preimpact anomalies that would have precluded normal operations. The circumstances of the accident are consistent with the pilot commanding the airplane to rotate before rotation speed, resulting in a loss of control.
Probable cause
The pilot’s failure to maintain control of the airplane during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20C
Amateur built
false
Engines
1 Reciprocating
Registration number
N6750U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2472
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-11T01:33:35Z guid: 104688 uri: 104688 title: ANC22FA018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104681/pdf description:
Unique identifier
104681
NTSB case number
ANC22FA018
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-22T12:20:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2022-03-02T04:09:20.852Z
Event type
Accident
Location
Kekaha, Hawaii
Airport
Barking Sands Navy Base (BKH)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
On February 22, 2022, about 1020 Hawaii-Aleutian Standard Time, a Sikorsky S-61N helicopter, N615CK, was destroyed when it was involved in an accident at the Pacific Missile Range Facility (PMRF), Barking Sands, Kekaha, Hawaii, on the island of Kauai. The two pilots and two crewmembers were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 133 flight. The accident helicopter, owned and operated by Croman Corporation, was under contract to the United States Navy, being used to retrieve inert training torpedoes from the Pacific Ocean as part of the Navy’s ongoing, Pacific submarine training operations. According to the director of operations for the operator, the accident mission involved locating a training torpedo in the open waters, retrieving the torpedo using a recovery basket/cage system, then returning the torpedo to PMRF by sling load. The helicopter was one of two helicopters stationed at a hangar in PMRF Barking Sands. At the time of the accident, three mechanics were located at PMRF Barking Sands to maintain the two helicopters. The helicopter was equipped with ADS–B, which provided aircraft tracking to determine its position via satellite navigation or other sensors and periodically broadcasts it, enabling it to be tracked. The information can be received by air traffic control ground stations as a replacement for secondary surveillance radar, as no interrogation signal is needed from the ground. According to archived Federal Aviation Administration ADS-B data, after the helicopter departed PMRF, it proceeded north-northwest to an area about 44 miles away. After maneuvering in the area, the helicopter proceeded south-southeast towards PMRF to return to the facility. As the helicopter approached PMRF, it crossed the shoreline and began a shallow left turn as it maneuvered to the north, into the prevailing wind. As the helicopter neared the predetermined drop-off site, known as the ordnance recovery clear area (ORCA), the left turn stopped, and the helicopter proceeded in a northeasterly direction before the data ended. Multiple witnesses located near the accident site consistently reported that as the helicopter continued the left turn towards the ORCA, the turn stopped, and it began to travel in a northeast direction. The witnesses noted that as the helicopter flew about 200 ft above the ground, it gradually pitched nose down and impacted nose first, in a near-vertical attitude. Figure 1. N615CK at accident site The helicopter came to rest on its left side on a heading of about 230° magnetic. Three ground scars consistent with main rotor blade impact marks were present near the initial airframe ground impact location. The nose bay door for avionics was found near the start of the debris trail, followed by pieces of debris from the cockpit structure and cockpit instruments, and then the remainder of the helicopter. The initial ground impact mark and debris trail leading up to the main wreckage was oriented about 65° magnetic. A postcrash fire consumed most of the cockpit and the cabin, though remnant frame sections were present near the main (forward) landing gear as well as the transmission deck. The cockpit voice recorder was found near the forward end of the main wreckage. The main transmission gearbox remained whole and installed on the airframe. The main gearbox exterior was coated in soot from the postcrash fire but was not consumed by the postcrash fire. The main rotor blades exhibited considerable fragmentation, with numerous fragments of main rotor blades found throughout the vicinity of the accident site. An examination of the wreckage revealed that the flight control fore/aft servo input link remained connected at its clevis end to the flight control fore/aft bellcrank, located adjacent to the main gearbox. The rod end was partially connected to the fore/aft servo input clevises, but the attaching hardware had mostly backed out of its normally installed position and the bolt was cocked (Figure 2). Figure 2. Fore/Aft Primary servo N615CK at accident site This bolt remained partially within the rod end bearing inner race, which was also cocked, exposing a portion of the bearing’s rolling elements. The bolt head-side bushing and three washers were present between the bolt head and rod end. The nut, nut-side bushing, nut-side washers, and cotter pin were not present. A search of the main transmission deck found a loose bushing within the right-side longitudinal beam. The bolt between the fore/aft servo input link and the fore/aft servo input clevises was removed and it exhibited no evidence of fractures or visible deformation of the bolt shank. According to maintenance records, from December 17-29, 2021, multiple maintenance actions were performed. The director of maintenance and another mechanic traveled from the operator’s base in Oregon to PMRF Barking Sands and worked with two additional mechanics, based in PMRF Barking Sands, to complete these maintenance actions. The fore/aft primary servo of the flight control system was installed on December 28, 2021. About 7.5 flight hours had elapsed from the time the fore/aft primary servo was installed until the day of the accident. According to both the director of maintenance and a mechanic who traveled to PMRF, when the main gearbox assembly is removed from the helicopter, the primary servos typically remained installed on the main gearbox housing. Furthermore, the primary servos were typically disconnected from the flight control system at each servo input link’s clevis connection to the main gearbox bellcranks. During a primary servo replacement, the servo input link would be removed from the old primary servo and transferred to the new primary servo. The condition of the removed hardware, such as bolts and washers would be checked and replaced as needed. One-time-use hardware such as cotter pins and nuts with nylon locking features would be discarded after each removal. After all the work on a work order was complete, a company certified inspector inspected all work performed. -
Analysis
The accident helicopter was under contract to the United States Navy. The mission for the accident flight involved locating a training torpedo in the open waters, retrieving the torpedo using a recovery basket/cage system, then returning the torpedo to Pacific Missile Range Facility (PMRF) by sling load. According to automatic dependent surveillance-broadcast (ADS-B) data, after the helicopter departed, it proceeded north-northwest to an area about 44 miles away. After maneuvering in the area, the helicopter proceeded south-southeast to return to PMRF. As the helicopter approached the facility, it crossed the shoreline and began a shallow left turn as it maneuvered to the north, into the prevailing wind. As the helicopter neared the predetermined drop-off site, the left turn stopped, and the helicopter proceeded in a northeasterly direction. Multiple witnesses located near the accident site reported that as the helicopter continued the left turn towards the drop-off site, the turn stopped, and it began to travel in a northeast direction. The witnesses noted that as the helicopter flew about 200 ft above the ground, it gradually pitched nose down and impacted nose first, in a near-vertical attitude. An examination of the wreckage revealed the flight control fore/aft servo input link remained connected at its clevis end to the flight control fore/aft bellcrank, located adjacent to the main gearbox. However, the rod end was partially connected to the fore/aft servo input clevises and its bolt had mostly backed out of its normally installed position. The bolt exhibited no evidence of fractures or visible deformation and its threads exhibited no unusual wear. Therefore, the bolt likely backed out of its normally installed position during the accident flight due to the absence of its nut and cotter pin. This would have caused an uncommanded input to the fore/aft servo, resulting in the helicopter’s nose-down attitude, and the inability of the crew to control the pitch attitude of the helicopter. The fore/aft primary servo was installed on December 28, 2021. About 7.5 flight hours had elapsed from the time the fore/aft primary servo was installed until the day of the accident. The mechanic who installed the fore/aft servo input link to the fore/aft primary servo likely failed to correctly install the attaching hardware. The company’s certified inspector and who oversaw and inspected all of the work at completion, failed to ensure the hardware attaching the fore/aft servo input link to the fore/aft primary servo was installed correctly.
Probable cause
The improper installation of the fore/aft primary servo by maintenance personnel, which resulted in the attaching hardware backing out and which subsequently rendered the helicopter uncontrollable. Contributing to the accident was the company’s quality control personnel to identify the improper installation before certifying the helicopter for flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
SIKORSKY
Model
S-61N
Amateur built
false
Engines
2 Turbo shaft
Registration number
N615CK
Operator
CROMAN CORP
Second pilot present
true
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
External load
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
61814
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-02T04:09:20Z guid: 104681 uri: 104681 title: CEN22FA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104683/pdf description:
Unique identifier
104683
NTSB case number
CEN22FA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-23T00:41:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2022-02-25T05:37:59.188Z
Event type
Accident
Location
Fostoria, Ohio
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Spatial Disorientation The Federal Aviation Administration’s (FAA) Airplane Flying Handbook (FAAH80833B) described some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. - On February 22, 2022, about 2241 eastern standard time, a Piper PA32 airplane, N3952W, was destroyed when it was involved in an accident near Fostoria, Ohio. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The flight was conducted as an instrument flight rules (IFR) flight from Effingham County Memorial Airport (1H2), Effingham, Illinois to Findlay Airport (FDY), Findlay, Ohio. The filed IFR flight plan stipulated a cruise altitude of 9,000 ft mean sea level (msl), an estimated time en route of 1 hour 28 minutes with 4 hours of fuel on board. A review of archived Federal Aviation Administration (FAA) automatic dependent surveillance broadcast data revealed that the airplane departed 1H2 about 1956 central standard time, climbed to about 7,000 ft msl and proceeded on a relatively direct track toward DOYET, the initial approach fix for the RNAV/GPS runway 25 instrument approach, as shown in figure 1. Figure 1: Published Instrument Approach Procedure After passing DOYET, the airplane made about a 30° left turn, consistent with a teardrop entry into the procedure turn. The airplane aligned with the outbound side of the holding pattern for about a mile before turning left again. As the airplane flew north of the published holding pattern in its final minute of flight its altitude decreased from about 3,000 ft to about 2,600 ft before climbing back to about 3,000 ft About 4 nm from the IAF, the airplane turned right, and descended rapidly in a spiral and impacted terrain on a heading of 340° (see figure 2). Figure 2: Instrument Approach with Flight Track Overlay A review of commercially available communications data revealed that the last confirmed communication between the accident airplane and air traffic control (ATC) took place when ATC instructed the pilot to cross DOYET at or above 3,000 ft and cleared them for the RNAV runway 25 approach, to which the pilot read back the clearance and altitude restriction. Shortly thereafter, ATC attempted to contact the pilot and subsequently issued a low altitude alert, but no reply or acknowledgement was received. A witness inside their residence described hearing an airplane low near their house. They described the noise as a loud engine or high rpm engine followed by silence. Another nearby witness saw the lights of the airplane but did not hear anything because they were in a car with the radio on. They said that at first sight, the airplane was estimated between 300 and 500 ft above ground level (agl). When they lost sight of the airplane as it descended behind houses, they estimated the altitude between 150 and 250 ft agl. - The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the pilot. Diphenhydramine was detected in liver and muscle and Doxylamine was detected in muscle; the liver specimen was unsuitable for reporting a doxylamine result. Dextromethorphan was detected in liver and muscle, and the dextromethorphan metabolite dextrorphan was detected in liver (not in muscle). Diphenhydramine is a sedating antihistamine medication available over the counter in multiple cold and allergy products and sleep aids. Doxylamine is another sedating antihistamine medication that is available over the counter as a sleep aid and as an ingredient in various cold and allergy products. Sedating antihistamines can cause cognitive and psychomotor slowing and drowsiness, and products containing sedating antihistamines often carry warnings that they may impair performance of tasks like driving and operating heavy machinery., , , , The FAA states that pilots should not fly within 60 hours of using diphenhydramine or doxylamine, to allow time for the drugs to be cleared from circulation. Dextromethorphan is a cough suppressant medication that is available over the counter in a variety of cold and allergy products. Dextrorphan is the main active metabolite of dextromethorphan. Dextromethorphan and dextrorphan are not typically impairing at levels associated with medicinal dextromethorphan use. The FAA states that pilots who use dextromethorphan should observe a waiting period for the drug to be cleared from circulation before flying. - The airplane impacted a field in a relatively flat attitude and continued on a 340° track into a forest, where it collided with multiple trees and became highly fragmented. Flight control continuity could not be established due to the highly fragmented nature of the wreckage, but all lengths of control cables were accounted for at the accident location. All major pieces of the airplane were observed at the accident location. A postaccident examination of the engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The pilot was conducting a night cross-country flight in instrument meteorological conditions. After passing the initial approach fix (IAF) for the RNAV (GPS) instrument approach at the destination airport, the airplane made about a 30° left turn, consistent with a teardrop entry into the procedure turn. The track data showed the airplane aligned with the outbound side of the holding pattern for about a mile before turning left again. As the airplane flew north of the published hold in its final minute of flight its altitude decreased from about 3,000 ft to about 2,600 ft before climbing back to about 3,000 ft and about 4 nautical miles (nm) from the initial approach fix (IAF), the airplane turned right, and descended rapidly in a spiral. The airplane traveled through heavily forested terrain and was highly fragmented. A witness who was inside a residence described hearing an airplane at a low altitude near the house. The witness described the noise as a loud or high pitch engine followed by silence. Another nearby witness saw the lights of the airplane but did not hear anything because they were in a car with the radio on. The witness stated the airplane was between 300 and 500 ft above ground level (agl). When they lost sight of the airplane as it descended behind houses, they estimated the altitude between 150 and 250 ft agl. A postaccident examination of the airframe and engine revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. The pilot’s toxicology results revealed that sedating antihistamines diphenhydramine and doxylamine were present in tissue samples. It is possible that the combined effects of those drugs might have increased the pilot’s susceptibility to spatial disorientation. However, the diphenhydramine and doxylamine results in tissue cannot be used to establish whether the drugs contributed to spatial disorientation or were otherwise impairing the pilot at the time of the accident. Based upon the wreckage fragmentation, which was consistent with a high-speed impact, the constant descending turn and IMC, it is likely that the accident pilot experienced spatial disorientation and lost airplane control.
Probable cause
The pilot’s loss of airplane control in night instrument meteorological conditions during the procedure turn of an instrument approach due to spatial disorientation, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N3952W
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
32-936
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-02-25T05:37:59Z guid: 104683 uri: 104683 title: ERA22LA136 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104699/pdf description:
Unique identifier
104699
NTSB case number
ERA22LA136
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-24T13:45:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-03T01:18:01.771Z
Event type
Accident
Location
Holly Hill, South Carolina
Airport
HOLLY HILL (5J5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On February 24, 2022, about 1145 eastern standard time, a Flightstar II, N194PG, was substantially damaged when it was involved in an accident near Holly Hill, South Carolina. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness was in his hangar at the airport when he first heard the airplane. He saw the airplane’s shadow on the centerline of the runway before it veered left, the “engine got really loud,” and the airplane impacted the hangar. The airplane continued over the hangar and struck trees before impacting the ground. The witness ran to the airplane and noted that the engine was still running. He turned it off, and then began assisting the pilot. Photographs taken at the accident site showed that the wings, fuselage, and empennage were substantially damaged. The pilot was contacted multiple times; however, he did not respond. The owner of the hangar where the airplane was being stored was contacted multiple times and he did not respond. Therefore, the wreckage could not be examined. -
Analysis
According to a witness, during the takeoff, the airplane veered to the left and impacted a hangar and trees before coming to rest. Photos of the airplane showed that the airplane’s wings, fuselage, and empennage were substantially damaged. Multiple attempts to contact the pilot were unsuccessful, and the airplane could not examined following the accident. The witness’s description of the airplane’s flightpath is consistent with a loss of control during the takeoff; however, the reason for the loss of control could not be determined based on the available information.
Probable cause
A loss of control during takeoff for reasons that could not be determined based on the available information, which resulted in a collision with a hangar and trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FLIGHTSTAR INC
Model
FLIGHTSTAR II
Amateur built
false
Engines
1 Reciprocating
Registration number
N194PG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1993P
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-03T01:18:01Z guid: 104699 uri: 104699 title: WPR22FA109 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104703/pdf description:
Unique identifier
104703
NTSB case number
WPR22FA109
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-24T15:40:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-04T02:44:03.605Z
Event type
Accident
Location
Boulder City, Nevada
Airport
BOULDER CITY MUNI (BVU)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On February 24, 2022, about 1340 Pacific standard time, a Distar CZ AS Sun Dancer motorglider, N588V, was destroyed when it was involved in an accident near Boulder City, Nevada. The pilot was fatally injured. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. An employee of the fixed base operator (FBO) at Boulder City Municipal Airport (BVU), Boulder City, Nevada, the departure airport, reported that “something was off” with the accident pilot’s demeanor, and, although his speech was clear, “he still seemed a little woozy.” Recorded automatic dependent surveillance-broadcast (ADS-B) and L3Harris' OpsVue data showed that the glider departed from BVU about 13:15 local, on a westerly heading, climbed to 2,850 ft mean sea level (msl) and entered a left turn. The glider continued the left climbing turn to an altitude of 3,100 ft msl, then began descending on an easterly heading until contact was lost about 13:19 local, at an altitude of 2,375 ft msl, about 1 mile northwest of the accident site.  A witness located near the accident site reported that, while performing duties as a site foreman at the solar panel farm near the airport, she observed the glider circling above the solar panel farm at low altitude. The glider’s height appeared to vary from about the top of the power lines to slightly higher. The glider’s engine sounded like it was operating normally, and she did not hear any irregularities, such as backfiring or popping. Shortly after returning to work, she observed black smoke south of the solar panel farm. At the time, she was unaware of any accident. Concerned, she had an employee proceed to the fire and notified emergency services. First responders reported that it appeared that the glider impacted three power lines. The power lines were about 60 ft above the ground, running east to west and black with debris entangled within the power lines. The debris field was located to the south of the power lines and the main wreckage was nearly directly below the power lines. An employee of a FBO located at BVU reported that the accident pilot had rented a vehicle through their rental car service. On the expected date of vehicle return, the employee was informed of motor glider accident. Concerned it may have involved the accident pilot, he proceeded to the parking lot to secure the rental vehicle. While securing the vehicle, he detected an odor of alcohol and observed an open beer can. He locked the vehicle and notified airport operations. - The Clark County Coroner's Office, Las Vegas, Nevada, performed an autopsy of the pilot. The pilot's cause of death was multiple blunt force trauma. Toxicology testing performed for the coroner’s office was positive for ethanol in the pilot’s peripheral blood at 0.270 grams per deciliter (gm/dL) and his vitreous fluid at 0.308 gm/dL. The sedating antihistamine diphenhydramine was detected at 100 nanograms per milliliter (ng/mL) in his peripheral blood. Caffeine, cotinine (a marker of tobacco use), and nicotine were presumptive positives in his peripheral blood. Toxicology testing performed at the FAA Forensic Sciences Laboratory detected ethanol at 0.251 gm/dL in cavity blood. Ethanol was also detected in vitreous fluid at 0.303 gm/dL and urine at 0.328 gm/dL. Methanol was detected in cavity blood and urine. Diphenhydramine was detected in cavity blood at 296 ng/mL and in urine. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilot performance, even at very low levels. While the acute effects of ethanol can vary depending on an individual's frequency of use, body weight, and tolerance, in general, at blood ethanol concentrations as low as 0.02 gm/dL there is relaxation and some loss of judgment and at 0.05 gm/dL there is further degradation of judgment, psychomotor functioning, and alertness. At blood ethanol concentrations above 0.10 gm/dL, there is prolonged reaction time, altered perception of the environment, lack of coordination, slowed thinking, and mood and behavioral changes. Above 0.15 gm/dL, individuals may have significant loss of muscle control and major loss of balance. Methanol, sometimes referred to as wood alcohol, occurs naturally at low levels in most alcoholic beverages. Higher concentrations are found in alcoholic beverages made with denatured ethanol or home-distilled products. Diphenhydramine, commonly marketed as Benadryl, is available over-the-counter in many products used to treat colds, allergies, and insomnia. Diphenhydramine carries the warning that use of the medication may impair mental and physical ability to perform potentially hazardous tasks, including driving or operating heavy machinery. The therapeutic range is 50 to 100 ng/mL, and it has a half-life of 3 to 14 hours. Diphenhydramine undergoes postmortem distribution and central levels may be two to three times higher than peripheral levels. The FAA provides guidance on wait times before flying after using this medication; post-dose observation time is 60 hours, and the medication is not for daily use. - The pilot held an airplane multi-engine land, airline transport pilot certificate and a commercial certificate with ratings that includedairplane single-engine land and glider. A review of the pilot’s logbook revealed that he had accumulated about 2,418 total hours of flight experience. He completed about 7 hours of transition training with a flight instructor in the accident airplane about 1 week before the accident flight. His most recent Federal Aviation Administration (FAA) medical certificate examination was in 2008, at which time he reported a recent driving under the influence arrest and was denied issuance based on his history of alcohol use and possible substance dependence. - The main wreckage, which comprised the cockpit and forward fuselage, came to rest upright on a heading of about 172° magnetic, at an elevation of 1,869 ft msl underneath the set of three powerlines. System components and flight control surfaces were scattered throughout the debris path (see figure). Figure: View of accident site diagram. Postaccident examination of the recovered airframe and engine did not reveal evidence of any mechanical anomalies that would have precluded normal operation. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. -
Analysis
The pilot departed in the motorglider and impacted powerlines and terrain near the airport shortly thereafter. An individual who interacted with the pilot before the accident flight reported that “something was off” and that the pilot “seemed a little woozy.” A witness near the accident site reported seeing a low-flying airplane and stated that the engine sounded normal; however, she did not see the accident. Postaccident examination of the glider revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. Toxicological testing of the pilot detected impairing levels of ethanol and diphenhydramine consistent with the pilot having recently consumed alcohol before the flight. Therefore, it is likely that the pilot’s impairment from consuming alcohol contributed to his failure to maintain clearance from power lines. Diphenhydramine is available over-the-counter in many products used to treat colds, allergies, as well as insomnia because of its strong sedating effects. Patients are advised not to use diphenhydramine with ethanol because that increases drowsiness. Diphenhydramine alone would have caused drowsiness and diminished reaction time and performance; in combination with ethanol, these effects would be enhanced. Thus, the effects from the pilot’s use of diphenhydramine contributed to this accident.
Probable cause
The pilot’s failure to maintain clearance from powerlines while maneuvering, which resulted in a wire strike and impact with terrain. Contributing to the accident was the pilot’s impairment from alcohol consumption and his use of diphenhydramine before the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
DISTAR CZ AS
Model
D 13/15 SUN DANCER
Amateur built
false
Engines
1 Reciprocating
Registration number
N588V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
145/13DF
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-04T02:44:03Z guid: 104703 uri: 104703 title: ERA22FA137 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104702/pdf description:
Unique identifier
104702
NTSB case number
ERA22FA137
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-24T18:56:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-01T20:25:07.63Z
Event type
Accident
Location
Hilltown Township, Pennsylvania
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Video Study The National Transportation Safety Board (NTSB) conducted a video study to estimate the speed of the airplane’s engine based on a video recorded by a camera installed on a residential building. The video was 65 seconds long and included sound. The study found that the engine was operating erratically near its expected operating speed—about 2,600 rpm. The last 11 seconds before ground impact included a 3-second period during which there was likely no combustion or the engine was idling. The airplane’s rapid descent toward the ground started about the same time as this 3-second period. Aircraft Performance Study The NTSB also conducted a performance study for the accident flight. ADS-B data showed that the airplane’s altitude varied between 1,400 and 4,000 ft mean sea level and that the calibrated airspeed varied between 50 and 150 knots. The study found that the airplane’s maneuvers during the final portion of flight were below its flaps-up, idle power stall speed and were twice briefly below the flaps-down stall speed. The performance study also used images toward the end of the flight from the video recording to correlate the video data with the flightpath data. The study found that, during the final 30 seconds of flight, the airplane rolled left when engine noise was reduced. - On February 24, 2022, about 1656 eastern standard time, a Beech 35-C33, N6129V, was destroyed when it was involved in an accident near Hilltown Township, Pennsylvania. The flight instructor and the pilot receiving instruction were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot receiving instruction owned the airplane and had successfully completed the commercial pilot written examination. The purpose of the accident flight was to prepare him for the commercial pilot practical examination. Review of Automatic Dependent Surveillance-Broadcast (ADS-B) data revealed that the airplane departed Doylestown Airport (DYL), Doylestown, Pennsylvania, about 1626. The data also showed that the airplane, while maneuvering at an altitude of about 2,000 ft mean sea level (about 1,600 ft above ground level), the airplane began to descend. A witness to the accident was a licensed private pilot who tended to look up at the sky as small airplanes flew over. When the witness was standing in his neighbor’s driveway, he heard a single-engine airplane overhead and thought the airplane’s engine was loud and the airspeed was slow, which indicated to him that the airplane was most likely in a steep climb to practice a stall. By the time that he looked up at the sky again, he saw the airplane “diving, almost straight down” and “twisting toward the ground.” The airplane was out of the witness’ view after it descended behind a tree line. The witness then saw “a black ball of smoke.” The airplane impacted a residential street. During the impact, a propeller blade separated and landed in a residence. The wreckage came to rest upright, oriented about 125° magnetic and no debris path was observed. A postimpact fire consumed most of the wreckage. - The Bucks County Coroner’s Office, Warminster, Pennsylvania, performed autopsies for both the pilot receiving instruction and the flight instructor by. Their cause of death was multiple blunt force injuries. The flight instructor had a heart attack about 3 weeks before the accident. The autopsy examination of his heart was limited by the extent of his injuries. Toxicology testing was performed on the pilot receiving instruction and flight instructor by the FAA Forensic Sciences Laboratory. The testing was negative for the pilot receiving instruction. The testing for the flight instructor identified ethanol in liver tissue but not in his muscle tissue. The testing also identified metoprolol in both tissues. Ethanol is primarily a social drug found in beer, wine, and liquor and is a central nervous system depressant. Ethanol can also be produced by body tissues after death. Metoprolol is a beta-blocking drug used to treat high blood pressure, control heart rate, and prevent recurrent heart attacks. The drug is generally considered not to be impairing. - The pilot’s logbook was not recovered. On an application for his commercial pilot certificate, dated February 15, 2022, he reported a total flight experience of 733 hours. During a previous insurance renewal quote for the accident airplane, he reported 385 hours of flight experience in the make and model airplane. Review of the flight instructor’s logbook revealed that he had a total flight experience of approximately 11,500 hours; of which, 8,000 hours were providing flight instruction. - The wreckage came to rest upright on a magnetic heading of about 125°, and no debris path was observed. The cockpit and cabin were mostly consumed by fire. Both wings separated from the airplane, but their respective flaps and ailerons remained attached. The empennage remained intact with the rudder and elevator still attached. The flaps and landing gear were retracted. Flight control continuity was confirmed from all flight control surfaces to the cockpit area. Measurement of the two elevator trim actuators corresponded to a 5° trim-tab-down (nose-up) position. The engine came to rest upright separate from the airframe. The three propeller blades separated from the hub. One blade was consumed by fire about 12 inches outboard of the root. Another blade exhibited fire damage, s-bending, chordwise scratching, and leading-edge gouging. The other propeller blade exhibited s-bending, chordwise scratching, and leading-edge gouging. -
Analysis
The flight instructor and the pilot receiving instruction were conducting a flight in an airplane that the pilot receiving instruction owned, and the purpose of the accident flight was to prepare him for the commercial pilot practical examination. About 30 minutes after takeoff, the airplane was maneuvering at an altitude of about 1,600 ft above ground level. The airplane then entered a left spin and descended toward the ground, impacting a residential street. A witness stated that he heard a singleengine airplane overhead and thought the airplane’s loud engine sound did not match its slow airspeed, which meant to him that the airplane was most likely in a steep climb to practice a stall. The witness looked up again and saw the airplane diving almost straight down and twisting toward the ground. Examination of the wreckage revealed no preimpact mechanical malfunctions. Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane’s maneuvers during the final portion of flight were conducted below its flaps-up, idle power stall speed and were twice briefly below the flaps-down stall speed. During the final 30 seconds of flight, the airplane rolled rapidly to the left when engine noise was reduced. The airplane’s rapid left roll and loss of altitude were consistent with an aerodynamic stall. Thus, the pilot who was flying (which could not be determined based on the available evidence) allowed the airplane’s critical angle of attack to be exceeded, resulting in a loss of airplane control. Toxicological testing detected ethanol and metoprolol in the flight instructor’s specimens. The most likely source of the ethanol was postmortem production; therefore, the identified ethanol did not contribute to the circumstances of the accident. Although direct effects from the flight instructor’s use of metoprolol likely did not contribute to the events, the available evidence precluded a determination of whether effects from the flight instructor’s recent heart attack and underlying heart disease contributed to the circumstances of the accident. In addition, if the flight instructor had experienced a medical event during the flight, should have been reasonable able to control the airplane.
Probable cause
The pilots’ exceedance of the airplane’s critical angle of attack while practicing maneuvers during an instructional flight, which resulted in an aerodynamic stall and and a loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35
Amateur built
false
Engines
1 Reciprocating
Registration number
N6129V
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
CD-858
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-01T20:25:07Z guid: 104702 uri: 104702 title: ERA22LA144 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104724/pdf description:
Unique identifier
104724
NTSB case number
ERA22LA144
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-26T12:43:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-03-12T20:20:29.058Z
Event type
Accident
Location
Savannah, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 26, 2022, at 1043 eastern standard time, a Piper PA-28-150, N5208W, was substantially damaged when it was involved in an accident in Savannah, Georgia. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 solo instructional flight.   According to the student pilot, he was on short final for landing on runway 01 at his home airport at the conclusion of a solo flight when the tower controller instructed him to discontinue his approach, turn right, and enter the left downwind leg of the traffic pattern for runway 28. Once established on the downwind leg, the pilot completed a right 360° turn as directed by the controller before he continued the downwind leg and turned left onto the base leg of the airport traffic pattern.   When approaching the turn onto the final approach leg of the traffic pattern, the engine lost power. According to the pilot, the engine “sputtered,” and the engine rpm “dropped, then came back up” before it reduced to 300 rpm. Engine rpm was never restored, and the pilot chose to perform a forced landing in the Savannah River. According to Federal Aviation Administration (FAA) and maintenance records, the airplane was manufactured in 1961 and was equipped with two 25-gallon wing tanks of which 24 gallons in each tank were usable. The manufacturer’s Owner’s Handbook stated that the airplane’s fuel consumption rate at 75% power was 9 gallons per hour (gph). The consumption rate at cruise does not include fuel consumed during engine start, taxi, takeoff, and climb. The airplane was recovered from the Savannah River under the supervision of an FAA inspector. The airplane’s left wing was substantially damaged. Flight control continuity was established from the flight controls to all flight control surfaces. The fuel selector was found in the right tank position. Twenty gallons of liquid were drained from the airplane’s fuel tanks of which “maybe 3 or 4 gallons” were fuel and the rest water. According to the recovery specialist, “About 75% of that was from the left tank. There [were] about 5 gallons in the right tank, and maybe a gallon of that was fuel.” When asked if the fuel tanks were breached, he replied, “No, when the diver went down there were no ‘rainbows’ going to the surface or any evidence of fuel leaking. There were no ‘rainbows’ on the surface either.” The engine was examined at an aircraft recovery facility in Jacksonville, Florida. The spark plugs were removed; the engine was rotated by hand at the propeller; and water was pumped from the cylinders. During rotation, continuity was confirmed from the powertrain to the valvetrain and the accessory section. Compression was confirmed using the thumb method. The magnetos were removed and dried with compressed air. When actuated with a drill, they produced spark at all terminal leads. The carburetor was removed and disassembled and contained no water or fuel. The fuel inlet screen was intact and unobstructed. The engine driven fuel pump was removed, contained no water or fuel, and pumped fluid when actuated by hand. The electric fuel pump was removed, contained no fuel, and operated when powered by a battery. Review of company dispatch and fueling records revealed that, before the accident flight, the airplane had flown 4.1 hours since it was fueled to capacity. At the nominal cruise fuel consumption rate of 9 gph, the airplane would have consumed 27 gallons of fuel in 3.0 hours, and the amount of fuel remaining in the tanks would have been about 21 gallons. An interview with the pilot’s flight instructor revealed that the normal convention was to refuel airplanes before departure based on the planned mission. The instructor estimated that the airplane was adequately fueled for the planned solo flight and that the fuel quantity on board was about 34 gallons. Review of surveillance video revealed that the instructor visually inspected the fuel tanks while the student conducted his preflight inspection, but the student pilot did not. The instructor explained that the fuel quantity measuring device for the airplane was not used during the preflight inspection as “it was broken.” The student pilot stated that he “believes he departed on the “Left” tank position, switched to the “Right” tank position, and that the selector remained in that position throughout the remainder of the flight.   Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that, on the accident flight, the airplane climbed to traffic pattern and/or cruise flight altitude four times. Examination of data downloaded from the airplane’s engine data monitor revealed fuel flow rates at or above 10 gph for about 21 minutes of the 1.1-hour flight. -
Analysis
The student pilot was conducting a solo flight and was on the base leg of the traffic pattern at the conclusion of the flight when the engine lost total power. The pilot determined that he could not reach the runway and chose a river for the forced landing, during which the airplane sustained substantial damage. Examination of fueling and dispatch records revealed that at the time of the accident, the airplane had logged 4.1 hours of flight since it was most recently fueled to capacity, which would have provided about 5.3 hours of endurance in a nominal cruise flight configuration of 75% power with a fuel consumption rate of about 9 gallons per hour (gph). Interviews with the student pilot and his flight instructor, as well as a review of surveillance video of the preflight inspection, revealed that the student pilot did not visually inspect the fuel quantity. Although the instructor performed a visual inspection, the fuel quantity measuring device for the airplane “was broken” and was not used. Recovery and examination of the airplane revealed that the fuel tanks were intact. The right fuel tank contained about 1 gallon of fuel, and the left fuel tank contained about 2 to 3 gallons of fuel. There was no evidence of fuel spillage in the water at the accident site. The fuel selector was found in the right tank position. There was no evidence found of mechanical deficiencies with the airplane that would have precluded normal operation. Examination of data downloaded from the airplane’s engine data monitor revealed fuel flow rates at or above 10 gph for about 21 minutes of the 1.1-hour flight. Given the position of the fuel selector, the small amount of fuel found in the right tank, and the lack of mechanical anomalies, it is likely that the loss of engine power was the result of fuel starvation when the fuel supply in the right tank was exhausted.
Probable cause
The student pilot’s improper fuel management, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N5208W
Operator
FlyCorps Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-244
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-12T20:20:29Z guid: 104724 uri: 104724 title: ERA22LA142 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104722/pdf description:
Unique identifier
104722
NTSB case number
ERA22LA142
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-27T11:58:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-15T17:49:55.627Z
Event type
Accident
Location
Big Pine Key, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On February 27, 2022, about 0958 eastern standard time, an experimental amateur-built Vans RV-12IS, N123RR, was destroyed when it was involved in an accident about 20 miles northwest of Big Pine Key, Florida. The sport pilot and passenger have not been located. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was reported overdue to the Federal Aviation Administration (FAA) on February 28, 2022, after the sport pilot did not report to work. The vertical stabilizer and right horizontal stabilizer were located by the US Coast Guard on March 4, 2022. As of the publication of this report, no other sections of the airplane have been located. According to a friend of the sport pilot, who kept his airplane in an adjacent hangar, they planned to complete a flight of two to Key West, Florida (EYW). Prior to departure, the friend discussed using Everglades City, Florida (X01) in case they had to divert due to weather. Although they were cruising at 6,500 ft msl, the friend had to descend to 1,500 ft msl to remain below a broken cloud layer. He advised the sport pilot that he was diverting to Marathon, Florida (MTH) and encouraged him several times via radio to do the same; however, the sport pilot stated that he was descending from 6,500 ft msl to 4,500 ft msl and continuing to EYW. That was the last communication the friend received from the sport pilot. The friend added that the sport pilot usually checked weather via a ForeFlight app on his phone; however, review of flight service and ForeFlight records did not reveal any weather briefing for the accident flight. The sport pilot was not in radio contact with air traffic control at the time of the accident. Automatic Dependent Surveillance-Broadcast (ADS-B) data revealed that the airplane was in the vicinity of moderate precipitation, which was forecast, at the end of the data (for more information, see Meteorologist Specialist’s Factual Report in the public docket for this investigation). During the last mile of track data, the airplane entered a descending right spiral. The pilot and aircraft maintenance logbooks were not recovered. According to FAA records, the sport pilot received his pilot certificate on January 20, 2022. At that time, he reported a total flight experience of 88 hours; of which, 24 hours were as pilot-in-command and 0 hours were instrument experience. -
Analysis
The sport pilot did not obtain a weather briefing before departing on a day visual flight rules cross-country flight over open water to an island airport along with a friend, who was flying a second airplane. The pilot of the second airplane reported that he had to descend from 6,500 ft mean sea level (msl) to 1,500 ft msl to remain below a broken cloud layer, diverted, and encouraged the accident pilot via radio several times to do the same. However, the accident pilot stated that he was descending from 6,500 ft msl to 4,500 ft msl and continuing to the original planned destination. No further communications were received from the accident pilot. Automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane was in the vicinity of moderate precipitation, which had been forecast, when it entered a descending right spiral before the flight track ended. Only the airplane’s vertical stabilizer and the right portion of the horizontal stabilizer were recovered after the accident. The pilot received his sport pilot certificate about one month before the accident. At that time, he reported a total flight experience of 88 hours; of which, 24 hours were as pilot-in-command and 0 hours were instrument experience. Given the pilot’s limited overall experience and lack of instrument flight experience, it is likely that the pilot experienced spatial disorientation and lost control of the airplane after encountering limited visibility conditions in the moderate precipitation while flying over open water.
Probable cause
The pilot’s inadequate preflight and in-flight weather planning and his improper decision to continue visual flight rules flight into an area of limited visibility in moderate precipitation, which resulted in a loss of airplane control due to spatial disorientation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS AIRCRAFT INC
Model
RV-12IS
Amateur built
true
Engines
1 Reciprocating
Registration number
N123RR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
121166
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-15T17:49:55Z guid: 104722 uri: 104722 title: ANC22LA020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104713/pdf description:
Unique identifier
104713
NTSB case number
ANC22LA020
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-27T14:32:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-03-01T23:13:31.595Z
Event type
Accident
Location
Wasilla, Alaska
Airport
Wolf Lake Airport (4AK6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On February 27, 2022, about 1232 Alaska standard time, a Piper P-18 airplane, N99640, sustained substantial damage when it was involved in an accident near Wolf Lake Airport (4AK6), Wasilla, Alaska. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The noncertificated pilot stated that, after departure from 4AK6 and while the airplane was about 100 ft above ground level, the engine began to lose power, run roughly, and shake violently. To restore engine power, he applied carburetor heat and selected the left fuel tank and then the right fuel tank before selecting both tanks, but those actions did not restore power. He reduced engine power to control the airplane shaking and conducted an emergency landing. During the emergency landing, the airplane impacted a burn barrel and came to rest against a hangar, which resulted in substantial damage to the wings and fuselage. A postaccident examination revealed that the Maule-type fuel selector had been mislabeled. Specifically, the position labeled “both” was for the right tank, the position labeled “left” was the “off” position, the position labeled “right” was for the left tank, and the position labeled “off” was for both tanks. The examination of the engine, its accessories, and the other fuel system components revealed no mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The noncertificated pilot stated that, shortly after takeoff, the engine began to lose power, run roughly, and shake violently. He applied carburetor heat and selected the left fuel tank, then the right fuel tank before selecting both fuel tanks with no change noted. He reduced engine power to control the airplane shaking and conducted an emergency landing. During the emergency landing, the airplane sustained substantial damage to the wings and fuselage.   A postaccident examination revealed that the fuel selector was improperly labeled. However, the examination of the engine, accessories, and the other fuel system components revealed no mechanical malfunctions or anomalies that would have precluded normal operation. As a result, the reason for the partial loss of engine power and the engine’s rough operation could not be determined.
Probable cause
A partial loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-135
Amateur built
false
Registration number
N99640
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
54-2642
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-01T23:13:31Z guid: 104713 uri: 104713 title: ERA22LA139 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104708/pdf description:
Unique identifier
104708
NTSB case number
ERA22LA139
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-02-28T19:30:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-03-10T22:33:07.124Z
Event type
Accident
Location
Madisonville, Tennessee
Airport
MONROE COUNTY (MNV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On February 28, 2022, about 1730 eastern standard time, a Cessna 152, N68218, was substantially damaged when it was involved in an accident near Madisonville, Tennessee. The pilot and passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after a normal preflight inspection, he departed with 20 gallons of fuel for a local flight. After a 30-minute flight, about 5 miles from the airport, he initiated a descent from 3,000 ft and slightly reduced engine power. About 10 seconds later, the engine rpm suddenly dropped to 900 to 1,000 rpm. He advanced the throttle and turned on the carburetor heat, with no effect on the engine. He performed a forced landing and touched down on a wet grassy field. During the rollout the main landing gear wheels locked up, the airplane hit a tree stump and came to a stop. According to the Federal Aviation Administration (FAA) inspector who responded to the site, the left wing was nearly separated at the wing root, and the firewall was bent. A detailed examination of the engine supervised by the FAA inspector confirmed crankshaft continuity. Compression and suction were observed on all four cylinders and a lighted borescope was used to view the interior of the cylinders and no anomalies were noted. The propeller was separated at the crankshaft flange. The carburetor was separated, the throttle cable remained partially attached. The magnetos remained attached to the engine, and spark was observed from all towers when rotated by hand. The oil suction screen and filter were absent of debris. According to the manufacturer’s maintenance manual, the engine should be overhauled every 12 years. Review of the maintenance logbooks revealed the engine had not been overhauled since 1998. The engine had accumulated 1,598 hours since the overhaul. Between the annual inspection in 2021 and the previous annual in 2017, the airplane accumulated 4 hours of flight time. -
Analysis
During descent, after a short local flight, the engine lost partial power. The pilot advanced the throttle and turned on the carburetor heat; however, power was not restored to the engine. He performed a forced landing to a wet, grassy field. The main landing gear wheels locked up and the airplane contacted a tree stump during the landing roll. Although a review of the maintenance records revealed the airplane’s engine had not been overhauled in 24 years, exceeding the recommended engine overhaul time of 12 years, a postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The reason for the partial loss of engine power could not be determined.
Probable cause
A partial loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N68218
Operator
Monroe County Flyers and Aircraft Sales
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15282192
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-10T22:33:07Z guid: 104708 uri: 104708 title: WPR22LA115 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104717/pdf description:
Unique identifier
104717
NTSB case number
WPR22LA115
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-02T10:13:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-03-08T09:21:45.781Z
Event type
Accident
Location
Desert Camp, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 02, 2022, about 0813 Pacific standard time, a Cessna 182D, N8814X, sustained substantial damage when it was involved in an accident near Desert Camp, California. The commercial pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 aerial survey flight.   According to the pilot, the flight was intended to be a low-altitude geophysical survey flight in the Salton Sea area flying a 200-meter grid pattern under contract with the United States Geological Survey. The pilot reported that after a normal preflight inspection and runup, he departed runway 12 at Jacqueline Cochran Regional Airport (TRM), Palm Springs, California with 55 gallons of fuel aboard. He performed a straight-out departure with the fuel selector in the both position and leveled off at 600 ft above ground level (agl). He reduced power to 20 inches of manifold pressure and maintained 2,300 rpmon the engine tachometer. He leaned the mixture until the fuel flow gauge indicated 10.5 gallons per hour and then switched the fuel selector to the right tank about four miles into the flight. While flying on a heading of 090° about 600 ft agl, a partial loss of power occurred, which the pilot noted to be about 60 percent of the normal power available. As the airplane descended, he initiated a right turn back to TRM and started troubleshooting. To troubleshoot the partial loss of power he applied a full rich mixture setting, set the propeller to maximum rpm, turned the carburetor heat on, and performed a magneto check. Subsequently, a total loss of power ensued, and he executed a forced landing. During the landing flare, he added 3 notches of flaps and the tailwheel-equipped airplane touched down in a three-point attitude on a dry, freshly plowed farm field. About 200 ft into the landing roll, the tail started to “come up” and the airplane nosed over. The quantity of fuel in the airplane’s fuel tanks or even the presence of fuel at the accident site could not be determined, as the airplane came to rest inverted. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The gascolator contained 100LL aviation fuel, and the propeller rotated through when turned by hand. Subsequently, an engine test run was completed with no anomalies or malfunctions noted. The engine was started and idled for several minutes in a maximum pitch propeller configuration, and with the mixture in a rich and lean position. The throttle was advanced to full power and the engine operated up to 2,672 rpm. The fuel selector was removed and examined from handle to valve, which revealed no anomalies, binding, or restriction. The closest weather reporting station was located at the departure airport about 10 miles northwest of the accident site. About 21 minutes prior to the accident, recorded weather conditions included a temperature of 61° F, and the dew point of 28° F. The Carburetor Ice Probability Chart in the Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 showed at that time, a carburetor icing probability of icing – glide and cruise power, with a relative humidity of about 30 percent. Recorded weather conditions about 39 minutes after the time of the accident, was a temperature of 66° F, and the dew point was 45° F. The recorded conditions equated to a probability of carburetor icing of serious icing (glide power) with a relative humidity of about 50 percent. The pilot provided multiple written statements pertaining to the sequence of events during the accident flight. None of the statements indicated the pilot manipulated the fuel selector any time after the partial loss of power occurred. Examination of accident site photographs revealed that the fuel selector handle was in or near the right fuel tank position. -
Analysis
The pilot reported that after takeoff, while operating in the vicinity of the Salton Sea, he leveled off about 600 ft above ground level. The wind was out of the southeast and coming off the large body of water. After flying straight and level for about 4 miles, he moved the fuel selector from the “both” position to the “right” tank position. About 4 miles later a partial loss of engine power occurred. The engine continued to operate but was unable to produce adequate power to sustain flight. The pilot made a right turn and attempted to troubleshoot the loss of power to no avail, and the engine subsequently lost total power. The pilot landed on a soft dirt field and the airplane nosed over. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. An engine test run was completed with no anomalies or malfunctions identified. A review of the Federal Aviation Administration Carburetor Icing Probability Chart revealed that a serious probability of carburetor icing existed while operating within the atmospheric conditions, which included a relative humidity of greater than 50 percent that was present at the time of the accident. The pilot reported applying carburetor heat after the partial loss of power, per the emergency checklist, followed by the subsequent total loss of engine power. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation; therefore, the loss of engine power during low altitude flight near a large body of water without the application of carburetor heat, was likely the result of carburetor icing.
Probable cause
The airplane’s loss of engine power due to carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182D
Amateur built
false
Engines
1 Reciprocating
Registration number
N8814X
Operator
CLOUDSTREET FLYING SERVICES
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft - federal
Commercial sightseeing flight
false
Serial number
18253214
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-08T09:21:45Z guid: 104717 uri: 104717 title: ERA22FA141 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104721/pdf description:
Unique identifier
104721
NTSB case number
ERA22FA141
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-02T19:02:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2022-03-16T22:17:53.11Z
Event type
Accident
Location
St. Augustine, Florida
Airport
NORTHEAST FLORIDA RGNL (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Data downloaded from a Garmin G3X captured engine data for the accident flight. The data indicated there was an increase in CHT in the No. 4 cylinder for 5 minutes, followed by loss of oil pressure at 1657. Following the loss of oil pressure, the No. 4 CHT and EGT dropped as well. The engine power was steady until 1657, then decreased to 50% until 1701. According to the pilot’s operating handbook, the recommended airspeed for a precautionary landing with engine power is 90 knots indicated. The final ADS-B target depicted the airplane at 165 knots groundspeed just before crossing over the runway threshold. - On March 2, 2022, at 1702 eastern standard time, an Extra NG airplane, N100NG, was substantially damaged when it was involved in an accident near St. Augustine, Florida. The private pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot of a second Extra 300, N331FZ, stated he was flying in a flight of two with his fiancée flying lead in the accident airplane. They were returning to their home airport after a short local flight. After several moments of watching smoke come from the exhaust of the accident airplane, he asked over the radio if the airplane’s smoke-generator was on. The pilot replied that it was not, and she added that the engine was producing only 1,380 rpm, which was below the expected 2,200 rpm cruise power setting. The accident pilot stated over the tower frequency “my engine is doing something weird, what do I do?” While at 2,800 ft, and 7 miles west of Northeast Florida Regional Airport (SGJ), the pilot of N331FZ advised air traffic control (ATC) that N100NG had a partial loss of engine power, was trailing smoke, declared an emergency for the accident airplane, and told ATC that N100NG was “making a b line for 13.” ATC cleared N100NG to land runway 13. As both airplanes approached SGJ, the pilot of N331FZ stated over the tower frequency “you’re going to make it down, cut the throttle, slip it in…you have a lot of energy now, cut the throttle, slip it deep, deep, slip, you got it.”   A review of the ADS-B data provided by the Federal Aviation Administration (FAA) depicted the airplane at 200 ft and 165 knots groundspeed as it crossed the airport boundary at 1701. The airplane overflew the 8,000 ft runway and came to rest inverted in marshland about 1,500 ft past the departure end of the landing runway. Afterwards, the pilot transmitted over the tower frequency, “I had too much speed; I should have come in slower.” - According to the autopsy performed by the Office of the Medical Examiner, Jacksonville, Florida, the cause of death in the pilot was drowning and the manner of death was accident. Toxicological testing performed by the FAA’s Forensic Sciences Laboratory identified the sedatives midazolam at 4 nanograms per milliliter (ng/mL) and lorazepam at 39 ng/mL in the pilot’s heart blood and in her liver tissue. The antidepressant vilazodone was detected at 49 ng/mL in heart blood and in liver tissue; vilazodone is not an approved FAA antidepressant medication. The major metabolite of naltrexone, 6-beta-naltrexol, was detected in her heart blood and liver tissue; naltrexone is used to treat alcohol and opiate dependency. Ethanol was detected in the pilot’s heart blood at 0.010 grams per deciliter (gm/dL) but was not detected in her vitreous fluid. Toxicological testing performed for the medical examiner’s office detected the opioid fentanyl at 13 ng/mL and caffeine in her hospital blood. - Two months before the accident the pilot completed an experience questionnaire and reported 337 total flight hours, with 11 total hours in the accident make and model. According to the National Transportation Safety Board Pilot/Operator Accident Report (Form 6120.1), she had accumulated 350 total flight hours, with 25 hours in the accident make and model. - At 1700, the tower controller cleared the airplane to land and notified fire and rescue there was an airplane inbound with an emergency. At 1703 the tower controller advised them the airplane overran the runway and was in the marsh. Additional emergency personnel arrived on scene at 1704 and staged at the end of the runway to search for the airplane. A riverboat was dispatched and attempted to access the marsh and locate the airplane; however, low tide and terrain hindered progress. The boat repositioned and attempted another route which was also unsuccessful. About 1726 an airboat was launched in addition to the riverboat to search for the airplane. About 1736 a drone was launched to aid the search, along with an additional airboat. A good Samaritan was the first to reach the airplane and provided visual directions to assist the emergency boats in locating the airplane. The good Samaritan reported the airplane was inverted in the marsh and that he was able to reach in and hold part of the pilots face out of the water. About 1743 both airboats reach the airplane and began the extrication process. During the extrication the water level was rising fast, and responders were no longer able to see the pilot. About 1752 the pilot was extricated, taken to the ramp, and transported to a local hospital about 1808. - Examination of the wreckage revealed no evidence of in-flight or post-crash fire. Flight control continuity was established from the cockpit controls to all flight control surfaces. About 11 gallons of fuel were drained from the fuel tanks; the fuel appeared clear and free of contaminants.   Two of the three composite propeller blades were fractured off at the hub. The engine’s crankshaft was rotated by hand at the propeller hub and continuity was established from the powertrain to the valvetrain and the accessory section. The propeller was rotated by hand and engine continuity was established to the rear accessory case. Thumb compression was established on all cylinders. The No. 4 cylinder had low compression and suction; debris was present on the valve seat. Examination of the cylinders, valves, and pistons with a lighted borescope revealed no anomalies. Both magnetos were removed, actuated with an electric drill, and spark was produced at all terminal leads. The propeller governor was removed, rotated by hand, and oil flowed through the governor as designed.   The mechanical fuel pump was removed and pumped fluid when actuated by hand; no anomalies were noted. The electric fuel pump operated normally with electrical power applied; the pump rotated normally. The throttle body fuel filter, fuel nozzles, and fuel flow divider were clear and free of debris. -
Analysis
The accident pilot was the lead pilot of a flight of two returning to their home base after a local flight. The pilot reported a loss of engine rpm and the pilot of the second airplane reported the accident airplane was trailing smoke. An emergency was declared, and the airplane was cleared to land. Automatic dependent surveillance-broadcast (ADS-B) data showed the airplane crossed the airport boundary at an altitude of 200 ft with a groundspeed of 165 knots. The recommended speed for a precautionary landing with engine power is 90 knots. The pilot overflew the runway, and the airplane came to rest inverted in a marsh, about 1,500 ft past the end of the runway. The airplane was not visible from shore. First responders used multiple boats and a drone to search for the airplane; however, shallow water and the terrain slowed responders’ progress. A good Samaritan, who first located the airplane, provided assistance to the pilot and guided emergency responders to the airplane. During the time responders searched for and extricated the pilot the tide continued to rise and submerged the pilot before extrication. Downloaded engine data indicated an increase in cylinder head temperature (CHT) in the No. 4 cylinder followed by loss of oil pressure, a drop in exhaust gas temperature (EGT), and a decrease in engine power to 50%. The No. 4 cylinder exhibited low compression and suction during the postaccident examination, which was most likely due to environmental debris from the accident sequence that was found on the valve seat. No other anomalies were found during the examination that would have resulted in the loss of engine power. Review of postaccident medical records, including the autopsy data and toxicology reports, revealed no medical issues that would have contributed to the accident. Although the toxicology detected therapeutic levels of the unapproved antidepressant vilazodone, which is associated with side effects such as dizziness, it is unknown how long the pilot was taking this medication or the severity of her depression. Given the pilot’s actions during the flight, it is unlikely that effects from this medication or the pilot’s depression were factors in this accident. The metabolite of naltrexone, 6-beta-natrexol, was detected but not quantified, suggesting that any effects from the use of naltrexone were likely minimal and not a factor in this accident. ADS-B data revealed the airplane crossed over the runway threshold at a significantly higher airspeed than recommended in the pilot’s operating handbook. It’s likely the pilot’s perceived emergency and urgency to land led to the excessive airspeed on final approach and inability to touchdown on the runway.
Probable cause
The pilot’s excessive airspeed during landing, which resulted in a runway excursion and collision with terrain. Contributing to the accident was the loss of engine power for undetermined reasons and contributing to the severity of the accident were the environmental challenges related to the airplane’s location in a marsh, which increased the emergency response time.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EXTRA
Model
NG
Amateur built
false
Engines
1 Reciprocating
Registration number
N100NG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
NG001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-16T22:17:53Z guid: 104721 uri: 104721 title: CEN22LA135 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104730/pdf description:
Unique identifier
104730
NTSB case number
CEN22LA135
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-05T14:00:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2022-03-17T19:50:05.343Z
Event type
Accident
Location
Monee, Illinois
Airport
Bult Field Airport (C56)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 5, 2022, about 1200 central daylight time, a Piper PA-28-235, N5078M, was substantially damaged when it was involved in an accident near Monee, Illinois. The private pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the flight was to remain in the departure airport traffic pattern. During the departure climb, the engine lost power. He said that he checked the position of the throttle, mixture, and the magnetos. He then made a 180º turn to return to the departure airport and during the approach to the airport, he determined that the airplane was unable to make it back to the airport. He landed the airplane on a field, and the airplane sustained substantial damage on impact with terrain to engine mount. Postaccident examination of the airplane revealed that the left tip fuel tank contained about 0.18 gallons of fuel, the left main fuel tank contained about 16 gallons of fuel, the right tip fuel tank contained no useable fuel, and the right main fuel tank contained about 6.5 gallons of fuel. The airplane battery switch was turned on, and the fuel gauge indications were as follows: left tip tank – 0 gallons, the left main tank – 5 gallons, the right tip tank – 0 gallons, the right main tank – 0 gallons. The pilot stated that he had the fuel selector on the left main fuel tank but moved it to the OFF position after the accident. The carburetor was disassembled, and the carburetor bowl contained about 0.4 inch of fuel. There was no fuel in the fuel line leading to the carburetor. No mechanical anomalies were identified during the postaccident examination that would have precluded normal engine operation. -
Analysis
The pilot of the personal flight planned to remain in the departure airport’s traffic pattern. During the departure climb, the airplane experienced a loss of engine power. The pilot preformed a forced landing on a field, and the airplane sustained substantial damage on impact with terrain to the engine mount. The pilot stated that he had the fuel selector positioned to the left main fuel tank for the flight. Postaccident examination revealed 16 gallons of fuel in the left main fuel tank. Minimal fuel was found in the engine carburetor bowl, and no fuel in the fuel line leading to the carburetor, which was consistent with fuel starvation to the engine. There were no mechanical anomalies identified that would have precluded normal engine operation.
Probable cause
The loss of engine power due to fuel starvation for undetermined reasons during a departure climb that resulted in a forced landing and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N5078M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-10111
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-17T19:50:05Z guid: 104730 uri: 104730 title: DCA22FM011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104742/pdf description:
Unique identifier
104742
NTSB case number
DCA22FM011
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-03-06T02:35:00Z
Publication date
2024-02-06T05:00:00Z
Report type
Final
Last updated
2024-01-24T05:00:00Z
Event type
Accident
Location
Santo Domingo Cay, Atlantic Ocean
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the flooding and subsequent sinking of the Carib Trader II while under dead ship tow was the uncontrolled flooding of the engine room from an undetermined location below the waterline.
Has safety recommendations
false

Vehicle 1

Callsign
J8QO3
Vessel name
Carib Trader II
Vessel type
Cargo, General
IMO number
7396599
Maritime Mobile Service Identity
377907287
Port of registry
Kingstown
Flag state
VC
Findings

Vehicle 2

Callsign
WDG5150
Vessel name
Capt. Beau
Vessel type
Towing/Barge
IMO number
8424862
Maritime Mobile Service Identity
367543820
Port of registry
Miami, FL
Classification society
ABS
Flag state
USA
Findings
creator: Coast Guard last-modified: 2024-01-24T05:00:00Z guid: 104742 uri: 104742 title: ERA22LA146 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104731/pdf description:
Unique identifier
104731
NTSB case number
ERA22LA146
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-06T12:15:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-21T18:06:01.37Z
Event type
Accident
Location
Waco, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 6, 2022, about 1015 eastern standard time, a Beech A35, N764B, was substantially damaged when it was involved in an accident near Waco, Georgia. The commercial pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during the short cross-country flight, the engine began to lose power. As he attempted to regain power, he noticed that the fuel pressure indication fell to zero. The engine stopped producing power and he elected to perform an emergency landing to a road. During the approach to land, the airplane collided with power lines over the road before landing. The pilot exited the airplane and when he opened the engine cowling, he discovered a leaking fuel line. Examination of the airplane by a Federal Aviation Administration inspector revealed structural damage to the vertical stabilizers and fuselage. Examination of the fuel pressure indicator revealed the fuel line connecting the indicator to the carburetor ruptured. When fuel was supplied to the line, it was subsequently observed leaking from the rupture in the line. The line was removed for further examination, and during the examination visible signs of minor corrosion were discovered around the rupture. A review of the Beech 35 shop manual showed that all fuel lines should be inspected for condition during 100-hour or annual inspections. The fuel line that ruptured was made of a soft aluminum alloy material. Review of the engine and airframe maintenance logbook records indicated that an annual inspection was completed about 8 months prior to the accident. The airplane had accumulated 22 flight hours since the last annual inspection. -
Analysis
The pilot reported that during the cross-country flight, the engine began to lose power and as he attempted to regain power, he noted a decrease in fuel pressure. The engine then lost all power, and the pilot made a forced landing on a road. Postaccident examination of the airplane found that the aluminum fuel line from the fuel indicator to the carburetor had ruptured. Additionally, minor corrosion was present around the ruptured area. Based on this information, it is the likely that this corrosion ultimately resulted in the rupture of the fuel line and loss of engine power. Additionally, the airframe maintenance manual prescribed that all fuel lines should have been inspected during the airplane’s most recent annual inspection, which had occurred 8 months and 22 flight hours prior to the accident. Had the corrosion been detected, and the fuel line replaced at that time, it is likely that the loss of engine power would not have occurred.
Probable cause
The failure of the fuel pressure indicator line due to corrosion that was not detected during the last annual inspection, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A35
Amateur built
false
Engines
1 Reciprocating
Registration number
N764B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-1772
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-21T18:06:01Z guid: 104731 uri: 104731 title: ERA22LA145 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104725/pdf description:
Unique identifier
104725
NTSB case number
ERA22LA145
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-07T01:59:00Z
Publication date
2023-06-08T04:00:00Z
Report type
Final
Last updated
2022-03-08T18:21:46.588Z
Event type
Accident
Location
Abingdon, Virginia
Airport
VIRGINIA HIGHLANDS (VJI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On March 6, 2022, at 2359 eastern standard time, an Airbus Helicopters Deutschland GmbH, MBB-BK 117-C-2 helicopter, N29VA, was substantially damaged when it was involved in an accident at Virginia Highlands Airport (VJI), Abingdon, Virginia. The pilot sustained serious injuries, and the two flight paramedics were not injured. The helicopter was operated by the Virginia Department of State Police (VSP) as a public aircraft. The pilot reported that his duty day started at 0800 and that he had completed four air medical transportation flights before receiving a call at 2200 for a patient transfer from Lonesome Pine Hospital (VG50), Big Stone Gap, Virginia, to Holston Valley Hospital (3TN5), Kingsport, Tennessee. The flights from VJI to VG50 and from VG50 to 3TN5 occurred without incident. During the return flight from 3TN5 to VJI, the pilot reported that, on liftoff, he “slowly pulled up on the collective,” and “the helicopter became light on the skids.” The pilot then noticed “what sounded like a surge in the engines,” and the engine power needles “surged upward.” The pilot asked the flight paramedic seated in the front seat whether he heard the noise, but he could not recall whether the paramedic responded to the question. (After the accident, the paramedic reported that he heard the pilot’s question but that he did not hear the engine surge.) The pilot continued the liftoff into a hover, evaluated the engine instruments, and noted normal indications. The helicopter then proceeded en route to VJI without incident. At VJI, the pilot conducted a visual approach to runway 6 and entered a hover taxi via a taxiway that led straight toward the VSP ramp hangar, and landing dolly . When the helicopter entered the ramp environment, the pilot completed a pedal turn to orient the helicopter 180° opposite the direction of the taxiway. The pilot then performed a side-step maneuver to align the skids and fuselage with reference points on the dolly and its tractor. The pilot reported that he saw the reference points, descended the helicopter to descend; afterward, he briefly felt what he thought was a skid touchdown on the dolly; simultaneously, the pilot heard what he thought was an engine surge similar to the one earlier in the flight. The helicopter abruptly entered a nose-low attitude and right bank, causing the helicopter to become oriented opposite the direction that it had been facing for landing. The pilot observed terrain and hangars ahead, so he applied aft cyclic and abruptly lowered the collective. The helicopter subsequently impacted terrain. Figure 1 provides an overview of the helicopter’s flight track and sidestep maneuver to land on the dolly. Figure 1 - Overview of the flight track to land on the dolly along with postaccident photographs (Source: Virginia State Police). The helicopter came to rest upright, the skids had collapsed, and the dolly was found near the area where the helicopter impacted terrain. The helicopter came to rest about 50 ft to the east of the original dolly position. The engines continued to run afterward. The pilot shut down the helicopter, and he and flight paramedics had no difficulties evacuating. Neither flight paramedic reported hearing or feeling an anomaly with the engines at any point during the flight. Postaccident examination of the helicopter and its engines revealed no evidence of preimpact mechanical malfunction or failure. The flight and throttle controls operated normally during postaccident testing. Both engines were removed from the helicopter and operated on an engine test cell. The engines produced normal power, and an uncommanded engine surge could not be duplicated when the engines were operated at various power settings. The landing dolly, portions of which were painted yellow, sat 18 inches from the ground on wheels and was manufactured with an open center gap that was 3.5 ft wide. Figure 2 provides an overview of the landing dolly (shown in yellow) and shows how the accident helicopter would look atop it when properly positioned. Figure 2- Forward view of the helicopter and top-down view of the dolly with the helicopter atop (Source: Airbus Helicopters). Note: The three-dimensional model was developed using National Transportation Safety Board measurements. The landing dolly sustained impact-related twisting and deformation. Several witness marks were observed on the left edge, right top, and underside of the dolly. Examination of the helicopter’s skids revealed evidence of yellow paint transfer on the inboard forward area of the left skid. Additional yellow paint transfer was observed on the right skid forward area and rearward top portions. The forward portion of the right skid had sheared off; yellow paint transfer and an indentation were observed within that portion. The landing dolly manufacturer reported that the center-gap style was about 10- to 12years old at the time of the accident. The manufacturer reported that, about 2015, the dolly’s standard equipment included a center metal plate to prevent helicopters or their occupants from falling into the center gap. The VSP aviation division commander reported that the base’s replacement dolly was equipped with a center plate. According to the VSP aviation division commander, VJI was one of three operating bases in the state. The base’s primary missions were public emergency medical evacuation flights (Med-Flight) and law enforcement operations; all flight operations were conducted with public aircraft as public-use operations. Such operations were not required to comply with 14 Code of Federal Regulations Part 91 or 135. Review of the VSP scheduling standard operating procedures found that pilots assigned to Med-Flight operations worked 24.3-hour duty shifts. The length of the shift was based on the number of qualified pilots on staff and the need to maintain continuous operational coverage. The standard Med-Flight shift started at 0800 and ended at 0820 on the next day. On the day of the accident, the pilot awoke at home at 0630 and arrived at VJI about 0800 to begin his 24.3-hour shift. The pilot reported that his total task time was 8 hours 27 minutes during five mission flights (including the accident flight). (The standard operating procedures defined task time as the time necessary to complete the flight, including preflight, the flight, postflight, and postflight paperwork. Supervisor approval was required to exceed 10 hours of task time. The pilot’s total duty period, from the time that he began his shift at 0800 to the accident time, was 15 hours 59 minutes. The pilot’s total time awake on the day of the accident was 17 hours 29 minutes, and he did not take a nap during this period. During postaccident interviews, the pilot reported that he could not recall exceeding 10 hours of task time while working with VSP. The pilot reported “no pressure” from supervisors to accept a mission if he was tired. The pilot added that, if he had felt tired before the accident flight, he would have reported that to his supervisors, and he would not have conducted the flight. The pilot thought that fatigue was not a factor in the accident and recalled that, even though he flew multiple flights on the day of the accident he did not “feel too bad” then. The VSP aviation division commander reported that, after the accident, multiple scheduling procedures had been revised. He reported that VSP eliminated 24.3-hour pilot shifts at each Med-Flight base and that VJI currently conducts 12-hour pilot shifts with 24 hours of mission coverage. VSP pilots at other bases work shifts up to 16 hours until additional pilots can be hired and trained. -
Analysis
The helicopter pilot had just completed a night public-use medical flight to a hospital and was returning to the base airport along with two flight paramedics. The pilot initiated the takeoff and increased power to enter a hover, at which time he observed (via engine instrumentation) an uncommanded surge (increase) in power, which he also heard. The pilot continued the liftoff into a low hover and found that, despite the momentary power surge, all engine parameters and flight controls appeared normal, so the flight continued to its operational base. The pilot arrived at the base without any en-route anomalies and maneuvered the helicopter in the ramp area to align with a landing dolly connected to a tractor. The maneuver required the pilot to complete a right sidestep over the dolly. When visual alignment was attained, the maneuver required the pilot to reduce power to allow the skids to settle on the dolly. During the sidestep maneuver, the pilot felt a skid touch down momentarily; however, he heard an engine surge that was similar to what he experienced during takeoff. Simultaneously, the helicopter abruptly entered a steep nose-low attitude and right bank and began rotating to the right 180° opposite of the direction of landing. The pilot lowered the collective and pulled the cyclic aft, and the helicopter impacted terrain about 50 ft east of the dolly’s original location. (During the accident sequence, the dolly had been lifted and rotated from its original orientation and position.) Neither flight paramedic reported hearing or feeling an anomaly with the engines at any point during the flight. Postaccident examination of the helicopter and its engines revealed no evidence of preimpact mechanical malfunction or failure. The flight and throttle controls operated normally during postaccident testing. Both engines were removed from the helicopter and operated in an engine test cell. The engines produced normal power, and an uncommanded engine surge could not be duplicated when the engines were operated at various power settings. Several witness marks were observed on the left edge, right top, and underside of the dolly, portions of which were painted yellow. Examination of the helicopter’s skids revealed evidence of yellow paint transfer on the inboard forward area of the left skid. Additional yellow paint transfer was observed on the right skid forward area and rearward top portions. The forward portion of the right skid had sheared off; yellow paint transfer and an indentation were observed within that portion. Available evidence suggests that the helicopter skids were misaligned during the attempted landing on the dolly, and the right skid likely fell into the dolly’s 3.5-ft-wide center gap, which resulted in a rapid loss of helicopter control. This likelihood is consistent with the pilot’s report that the helicopter abruptly entered a noselow attitude and right bank. The helicopter likely dragged the dolly and tractor during the bank to the right before breaking free of the dolly and impacting terrain. The dolly and its design is no longer sold by the manufacturer without a center plate that covers the gap. The pilot had been awake for more than 17 hours and on duty for about 16 hours, and he was completing his fifth flight of the day as part of the operator’s standard 24.3-hour shift. The length of the shift was based on the number of qualified pilots on staff and the need to maintain continuous operational coverage. The standard shift started at 0800 and ended at 0820 on the next day. The landing maneuver required precision from the pilot under normal circumstances; however, he was attempting the landing at night (a time when limited lighting would be available) and at the end of a long duty day. In addition, the accident occurred about midnight, a time when the pilot likely would have been experiencing fatigue based on his sleep schedule. Although the pilot reported that he was not fatigued, research has shown that performance decrements can occur after 17 hours of continuous wakefulness. Further, flying multiple flight segments can be more fatiguing than flying a single, longer segment. Therefore, the pilot was likely fatigued at the time of the accident due to his time since awakening, the time of day, and the multiple flight segments that he flew on the day of the accident. The operator’s 24.3 hour shift practices did account for total task time limitations, however, other than a pilot self-reporting that they were fatigued, there were no limitations preventing pilots from initiating flights after being awake for total durations, or times during the night, when fatigue is commonly experienced. Several factors contributed to the pilot’s misalignment of the helicopter skids: the pilot’s fatigue, the operator’s scheduling practices, and the dolly’s design with a center gap. Following the accident, the operator reduced the standard scheduled shifts from 24.3 hours to a maximum of 16 hours and 12 hours where staffing permits. In addition, the operator no longer utilizes landing dollies that possess a center gap.
Probable cause
The pilot’s misalignment of the helicopter skids while landing on a dolly at night, which resulted in the skids becoming entangled with the dolly and a loss of control. Contributing to the accident was the pilot’s fatigue as a result of the time the accident occurred, his total time awake, the multiple flight segments flown, and the operator’s pilot scheduling practice. Also contributing to the accident was the center gap design of the landing dolly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
AIRBUS HELICOPTERS
Model
MBB-BK 117 C-2
Amateur built
false
Engines
2 Turbo shaft
Registration number
N29VA
Operator
VIRGINIA DEPARTMENT OF STATE POLICE
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft - state
Commercial sightseeing flight
false
Serial number
9374
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-08T18:21:46Z guid: 104725 uri: 104725 title: ERA22LA148 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104737/pdf description:
Unique identifier
104737
NTSB case number
ERA22LA148
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-07T12:45:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-03-09T00:00:54.849Z
Event type
Accident
Location
Middle River, Maryland
Airport
MARTIN STATE (MTN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
A performance study revealed that main gear touchdown occurred at about 110 knots airspeed and about 104 knots groundspeed about 2,000 ft beyond the approach end of runway 15, within the first third of the landing distance available. However, the airplane aerodynamics and flight-idle thrust models indicated that during the landing ground rollout, configured with ground flaps and speed brakes deployed, the airplane experienced a prolonged period of low equivalent retarding force at the wheel/runway interface. The airplane performance model indicated that, during the ground rollout, the deceleration was primarily due to aerodynamic drag and free rolling (unbraked) wheel friction. The accident airplane did not slow to a safe taxi speed over a pavement rollout distance of about 5,000 ft. The unexpected, prolonged, low equivalent retarding force at the wheel/runway interface during the ground rollout substantially reduced the airplane’s deceleration and prevented the airplane from dissipating sufficient energy to slow to a safe taxi speed or stop prior to the runway departure end. The airplane overran the departure end of runway 15 at a groundspeed of about 58 knots. According to published airplane performance and landing data, based on the landing weight, dry surface runway conditions, flaps 35 and anti-ice protection either on or off, the maximum landing distance required was 2,900 ft. (total runway length was 6,997) This calculation was similar to the crew’s report of about 3,000 ft. As configured, the average airplane deceleration was about 1.25 knots per second, significantly less than the expected maximum airplane deceleration capability of 5 to 6 knots per second. - The Cessna Citation 525B was a medium-size business jet powered by two medium bypass ratio, Williams International FJ44-3A turbofan engines (about 2,800 pounds of flat-rated static thrust at sea level, 22°C, takeoff power) mounted on the aft fuselage. It was not equipped with thrust reversers but had an antiskid braking system designed to maximize braking effectiveness by reducing hydraulic pressure when the wheel speed transducers sense a sudden deceleration on a wheel that skids, without the loss of braking effectiveness, control, or lockup. The main components of the power brake and antiskid system are the hydraulic pack assembly, accumulator, antiskid control unit, control valve, transducers, fault display and brake metering valve. Other components include the squat switches, which indicate when the airplane is safely settled on the ground, high and low pressure switches, and an emergency brake system that includes a pneumatic storage bottle and emergency brake valve. The emergency brake system was actuated when the nitrogen pneumatic storage bottle contents were released into the brake system through the emergency brake lever (figure 1). When the lever is pulled, compressed nitrogen is released from the bottle to apply the wheel brakes. Although antiskid protection is unavailable with the emergency brake system, the pilot can modulate the lever to achieve the desired airplane deceleration rate. Figure 1. Emergency brake (red knob/handle) location Under the published Pilots Abbreviated Checklist for the Model 525B, Normal Procedures, Decent/Approach/Landing, after application of brakes, the subsequent Caution message read, “IF DURING LANDING A NO BRAKING CONDITION IS ENCOUNTERED, OPERATE THE EMERGENCY BRAKING SYSTEM. MAINTENANCE IS REQUIRED BEFORE THE NEXT FLIGHT.” Under the Emergency Procedures (Section 2), for Wheel Brake Failure line item #1 states to remove feet from brake pedals and #2 states Emergency Brake Handle……Pull as required. (See Figure 2) Figure 2. Brake failure procedures - MTN runway 15 was grooved and 6,997 ft long. The runway had a downslope of 0.17%. At the time of landing, the runway was in good condition and dry. - The accident airplane was equipped with a Cessna Aircraft Recording System (AReS) and a Cockpit Voice Recorder (CVR). The AReS data were collected, processed by Textron/Cessna staff, and provided to the National Transportation Safety Board (NTSB) investigation. The CVR data were collected and processed by an NTSB recorder specialist. Both recording device data and reports are in the public docket. - On March 7, 2022, about 1045 eastern standard time, a Cessna 525B, N22AU, was substantially damaged when it was involved in an accident in Middle River, Maryland. The two pilots were not injured. The airplane was operated by Executive Flight Services, LLC, as a Title 14 Code of Federal Regulations Part 135 on demand charter flight. The pilots reported they flew a stabilized approach to runway 15 at Martin State Airport (MTN), Baltimore, Maryland after the positioning flight from Washington Dulles International Airport (IAD) Washington, District of Columbia. They added 5 knots to their Vref speed to account for the gusting wind. The pilot reported the landing performance data indicated they would need about 3,000 ft of runway to land, and pilot reported that they landed in the touchdown zone of the 6,997 ft runway. The landing rollout appeared normal until the pilot asked, “Why aren’t the brakes working?” The copilot applied brakes on his side also and was unsuccessful in achieving any braking action. They attempted to locate the emergency brake (located under the instrument panel in front of the pilot’s legs) but were unable to locate it so they applied the parking brake instead. The airplane departed the runway and travelled 450 ft before impacting the airport perimeter fence. A witness located in the parking lot of the control tower stated that the airplane appeared to be landing very long and that it looked like it touched down near taxiway J, which was located about 3,900 ft past the runway threshold. Automatic dependent surveillance - broadcast (ADS-B) data, recovered onboard flight data and review of video footage from two airport surveillance cameras were utilized to determine that the airplane touched down about 2,000 ft beyond the approach end of the runway at about 110 knots. - At 1053 EST, the MTN Automated Surface Observing System reported wind from 210° at 12 knots gusting to 21 knots, visibility 10 statute miles or greater, clear skies to 10,000 ft above ground level or greater, temperature of 23° C, dew point 13° C, and altimeter setting of 29.79 inches of mercury. The wind crosswind component as calculated was a crosswind of 10.4 kts and a headwind of 6 kts and gust conditions were calculated to be 18 kts crosswind and 10.5 kts headwind. - The pilot, an airline transport pilot occupying the left seat, had over 2,780 hours total time with 248 hours in the accident airplane make and model. In May 2021 the pilot completed Part 135 initial/training (Flight Safety Textron Aviation) for the Cessna 525 ground school that included 45.5 hours of ground training and 11 hours of briefing/debriefing hours. The training included, but was not limited to, general systems, pneumatics, hydraulics, flight controls and landing gear and brakes. In addition, the pilot received 14 hours of flight simulator time with an additional 14 hours of pilot monitoring (co-pilot) time. Airplane recurrent Part 135 training was completed in October 2021. The co-pilot, an airline transport pilot occupying the right seat, had over 7,500 hours total time with 115 hours in the accident airplane make and model. In December 2017 the co-pilot completed Part 135 initial/training (Flight Safety Textron Aviation) for the Cessna 525 ground school that included 48.5 hours of ground training and 10.5 hours of briefing/debriefing hours. The training included, but was not limited to, general systems, pneumatics, hydraulics, flight controls and landing gear and brakes. In addition, the pilot received 14 hours of flight simulator time with an additional 2 hours of pilot monitoring (co-pilot) time. Airplane specific recurrent Part 135 training was completed in May 2018, October 2018, and December 2021. - The airplane departed the runway surface, leaving light skid marks on the last 100 ft of runway before departing the paved runway surface. Three wheel indentation/skid marks continued through the grass for about 450 ft, where the airplane impacted an airport perimeter security fence and came to rest. The resulting impact resulted in substantial damage to the wings and fuselage. Postaccident examination of the brake system revealed that the pneumatic storage bottle for the emergency brake system and emergency landing gear deployment was removed by the operator after the accident but before the examination on an unknown date and was not observed. It was reported by the operator to be fully charged before it was removed. A visual inspection of the main landing gear brakes was conducted with no anomalies noted. No evidence of hydraulic leaks was observed near the brakes or any of the associated lines and fittings located in the wheel well. The brake reservoir and brake accumulator were properly serviced. The Valve and Control Unit BIT indicators were observed tripped. The indicators were reset before any testing was accomplished. The parking brake was set and the wear pins on each wheel were examined. The brakes were in a serviceable condition. The On-ground Mode Antiskid Functional Test was accomplished. The PWR BRK LOW PRESS annunciator illuminated while the accumulator was charged by the airplane pump from a pre-charge state until it reached the normal operating range (green) when the annunciator extinguished. A single pressure gauge was attached at each brake’s highest bleed port and with full pressure applied both brakes performed as designed, holding and maintaining minimum pressure. The rotary test switch was placed in the ANTISKID position and then quickly placed in the OFF position. The ANTISKID INOP annunciator illuminated for about6 seconds and then extinguished. Both pilots’ left and right brake pedals were depressed fully and held. With the ANTI-SKID switch in the ON position, the left antiskid speed transducer was turned with a drill and the right brake pressure decreased appropriately, then as the transducer was suddenly stopped, and the left brake pressure decreased before gradually returning to the initial level. The right antiskid speed transducer was turned with a drill and exhibited the same behavior as the left transducer. The behavior of the system was normal with no anomalies observed. The landing gear tires and treads were down to about 80% of their useful treadwear and had reached the normal removal wear limit. Postaccident examination and testing of the airplane’s braking system revealed no evidence of any preaccident mechanical malfunctions or failures. -
Analysis
The flight crew reported they flew a normal flight and a stabilized approach in gusty wind conditions. Performance data indicated they would require about 3,000 ft of runway for landing on the 6,995 ft long runway, and they added 5 knots (kts) to the approach speed due to the gusts. Data indicated that the airplane landed in the touchdown zone and at an appropriate airspeed of 110 kts (104 kts groundspeed); however, the pilot’s and co-pilot’s application of brakes was unsuccessful in achieving sufficient braking action. The airplane departed the runway at a groundspeed of 58 kts and came to rest against a perimeter fence 450 ft past the runway. A witness stated the airplane landed long; however, his distance from the runway and his angle of view of the airplane may have prevented an accurate assessment. Although the airplane flight manual states that if the brake system or antiskid fails, the pilot(s) are to attempt to pull the emergency brake, the pilots were unable to locate the emergency brake and instead pulled the parking brake. Although an examination of the braking system failed to find an anomaly, a performance study revealed that during the ground rollout the deceleration was primarily due to aerodynamic drag and free rolling “unbraked” wheel friction for about 5,000 ft and that there was virtually no evidence of deceleration due to hydraulic or pneumatic wheel braking during the rollout. However, the pilots’ inability to locate and use the emergency brake contributed to the insufficient braking. The crew failed to immediately recognize the issue and locate and utilize the emergency brake for supplemental braking authority.
Probable cause
And undetermined failure of the brake system. Contributing to the accident was the failure of the pilots to locate and operate the emergency brake control, which resulted in a runway excursion and collision with terrain and an object.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
525
Amateur built
false
Engines
2 Turbo fan
Registration number
N22AU
Operator
Executive Flight Services LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Positioning
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
525B0304
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-09T00:00:54Z guid: 104737 uri: 104737 title: CEN22LA137 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104753/pdf description:
Unique identifier
104753
NTSB case number
CEN22LA137
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-08T16:17:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2022-03-10T02:48:51.581Z
Event type
Accident
Location
Englewood, Colorado
Airport
Centennial (APA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On March 8, 2022, at 1417 mountain standard time, a Cessna P210N airplane, N210GE, was destroyed when it was involved in an accident near Englewood, Colorado. The pilot and flight instructor both sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was established on the instrument landing system (ILS) approach to runway 35R as it approached Centennial Airport. The tower controller subsequently instructed them to sidestep to runway 35L. This required the pilot to extend the glide path because the runway arrival thresholds are offset. However, as the pilot attempted to increase engine power, he realized that it was not responding. Attempts to restore engine power by activating the auxiliary fuel pump and changing fuel tanks were not successful. Unable to glide to the runway, the flight instructor executed a forced landing about 1/2-mile short of the runway. The airplane landed in the grass median area between traffic lanes of an interstate highway and came to rest on a steel-cable safety barrier. A postimpact fire ensued. The airplane sustained impact damage to the forward fuselage and both wings. The postimpact fire consumed portions of the fuselage, cockpit/cabin area, and right wing. Postrecovery airframe and engine examinations did not reveal any anomalies consistent with an inability of the fuel-injected engine to produce rated power. However, examination of the airframe fuel system was hindered by the extent of the fire damage. The airplane was equipped with two wing fuel tanks each capable of holding about 44 gallons of useable fuel. The airplane was also equipped with an auxiliary fuel tank, located in the aft baggage compartment, capable of holding about 30 gallons of fuel. Automatic Dependent Surveillance – Broadcast (ADS-B) data revealed that the accident flight was 1 hour and 48 minutes in duration. The pilot’s operating handbook indicated that the expected fuel consumption was 18 – 20 gallons per hour during cruise flight. Accordingly, the expected fuel consumption for the flight would be approximately 36 gallons. The pilot reported that the flight departed with 118 gallons of fuel onboard. The airplane was equipped with two wing fuel tanks each capable of holding about 44 gallons of useable fuel. The airplane was also equipped with an auxiliary fuel tank, located in the aft baggage compartment, capable of holding about 30 gallons of fuel. -
Analysis
The fuel-injected engine lost power on final approach. Efforts to restore engine power were not successful and the flight instructor executed a forced landing about 1/2-mile short of the runway. A postimpact fire consumed portions of the fuselage and right wing. Postrecovery airframe and engine examinations revealed no anomalies that would have precluded normal operations. However, examination of the airframe fuel system was hindered by the extent of the fire damage. Available information indicated that sufficient fuel was onboard for the airplane. As a result, the investigation was unable to determine the reason for the loss of engine power.
Probable cause
A total loss of engine power on short final for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
P210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N210GE
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
P21000655
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-10T02:48:51Z guid: 104753 uri: 104753 title: ERA22FA149 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104744/pdf description:
Unique identifier
104744
NTSB case number
ERA22FA149
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-08T20:46:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-16T04:33:57.431Z
Event type
Accident
Location
Panama City, Florida
Airport
NORTHWEST FLORIDA BEACHES INTL (ECP)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
According to maintenance records and interviews with individuals who had spoken with the pilot before the accident flight, the airplane had a persistent autopilot problem. The autopilot, when engaged and selected to altitude hold mode (ALT HOLD), would begin an altitude oscillation that would eventually reach 1,500 ft per minute in climbs and descents. Disengaging the autopilot had not been an issue. Maintenance records showed autopilot discrepancies and corrective actions from October 2020 to January 21, 2022. The maintenance shop that worked on the autopilot thought that the issue had been corrected, and, on January 31, 2022, the pilot departed with his airplane. The oscillations still persisted, so the pilot brought his airplane back to the maintenance shop on February 14, 2022. The airport manager at IKW spoke with the pilot 3 days before the accident. She stated that, according to the pilot, he was “chasing an autopilot issue” that was still not fixed. She also stated that the pilot had indicated that he would be completing his planned trip to ECP without the autopilot operating. In addition to the original autopilot altitude porpoise issue, the pilot reported that he had performed autopilot/trim system troubleshooting, but he did not describe the specific actions he took to the maintenance shop manager. The pilot indicated that the programmer/computer for the autopilot displayed a fault but that the manual elevator trim wheel operation was normal. The pilot did not have an appointment for service, and the shop could not evaluate the airplane at that time; thus, the pilot decided to return to the shop at a later time. No record indicated any maintenance performed after January 2022. According to a friend of the pilot who spoke with him 3 days before the accident, the pilot stated that he was going to fly to Florida as soon as his airplane was fixed. The friend asked the pilot, “are you comfortable flying without autopilot and single pilot that far?” The pilot responded, “yeah I’ll be fine.” - The instrument approach procedure for ECP runway 16 stated that the decision altitude for a straight-in ILS approach was a 269 ft (200-ft agl), and the runway visual range listed was 2,400 ft. The airport had a medium intensity approach light system with runway alignment indicator lights, touchdown zone lights, and runway centerline lights. - On March 8, 2022, about 1846 central standard time, a Cessna 182Q airplane, N182XT, was destroyed when it was involved in an accident near Northwest Florida Beaches International Airport (ECP), Panama City, Florida. The private pilot and passenger were fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to a family member, the pilot and passenger (his wife) planned a cross-country flight departing from their home airport, Jack Barstow Airport (IKW), Midland, Michigan, with a final destination of Panama City, Florida. Review of Federal Aviation Administration (FAA) Automatic Dependent Surveillance–Broadcast (ADS-B) data revealed that the pilot completed a 10-minute local flight at IKW that concluded about 1118 (1018 eastern standard time). The pilot then initiated an instrument flight rules (IFR) cross-country flight from IKW about 1212 (1112 eastern standard time) and arrived at Warren County Memorial Airport (RNC), McMinnville, Tennessee, about 1503 central standard time, resulting in a total flight time of 3 hours 51 minutes. A fuel receipt showed that, about 1520, the pilot purchased 74 gallons of 100 low-lead fuel. The airplane departed RNC about 1554 and arrived in the ECP area after about 2 hours 45 minutes of flight time.   Review of air traffic control (ATC) communications provided by the US Air Force and the FAA revealed that the flight was in contact with Tyndall Air Force Base. The approach controller informed the pilot that automatic traffic information service information Quebec was current, cleared him to the initial approach fix, and instructed the pilot to cross the initial approach fix at or above 3,000 ft mean sea level (msl). Subsequently, the controller issued an approach clearance for the straight-in instrument landing system (ILS) runway 16 approach. A few minutes later, the pilot confirmed that the airplane was established on the approach, and the controller then instructed the pilot to contact the ECP ATC tower. The pilot informed the ECP tower that the airplane was inbound on the ILS runway 16 approach. The controller acknowledged the transmission and provided the current weather observation at the airport, which indicated that the wind was from 150° at 6 knots, visibility was 2 statute miles, an overcast ceiling was present at 200 ft above ground level (agl) and the barometric pressure was 29.92 inches of mercury. The pilot stated, “200 overcast we’ll give it [a] try and see if we can get her down.” The controller then issued a landing clearance and offered to turn up the approach lights to the highest setting available. The pilot stated, “affirmative that would be good.” The controller subsequently told the pilot that, if the airplane were able to descend beneath the overcast clouds, the approach lights might be “pretty bright,” and the pilot acknowledged this information. About 40 seconds later, the controller stated, “I’m receiving a low altitude alert. Check your altitude,” to which the pilot stated “affirmative.” The controller then informed the pilot that the Tyndall approach controller noticed that the airplane’s flight track was deviating to the right of the final approach course and advised the pilot to use caution. The controller again provided the wind and ceiling information, which had not changed from the previous report; the pilot stated “affirmative.” The controller then stated, “there are other airports nearby with better weather conditions.” The pilot replied, “alright we’ll try this down to minimums and go around if need be.”   About 12 seconds later, the controller stated that the airplane appeared to be “drifting a little to the right” and then “well to the right.” No further communications were received from the pilot despite several attempts by the controller to reach him. The controller subsequently alerted airport operations of a possible downed airplane. Review of the ADS-B flight track in the final approach phase found that the airplane’s course continuously deviated left and right from the initial approach fix to the accident site, which was 1.55 nautical miles from the runway threshold. The airplane’s altitude showed momentary descents and climbs while on final approach. At both instrument approach fixes, OTTOE (initial) and LIVVY (final), the airplane crossed the waypoints below the minimum altitudes prescribed in the instrument approach chart by about 500 and 700 ft, respectively. The final ADS-B data point recorded the airplane at 75 ft msl at a groundspeed of 144 knots and a ground track heading of 130°. Figures 1 and 2 provide an overview of the ADS-B data recorded during the final approach segment. Figure 1 - Overview of the flight track, final approach course, and accident site. Figure 2 - Final 6 minutes of ADS-B altitude and groundspeed data overlaid with waypoint information for the ECP ILS runway 16 approach. The total time en route from RNC to the time that the accident occurred was 3 hours 51 minutes. The total flight time on the day of the accident was 6 hours 53 minutes. - The District Fourteen Medical Examiner, Panama City, Florida, performed an autopsy of the pilot. His cause of death was blunt impact to the head and neck. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected no drugs, carboxyhemoglobin, ethanol, or glucose in the pilot’s specimens. - According to a customer service employee at RNC, the pilot discussed that he was on his way to Florida and was trying to beat bad weather arriving at the ECP area. The pilot explained that he was trying to arrive between two lines of thunderstorms. The pilot appeared to be checking the weather and filing a flight plan on his personal iPad. According to ForeFlight archived records, the pilot filed an IFR flight plan from RNC to ECP with an alternate of Dothan Regional Airport (DHN), Dothan, Alabama. The flight plan was filed at 1028 eastern standard time (before the first flight leg of the day). The pilot received a standard preflight weather briefing as part of filing the flight plan. No records showed that the pilot received additional weather briefings later that day. A National Transportation Safety Board weather study reviewed National Weather Service forecast and observation data for ECP and surrounding airports. The weather at ECP at 1453 (while the pilot was on the ground at RNC) indicated the following: wind from 140° at 11 knots gusting to 19 knots, 7-statute mile visibility, and a broken ceiling at 1,800 ft agl. An AIRMET for IFR conditions was valid for the accident site at the accident time. The terminal aerodrome forecast issued for ECP at 1140 called for, between 1500 and 2000, visibility greater than 6 statute miles, scattered clouds at 2,500 ft, and broken clouds at 25,000 ft. At 2000, the forecast called for a visibility of 6 statute miles, mist, and overcast ceilings at 400 ft agl. At 1721, while the airplane was en route from RNC to ECP, another terminal aerodrome forecast was issued for ECP. The forecast called for, at 2000, a visibility of 1 statute mile, mist, and overcast ceilings at 500 ft agl. The ECP hourly weather observations showed that about 1700, IFR conditions were reported that continued to deteriorate throughout the evening. At 1756, about 45 minutes before the pilot’s approach into ECP, the weather conditions were visibility 4 statute miles, mist, ceiling broken at 400 ft agl, overcast at 800 ft agl; the remarks section indicated that the ceiling was variable from 300 to 700 ft agl. A special hourly weather observation, which was issued at 1827, indicated a visibility of 2 statute miles, mist, and an overcast ceiling at 300 ft agl; the remarks section indicated the ceiling was variable from 200 ft to 700 ft agl. The pilot’s alternate airport DHN, was about 60 nautical miles north of ECP, about a 25- to 30-minute diversion. The pilot’s route of flight from RNC to ECP resulted in the airplane passing about 28 miles west of DHN about 1815 (31 minutes before the accident occurred). The weather observations at DHN starting at 1753 included visual meteorological conditions with calm wind. Review of satellite imagery and model soundings found that an overcast cloud layer likely extended up to 3,250 ft msl. Review of astronomical information found that, for the accident area on the day of the accident, the sunset occurred at 1747, and civil twilight ended at 1811. - Review of the pilot’s logbook revealed that he had accumulated 691 hours of total flight time, of which 569 hours were in the accident airplane. He had logged a total of 35 hours of night flight experience and a total of 2.5 hours of night actual instrument flight experience. During the 12 months that preceded the accident, he had logged 13 hours of actual instrument experience; 1.5 hours of night flight experience, 0.5 hours of which was in actual instrument experience; and four night landings. During the 6 months before the accident, the pilot logged 11 instrument approaches. During the 90 days preceding the accident, he logged 51.3 hours of actual instrument flight experience and no night flights. His most recent flight review was competed on June 14, 2021. There was no record indicating that the pilot had landed at ECP within the 3 years before the accident. The pilot received his instrument airplane rating on June 27, 2019, on the third practical examination attempt. The pilot received a notice of disapproval during two separate practical examination flights (in May and early June 2019). The comments on the first notice of disapproval indicated that the pilot became distracted, lost situational awareness, and improperly managed tasks during partial panel operations. The comments on the second notice of disapproval indicated that the pilot had flown an ILS approach to a full-scale deflection on the glideslope. According to an individual who had flown with the pilot as a safety pilot during instrument training, the pilot would typically disengage the autopilot and hand fly approaches. - The wreckage came to rest in an area of heavily wooded terrain and was fragmented. The initial impact area coincided with 100-ft-tall trees, and the debris path was oriented on a magnetic heading of 130° to 140°. The airplane’s angle of descent through the trees was about 18° to 20°. All major components of the airplane were located in the debris path. Flight control and trim cable continuities were confirmed from the cockpit to each flight control surface except for the aileron balance cable. which exhibited tension overload and splayed ends. The flap actuator was found in a position that corresponded to flaps up. The cockpit and instrument panel sustained significant impact damage. Most of the instrumentation displayed unreliable indications. The altimeter was found set to a barometric pressure of 29.88 inches of mercury (which would have resulted in the altimeter displaying altitudes that were about 40 ft lower compared with the setting of 29.92 that was current at ECP during the accident approach). An S-TEC 55 X autopilot mode control unit was found loose in the cockpit and displayed significant impact damage. An S-TEC altitude alerter was found separated in the cockpit with impact damage. A second autopilot mode control panel had fragmented and sustained significant impact damage. The autopilot ON/OFF toggle switch was found on. The altitude alert ON/OFF toggle switch was found in a middle position that did not correspond to any setting. The ON/OFF trim switch was found on, and the NAV 1/2 mode was found in the NAV2 position. The engine had separated from the airframe and was found a few feet forward of the main wreckage. Evidence of angularly cut tree branches were observed covering the top and aft section of the engine. The engine’s crankshaft was rotated manually by hand through 360° of movement. Crankshaft, camshaft, and accessory section continuity was demonstrated. Thumb-compression was displayed on each cylinder. The majority of the vacuum pump had fractured from the accessory section of the engine and was not located in the debris. It’s engine driven gear operated normally when the engine was rotated. The three blade propeller had sheared from the propeller flange and was located a few feet from the engine. The blades exhibited leading edge gouging, chordwise scratches, and torsional twisting. -
Analysis
The pilot and passenger departed during the middle of the day for a nearly 7-hour instrument flight rules cross-country flight with one fuel stop. During the fuel stop, the pilot reported to an airport employee that he was trying to time his flight to arrive at the destination between two thunderstorms. The flight departed and entered the destination airport area at night without incident. Air traffic control cleared the pilot for a straight-in instrument landing system approach and advised him that the cloud ceiling was 200 ft above ground level, which was the decision height for the straight-in instrument landing system approach the pilot was about to perform. The pilot told the controller that the airplane was established on the final approach course. However, between the initial approach fix and final approach segment the airplane’s altitude and flightpath showed deviations, and the pilot was cautioned of those deviations by controller. Additionally, the airplane crossed the initial approach fix about 500 ft below the specified crossing altitude and about 700 ft below the expected altitude at the final approach fix. As the airplane continued in the final approach segment, continuous deviations to the left and right of course occurred. The airplane subsequently descended below the decision height for the approach and impacted heavily wooded terrain about 1.55 nautical miles from the runway threshold in a 18°-to-20° descent. The wreckage was highly fragmented, but all major components of the airplane were located in the debris path. No evidence indicated any preimpact mechanical malfunction or failure of the airplane. The evidence also indicated that the engine was producing power at the time of impact. Prior to the accident, the airplane had ongoing autopilot altitude-hold control issues despite several recent maintenance corrective actions. The pilot was aware that the autopilot issue persisted, and he told a friend a few days before the accident flight that he felt comfortable hand flying the airplane during the long cross-country flight. The investigation was unable to determine whether the autopilot was activated during the approach, and testing of the autopilot system could not be performed due to the significant impact damage to the airplane and autopilot components. Furthermore, a safety pilot who had flown with the accident pilot reported that it was typical of the pilot to turn off the autopilot for instrument approaches and hand fly the airplane. Thus, it is likely that the pilot flew the accident approach without the autopilot engaged. The weather observed at the destination airport had deteriorated significantly after the pilot departed for the last leg of the flight, and the weather was worse than the expected forecast conditions. During the approach, the controller advised the pilot of the low ceiling and visibility and advised that other nearby airports were reporting better weather conditions. The pilot responded that he would continue the approach. Review of the weather at the alternate airport for the flight, which was about 25 to 30 minutes away from the planned destination, found that visual flight rules conditions were occurring during the time surrounding the accident. It is likely that had the pilot discontinued the instrument approach and diverted to the alternate airport after the approach had become unstable, and after having been warned of his flightpath deviations, the accident would have been avoided. Review of the pilot’s logbook found that he had logged less than 2 hours of night experience during the 12 months preceding the accident and had logged no night flights in the 90 days before the accident. The pilot had logged 11 instrument approaches in the 6 months that preceded the accident. The pilot’s total actual instrument experience was 32 hours, but only 2.5 hours of this time was logged as night actual instrument experience. In addition, the pilot was disapproved twice when testing for his instrument airplane rating because he had become distracted and lost situational awareness and had a full-scale deflection on the glideslope during an instrument approach. Although the pilot was approved for an instrument rating on his third attempt, he likely did not possess the experience or ability to successfully complete the night instrument approach in low instrument meteorological conditions.
Probable cause
The pilot’s deviation from the final approach course during a night instrument approach with low instrument meterological conditions, which resulted in an impact with heavily wooded terrain. Contributing to the accident was the pilot’s decision to continue the approach after being warned of his flightpath deviations and his lack of experience in instrument conditions at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182Q
Amateur built
false
Engines
1 Reciprocating
Registration number
N182XT
Operator
SLATTERY DONALD J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18266723
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-16T04:33:57Z guid: 104744 uri: 104744 title: ERA22LA150 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104756/pdf description:
Unique identifier
104756
NTSB case number
ERA22LA150
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-09T10:27:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-03-11T00:04:37.799Z
Event type
Accident
Location
Pittsburgh, Pennsylvania
Airport
ALLEGHENY COUNTY (AGC)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
Aircraft Performance Study The planned landing weight for the flight was 9,632 lbs, and the corresponding flaps TO/APP VREF was 122 knots. The operator’s Standard Operating Procedures stated that, “For windshear avoidance and safety, crews should calculate and fly a VAPP [prescribed approach speed] speed to fly on final approach. This will be calculated as: VAPP = VREF + ½ Headwind factor + Gust factor, not to exceed a total correction of 20 knots.” For the accident flight, the winds were relatively calm, and VAPP was computed as VREF + 5 knots, or 122 knots + 5 kts = 127 knots, which coincided with the “selected airspeed” recorded by the airplane’s flight data recorder. The airplane was flying about 11 knots faster than VAPP as it descended through 1,000 ft above the touchdown zone (ATZ) in instrument meteorological conditions. This speed was within the operator’s stabilized approach criterion that below 1,000 ft ATZ the speed should not exceed VAPP +10/-5 knots “momentary deviations excepted.” However, as the airplane descended below 1,000 ft ATZ, the thrust levers and engine N1 speeds were at idle, contrary to the operator’s stabilized approach requirement that below 1,000 ft TDZ, the “power setting is appropriate for the aircraft configuration and is not at idle power.” The operator’s Standard Operating Procedures stated that, “if an approach becomes unstabilized … the crew will initiate a go-around and missed approach.” The airplane crossed the runway threshold at a true airspeed of about 131 knots, 9 knots faster than VREF, and touched down 2,300 ft from the threshold, or 893 ft past the touchdown zone assumed in the AFM landing distances. The airplane used the additional air distance to bleed off this excessive speed, which resulted in the touchdown speed 3 knots above the assumptions in the AFM performance calculations. Performance calculations demonstrated that the braking performance achieved during the landing, as indicated by the achieved wheel braking friction coefficient, was lower than that underlying the recommendation in the AFM to increase the dry runway landing distance by 30% on wet runways. The achieved wheel braking friction coefficient was also lower than that specified for wet runways in the RCAM guidance contained within FAA AC 25-32. The finding that the achieved friction coefficient was lower than that implied in the AFM and in the RCAM is consistent with similar findings in other NTSB wet runway overrun investigations including DCA08MA085, DCA11IA047, CEN14FA505, CEN15LA057, and DCA19MA143. The performance calculations also indicated that even with the longer-than-nominal touchdown point and 3-knot fast touchdown airspeed, the accident airplane might have stopped before the end of the runway had it achieved the wet runway wheel braking friction coefficient implied by the airframe manufacturer’s AFM recommendation to increase dry runway landing distance by 30%. Postaccident simulations of the accident airplane’s stopping performance indicated that the airplane would have stopped about 850 ft before the end of the runway had it achieved the wheel braking friction coefficient specified by the RCAM. Conversely, even with the 3-knot fast airspeed at touchdown and the lower friction coefficient actually achieved during the landing roll, the airplane would still have stopped on the runway had it touched down at the nominal touchdown point. Contaminated Runway and Dynamic Hydroplaning According to the Aeronautical Information Manual Pilot/Controller Glossary, a contaminated runway, "is considered contaminated whenever standing water, ice, snow, slush, frost in any form, heavy rubber or other substances are present." - The HondaJet HA-420 was a light business jet manufactured by the Honda Aircraft Company. The accident airplane was configured for 2 pilots and 5 passengers, and had a maximum takeoff weight of 10,900 lbs. The airplane was equipped with tailcone-mounted speed brakes. According to the HondaJet HA-420 AFM, the prescribed landing configuration required using “Flaps TO/APPR for landing whenever the aircraft cannot be confirmed clear of ice or if icing conditions may be encountered during approach and landing.” Landing Distance The HA-420 AFM did not include, nor was it required to include, landing distance tables on other than dry runways, but it did include the following note: “The landing field length provided is based on a dry runway. If landing on a wet runway, it is recommended to increase the predicted landing field length by 30%.” The landing distances published in the AFM were based on several assumptions about touchdown speed and location. Among these factors were that the touchdown airspeed would be about 95% of VREF, and that the touchdown would occur within about 1,400 ft of the runway threshold. Emergency Brake The HA-420 AFM emergency checklist for a failure of the airplane’s normal braking system cautioned that when utilizing the emergency brake, the anti-skid system would not operate. It also noted that landing distances would increase by 50% on a dry runway and 100% on a wet runway. - The Chart Supplement listed AGC runway 28 as grooved concrete, 6,501 ft long and 150 ft wide, at an elevation of 1,250 ft and with no gradient noted. The runway was situated on a flat plateau, and the terrain dropped off steeply about 100 ft past the west end of runway 28. - On March 9, 2022, about 0827 eastern daylight time, a Honda Jet HA-420, N903JT, was substantially damaged when it was involved in an accident near Pittsburgh, Pennsylvania. The two pilots and one passenger were not injured. The airplane was operated by Jet It, LLC as a Title 14 Code of Federal Regulations Part 135 air taxi flight. According to the flight crew, they checked the weather prior to departure from Teterboro Airport (TEB), Teterboro, New Jersey, which included an advisory for potential winter weather conditions upon landing at Allegheny County Airport (AGC), Pittsburgh, Pennsylvania. They discussed weather conditions and alternates, loaded the maximum amount of fuel permitted by the landing requirements of the operator’s Eligible-On-Demand operations specifications, and subsequently departed around 0720. The captain stated that he monitored ATIS once in range of AGC and did not recall hearing any remarks pertaining to runway braking action or surface contamination reports, although he noted remarks about contamination on taxiways and ramp areas. Subsequently, he checked in with the approach controller and was advised that snowplows were on the runway. The captain reported that he believed that the airport was “taking care of the runway in the light snow” and “never anticipated runway contamination.” The flight crew conducted their landing distance calculations with a wet runway factor. The first officer flew the ILS approach to runway 28 with the autopilot engaged, noting that the thrust levers were near idle during the final approach segment. The captain visually acquired the runway environment upon reaching decision altitude and the first officer continued the approach. The captain acquired the runway about 100 ft above ground level, noticing the runway shoulders were obscured by snow, and the center line was visible. The first officer disconnected the autopilot and continued the landing. The captain recalled feeling “faster than normal.” The airplane began to decelerate; however, the captain called for maximum braking when he detected the deceleration to be insufficient to stop the airplane on the remaining runway. He applied the emergency brake and steered to the left to try to stay on the airport property. The airplane skidded sideways, departed the end of the runway, and travelled tail-first over the edge of a steep incline. The airplane came to rest in trees about 143 ft past the runway end, and 91 ft to the left of the runway centerline. The pilots and passenger evacuated out the main cabin door. Review of flight data recorder data revealed that the airplane crossed the runway threshold at a true airspeed of about 131 kts and touched down 2,300 ft from the threshold of the 6,501 ft runway. - Weather conditions at the time of the accident included ½ statute mile visibility, light snow, and an overcast ceiling at 400 ft The current airport ATIS included a Braking Action Advisory with a braking action report of “good” by a Pilatus at 0755 and a field condition NOTAM reporting 10% runway coverage with 1/8-inch slush on the landing runway. An airport surveillance video showed the airplane during its landing roll in weather conditions that were consistent with those reported in Meteorological Terminal Air Reports and field condition reports. - Captain The captain, who was qualified to act as a training captain, was flying with the first officer on day 6 of the first officer’s Initial Operating Experience, during which the first officer was the pilot-flying. He stated that the preflight and flight were normal, with no malfunctions or anomalies noted that would have precluded normal operation. He further reported that on approach into AGC, he listened to ATIS and recalled hearing that there was slush on taxiway and ramp and that a previous landing pilot reported landing condition good, and that they flew the approach “assuming the runway was only wet since there were no other reports other than light snow.” First Officer The first officer received his type certificate on the airplane on February 10, 2022, and had accrued 34 hours in the airplane at the time of the accident. During the preflight planning, he added as much fuel as the performance calculations allowed given the forecasted weather and determined that they required 5,800 ft runway length for landing in AGC. - Upon recovery, the airplane was examined by representatives of the airframe and engine manufacturers under the supervision of a Federal Aviation Administration (FAA) inspector. Examination of the airplane revealed substantial damage to the fuselage and wings. The center fuel tank was ruptured. The right inboard flap mount had torn through the wing skin. The right aileron sustained damage on both the leading and trailing edges. Both main landing gear tires were shredded, consistent with reverted rubber hydroplaning, and the emergency brake was in the ON position. Postaccident examination and functional testing of the brake system bleed, the parking brake, the power brake, hydraulic pressure at the brakes, the anti-skid valve and the anti-skid brake system revealed no failures or anomalies. -
Analysis
At the time of the approach and landing, a Braking Action Advisory was in effect and a field condition NOTAM reported slush on the landing runway. The airplane was flying 11 knots faster than the prescribed approach speed as it descended through 1,000 ft with the engines at idle. The pilots continued the instrument approach and visually acquired the runway environment about 100 ft above ground level. The airplane crossed the runway threshold 9 knots faster than VREF (landing reference speed), and touched down 893 ft past the touchdown zone at a speed that was 3 knots faster than the speed assumed by the airplane flight manual (AFM) landing distances. The airplane began to decelerate; however, the captain called for maximum braking when he detected the deceleration to be insufficient to stop the airplane on the remaining runway. He applied the emergency brake and steered to the left to try to stay on the airport property. The airplane skidded sideways, departed the end of the runway, and travelled tail-first over the edge of a steep incline, which resulted in substantial damage to the wings and fuselage. When the airplane descended below 1,000 ft on the final approach segment of the flight, the thrust levers were at idle, contrary to the operator’s stabilized approach requirement. The operator’s standard operating procedures required that if an approach became unstabilized below 1,000 ft, the flight crew was to initiate a go-around and missed approach procedure. The crew did not initiate a go-around, but instead continued the approach, which resulted in a fast and long landing. This increased the runway length required to stop from that predicated on a nominal touchdown location. Further exacerbating the long and fast landing was the captain’s decision during the landing roll to fully engage the emergency brake. Per the AFM, this action would result in the anti-skid feature not operating and would increase the wet runway landing distance by 100%. Postaccident examination of both main landing gear tires revealed evidence of reverted rubber hydroplaning, consistent with a locked wheel skid. It is likely that the full application of the emergency brake put the airplane into a locked-wheel skid and reduced the braking performance of the tires. Postaccident examination of the braking system revealed no evidence of any preimpact anomalies or malfunctions that would have precluded normal operation. Performance calculations revealed that the wheel braking friction coefficient achieved during the landing was lower than that implied in the wet runway landing distances recommended by the AFM and specified in the FAA Runway Condition Assessment Matrix (RCAM) guidance for wet runways, consistent with the findings in other wet runway landing overruns investigated by the NTSB. Performance calculations and postaccident simulations of the airplane’s stopping performance indicated that even with the longer-than-nominal touchdown point and 3-knot fast airspeed at touchdown, the airplane might have stopped before the end runway had it achieved the wet runway wheel braking friction coefficient implied by the AFM wet runway landing distance recommendation, and would have stopped about 850 ft before the end of the runway had it achieved the wheel braking friction coefficient specified by the RCAM. Conversely, even with the 3-knot fast airspeed at touchdown and the lower friction coefficient actually achieved during the landing roll, the airplane would still have stopped on the runway had it touched down at the nominal touchdown point.
Probable cause
The flight crew's continuation of an unstable approach, which resulted in a long landing on a contaminated runway. Contributing to the outcome was the captain’s full application of the emergency brake, which resulted in hydroplaning and a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Honda Jet
Model
HA-420
Amateur built
false
Engines
2 Turbo fan
Registration number
N903JT
Operator
Jet It LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
42000224
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-11T00:04:37Z guid: 104756 uri: 104756 title: WPR22LA124 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104790/pdf description:
Unique identifier
104790
NTSB case number
WPR22LA124
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-10T16:30:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-03-19T02:32:59.138Z
Event type
Accident
Location
McGrath, Alaska
Airport
McGrath (PAMC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 10, 2022, about 1430 Alaska daylight time, a Cessna 310R airplane, N3UR, was substantially damaged when it was involved in an accident near McGrath, Alaska. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he back-taxied along runway 16 towards the departure end of the runway at McGrath Airport (PAMC). When he arrived at the end of the runway, he started to turn to the airplane to align it with the reciprocal runway. However, as he began the turn, the right main landing gear collapsed and the wing and propeller both contacted the runway. The right elevator also contacted the runway and was substantially damaged. A postaccident examination of the right main landing gear well by the pilot found fractures at the bellcrank lower arm fork (item “1” in Figure 1), bellcrank pivot bolt (item “2 in Figure 1), and the trunnion bellcrank lug (item “3” in Figure 2). An NTSB materials laboratory review of photographs of the fracture surfaces revealed fracture characteristics that were all consistent with overstress. No evidence of fatigue was observed on any of the fracture faces; however, the quality of the photographs precluded the observation of any small regions that may have exhibited fatigue cracking. According to the airplane manufacturer, an overstress failure of the bell crank assembly at the trunnion is commonly an indication that the down lock side brace was not in the down and locked position. Figure 1: Bellcrank assembly fracture points Figure 2: Bellcrank bolt fracture at trunnion A logbook entry from the airplane’s most recent annual inspection indicated that the right main landing gear door and gear strut were removed and replaced with new bolts. The landing gear was subsequently re-rigged in accordance with the maintenance manual before the airplane was returned to service. The accident pilot was also the certified airframe and powerplant mechanic responsible for completing the last annual inspection on the accident airplane. According to his recount, after he replaced the landing gear strut after a previous right main landing gear failure, he checked the down lock tension and discovered that it was “too tight.” However, when he subsequently made an adjustment to reduce the tension, he found that it was out of tolerance. He made one final adjustment that placed the down lock tension within tolerance before he returned the airplane to service, 22 flight hours prior to the accident. The accident airplane maintenance manual provided specific instructions for adjusting main landing gear down lock tension (Chapter 32, Section 32-30-00). “(1) Inspection the main gear down lock tension for proper adjustment (a) Position landing gear in down position (b) Check main gear down lock for proper engagement and tension (40 to 60 pounds) NOTE: When checking down lock tension always place a finger on the down lock switch, pull scale at a right angle to the lock link and read the scale at the point when switch actuation can be felt. (2) Adjustment (a)If the down lock tension is not 40 to 60 pound, adjust push-pull tube in one half turn increments until proper tension is obtained. If the down lock tension is in excess of 60 pounds, the down lock tension should be rigged to 40 to 50 pounds. Lengthening the push-pull tube decreases and shortening the push-pull tube increases tension.” The pilot recalled using a spring scale to measure the down lock tension and the push-pull tube to adjust the tension. He added that he was particular about following each step in the Cessna maintenance manual during this inspection as he was new to maintaining the accident airplane make and model. -
Analysis
The pilot back-taxied the airplane for departure and then began a 180° left turn to align the airplane with the runway centerline when the right main landing gear collapsed. The gear collapse resulted in substantial damage to the right elevator. A postaccident examination of the airplane revealed fractures to the bellcrank lower arm fork, bellcrank, pivot bolt, and trunnion bellcrank lug at the right main landing gear, which all displayed signatures consistent with overstress. The airplane had recently been repaired following another right main landing gear failure. During the repair the accident pilot, who was also the mechanic, adjusted the down lock tension as required by the maintenance manual and returned the airplane to service after he determined that the tension was within limits. A statement from the airplane manufacturer suggested that the failure may have been the result of an improper down lock tension adjustment. However, there was insufficient evidence in the investigation to show whether the pilot performed the adjustment incorrectly, thus the cause of the landing gear failure is undetermined.
Probable cause
A failure of the right main landing gear bellcrank lower arm fork, bellcrank, pivot bolt, and trunnion bellcrank lug for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310R
Amateur built
false
Engines
2 Reciprocating
Registration number
N3UR
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310R0061
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-19T02:32:59Z guid: 104790 uri: 104790 title: ERA22FA153 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104764/pdf description:
Unique identifier
104764
NTSB case number
ERA22FA153
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-11T04:30:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-03-18T21:08:10.348Z
Event type
Incident
Location
Bay Minette, Alabama
Airport
Bay Minette Municipal Airport (1R8)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The pilot’s vehicle was found parked in front of an open hangar where the pilot stored the airplane. The vehicle doors were unlocked, and the keys were in the ignition with the windows rolled halfway down. - The incident airplane was a two-seat, single-engine, low-wing, monoplane of all metal bonded construction. It was equipped with an air-cooled, horizontally opposed, 4-cylinder, 140-horsepower, Lycoming O-320-E2A engine driving a 2-bladed metal propeller. The time recorded on the engine’s tachometer was, 3,732.27 hours of operation. No airplane maintenance records were recovered. - The airport elevation was 248 ft above mean sea level and it had a 5,500 ft-long runway oriented in an 8/26 configuration. A taxiway parallel to the runway was equipped with taxiway edge lights (TEL) for the full length of the taxiway. The lights for the TELs could be activated by a pilot actuating the push to talk switch of a radio tuned to the common traffic advisory frequency for the airport. - On March 11, 2022, about 0230 central standard time, an American AA1, N5774L, was substantially damaged when it was involved in an incident in Bay Minette, Alabama. The commercial pilot was fatally injured. The airplane was operated under Title 14 Code of Federal Regulations Part 91. According to a family member, the pilot purchased the airplane about 6 months before the incident and had not flown it previously. The pilot would often travel from his residence in Mobile, Alabama, to the airport in the early morning hours (0001 to 0300) to start the engine and taxi the airplane around the airport, but not fly the airplane. The family member stated that on occasion he would accompany the pilot. On the night of the incident, the pilot departed his residence in Mobile, Alabama, about 0030 and traveled to Bay Minette Municipal Airport (1R8), Bay Minette, Alabama, to run the airplane’s engine and taxi around the airport property. Later that day, about 1256, a US Coast Guard helicopter conducting a training flight approached runway 8 at 1R8 and observed an airplane inverted west of the taxiway leading to runway 8. The flight crew contacted Mobile Approach Control, who then contacted local law enforcement. No emergency locator transmitter signal had been received and no flight plan had been filed by the pilot. - The 74-year-old male pilot held a medical certificate that was not valid for any class at the time of the incident. His most recent medical certification examination was in May 2004 when the pilot reported prior treatment for depression. In 2008, the FAA determined the pilot was medically disqualified for an airmen medical certification because of bipolar disorder. According to the autopsy report, the pilot’s cause of death was traumatic asphyxia, and the manner of death was incident. The medical examiner reported that the pilot had 70- 80% atherosclerosis in his left anterior descending coronary artery and 50-60% atherosclerosis in his right coronary artery. Toxicology testing detected delta-9-tetrahydocannabinol (THC) in the pilot’s blood at 2.2 ng/mL and in his urine at 1.6 ng/mL, 11-hydroxy-delta-9-THC (11-OH-THC) in his blood at 1.1 ng/mL and in his urine at 13.1 ng/mL, and carboxy-delta-9-tetrahydrocannabinol (THC-COOH) in his blood at 16.4 ng/mL, and in his urine at 178.4 ng/mL. - The recorded weather at 1R8, at 0235, included: winds 330 degrees at 3 knots, 1 mile visibility in mist, overcast at 300 feet, temperature 16° C, dew point 16° C, and an altimeter setting of 29.92 inches of mercury. - According to FAA records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land and instrument airplane. His most recent FAA third-class medical certificate was issued on March 24, 2015. He reported on that date that he had accrued about 700 hours of total flight experience. - The airplane was found inverted in the grass at the bottom of an embankment, 130 ft from the west end of the taxiway on a magnetic heading of 082°. Tire marks consistent with the left and right main landing gear tires braking were observed on the taxiway for 20 ft leading up to the edge of the taxiway and top of the embankment. The master switch was on, and the ignition key was positioned to both. The auxiliary fuel pump was in the off position, and the rotating beacon, landing light, nav light and pitot heat were all on. The throttle was pulled out about ¾ (almost at idle) and bent, the mixture was full rich, and the cabin heat was in the open/on position. The fuel primer was in and locked, and the fuel selector was positioned to the right tank. Additionally, the emergency locator transmitter switch which was supposed to be in the ‘ARMED” position for flight was in the “OFF” position, and both left and right seat belts were found in the unlatched position. No shoulder harnesses were installed. The upper surface of the right wing was separated from the lower surface near the wing tip and the left wing was impact damaged near the wing tip. The pitot tube cover, which was supposed to be removed before flight, was still installed over the pitot tube. The fuselage cabin roof was crushed near the sliding canopy frame and the rudder tip was crushed consistent with impact damage. The free-castering nosewheel was still attached to the nose fork assembly which had separated from the airplane and was located about 20 ft east between the airplane and taxiway. All structural components, fuselage, and flight control surfaces were accounted for at the incident site. Flight control continuity was confirmed from all flight control surfaces to the cockpit. The free-castering nosewheel was functional, and both left and right wheel brakes functioned normally when brake pressure was applied at the rudder pedals. The engine had impact damage and the engine mounts were broken. The engine was removed from the airplane and the propeller was rotated. Compression was observed on all four cylinders, oil was present in the engine, and fuel was observed while disassembling the fuel line from the engine and from near the wing fuel vent. -
Analysis
The pilot purchased the airplane about 6 months before the incident; however, he did not have a current Federal Aviation Administration (FAA) medical certificate and had not previously flown the airplane. A family member reported that the pilot often went to the airport at night to run the airplane’s engine and taxi around the airport property. In the early morning hours on the night of the incident, the airport was unattended and the weather conditions were conducive to low visibility in mist. Later that day, the airplane was found inverted in the grass off the end of a taxiway and down an embankment. The pilot was fatally injured. Examination of the incident site revealed that the airplane likely traveled off the end of the taxiway and went about 130 ft down an embankment before it came to rest inverted, sustaining substantial damage to the airframe in the process. Tire (skid) marks consistent with the left and right main landing gear tires braking were observed leading up to the edge of the taxiway at the top of the embankment. The postincident examination of the airplane also revealed that it was not configured for takeoff. Even the pitot tube cover had remained installed on the pitot tube. During the examination, no evidence of any preimpact failures or malfunctions of the airplane or engine were discovered that would have precluded normal operation. The pilot had moderate to severe atherosclerosis of two coronary arteries. While this condition placed him at an increased risk for a sudden cardiac event, the autopsy findings indicated that the pilot initially likely had initially survived the impact. Thus, the pilot’s cardiovascular disease was not a contributing cause to the incident. Toxicology testing revealed that the pilot had used cannabis. THC and 11-OH-THC were detected in his blood at low concentrations. While the pilot was found to have cannabis in his system, it could not be determined if the concentration would have been impairing and influenced his ability to control the airplane on the taxiway. The late-night taxiing of his airplane was typical behavior for the pilot. All evidence indicated that there was no intent for flight as the airplane was not configured for, or in a position to conduct a takeoff. It is likely that, with the pitot cover still on the pitot tube, which would have prevented use of the airspeed indicator, the pilot did not realize how fast he was taxiing. He also may not have realized in the darkness and reduced visibility due to mist that he was quickly approaching the end of the taxiway. This was supported by the presence of the skid marks leading up to the edge of the taxiway and the top of the embankment. Based on this information, it is likely that the pilot lost control of the airplane while taxiing and overran the taxiway edge, after which the airplane traveled down the embankment and came to rest inverted.
Probable cause
The pilot’s loss of control during taxi, which resulted in a taxiway overrun and subsequent impact with terrain. Contributing to the incident were the low visibility conditions that existed at the airport around the time of the incident.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN
Model
AA-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N5774L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA1-0174
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-18T21:08:10Z guid: 104764 uri: 104764 title: PLD22FR002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104763/pdf description:
Unique identifier
104763
NTSB case number
PLD22FR002
Transportation mode
Pipeline
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-11T10:15:00Z
Publication date
2024-01-02T05:00:00Z
Report type
Final
Event type
Accident
Location
Edwardsville, Illinois
Injuries
null fatal, null serious, null minor
Pipeline operator
Marathon Pipe Line LLC
Pipeline type
Hazardous Liquid - Regulated
Regulator type
Pipeline and Hazardous Materials Safety Administration
Probable cause
The National Transportation Safety Board determines that the probable cause of the Edwardsville, Illinois, crude oil pipeline rupture was an overstress fracture of a girth weld from external loads caused by slope instability that had not been completely mitigated by Marathon before the accident.
Has safety recommendations
false

Vehicle 1

Findings
creator: NTSB last-modified: 2024-01-02T05:00:00Z guid: 104763 uri: 104763 title: CEN22LA140 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104768/pdf description:
Unique identifier
104768
NTSB case number
CEN22LA140
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-12T14:45:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2022-03-18T02:04:33.002Z
Event type
Accident
Location
Heavner, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 12, 2022, about 1245 central standard time, a Beech A36, N9410Q, was substantially damaged when it was involved in an accident near Heavener, Oklahoma. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the flight was from the Bentonville Municipal Airport/Louise M Thaden Field (VBT), Bentonville, Arkansas, to the Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas. After beginning his descent into to the destination airport, he noticed a dramatic drop in oil pressure to 14 psi. He began to search for alternate airports since his destination was not reachable and the terrain was mountainous. He turned the airplane toward the west to attempt to reach the Robert S. Kerr Airport (KRKR), Poteau, Oklahoma, but within 1-2 minutes the oil pressure dropped to zero and the engine seized. The pilot executed a forced landing to a field. During the landing, the airplane struck fences and livestock feeding troughs, which resulted in substantial damage to the wings. Postaccident examination revealed that the engine No. 4 cylinder rocker cover was completely off, and the No. 6 cylinder rocker cover was only being held on by 4 bolts, all of which were very loose. The No. 4 cylinder rocker cover gasket was not located after the accident. The No. 4 cylinder rocker arm shaft bolt was missing. Multiple rocker cover bolt holes were elongated and embossed with the bolt thread pattern. Metal shavings were observed throughout the valve assembly area as well as deposited on the cowling and airplane along with the lost engine oil. Review of maintenance records revealed that the most recent maintenance on the engine was an oil change performed on December 22, 2021. The entry for the oil change noted that a post-maintenance engine run did not reveal any leaks and included no mention of work performed on the rocker covers. On November 17, 2021, an annual/100-hour inspection was performed on the engine. The entry for the inspection noted that a post-maintenance engine run was normal. A specific notation regarding leaks was not included in the endorsement. No mention of work performed on the rocker covers was noted. Further examination of the engine maintenance records showed that the engine had undergone an overhaul and was reinstalled on the airplane on November 2, 2016. Subsequent to the overhaul, several maintenance entries were made; however, none of the entries since the overhaul noted any work performed on the rocker covers of the engine. Interviews of personnel at the maintenance facility that performed the most recent overhaul revealed that approved hardware and gaskets were used to secure the rocker covers at the time of the overhaul. An interview of the mechanic that performed the most recent oil change revealed that he had not accessed the rocker covers and had no reason to while performing the oil change. Further attempts to discover when the rocker covers were last removed were unsuccessful. -
Analysis
The pilot reported that he noticed the engine oil pressure dropped to 14 psi after he began the descent to his destination airport. He turned toward a nearby airport, but shortly thereafter the oil pressure dropped to 0 psi and the engine seized. The pilot executed a forced landing to a field and the airplane sustained substantial damage to its wings when it struck fences and livestock feeding troughs during the landing. Postaccident examination of the airplane revealed several missing and loose bolts securing the engine valve covers. The No. 4 cylinder valve cover was completely off and its gasket was not located after the accident. The No. 6 cylinder valve cover was very loose and was only held on by 4 of the 8 bolts normally used to secure the cover. The No. 4 cylinder valve arm shaft bolt was missing. Metal shavings were observed throughout the valve assembly area as well as deposited on the cowling and airplane along with the lost engine oil. Review of maintenance records did not reveal any recorded maintenance to the rocker covers since the most recent engine overhaul 6 years before the accident. Maintenance entries since the overhaul indicated routine maintenance, including annual/100-hour inspections and oil changes, with no leaks detected during post-maintenance engine runs. Attempts to discover when the rocker covers were last accessed for maintenance were unsuccessful. Based on the available evidence the loss of engine power was due to oil exhaustion that resulted from improper installation of the engine valve covers. Determination of when the improper maintenance was performed could not be determined based on the maintenance entries that were available.
Probable cause
A total loss of engine power due to oil exhaustion which resulted from improper engine maintenance.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N9410Q
Operator
HOOK EM LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-286
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-18T02:04:33Z guid: 104768 uri: 104768 title: CEN22LA141 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104769/pdf description:
Unique identifier
104769
NTSB case number
CEN22LA141
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-13T13:40:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-14T18:30:08.258Z
Event type
Accident
Location
Brodhead, Wisconsin
Airport
BRODHEAD (C37)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On March 13, 2022, about 1240 central daylight time, a Cessna 150M, N63246, was substantially damaged when it was involved in an accident at Brodhead Airport (C37), Brodhead, Wisconsin. The two pilots sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilots reported that they flew two visual approaches without incident to runway 27 at C37. While on downwind for a third approach, the engine began to vibrate violently and lost power. The pilots attempted a forced landing to runway 9. The flight path continued beyond the end of the turf runway and the airplane nosed over, which resulted in damage to both wings and the vertical stabilizer. During the postaccident examination of the engine the No. 1 cylinder valve rocker cover was removed and the two rocker arms, pivot shaft, and pieces of the cylinder shaft rocker bosses came off freely with the rocker cover. Examination of the rocker boss fracture surfaces with the aid of a stereomicroscope revealed fatigue crack initiation at and progression from the rocker shaft bore hole. In 1996, the Federal Aviation Administration issued an AD 94-05-05 R1 that required inspection of the cylinder rocker shaft bosses at the next engine overhaul or cylinder removal, whichever occurred first. The AD was issued based on a history of fatigue cracking and separation of cylinder rocker shaft bosses of the installed cylinders. A review of maintenance records indicated the AD was not required to be complied with for the installed cylinders since the engine was last overhauled in 1978 and the No. 1 cylinder was last removed in 1991. A search of previous National Transportation Safety Board reports revealed one accident after the AD issuance that involved failure of rocker shaft bosses. This accident occurred on June 27, 1998. -
Analysis
The pilots reported the engine began to vibrate and lose power while on the downwind leg in the traffic pattern. The pilot in the right seat took control and attempted to conduct a downwind forced landing to the runway, but the airplane’s flight path continued beyond the end of the runway into uneven terrain and the airplane nosed over. The airplane sustained substantial damage to both wings and the vertical stabilizer. Postaccident examination revealed the No. 1 cylinder rocker shaft bosses were fractured. Further examination of fracture surfaces with a stereomicroscope revealed fatigue crack initiation at and progression from the rocker shaft bore hole. In 1996, based on a history of fatigue cracking of cylinder rocker shaft bosses, the Federal Aviation Administration issued an airworthiness directive (AD) that required inspection of the cylinder shaft rocker bosses at the next overhaul or cylinder removal. Since the engine was last overhauled in 1978 and the No. 1 cylinder was last removed 1991, compliance with the AD was not required for the accident airplane’s No. 1 cylinder.
Probable cause
A loss of engine power due to the fatigue fracture of the No. 1 cylinder’s rocker shaft bosses, which resulted in a forced landing into uneven terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N63246
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15077200
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-14T18:30:08Z guid: 104769 uri: 104769 title: ERA22LA155 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104782/pdf description:
Unique identifier
104782
NTSB case number
ERA22LA155
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-13T16:00:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-04-05T16:39:18.511Z
Event type
Accident
Location
Ridgeland, South Carolina
Airport
Ridgeland Claude Dean Airport (3J1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 13, 2022, at 1500 eastern daylight time, an experimental, amateur-built Aircraft Designs Inc. Stallion airplane, N262KT, was substantially damaged when it was involved in an accident in Ridgeland, South Carolina. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight test flight.   The pilot reported that the accident flight was the airplane’s 5th flight during phase 1 flight testing for the experimental amateur-built airworthiness certificate. During the takeoff roll on runway 18 at the Ridgeland Claude Dean Airport (3J1), Ridgeland, South Carolina, he noticed an amber caution message for high voltage on the electronic flight instrumentation system. He elected to continue the takeoff and at an altitude of about 50 ft above ground level, when he raised the landing gear, the engine immediately lost all power. He moved the landing gear handle back to the “down” position, deployed the flaps, and performed a forced landing straight ahead into an open field. After a landing roll of about 100 yards, the airplane yawed to the right about 90°.   Examination of the wreckage by a Federal Aviation Administration inspector revealed that the airplane sustained substantial damage to the lower fuselage structure.   The pilot further reported that after the accident, he found the primary alternator field circuit breaker in the open position. Both batteries (one on the airframe electrical bus, the other on the engine electrical bus) retained some power. The engine electrical bus had power when activated by its independent switch; however, neither of the electric fuel pumps would operate, though they appeared to draw some current. According to the pilot, the engine was equipped with a Simple Digital System electronic fuel injection and ignition system. The system was powered by a dedicated 12 volt engine electrical bus, which included a backup battery and dual redundant electric fuel pumps. The system required an estimated 24 amps to operate. The engine electrical bus received its power from the 28 volt airframe bus, through a DC-DC converter. The engine was equipped with a primary 60-amp alternator and a backup 20-amp alternator, both of which were connected to the airframe electrical bus. The airplane was also equipped with an electric/hydraulic power pack that provided hydraulic pressure to operate the retractable landing gear. The electric motor required about 40-42 amps at startup and about 20-22 amps when running. -
Analysis
The pilot observed a high voltage warning during the experimental amateur-built airplane’s takeoff roll on the 5th flight during phase 1 testing. The pilot continued the takeoff and the airplane climbed normally to an altitude of 50 ft. When the pilot raised the landing gear, the engine immediately lost all power. He performed a forced landing straight ahead to a field, during which the fuselage sustained substantial damage. A postaccident examination of the airplane by the pilot revealed that the primary alternator circuit breaker was open. The airplane was equipped with two electrical busses, an airframe bus and an isolated engine bus. The airframe bus included a 60-amp primary alternator, a 20-amp secondary alternator, and an electro-hydraulic power pack that provided hydraulic pressure to operate the landing gear. The power pack’s electric motor required an estimated 40-42 amps for startup. Given the high voltage warning and open primary alternator circuit breaker, it is likely that the primary alternator went offline at some time during the takeoff before the pilot attempted to raise the landing gear. As he moved the landing gear lever, the hydraulic pump startup demand likely exceeded the capacity of the airframe electrical bus while operating with only the 20-amp secondary alternator. The airframe electrical bus provided power to the engine electrical bus. The engine electrical bus powered the engine’s electronic fuel injection and ignition system, which required an estimated 24 amps to operate. The high demand on the airframe bus due to the landing gear operation while the bus was operating off of the secondary alternator likely reduced or interrupted its ability to provide power to the engine electrical bus. The engine bus was equipped with a backup battery intended to provide power to the fuel injection and ignition systems in the event of a loss of electrical power from the airframe bus. The battery remained intact and able to energize the engine bus after the accident; however, neither of the electric fuel pumps would rotate. Although the fuel pumps were not examined and may have been damaged during the accident, given the loss of electrical power followed by loss of engine power, it is more likely that the backup battery system was unable to sustain the required load of the fuel injection/ignition system. The cause of the initial overvoltage and the alternator circuit breaker opening was not determined. The pilot suggested that an alternator overspeed due to an improper pully diameter, or loss of an electrical ground connection, could have resulted in an overvoltage.
Probable cause
A loss of sufficient electrical power to the engine’s electronic fuel injection/ignition system for undetermined reasons, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Aircraft Designs Inc.
Model
Stallion
Amateur built
true
Engines
1 Reciprocating
Registration number
N262KT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
036
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-05T16:39:18Z guid: 104782 uri: 104782 title: HWY22MH006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104784/pdf description:
Unique identifier
104784
NTSB case number
HWY22MH006
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-15T21:17:00Z
Publication date
2024-01-09T05:00:00Z
Report type
Final
Event type
Accident
Location
Andrews, Texas
Injuries
9 fatal, 2 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Andrews, Texas, crash was the pickup truck driver’s excessive speed and his crossing into the oncoming lane of travel, likely because of impairment from methamphetamine use.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2017 Ford Transit van
Traffic unit type
Combination Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2007 Dodge Ram 2500 3/4-ton pickup truck
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2024-01-09T05:00:00Z guid: 104784 uri: 104784 title: ERA22LA157 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104793/pdf description:
Unique identifier
104793
NTSB case number
ERA22LA157
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-16T16:56:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-06-15T03:22:41.15Z
Event type
Accident
Location
Harveysburg, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 16, 2022, about 1556 eastern daylight time, an Aeronca 11AC, N9588E, was substantially damaged when it was involved in an accident near Harveysburg, Ohio. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the instructor, before the flight he met with his new student at his hangar at Warren County Airport / John Lane Field (I68), Lebanon, Ohio. They spoke briefly about what they wanted to accomplish for the instructional flight, mostly aircraft familiarization and basic control coordination skills. They conducted a preflight inspection as part of the instruction given. The airplane had flown twice (about 3.7 hours) just before the accident flight. The instructor added 10 gallons of automotive premium 93 octane fuel that contained ethanol to the airplane, which had a supplemental type certificate (STC) to be able to use automotive fuel. The fuel was screen-filtered through a funnel when added. They also confirmed that the oil level was at the specified 4-quart level, and the instructor showed the student how to sample the fuel and confirmed that there was no water or debris in the sample. All other inspections of the aircraft indicated it was ready for another flight. Once onboard, the instructor had him practice ground handling techniques with rudder and brake usage. After conducting about 10 minutes of ground handling instruction around the ramp, they proceeded to the designated run-up area on the south ramp at I68. Using the “CIGAR” checklist, the instructor conducted the run-up while talking about each letter in the acronym (Controls, Instruments, Gas, Airplane, Run-up) and what they were looking for with each. All checks indicated the aircraft was ready for flight. They then proceeded to runway 19 and departed about 1500. The instructor conducted the takeoff and initial climb to 2,500 ft msl with an east bound turn out. Once established, the instructor let the student handle the flight controls, and asked him to maintain their heading but to continue to climb to 3,000 ft msl. Once they were at 3,000 ft msl, the instructor began to give him instruction in basic flight maneuvers including shallow coordinated turns. After several maneuvers they had descended back to 2,500 ft msl but the instructor determined their altitude to still be safe for their operations. They then flew straight and level so the student could have a short break and observe the surrounding area as they entered the class E airspace around and above Caesars Creek Lake. While they were roughly over the center of the lake the engine sustained a “severe loss of power.” The instructor immediately took the controls while trying to diagnose the problem. He quickly pitched for 55-60 mph, the published best glide speed. He observed the oil temperature and pressure gauges to be normal just before and after the power loss. The fuel quantity gauge was still indicating “F” (Full). He worked the throttle in and out but without effect. He then pulled the carburetor heat to on. The propeller continued to windmill under no power. When the instructor realized the engine “wasn't coming back,” he had to decide where to put the plane down as Caesars Creek Lake was surrounded by a high, dense tree line. He quickly observed that their glidepath would not permit them to fly beyond the tree line in any direction. The instructor thought that they could either land on top of the trees, which was a long way down if the airplane did not stay on top, or he could nose the airplane into the tree line in hopes of tearing the wings off, but not directly impact the fuselage. These options seemed far too risky, with certain catastrophic damage, so he chose to fly as close to the bank as possible without impacting the tree line with their right wingtip. He instructed the student to hold on to the upright steel tubing of the fuselage, to brace himself for the impact with the water, and to expect the plane to flip over upon impact. Then, as they were gliding only a few feet over the water, he held the airplane off the surface until he could bleed off all excessive airspeed gained in the descent. Once they were at a minimum controllable airspeed, inches off the surface, he pulled back on the stick in hopes of dragging the tailwheel through the water to reduce the forward momentum, hoping to reduce the risk of flipping over. However, as soon as the main wheels impacted the water, the airplane nosed over and stopped, resting on the leading edge of the wing, windscreen, propeller, and spinner, and resulting in substantial damage to the airplane. The instructor then directed the student to exit the airplane and get to the lake shore. After they both exited, they waded through waist-high water to shore safely and without injury. The pilot called 911. The dispatcher confirmed their location and rescue arrived about 15 minutes later. An Ohio Department of Natural Resources boat picked them up and transferred them into the care of local medical services. Both the pilot and the student declined further medical aid and the Ohio State Highway Patrol drove them to a marina to be picked up by their own transportation. The postaccident examination of the airplane and engine did not reveal any evidence of preimpact failures or malfunctions that would have precluded normal operation. Examination of Federal Aviation Administration (FAA) records showed that the airplane and engine had an STC for the use of automobile gasoline. When asked, the flight instructor did not know that he should not be using premium automobile gasoline that contained ethanol, and further examination of the airplane revealed that the placards which were required to be installed as part of the STC were not present. According to the STC holder, ethanol should not be used in the airplane, and pilots should revert to 100LL aviation fuel if ethanol-free gasoline cannot be found. The STC holder also advised that: o Ethanol fuels can damage the rubber and aluminum components of an aircraft fuel system. o Ethanol increases the volatility of fuel. o Ethanol can absorb significant amounts of water in flight. o Ethanol may vent off at altitude, reducing both range and octane. The STC holder further advised that ethanol has an affinity for water and can pull moisture from inlet air on humid days to such extent that the engine may malfunction, and allowing gasoline with ethanol to remain in the airplane for extended periods of time has resulted in the need to replace carburetors, hoses, and gaskets. It has also been reported to clean the interior of fuel tanks, leaving the accumulated sludge in the fuel screen. According to Transport Canada TP 10737 (Use of Automotive Gasoline [Mogas] in Aviation), fuels containing alcohol (methanol or ethanol) other than de-icing fluids are not permitted for use in aircraft. Alcohol can attack some seal and fuel system rubbers and plastics, resulting in potentially serious damage. Furthermore, alcohol and water will mix, and ethanol may separate from gasoline. Since it is not required of fuel suppliers to indicate the presence of alcohol in gasoline, it is the responsibility of the pilot to ascertain its presence. It also stated that Mogas is generally higher in volatility than Avgas. Mogas will thus absorb more heat from the mixing air when vaporizing, resulting in ice accumulation at higher ambient temperatures. It goes on to say that “THE LIKELIHOOD OF CARB ICING WHILE FLYING ON MOGAS IS HIGHER”, and advises that, “Although the severity of the carb icing and the methods to deal with it are similar for both Avgas and Mogas, its ONSET is likely to occur at HIGHER AMBIENT TEMPERATURES and at LOWER HUMIDITY with Mogas. In other words, conditions under which a pilot may feel there is only a slight risk for carb icing on Avgas may in fact be ideal for the formation of ice while using more volatile Mogas. This will result in the need to select ‘carb heat on’ in less severe icing conditions and for a longer duration while using Mogas.” Review of a carburetor icing probability chart indicated that meteorological conditions that existed at the time of the accident were conducive to carburetor icing at glide and cruise power. According to FAA Special Airworthiness Information Bulletin CE-09-35 (Carburetor Ice Prevention), pilots should be aware that carburetor icing doesn’t just occur in freezing conditions: it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor (Venturi effect), causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. The bulletin goes on to say, in part, that there are some steps a pilot can take to prevent, recognize, and respond to carburetor icing. To prevent carburetor icing, the pilot should: o Assure the proper functionality of the carburetor heat during the ground (Before Takeoff) check. o Use carburetor heat on approach and descent when operating at low power settings, or in conditions where carburetor icing is probable. To recognize carburetor icing, the warning signs are: o A drop in rpm in fixed pitch propeller airplanes. o A drop in manifold pressure in constant speed propeller airplanes. o In both types, usually there will be a roughness in engine operation. The pilot should respond to carburetor icing by applying full carburetor heat immediately. The engine may run rough initially for short time while ice melts. The above recommendations are general suggestions. The pilot should consult the airplane flight manual or the pilot's operating handbook for the proper use of carburetor heat. -
Analysis
Before departing on an instructional flight with a new student, the flight instructor added 10 gallons of automotive premium 93 octane fuel that contained ethanol to the airplane, which had a supplemental type certificate (STC) to be able to use automotive fuel. The instructor conducted the takeoff and initial climb to 2,500 ft mean sea level (msl). Once established, the instructor let the student handle the flight controls and instructed the student to maintain their heading but to continue to climb to 3,000 ft msl. After practicing some basic flight maneuvers, the instructor had the student fly straight and level about 2,500 ft msl over a lake. While they were roughly over the center of the lake, the engine sustained a “severe loss of power.” The instructor immediately took the controls and established best glide airspeed. He observed the oil temperature and pressure gauges to be normal. The fuel quantity gauge was still indicating full. He worked the throttle in and out but without effect. He then pulled the carburetor heat to on, but the propeller continued to windmill under no power. The lake was surrounded by high, dense trees, so he elected to conduct a forced landing to the water. During landing the airplane nosed over, resulting in substantial damage to the airplane. The instructor and student were uninjured and were able to exit the airplane and walk to shore. The postaccident examination of the airplane and engine did not reveal any evidence of preimpact failures or malfunctions that would have precluded normal operation. A review of a carburetor icing probability chart indicated that meteorological conditions at the time of the accident were conducive to carburetor icing at glide and cruise power. Guidance published by the automotive fuel-use STC holder advised that automotive fuel containing ethanol should not be used in the airplane as, among other things, ethanol can absorb significant amounts of water in flight, and has an affinity for water and can pull moisture from inlet air on humid days to such extent that the engine may malfunction. Furthermore, carburetor icing is likely to occur at higher ambient temperatures, and at lower humidity with automotive fuel than with aviation fuel. The flight instructor did not know that he should not have been using automobile gasoline that contained ethanol. Thus, the evidence in this case indicates that in addition to not using fuel containing ethanol, the flight instructor should have responded to the carburetor icing by applying full carburetor heat immediately, instead of applying it after the engine had stopped producing power, as the carburetor heat system needed hot air from the exhaust manifold while the engine was running to function properly. He also could have recognized the potential for the formation of carburetor ice and preemptively activated it to prevent the formation of carburetor ice. Therefore, it is likely the engine sustained a complete loss of engine power due to the formation of carburetor ice.
Probable cause
A complete loss of engine power as a result of carburetor ice due to the flight instructor’s failure to effectively use carburetor heat in conditions conducive to the formation of carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
11AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N9588E
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
11AC-1229
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-15T03:22:41Z guid: 104793 uri: 104793 title: ERA22LA159 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104798/pdf description:
Unique identifier
104798
NTSB case number
ERA22LA159
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-17T12:30:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-04-12T21:41:15.505Z
Event type
Accident
Location
Spring Hill, Florida
Airport
Brookville-Tampa Bay Regional Airport (BKV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 17, 2022, about 1130 eastern daylight time, an experimental amateur-built Q200 airplane, N3QP, was substantially damaged when it was involved in an accident near Spring Hill, Florida. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot, who was also the airplane owner, built the airframe and engine. He stated that, during a local flight, the engine lost oil pressure, so he diverted toward the nearest airport. The engine then began to run roughly and lost partial power. Because the airplane would not be able to glide to the runway, the pilot performed a forced landing to a field. Subsequently, the airplane collided with a ditch, resulting in substantial damage to the wings and fuselage.   The airplane was equipped with a pull starter motor, which turned a large gear (through a sprag clutch) to a small gear, which drove the crankshaft. The pilot stated that the starter motor was a certificated airplane part that had been operated for about 100 hours since its overhaul in 2018. The pilot also stated that he had modified the pull starter motor to fit in the airplane. The pilot’s postaccident examination of the small gear found that it was fractured into several pieces that had entered the accessory gear case. The pilot added that oil streaks were present on the empennage. The pull starter motor was provided to the National Transportation Safety Board Materials Laboratory, Washington, DC. Metallurgical examination confirmed that the pull starter motor had been modified from its original design. Specifically, the pivot lever was shortened, and the starter motor power switch was removed and replaced with a power cable leading to a battery post. The pivot lever arm that was shortened was designed to move the starter clutch and engage the pinion (small) gear to the crankshaft gear. The pinion gear teeth had displayed indentations in their surfaces that indicated that they were only partially engaged to the crankshaft gear when the starter was being operated. The pinion gear teeth had fractured edges consistent with overstress. -
Analysis
The pilot was also the owner and builder of the experimental amateur-built airplane. While returning to the airport after a local flight, the engine lost oil pressure, so the pilot diverted toward the nearest airport. The engine then began to run roughly and lost partial power. The airplane was not able to glide to the runway and collided with a ditch in a field during the forced landing. The pilot described that his postaccident examination of the engine revealed that the pinion gear on the pull starter motor fractured into several pieces that entered the accessory gear case, likely seizing the oil pump. About 4 years and 100 flight hours before the accident, the pilot had modified the pull starter motor from its original design so that the motor would fit in the airplane. Postaccident metallurgical examination found that the pull starter motor’s pivot lever was shortened. The pivot lever arm was designed to move the starter clutch and engage the pinion (small) gear to the crankshaft gear. The pinion gear teeth displayed indentations in their surfaces that indicated that they were only partially engaged to the crankshaft gear when the starter was being operated, a condition which was likely the result of the shortened pivot lever. This ultimately resulted in increased stress on the gear teeth during engine start and the subsequent failure of the gear in overstress. The liberated gear teeth likely damaged and seized the engine oil pump, and resulted in the partial loss of engine power.
Probable cause
The pilot’s improper modification of the pull starter motor, which resulted in its failure and the subsequent loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DWYER MICHAEL D
Model
Q
Amateur built
true
Engines
1 Reciprocating
Registration number
N3QP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2841
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-04-12T21:41:15Z guid: 104798 uri: 104798 title: ERA22LA162 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104804/pdf description:
Unique identifier
104804
NTSB case number
ERA22LA162
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-17T14:45:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-03-29T01:31:23.975Z
Event type
Accident
Location
Homestead, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On March 17, 2022, about 1345 eastern daylight time, an experimental, light sport Czech Sport Aircraft Piper Sport airplane, N811PS, was lost from radar and presumed destroyed about 15 nautical miles west of Everglades National Park, Florida. The pilot has not been located and is presumed fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Federal Aviation Administration (FAA) flight track data showed that the airplane departed The Florida Keys Marathon International Airport (MTH), Marathon, Florida, about 1312. The airplane climbed to a cruise altitude of about 1,450 ft mean sea level (msl) and flew northwest toward Naples Municipal Airport (APF), Naples, Florida. The airplane maintained its altitude, 336° heading, and 125-knot groundspeed until 1323, when it descended and gradually increased airspeed. The track data depicted a rapid climb from 1,200 ft msl to 1,800 ft msl at 1324 while the airplane slowed to 74 knots groundspeed. The airplane then resumed its previous heading and groundspeed at an altitude of about 1,450 ft msl until 1327, when it began a series of erratic heading, altitude, and groundspeed excursions. The track depicted a brief climb before the airplane descended, accelerated, and completed a 240° turn to the east. During the turn, the altitude varied between 1,600 ft msl and 800 ft msl, and groundspeeds varied between 83 and 143 knots. The airplane then continued in a wide, arcing left turn until it intercepted its original course. Once reestablished on its same approximate course, the airplane assumed a cruise profile about 800 ft msl and 100 knots groundspeed about 1331. The altitudes varied only slightly between 800 and 900 ft msl, and groundspeed remained about 100 knots until 1343:38, when the airplane’s track ended on a 336° heading at 825 ft msl and 100 knots groundspeed. No further targets were identified, and air traffic control (ATC) records revealed that the airplane never established communication with any ATC facilities after departing MTH. Figures 1 and 2 show flight track information, with the accident flight depicted in green and the previous flight depicted in yellow. Figure 1. Flight track information Figure 2. Flight track information   Airplane wreckage and paperwork associated with both the airplane and the pilot were recovered from the surface of the ocean and secured by the U.S. Park Service following the accident. The airplane was manufactured in 2010. According to the pilot’s family, both the airplane maintenance logs and the pilot’s logbook were likely on board the airplane. Invoices reflecting three consecutive “annual condition inspections” were provided by an aircraft maintenance facility and indicated that the most recent inspection was completed January 19, 2022, at 569.2 total airplane hours. The invoices reflected that, in the 2 years before this inspection, the airplane had flown 31.0 and 24.7 hours, respectively. The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent third-class medical certificate was issued May 20, 2014, and he reported 1,350 total hours of flight experience on that date. The pilot completed the BasicMed course on August 30, 2017. Review of flight track information for the flight from APF to MTH earlier on the day of the accident revealed similar erratic altitude, heading, and speed excursions as those displayed during the accident flight. The data indicated that the pilot flew a left downwind leg for landing on runway 07 at MTH at an altitude of 200 ft msl. At a point consistent with a left base leg, the airplane completed a 180° turn and flew a right downwind for runway 25 at 200 ft msl, landing opposite the direction of other landing traffic. Automatic dependent surveillance-broadcast (ADS-B) data showed that the accident airplane landed on runway 25 when a business jet was on short final for landing on runway 07. In written statements, the crew of the business jet advised that the accident airplane cleared the runway before they were required to abort their landing. The data showed that the accident airplane taxied erratically on the airport surface, with numerous heading changes and course reversals, over a 6-minute span. Ground personnel stated that the pilot did not respond to radio calls and had to be told in person by a lineman that his party was parked at the opposite end of the airport. The airplane also experienced another head-on encounter with the landing business jet while on the taxiway. Two friends of the pilot were interviewed by telephone, and their versions of events were consistent throughout. The three had agreed to fly their individual airplanes from APF, where they were based, to MTH, have lunch, then fly back to APF. The accident occurred on the return flight. Neither heard the accident pilot over the radio, and they became concerned when they felt his arrival at APF was overdue. The friends described the departure from APF, their arrival at MTH ahead of the accident pilot, and how his arrival “took longer than expected.” Each was a retired airline pilot, and the tracks of both the accident pilot’s flights were discussed with them. They said that the pilot explained his opposite-direction landing based on his interpretation of the windsock. Each was asked to describe the pilot’s appearance, behavior, and if any of those behaviors concerned him. One responded, “Yes, he didn’t eat his lunch, which was unusual.” The other individual said that the pilot was engaged in their lunch conversation and that he would have acted if he had any concerns. He added, “My wife said he seemed off, but I didn’t notice anything unusual except that he didn’t eat the dinner he ordered.” In a telephone interview, the lineman who parked the accident pilot next to his waiting friends said he had been an emergency medical technician “for 15 years” and immediately noticed that the pilot struggled to egress his airplane and appeared “befuddled” when he got out. He asked if the pilot wanted fuel or any other services, and the pilot “wouldn’t” respond. A pilot outside the party of three confronted the accident pilot about entering the traffic pattern and landing in the opposite direction without making any radio calls. The lineman said that the pilot did not respond, continued to appear “befuddled,” and that his friends “defended him” and then took him away to go to lunch. The other pilots explained that the accident pilot “didn’t have a radio” as the radio in his airplane was inoperative. He added, “I feared for the pilot because he was ‘devastated’ by what he had done. He was wrong, both on the landing and when he taxied. He looked devastated.” The Federal Aviation Administration (FAA) medical certification file and the pilot’s pre-event medical records were reviewed by a National Transportation Safety Board medical officer. The 68-year-old male pilot was operating under the provisions of BasicMed. His most recent FAA medical certification examination was on May 20, 2014, at which time he reported taking aspirin and having no medical conditions. The remains of the pilot were not found; no autopsy report or toxicology testing results were available. Pre-event medical records showed that the pilot had a history of coronary artery disease and had angioplasty and stenting of his left main, left anterior descending, and left circumflex coronary arteries in 2018. His exercise nuclear study on November 9, 2021, was abnormal with a reduced ejection fraction and systolic function. While there was no current ischemia, there was evidence of a past infarct. He had swelling of both legs and was being treated for fluid retention and high blood pressure. He was also being treated for high lipid levels, diabetes, and gastric reflux disease. The pilot had a body mass index of 35. There were no other significant physical exam findings. -
Analysis
The pilot and two friends flew their individual airplanes from their home airport on the mainland to an airport on an island in the Florida Keys to meet for lunch. Upon arrival, the pilot landed opposite the direction of other landing traffic and subsequently taxied erratically for 6 minutes, unresponsive to radio calls. The pilot had to be directed by a lineman to park at the location where his friends waited. The lineman stated that the pilot had difficulty getting out of the airplane, appeared “befuddled,” and did not respond to questions. When confronted by another pilot about the opposite-direction landing, the pilot did not respond, and his friends defended him. The lineman reported that the pilot was “devastated” by what he had done, but the only unusual behavior cited by his friends was that the pilot did not eat his lunch. The accident occurred on the return flight, which was conducted during the day and in visual meteorological conditions, and during which the airplane was lost from radar over the Gulf of Mexico. Debris from the airplane was recovered from the surface of the ocean, and the airplane was presumed to be destroyed. Flight track data revealed multiple altitude, heading, and speed excursions on both the accident flight and the previous flight; however, the airplane’s flight track was not erratic at the time radar contact was lost. Pre-event medical records showed that the pilot had multiple medical conditions that significantly increased his risk for a sudden cardiovascular event, including coronary artery disease with stenting of several coronary arteries, previous myocardial infarct, hypertension, high lipid levels, diabetes, and obesity. The pilot’s remains were not recovered, and no autopsy was performed. Based on operational evidence, including interviews, flight track data, and medical risk factors, the pilot may have been medically impaired or incapacitated at the time of the accident; however, given the available medical evidence, the reason for the impairment could not be determined.
Probable cause
The airplane’s collision with water for underdetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CZECH SPORT AIRCRAFT AS
Model
PIPER SPORT
Amateur built
false
Engines
1 Reciprocating
Registration number
N811PS
Operator
READ AVIATION INC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
P1001028
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-29T01:31:23Z guid: 104804 uri: 104804 title: CEN22FA145 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104794/pdf description:
Unique identifier
104794
NTSB case number
CEN22FA145
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-17T17:38:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-21T04:44:04.303Z
Event type
Accident
Location
Pond Creek, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
3 fatal, 0 serious, 0 minor
Factual narrative
Weather-Related Accidents The FAA Risk Management Handbook, FAA-H-8083-2, states: Weather is the largest single cause of aviation fatalities. Most of these accidents occur to a GA operator, usually flying a light single- or twin-engine aircraft, who encounters instrument meteorological conditions (IMC) while operating under VFR. Over half the pilots involved in weather accidents did not receive an official weather briefing. Once the flight is under way, the number of pilots who receive a weather update from automated flight service station (AFSS) is dismal….. Scud running, or continued VFR flight into instrument flight rules (IFR) conditions, pushes the pilot and aircraft capabilities to the limit when the pilot tries to make visual contact with the terrain. This is one of the most dangerous things a pilot can do and illustrates how poor ADM [aeronautical decision making] links directly to a human factor that leads to an accident…. Continuing VFR into IMC often leads to spatial disorientation or collision with ground/obstacles. It is even more dangerous when the pilot is not instrument rated or current. Spatial Disorientation The FAA Civil Aerospace Medical Institute's publication, "Introduction to Aviation Physiology," defines spatial disorientation as a "loss of proper bearings; state of mental confusion as to position, location, or movement relative to the position of the earth." Factors contributing to spatial disorientation include changes in angular acceleration, flight in IFR conditions, frequent transfer from VFR to IFR conditions, and unperceived changes in aircraft attitude. This document states, "anytime there is low or no visual cue coming from outside of the aircraft, you are a candidate for spatial disorientation." The FAA's Airplane Flying Handbook, FAA-H-8083-3B, describes hazards associated with flying when the ground or horizon is obscured. The handbook states in part the following: The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. Hypoxia and Oxygen Requirements The FAA Civil Aerospace Medical Institute's publication, “Effects of Mild Hypoxia on Pilot Performance at General Aviation Altitudes” defines Hypoxia as a state of oxygen deficiency in the blood, cells, or tissues of the body sufficient to cause an impairment of function. In aviation, a reduction in total atmospheric pressure occurs with increasing altitude. This change produces a reduction of oxygen partial pressure and hence, a reduction of alveolar oxygen pressure and the pressure gradient between the alveoli and mixed venous blood in the pulmonary capillaries. By breathing the “ambient air” of a reduced pressure environment, less oxygen diffuses across the alveolar-capillary membranes into the blood stream and to the tissues of the body. Among the various tissues of the body, neural tissue is particularly sensitive to reduced oxygen tension. Normal brain functioning requires a relatively constant and high supply of oxygen. Although the minimum altitude at which cognitive and psychomotor performance becomes significantly impaired remains controversial, a review of hypoxia literature between 1950 and 1963 concluded that 10,000 ft was the minimum altitude at which significantly degraded perceptual-motor performance occurred. Title 14 Code of Federal Regulations Part 91.211, “Supplemental Oxygen,” states that no person may operate a civil aircraft of U.S. registry: (1) at cabin pressure altitudes above 12,500 ft MSL up to and including 14,000 ft. MSL unless the required minimum flight crew is provided with and uses supplemental oxygen for that part of the flight at those altitudes that is of more than 30 minutes duration: (2) At cabin pressure altitudes above 14,000 ft. MSL unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes; and (3) At cabin pressure altitudes above 15,000 MSL unless each occupant of the aircraft is provided with supplemental oxygen. - The A&P mechanic reported the airplane had an oxygen system and it had been serviced. He reported that if the airplane had oxygen masks or cannulas, they were not on the airplane, and that he could recall only one time where he observed the pilot use supplemental oxygen on a cross-country flight. - On March 17, 2022, about 1638 central daylight time, a Piper PA-30 airplane, N8357Y, was destroyed when it was involved in an accident near Pond Creek, Oklahoma. The pilot and 2 passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Mineral Wells Regional Airport (MWL), Mineral Wells, Texas, with a destination of Fairmont, Nebraska. Radar and ADS-B data indicated that the airplane first appeared at 1509 about 1.5 nautical miles west of MWL. The airplane tracked north and climbed initially to a cruise altitude of 8,500 ft and then later climbed to 16,500 ft. The airplane began a descent after it passed over Vance Air Force Base (END), Enid, Oklahoma, and turned momentarily to the east. The airplane then turned west and back to the north while it descended. The ground speed decreased from over 200 kts to under 100 kts. About 1631, and 5 miles southwest of Pond Creek, Mode C position reporting data was lost followed by the loss of all track data. The airplane was not in contact, nor was it required to be in contact, with air traffic control. Figure 1. ADS-B Flight Track. Figure 2. Radar Depiction of the End of the Flight Track. A witness in the area reported he heard what sounded like a motocross bike engine revving to full throttle. He then looked up and saw what he initially thought was a weather balloon coming straight down. He realized it was an airplane and videoed the airplane in its descent. The airplane was in a right-hand nose-down spin. The video showed the airplane descend until, moments before impacting terrain, it became obscured by tall grass. In the video, the airplane’s aft fuselage and empennage were separated and neither the propellers nor the outboard wings and fuel tip tanks were seen. - Doppler radar imagery from 13 miles northwest of the accident location revealed light values of reflectivity along the final portion of the accident airplane’s flight path and in the immediate vicinity of the accident location. The base reflectivity is presented in Figure 3. Figure 3. 10o Level II Doppler radar return with the accident airplane’s flight path denoted by the thin white line. Accident location is denoted by the red circle. Figures 4, 5, and 6 present a 3-dimensional model of radar data that includes all available tilts. Isosurfaces, depicted in decibels (dBZ) describe values of precipitation. Reflectivity values express the amount of transmitted power returned to the radar receiver after hitting objects, as compared to a reference power density. Isosurfaces of 0, +10, +20 dBZ generally identify light values of precipitation. Figure 4. Accident aircraft flight path without weather radar depicted. Figure 5. Accident aircraft flight path with 3-Dimensional 0, +10, and +20 dBZ isosurfaces overlaid. Oblique view. Figure 6. Accident aircraft flight path with 3-Dimensional 0, +10, and +20 dBZ isosurfaces overlaid. Side view. A High-Resolution Rapid Refresh (HRRR) Model provided by the National Oceanographic and Atmospheric Administration’s Air Resources Laboratory and analyzed by the RAwinsonde OBservation (ROAB) program showed the potential for clouds above 9,000 ft. The freezing level was noted at about 8,800 ft. The potential for significant turbulence was between about 15,400 and 17,400 ft, and for light rime icing between about 15,400 ft and 19,400 ft. Visible and infrared data satellite imagery from a Geostationary Operational Environmental Satellite (GOES)-16 was obtained from the Space Science Engineering Center at the University of Wisconsin-Madison. Visual imagery from 1636 showed cloudy conditions across the accident region. Infrared imagery depicted minimum brightness temperatures of -25oC over the accident location, which when considering the HRRR sounding corresponded to cloud top heights near 21,000 ft. - The pilot’s flight instructor, who was also the Airframe and Powerplant (A&P) mechanic who maintained the airplane, reported that he instructed the pilot through his multiengine land rating. The flight instructor stated he tried to get the pilot to get his instrument rating, but the pilot was too busy. - The accident site was located across several fields about 6 miles southwest of Pond Creek. The main wreckage was located on the west side of a creek bed in a field. The elevation of the accident site was about 1,100 ft and the terrain was predominately flat and consisted of tall grass. The main wreckage consisted of the forward fuselage, cabin, and baggage compartment, left and right inboard wings, left and right engines and nacelles, and came to rest inverted. The wreckage was crushed aft, fragmented, and showed evidence of a near-vertical impact. The airplane’s oxygen bottle was located on the east side of the creek bed 14 ft south of the main wreckage. The oxygen ports in the cabin did not show that oxygen masks or cannulas had been connected and no oxygen masks or cannulas were found in the wreckage. The aft fuselage and empennage consisted of the vertical stabilizer and rudder. The inboard sections of the horizontal stabilators were broken and held to the main wreckage by the flight control and trim cables. Both wings were broken about 5 ft outboard of the nacelles. The broken sections showed upward bending, aft twisting, and fractures consistent with overload failures. Several impact marks and paint transfers were found along the leading edge of the vertical stabilizer indicative of a component striking it before ground impact. Outboard sections of the left and right wings and outboard tip tanks were located about 600 ft south-southeast of the main wreckage. Also located in this area were the left and right propellers. An outboard section of the left wing was in a field about 1,146 ft west-northwest of the main wreckage. Pieces of wing skin, cowlings, plexiglass, and the outboard sections of the left and right horizontal stabilators were found in adjacent fields west and northwest of the main wreckage. The left propeller hub was broken open and one propeller blade was broken out. The blade showed no damage. The blade that remained with the hub showed S-bending, chordwise scratches, and trailing edge gouges. Two inches of the blade’s tip was missing. The hub was attached to the flange and 3 inches of the left engine crankshaft. The right propeller was also attached to the flange and about 3 inches of the right engine crankshaft. Both blades were bent slightly forward and showed chordwise scratches and trailing edge gouges. A postaccident examination of the airplane, engines, vacuum system, and flight and navigation instruments revealed no mechanical anomalies that would have precluded normal operation. -
Analysis
The non-instrument-rated pilot and 2 passengers departed on a visual flight rules cross-country flight. Air Traffic Control (ATC) radar and Automatic Dependent Surveillance-Broadcast (ADS-B) data indicated that after takeoff the airplane tracked north and climbed to a cruise altitude of 8,500 ft and then later climbed to 16,500 ft. About an hour and 25 minutes later, the airplane began a descent and turned momentarily to the east. The airplane then turned west and back to the north while it descended. The ground speed decreased from over 200 kts to under 100 kts. Mode C position reporting data was lost followed by the loss of all track data. The airplane was not in contact, nor was it required to be in contact, with ATC. A witness in the area reported that he heard what sounded like a motocross bike engine revving to full throttle. He then looked up and saw what he initially thought was a weather balloon coming straight down. He realized it was an airplane and videoed the airplane in its descent. The airplane was in a right-hand nose-down spin. The video showed the airplane descend until, moments before impacting terrain, it became obscured by tall grass. In the video, the airplane’s aft fuselage and empennage were separated and neither the propellers nor the outboard wings and fuel tip tanks were seen. Instrument meteorological conditions (IMC) existed in the area, where Mode C position reporting and all track data was unavailable. A postaccident examination of the airplane revealed no mechanical failures or malfunctions that would have precluded normal operation. The airplane had a serviced oxygen system; however, no oxygen masks or cannulas were found in the wreckage, and the pilot’s mechanic and flight instructor stated that they were not kept on board the airplane. Federal Aviation Regulations require all occupants on board to use supplemental oxygen above 15,000 ft mean sea level. The pilot’s operation of the airplane above this altitude for almost 90 minutes would have likely led to a performance impairment resulting from hypoxia. The airplane’s track deviations away from its intended destination could have been the result of one or more of the following: 1) an attempt to maneuver the airplane to avoid IMC; 2) the pilot’s impaired performance as a result of hypoxia; and/or 3) the onset of spatial disorientation. However, there was insufficient evidence from which to determine the degree to which hypoxia and spatial disorientation played a role in the sequence of events leading to the airplane’s departure from controlled flight.
Probable cause
The pilot’s loss of control of the airplane, resulting in an in-flight breakup.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N8357Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Commercial sightseeing flight
false
Serial number
30-1504
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-21T04:44:04Z guid: 104794 uri: 104794 title: ERA22FA160 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104799/pdf description:
Unique identifier
104799
NTSB case number
ERA22FA160
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-18T15:32:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-03-24T01:26:12.328Z
Event type
Accident
Location
Loxahatchee, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On March 18, 2022, at 1432 eastern daylight time, an MD Helicopters 369HM, N650AG, was destroyed after it impacted power lines near Loxahatchee, Florida. The commercial pilot and pilot-rated passenger were fatally injured. The helicopter was operated by the commercial pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. According to automatic dependent surveillance-broadcast (ADS-B) data obtained from the Federal Aviation Administration, the helicopter departed Antiquers Aerodrome (FD08), Delray Beach, Florida, about 1359 and flew north over swampy, state land. The data showed the helicopter flying at altitudes from 25 to 75 ft above ground level (agl), and at speeds between 83 to 100 knots, before colliding with high-voltage power lines. The power lines were measured at 80 ft agl. The data ended at 1432. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane single-engine sea, and instrument airplane. He did not possess a rotorcraft-helicopter rating at the time of the accident. He had a logbook endorsement for solo student flight in helicopters with the prohibition of carrying passengers. The commercial pilot was issued a FAA second-class medical certificate on October 28, 2021. He reported 1,200 hours of total flight experience at that time. The pilot-rated passenger held a private pilot certificate with a rating for airplane single-engine land and an instrument rating. The pilot-rated passenger did not have any helicopter experience. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a swampy field. Power lines were observed on the ground near the wreckage. The wreckage path began where the power lines were located and continued for about 250 ft on a 270° magnetic course. The wreckage was laying on its right side and oriented about a 320° heading. The skids were separated from the helicopter, and all four main rotor blades were fractured off the hub. One main rotor blade could not be located in the swamp. Power line impression marks were found on the landing light housing and the skid brackets. The tail rotor was located about 30 ft from the main wreckage. Parts from the engine cowling, tail section and engine were found scattered in the wreckage path. The instrument panel was intact. Examination of the engine and airframe did not reveal any preimpact mechanical malfunctions. The maintenance logbooks could not be located. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology testing performed by the FAA’s Forensic Services Laboratory did not reveal any evidence of drugs or alcohol. An autopsy was performed on the pilot by the Office of the Medical Examiner, District 15, West Palm Beach, Florida. The report listed the cause of death as multiple blunt force injuries. -
Analysis
The pilot held a commercial pilot certificate with airplane ratings but did not possess a helicopter rating at the time of the accident. He did have a logbook endorsement for solo student flight with helicopters with the prohibition of carrying passengers. The passenger was a pilot-rated for single-engine land airplanes and did not have any helicopter experience. According to automatic dependent surveillance-broadcast data, the helicopter departed an airport and flew north over swampy, state land. The data further showed the helicopter flying at altitudes from 25 to 75 ft above ground level (agl) and at speeds between 83 to 100 knots before colliding with high-voltage power lines. The helicopter came to rest in a swampy field about 250 ft from the power lines. The power lines were measured at 80 ft agl. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The circumstances of the accident are consistent with the pilot’s failure to maintain clearance from power lines while maneuvering at low altitude.
Probable cause
The pilot’s failure to maintain clearance from power lines while maneuvering at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MD HELICOPTERS INC
Model
369
Amateur built
false
Engines
1 Turbo shaft
Registration number
N650AG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1090203M
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-24T01:26:12Z guid: 104799 uri: 104799 title: ERA22LA195 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104962/pdf description:
Unique identifier
104962
NTSB case number
ERA22LA195
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-18T20:30:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2022-05-02T21:09:23.839Z
Event type
Accident
Location
Carlisle, Pennsylvania
Airport
Carlisle Airport (N94)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while in the landing flare, about 5 to 7 ft above ground level, the airplane “suddenly dropped” to the ground and the airplane’s tail struck the runway. The pilot then taxied the airplane to parking uneventfully. During a subsequent inspection of the airplane, the pilot and a mechanic found that the airplane’s empennage had sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in the airplane’s empennage impacting the runway surface during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32
Amateur built
false
Engines
1 Reciprocating
Registration number
N4468X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-7640024
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-02T21:09:23Z guid: 104962 uri: 104962 title: ERA22FA161 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104801/pdf description:
Unique identifier
104801
NTSB case number
ERA22FA161
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-19T19:52:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2022-03-24T00:17:57.254Z
Event type
Accident
Location
Dahlonega, Georgia
Airport
Lumpkin County-Wimpys Airport (9A0)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
A copy of the security video footage was forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory, Washington, DC (for more information, see Video Study in the public docket for this accident). - On March 19, 2022, about 1852 eastern daylight time, a Cessna 172H, N1410F, was substantially damaged when it was involved in an accident near Dahlonega, Georgia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane departed Athens Ben Epps Airport (AHN), Athens, Georgia, about 1817. According to the ADSB data, witness reports, and a video from an off-airport security camera, the airplane flew a straight-in approach to runway 33 at Lumpkin County-Wimpy’s Airport (9A0), Dahlonega, Georgia. Two witnesses stated that the airplane approached “fast” with the flaps retracted. ADS-B data showed that the groundspeed was about 85 knots. The airplane touched down on the runway and bounced twice on its nose landing gear. When the airplane was toward the end of the runway, the engine noise increased, and the airplane began a climbing left turn to clear trees, which was followed by the sound of impact. The airplane wreckage was located in a residential yard beyond the end of the runway. - The weather reporting station nearest to the accident site, about 20 nautical miles southeast, reported winds from 290° at 13 knots, gusting to 22 knots. Given the runway orientation, wind from 290° would have resulted in a left quartering headwind for the pilot’s straight-in approach. Witnesses at the airport reported “calm,” “very light,” or “little to no" wind about the time of the accident, with one noting that the pilot may not have known that “the winds blowing earlier in the day had died down.” No evidence indicated that the pilot received a weather briefing before the flight. - The pilot obtained his private pilot certificate about 1 year before the accident and had accumulated about 94 hours of total flight experience at the time of the accident. - The wreckage came to rest upright oriented on a magnetic heading of about 120°. Both wing tanks were breached, and a strong smell of fuel was present at the accident site. A 65-ft debris path was observed along a magnetic heading of 270°. the debris path began with tree scars that were at a height of about 50 ft. A branch recovered along the debris path exhibited a 45° cut with gray paint transfer. A crater that was about 3 ft long, 2ft wide, and 1 ft deep was observed along the debris path about 10 ft from the wreckage. The wreckage remained intact. Both wings exhibited leading-edge damage; the left wing exhibited more damage outboard. The flaps and ailerons remained attached to their respective wing. The empennage remained intact and was canted to the left; it was undamaged except for left horizontal stabilizer leading-edge damage. Flight control continuity was confirmed from all flight control surfaces to the cabin area. Measurement of the flap actuator corresponded to flaps in the retracted position. Measurement of the elevator trim jackscrew corresponded to a 10° trim-tab-up position; the trim wheel in the cockpit was set at the neutral/takeoff position. The cockpit area was crushed. GPS data were recovered from a ForeFlight application on the pilot’s iPad. The engine remained attached to the airframe, and the propeller remained attached to the engine. Both propeller blades exhibited chordwise scratching and leading-edge gouging. The propeller was able to be rotated by hand. Crankshaft, camshaft, and valve train continuity were confirmed, and thumb compression was attained on all cylinders. Both magnetos were rotated by hand and produced spark at all leads. The carburetor was disassembled, and its components remained intact. Examination of the engine revealed no preimpact mechanical malfunctions. -
Analysis
The pilot obtained his private pilot certificate about 1 year prior to the accident and had accumulated a total flight experience of approximately 94 hours at the time of the accident. Toward the end of the cross-country flight, the pilot flew a straight-in approach to a valley airport. The airplane made a highspeed approach (about 95 knots true airspeed) with the flaps retracted. Witnesses reported that the airplane touched down and bounced twice on its nose landing gear. When the airplane was toward the end of the runway, engine noise increased, and the airplane began a climbing left turn to clear trees. The airplane subsequently impacted terrain. Postaccident examination of the wreckage revealed no preimpact mechanical malfunctions. The debris path and impact signatures were consistent with an aerodynamic stall. Based on the evidence, the pilot likely made a delayed decision to perform a go-around after touchdown and exceeded the airplane’s critical angle of attack as the airplane began the climbing left turn to avoid trees.
Probable cause
The pilot’s delay in initiating a go-around and his failure to maintain airplane control during the initial climb, which resulted in the exceedance of the airplane’s critical angle of attack and an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N1410F
Operator
BLUE RIDGE MOUNTAIN FLYERS INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17254905
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-24T00:17:57Z guid: 104801 uri: 104801 title: ANC22LA024 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104803/pdf description:
Unique identifier
104803
NTSB case number
ANC22LA024
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-19T20:35:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-04-27T22:07:16.385Z
Event type
Accident
Location
Talkeetna, Alaska
Airport
Talkeetna (TKA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 19, 2022, about 1935 Alaska daylight time, a Cessna 172N airplane, N6332D, sustained substantial damage when it was involved in an accident near Talkeetna, Alaska. The pilot and three passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane had 20 gallons of fuel onboard before takeoff. The pilot reported that, after takeoff, when the airplane was about 150 to 200 ft above ground level, the engine lost total power. The pilot made an emergency landing to a snow-covered field. Upon touchdown, the nosewheel separated and the airplane nosed over, resulting in substantial damage to the wings and vertical stabilizer. Postaccident examination of the airplane revealed that the fuel selector was in the left fuel tank position. The pilot reported that the airplane had 20 gallons of fuel onboard. About 3 gallons of fuel were drained from the left tank, and 13 gallons were drained from the right fuel tank. Each tank had an unusable fuel quantity of 1.5 gallons. The Cessna Pilot’s Operating Handbook required the fuel selector handle to be in the “both” position for takeoffs and landings. Examination of the engine revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation of the engine. -
Analysis
The pilot reported that, after takeoff when the airplane was about 150 to 200 ft above ground level, the engine lost all power. The pilot made a forced landing in a snowcovered field, during which the airplane nosed over, causing substantial damage to the wings and vertical stabilizer. Postaccident examination of the airplane revealed that the fuel selector was in the left fuel tank position. The left fuel tank contained about 3 gallons of fuel, 1.5 gallons of which was usable. The Cessna Pilot’s Operating Handbook required the fuel selector handle to be in the “both” position for takeoffs and landings. Examination of the engine revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation of the engine. Given the fuel selector position, which was not consistent with takeoff procedures, and the limited fuel in the left tank, it is likely that the fuel in the left tank unported or had depleted to a level that resulted in fuel starvation and a subsequent loss of engine power.
Probable cause
The pilot’s improper positioning of the fuel selector during takeoff, which resulted in fuel starvation and a subsequent total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N6332D
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17272720
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-27T22:07:16Z guid: 104803 uri: 104803 title: ANC22LA025 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104805/pdf description:
Unique identifier
104805
NTSB case number
ANC22LA025
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-20T15:57:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-03-25T04:38:58.184Z
Event type
Accident
Location
Kekaha, Hawaii
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
In April 2003, the FAA published Advisory Circular 61-134, General Aviation Controlled Flight into Terrain Awareness. The circular stated in part: Operating in marginal VFR [visual flight rules]/IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC. As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR [instrument flight rules] applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT [controlled flight into terrain] accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough. The FAA defines a Controlled Flight into Terrain (CFIT) accident as one that "occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain … with inadequate awareness on the part of the pilot of the impending collision." In April 2003, the FAA published Advisory Circular (AC) 61-134, entitled " General Aviation Controlled Flight Into Terrain Awareness." The AC highlights the inherent risk that CFIT poses for general aviation (GA) pilots. The AC defined “situational awareness” as the pilot's knowledge “of what is happening around the aircraft at all times in both the vertical and horizontal planes. This includes the ability to project the near-term status and position of the aircraft in relation to other aircraft, terrain, and other potential hazards.” The AC stated that "in visual meteorological conditions, the pilot in command (PIC) is responsible for terrain and obstacle clearance (See and Avoid) …" and identified several CFIT risks, including: - Loss of situational awareness - Breakdown in good aeronautical decision making - Failure to comply with appropriate regulations - Failure to comply with minimum safe altitudes - The airplane was not equipped with an autopilot system. - On March 20, 2022, about 1457 Hawaii-Aleutian standard time, a Cessna 172N airplane, N98763, was destroyed when it was involved in an accident about 13 miles north of Kekaha, Hawaii, on the island of Kauai. The two pilots were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 aerial observation flight. The accident airplane, owned and operated by the Civil Air Patrol, was conducting a routine hurricane/tsunami practice flight. Witnesses reported to the Kauai Police Department that just before the accident they saw an airplane flying low, and close to the mountain, in poor weather conditions, then hearing a loud crashing noise. A search and rescue helicopter, operated by the Kauai Fire Department, subsequently located the fragmented airplane wreckage in an area of steep mountainous terrain, and confirmed that there were no survivors. The airplane was equipped with ADS–B, which provides aircraft tracking to determine its position via satellite navigation or other sensors and periodically broadcasts it, enabling it to be tracked. The information can be received by air traffic control ground stations as a replacement for secondary surveillance radar, as no interrogation signal is needed from the ground. According to archived Federal Aviation Administration ADS-B data, after the airplane departed the Lihue Airport, it initially proceeded southwest, then it turned north as it neared the northwest side of the island. The standard flight route was to fly inland, passing the radar dome at Barking Sands PMRF before turning west toward the coast. Once over the water, they were to maintain about 1/2 mile off the coast, at 1,000 ft above ground level (agl), and fly around the island. The starting altitude was 1,500 ft agl. ADS-B data shows the airplane never made the turn and continued over land and up the ridgeline, until impacting the mountain at about 3,600 ft. The ADS-B data stops near where the wreckage was found. Two witnesses at the Kalalau lookout, near the accident site, heard an aircraft flying towards them and then impacting the mountain. They were unable to see the aircraft due to poor weather conditions. One of the witnesses recalled that they could only see about 20 ft because of fog. A Blue Hawaiian helicopter was operating in the vicinity near the accident site. The pilot recalled the weather was getting worse on the Napali coast. He said the clouds were about 2,000 ft to 2,500 ft in the valley leading to the overlook. The pilot saw an airplane that was flying straight and level, about 500 ft above him, and watched it appear to go into the clouds while flying to the north. - Toxicology testing of the pilot performed by the Federal Aviation Administration Forensic Sciences Laboratory identified gabapentin 6612 (ng/ml) in the liver and 8079 (ng/ml) in the muscle. Based on the gabapentin level in the pilot’s liver, it is possible that his blood gabapentin level may have been in a range capable of producing impairing effects such as sleepiness, dizziness, and/or diminished coordination at the time of the accident. Gabapentin is used for seizure disorders, neuropathies, and restless leg syndrome (RLS). It has a high rate of impairing side-effects including dizziness, drowsiness, blurred vision, and sedation. Regular use for any reason is disqualifying. This medication was not reported at the most recent medical exam. - The airplane impacted a near-vertical mountain side in a nose-up, wings-level attitude. After impact, the airplane fell about 1,100 ft, scattering debris on the side of the mountain. During a postaccident examination, flight control continuity was established from the cockpit to all flight control surfaces. All primary flight control surfaces with their appropriate trim tabs and flaps were accounted for at the wreckage examination. The engine exhibited impact damage and damage from the fall down the mountain, which caused most components to separate from the engine. Several engine components were not located during the investigation. Drivetrain continuity was established from the propeller to the rear of the engine case. The propeller had impact damage to both blades. Both blades were curved aft and had rotational scoring. -
Analysis
The airplane departed on a visual-flight-rules flight to conduct a routine hurricane/tsunami warning mission. The standard flight route was to fly inland, passing a radar dome before turning west toward the coast. The airplane was then to fly offshore, following the coastline around the island. Automatic Dependent Surveillance–Broadcast (ADS–B) data showed the airplane never made the turn to the coast and it continued over land and up a ridgeline. The airplane impacted a near-vertical mountain side in a nose-up, wings-level attitude. Witnesses reported hearing the airplane, but they were unable to see it due to the poor visibility near the accident site. Postaccident examination of the airplane revealed leading edge damage to both wings indicative of a controlled flight into terrain. An examination of the available wreckage did not reveal any anomalies that would have prevented normal operation of the flight controls. Although several engine components were not located at the accident site, witnesses reported hearing the engine operating up to the time of impact. Toxicology testing of the pilot’s blood detected the presence of gabapentin, which can produce impairing effect such as sleepiness, dizziness, and/or diminished coordination. However, if the pilot’s judgment was impaired, the copilot could have mitigated his improper decision making. Thus, it is unlikely that gabapentin’s effects on the pilot contributed to the accident. Based on the level attitude of the airplane when it impacted the rising terrain, it is likely the pilot had control of the airplane and flew into terrain that was obscured by the poor visibility.
Probable cause
The pilot’s improper decision to continue the visual-flight-rules flight into low visibility conditions, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N98763
Operator
CIVIL AIR PATROL INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17276344
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-25T04:38:58Z guid: 104805 uri: 104805 title: CEN22LA178 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104963/pdf description:
Unique identifier
104963
NTSB case number
CEN22LA178
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-24T11:00:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-04-19T20:25:13.149Z
Event type
Accident
Location
Sunflower, Mississippi
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 24, 2022, about 1000 central daylight time, a Cessna L-19E airplane, N4583S, sustained substantial damage when it was involved in an accident near Sunflower, Mississippi. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he planned a 1-hour flight to verify airplane performance, systems, and navigation equipment in preparation for a cross-country flight the next day. For most of the accident flight, he operated the airplane with the fuel selector in the main tank position. While transitioning to the destination airport, about 500 ft above ground level (agl), the pilot switched the fuel selector to the auxiliary fuel tank. About 2 minutes later, the engine “missed much like if the mags [magnetos] were switched off then immediately back on.” He then turned on the boost pump and switched the fuel selector back to the main fuel tank. Shortly thereafter, the engine lost total power. The pilot’s attempts to restart the engine were unsuccessful. Because the airplane would not be able to reach the destination airport, the pilot executed a forced landing to a harvested cornfield. The pilot was concerned that the airplane would land past the field and travel into deep drainage ditches adjacent to the airport; as a result, while the airplane was about 10 ft agl, he decided to perform “a full stall landing followed by a roll out.” During the landing, the main landing gear sunk into the soft terrain, and the airplane nosed over (see the figure below). The airplane sustained substantial damage to the rudder, vertical stabilizer, and both wings. Figure 1. Accident airplane (Source: Federal Aviation Administration). Postaccident examination of the airplane revealed that the main and auxiliary fuel tanks were about one-half full. The fuel system was intact, and the fuel boost pump functioned normally when powered. After the airplane was recovered from the field, the pilot removed the airplane wings for transport to a repair facility. During the wing removal, the pilot noted no anomalies with the wing fuel lines or fuel tanks. At the repair facility, the airplane was further examined for a planned functional test of the Continental Motors O-470-11 engine. Damage was noted to the carburetor air box, and that component was replaced. An exemplar fuel tank was plumbed into the airplane’s fuel selector valve. The electric fuel boost pump operated without issue, and the engine, which was equipped with a pressurized carburetor, started with no problems. After the engine warmed up, it operated at full power for several minutes and at cruise power for 5 minutes with both the main and auxiliary fuel selector positions. No problems were noted during the functional engine test. A problem with the engine operation was induced when the fuel selector was positioned halfway between the fuel selector detents, but the mechanic stated, “all detents were distinct and did not have a tendency to not lock in [place].” Examination of the airplane wings and empennage revealed that the structures were “full of” mud dauber nests. In addition, the left fuel tank (main) vent line was completely obstructed with an unspecified material. According to an L-19 operation instructions manual, the following warning applied to the fuel selector valve: “Ensure that the fuel selector valve is properly seated in the detent for the selected tank. Positioning the valve out of the detent by as little as 1/8” can result in fuel starvation and engine failure.” Examination of the airplane wings and empennage revealed the structures were “full of mud dobber nests.” In addition, the left fuel tank (main) vent line was completely obstructed with an unidentified material. -
Analysis
The pilot planned a 1-hour flight to verify airplane performance, systems, and navigation equipment in preparation for a cross-country flight the next day. For most of the accident flight, he operated the airplane with the fuel selector in the main tank position. While transitioning to the destination airport about 500 ft above ground level, the pilot switched the fuel selector to the auxiliary fuel tank. About 2 minutes later, the engine “missed much like if the mags [magnetos] were switched off then immediately back on.” He then turned on the boost pump and switched the fuel selector back to the main fuel tank. Shortly thereafter, the engine lost total power. The pilot’s attempts to restart the engine were unsuccessful. The pilot executed a forced landing to a harvested cornfield. During the landing, the airplane nosed over and sustained substantial damage to the rudder, vertical stabilizer, and both wings. Postaccident examination of the airplane’s wing fuel lines (after the wings were removed) and fuel tanks revealed no anomalies that would have precluded normal operation. The engine was functionally tested at various power settings with an exemplar fuel tank, and no anomalies were noted. Engine operation was only interrupted when the fuel selector valve was placed between the detent selections. Further examination of the airplane wings found that the left fuel tank (main) vent line was completely obstructed with an unspecified material. Given the available evidence, this investigation could not determine if the blocked fuel vent line or an improper fuel selector position caused the loss of engine power.
Probable cause
The total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
L-19E
Amateur built
false
Engines
1 Reciprocating
Registration number
N4583S
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24707
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-19T20:25:13Z guid: 104963 uri: 104963 title: WPR22LA127 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104826/pdf description:
Unique identifier
104826
NTSB case number
WPR22LA127
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-24T14:49:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-04-05T03:07:57.705Z
Event type
Accident
Location
St. George, Utah
Airport
St George Municipal Airport (SGU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On March 24, 2022, about 1349 mountain daylight time, a Piper PA-32R-300, N111NW, was substantially damaged when it was involved in an accident near St. George, Utah. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that after refueling the airplane with 94 gallons of fuel they departed Casper/Natrona County International Airport (CPR), Casper, Wyoming, with a destination of St. George Regional Airport (SGU), St. George, Utah. During the approach to runway 19 at SGU, about 3,800 ft above ground level, the pilot reported to the SGU tower that he lost power. Despite several attempts, he was unsuccessful at restarting the engine. Concerned he did not have sufficient altitude to make the runway, he initiated a forced landing to rough desert terrain. During the landing roll, the landing gear collapsed and separated, and the airplane slid about 100 ft before coming to rest upright, resulting in substantial damage to both wings and fuselage. First responder photos from the accident site showed dark colored and fuel saturated ground underneath the left inboard tank. During the wreckage recovery efforts, the left-wing tanks were empty. Twenty gallons of fuel was recovered from the right-wing tanks. Figure 1-Accident site, view of the left wing and fuel spill. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuel selector valve handle position was undetermined due to impact damage. The fuel selector valve was undamaged and found in the right tank position. The fuel lines between the wings, fuel selector valve, electric pump, and engine were tested with air and no blockages were noted. Residual fuel was found in fuel lines and fuel components during the examination. Downloaded instrument flight data revealed that the fuel tanks were switched about every 20 minutes during the accident flight. Accurate fuel tank quantities were undetermined from the data. According to the data, shortly before the loss of engine power, the fuel pressure decreased to near zero, and about 5 seconds later, the fuel flow momentarily increased and then dropped to zero. Three seconds later, the RPM decreased to zero followed by the manifold pressure increasing to near ambient levels. -
Analysis
According to the pilot, the airplane sustained a total loss of engine power during the approach to land. Unable to maintain altitude, the pilot initiated a forced landing to rough desert terrain. During the landing roll, the landing gear collapsed and separated, and the airplane slid about 100 ft before coming to rest upright. Examination of the airframe and engine revealed no evidence of preimpact malfunctions or anomalies. Residual fuel was found in fuel lines and fuel components in the airframe and engine. The reason for the loss of engine power was undetermined.
Probable cause
The total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32R-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N111NW
Operator
Bruce Knell
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R7680499
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-05T03:07:57Z guid: 104826 uri: 104826 title: CEN22LA156 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104840/pdf description:
Unique identifier
104840
NTSB case number
CEN22LA156
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-24T18:30:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-31T05:35:31.387Z
Event type
Accident
Location
Springtown, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 24, 2022, about 1730 central daylight time, a Cessna 172N airplane, N733KP, was substantially damaged when it was involved in an accident near Springtown, Texas. The flight instructor was not injured, and the student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. Airport fuel transaction records showed that, at 1657:45, the flight instructor purchased 7.5 gallons of 100 low-lead fuel from the self-serve fuel pump at Bridgeport Municipal Airport (XBP), Bridgeport, Texas. The flight instructor stated that the fuel tanks were already “pretty full” when she added the fuel. About 7 minutes after the flight departed XBP to the south and while the airplane was in cruise flight at an altitude of about 3,500 ft mean sea level, the engine sputtered and the airplane was unable to maintain altitude. The flight instructor assumed control of the airplane from the student pilot at that time. She performed several troubleshooting steps, but engine power was not restored. Automatic dependent surveillance-broadcast (ADS-B) data showed that that airplane made a right descending turn and then continued to descend on a straight path. The flight instructor stated that, during the descent, the propeller windmilled and “randomly the engine would catch and operate for a few moments before dying again, so this wasn't something that could be remedied in the air.” During the forced landing, the airplane nosed over and came to rest inverted. The instructor added that the fuel selector valve was positioned to BOTH and that she did not manipulate the fuel selector during the event. Also, the instructor stated that she did not remember the rpm on the tachometer during the event and that she did not apply carburetor heat while troubleshooting the loss of power. The student pilot stated that during the event, when they would pull the throttle to idle, the engine “would smooth out somewhat, but would start missing” when the throttle was pushed forward. During the forced landing, the airplane nosed over and came to rest inverted in a field, which resulted in substantial damage to the fuselage, empennage, and both wings. Fuel was leaking from the wings after the accident. The XBP airport manager reported that the fuel source was checked for contaminants and that none were found. Also, two other airplanes were fueled from the same source about the same time, and the pilot of those airplanes did not report any issues with the fuel. The atmospheric conditions at the time of the accident were not conducive to the development of carburetor icing. A postaccident examination revealed uncontaminated blue fuel inside the carburetor and fuel strainer bowl. The propeller was manually rotated to confirm engine continuity. The propeller rotated with no binding or abnormalities noted with the engine. All pistons moved through each respective cylinder, and all rocker arms moved normally. Suction and compression were both obtained from each cylinder during the engine rotation. Each of the top ignition wires produced a spark during engine rotation. Examination of the airplane revealed no mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The flight instructor and student pilot were conducting an instructional flight. The instructor stated that, about 7 minutes after departure and while the airplane was in level flight at 3,500 ft mean sea level, the engine sputtered and the airplane was unable to maintain altitude. The instructor assumed control of the airplane from the student pilot at that time. She performed several troubleshooting steps; however, engine power was not restored. During the descent, the propeller windmilled and, according to the instructor, “the engine would catch” randomly and “operate for a few moments,” but the engine would lose power each time. The instructor also stated that, during a discussion with the student pilot, he indicated that, when he pulled the throttle to idle, the engine “would smooth out somewhat, but would start missing” when the throttle was pushed forward. The instructor executed a forced landing to a field, and the airplane nosed over. The airplane sustained substantial damage to the fuselage, empennage, and both wings The atmospheric conditions at the time of the accident were not conducive to the development of carburetor icing. A postaccident examination of the airplane revealed that there was uncontaminated fuel available in the engine and that there was no evidence of mechanical malfunctions or failures that would have precluded normal operation. As a result, the reason for the total loss of engine power could not be determined.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N733KP
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17268354
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-31T05:35:31Z guid: 104840 uri: 104840 title: WPR22LA137 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104854/pdf description:
Unique identifier
104854
NTSB case number
WPR22LA137
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-24T19:45:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-05-02T22:38:38.006Z
Event type
Accident
Location
Lanark, New Mexico
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 24, 2022, about 1845 mountain daylight time, a Czech Sport Aircraft Sportcruiser airplane, N823MM, was substantially damaged when it was involved in an accident near Lanark, New Mexico. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated the purpose of the flight was to calibrate a new angle-of-attack gauge that had been recently installed in the airplane. He climbed the airplane to an altitude of about 6,500 ft mean sea level and performed a power-off stall. As the nose of the airplane dropped, the left canopy latch “broke loose.” About 4 to 5 seconds later, the right canopy latch “blew open,” and the entire windscreen “popped up like a speed brake.” The airplane’s pitch remained nose down and the airplane impacted terrain, substantially damaging the left wing and fuselage. GPS data from a recovered device were consistent with the pilot’s statement. Postaccident examination of the wreckage revealed no preimpact anomalies with the canopy or canopy operating system. The canopy locking handle was located on the back console panel between the two cockpit seats and was attached to a connecting rod equipped with identical locking hook mechanisms on each side of the fuselage/canopy opening. The canopy locking mechanisms disengaged and engaged simultaneously when the handle was manipulated. The locking mechanisms disengaged when the locking handle was pulled up and engaged fully (locked) when it was pushed fully down into a stowed position. The locking mechanisms consisted of a welded tab on the connecting rod joined to a pushrod that was attached to the canopy latch. When the canopy locking handle was lifted, an over-center position was reached after about 1/4 inch of upward movement of the locking handle. The locking handle traveled about 3 additional inches before the locking mechanisms reached the fully disengaged position. -
Analysis
The pilot was performing a power-off stall at about 6,500 ft mean sea level during a personal flight. He stated that, as the nose of the airplane dropped, the left canopy latch “let loose.” About 4 to 5 seconds later, the right canopy latch “let go,” and the entire windscreen “popped up like a speed brake.” The airplane’s pitch remained nose down, and the airplane impacted terrain, substantially damaging the left wing and fuselage. Postaccident examination of the wreckage found no preimpact anomalies with the canopy or canopy operating system. Although the pilot reported that the left-side latch came loose before the right-side latch, the examination found that the locking mechanisms engaged and disengaged from both sides of the canopy at the same time when the canopy locking handle was lowered and raised. Examination of the canopy locking system showed that the canopy locking handle required about 1/4 inch of upward movement from the locked and stowed position for the locking mechanisms to reach an over-center position that effectively unlocked the canopy. The accident circumstances were consistent with the pilot’s loss of control of the airplane during flight after the inadvertent unlocking and opening of the canopy. The reason that the canopy locking handle became unstowed during the accident flight could not be determined based on the available evidence from the investigation.
Probable cause
The pilot’s loss of control of the airplane after the inadvertent unlocking and opening of the canopy for reasons that could not be determined based on available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CZECH SPORT AIRCRAFT A S
Model
SPORTCRUISER
Amateur built
false
Engines
1 Reciprocating
Registration number
N823MM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
C0526
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-02T22:38:38Z guid: 104854 uri: 104854 title: ERA22LA167 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104827/pdf description:
Unique identifier
104827
NTSB case number
ERA22LA167
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-25T11:48:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2022-03-25T22:52:23.919Z
Event type
Accident
Location
Winder, Georgia
Airport
BARROW COUNTY (WDR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On March 25, 2022, about 1048 eastern daylight time, a Cessna 172, N62283, was destroyed when it was involved in an accident near Winder, Georgia. The flight instructor was seriously injured and the student pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the student pilot, they performed a preflight inspection of the airplane with no anomalies noted. They departed Gwinnett County Airport (LZU), Lawrenceville, Georgia, and flew to Barrow County Airport (WDR), Winder, Georgia, and performed several circuits in the traffic pattern. While on the final approach leg of the traffic pattern to runway 31, the student pilot turned the yoke to the right “and felt it give as if a cable had become detached.” The flight instructor took control of the airplane and experienced the same effects; the yoke could be turned in a “complete circle with no response” from the airplane. The airplane veered to the right and descended into trees. A post-impact fire ensued that consumed the fuselage and wings. The airplane came to rest about ½-mile from the approach end of runway 31 in a wooded area. Examination of the airplane revealed that flight control continuity was established from the cockpit to the elevator and rudder. A review of the aileron control system revealed that the right direct aileron control cable was attached to the control yoke turnbuckle, but was separated in the area near the the control yoke pulleys under the cockpit floor (see figure 1). No other anomalies were noted with the airplane. Figure 1. Diagram and photograph of broken aileron cable. The aileron control cable was removed from the airplane and sent to the National Transportation Safety Board Materials Laboratory for examination. Examination of the cable revealed that about 10 wires that were elongated past the fracture surface exhibited erratic deformation directions. These wires exhibited angled fracture surfaces, or localized necking near the fractures. About half of the other broken wires, particularly in the core, exhibited flat surfaces with smearing or wear lines. The direction of these smearing lines was consistent across multiple wires. Furthermore, several wires exhibited features consistent with a tensile overstress fracture (see figure 2). Figure 2. View of the fractured ends of the aileron cable, positioned in the location consistent at fracture, post-cleaning of both sides. On August 17, 2021, at an aircraft total time of 24,420 flight hours, an entry in the airframe maintenance log indicated that the right inboard flap support rib was cracked. At that time, it was noted “disconnected right aileron and flap control cables…..re-connected control cables using new hardware, and set cable tensions to manufacturers specified limits.” A review of the airframe maintenance log revealed that between February 2, 2021, at a aircraft total time of 24,054.7 hours, and the date of the accident, there were 9 entries in the maintenance logbook that stated “completed a 100 HR inspection IAW [in accordance with] MM [maintenance manual].” Furthermore, all entries stated that the “aircraft has been inspected in accordance with a 100 Hr inspection IAW FAR 43 appendix D and maintenance manual and is approved for return to service.” The aircraft total time at the time of the accident was 24,830 hours. According to Appendix D to Part 43, “Each person performing an annual or 100-hour inspection shall inspect (where applicable)…flight and engine controls for improper installation and improper operation.” According to the Cessna 172 Maintenance Manual, during each 100-hour inspection, “Aileron structure, control rods, hinges, balance weights, bellcranks, linkage, bolts, pulleys, and pulley brackets – check condition, operation and security of attachment.” Furthermore, the 200-hour inspection lists “Ailerons and cables – Check operation and security of stops. Check cables for tension, routing, fraying, corrosion, and turnbuckle safety. Check travel if cable tension requires adjustment or if stops are damaged. Check fairleads and rub strips for condition.” -
Analysis
The flight instructor and student pilot completed several touch-and-go landings and on the final circuit in the traffic pattern, while on the final approach, the student pilot turned the yoke, and felt a sensation like the aileron cable disconnecting. The flight instructor took control of the airplane and noted that he could turn the control yoke 360° without a response from the airplane. Having no aileron control, the airplane veered to the right and descended into trees. A post-impact fire ensued that destroyed the airplane. Examination of the wreckage revealed that there was a break in the aileron control cable system near the right control column. A metallurgical examination of the break in the aileron control cable revealed that the mating fracture surfaces exhibited a flattened area over more than half the cable cross-section, with the remainder of the wires exhibiting features consistent with overstress fractures. The wires in the flattened area exhibited consistent, parallel streaks and witness marks. These marks may indicate wear from rubbing against an adjacent component in this area or they may be consistent with some partial cutting operation. If rubbing of the cable was creating wear, this process would have removed material wire-by-wire, and strand-by-strand over time. The remaining wires would have fractured from tensile overstress when there were no longer enough intact wires to carry the stress. It’s likely the overstress fracture occurred during the final leg of the traffic pattern, which was consistent with reports from the pilot and flight instructor that the flight controls no longer functioned properly during the final landing approach. According to maintenance records, the airplane was inspected, in accordance with the maintenance manual and Part 43 appendix D, 9 times during the 13 months before the accident. According to both inspection checklists, the aileron control cable should have been inspected and found unairworthy at some point due to its condition. Therefore, it’s likely maintenance personnel overlooked the damaged aileron control cable during the most recent inspections.
Probable cause
Maintenance personnel’s failure to detect the damaged aileron cable during the most recent inspections, which resulted in the separation of the aileron control cable and subsequent loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N62283
Operator
FLIGHT SCHOOL OF GWINNETT INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17275244
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-03-25T22:52:23Z guid: 104827 uri: 104827 title: ERA22LA169 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104831/pdf description:
Unique identifier
104831
NTSB case number
ERA22LA169
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-25T17:13:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-04-11T15:08:59.476Z
Event type
Accident
Location
Smithfield, North Carolina
Airport
Johnston Regional Airport (JNX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On March 25, 2022, about 1613 eastern daylight time, a Diamond DA-40NG, N471BL, was substantially damaged when it was involved in an accident near Johnston Regional Airport (JNX), Smithfield, North Carolina. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor and pilot receiving instruction, they conducted a preflight inspection of the airplane, with no anomalies noted, before departing from runway 21 at JNX. Review of radar data revealed that the airplane climbed to an altitude of about 650 ft while turning left. The flight instructor stated that she “heard a weird noise come from the engine” and saw the rpm gauge drop. Shortly afterward, the flight instructor directed the pilot receiving instruction to turn back to the airport, and the engine lost total power while in the turn. The flight instructor attempted to restart the engine while the airplane descended but was unsuccessful. The airplane subsequently impacted trees about 1 mile from the departure end of the runway, resulting in substantial damage to the fuselage. In addition, both wings and the empennage were fractured from the impact. A postaccident examination of the engine revealed that engine valvetrain was not timed correctly and that the resulting misalignment resulted in the piston striking the valve. The valve head had subsequently separated and fallen into the cylinder. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight. -
Analysis
According to the flight instructor, shortly after takeoff, she heard a “weird” noise coming from the engine and noted a drop in engine rpm. The flight instructor directed the pilot receiving instruction to turn back toward the airport; however, the engine lost all power, and the airplane impacted trees about 1 mile from the departure end of the runway. The airplane sustained substantial damage to the wings, fuselage, and empennage. A postaccident examination of the engine revealed that the engine valvetrain was not timed correctly and that the misalignment resulted in a piston striking a valve. The valve head had separated and fallen into the cylinder, resulting in the total loss of engine power. Examination of the maintenance logbooks revealed that the cylinder head and exhaust camshaft had been replaced the day before the accident flight. Thus, it is likely that the engine’s timing was not set correctly after this maintenance.
Probable cause
Maintenance personnel’s failure to set the correct engine timing after the replacement of a cylinder head and exhaust camshaft before the accident flight, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40 NG
Amateur built
false
Engines
1 Reciprocating
Registration number
N471BL
Operator
BLUE LINE AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
40.NC111
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-11T15:08:59Z guid: 104831 uri: 104831 title: CEN22LA152 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104829/pdf description:
Unique identifier
104829
NTSB case number
CEN22LA152
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-25T17:15:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-04-18T22:24:14.219Z
Event type
Accident
Location
Ash Flat, Arkansas
Airport
SHARP COUNTY RGNL (CVK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On March 25, 2022, about 1630 central standard time, a Bellanca 17-30A airplane, N8869V, was substantially damaged when it was involved in an accident near Ash Flat, Arkansas. The pilot was seriously injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The 80-hour pilot reported that he departed the Baxter County Airport (KBPK), Mountain Home, Arkansas, and it was the airplane’s first flight since the annual inspection. The flight back to the Sharp County Regional Airport (KCVK), Ash Flat, Arkansas, was uneventful until the airplane approached runway 22 to land. The pilot stated that when the airplane flew over the runway numbers, the wind suddenly became “super gusty.” When the airplane became unstable, he performed a go-around. When he added throttle, the engine stopped producing power and due to the low altitude, he was unable to perform an engine restart. He performed a forced landing near the runway but impacted terrain. The Federal Aviation Administration inspector examined the airplane. He confirmed flight control continuity. In addition, he found the right fuel tank full and the left fuel tank with a significant amount of fuel. The airplane was transported to a salvage facility for further examination. The postaccident examination of the airplane revealed that the engine controls remained properly secured to the engine and actuated normally. The left magneto was found to contain water; however, the wreckage had been stored outside partially tarped. When opening the secured baggage compartment, a fuel tester was found full of water, suggesting the water present in the magneto likely accumulated during storage. No other anomalies were detected with the engine. The airplane’s EDM-900 was downloaded, and the information plotted. The data was not time coded but did show a sharp reduction of horsepower, exhaust gas temperatures, fuel flow, and rpm, that restored briefly before dropping off, likely due to the accident. The responding FAA inspector located a GoPro camera in the wreckage and retrieved the files. The files were submitted to the NTSB Vehicle Recorders Laboratory for summary and sound spectrum analysis. The video showed that the airplane was attempting to land on runway 22. A flag was visible on the airport property and the wind appeared to be from the northwest. The airplane continued over the runway markings, but the airplane appeared to float. The airplane’s stall warning horn was briefly audible. A sound consistent with a slight increase in engine rpm was detected as the nose of the airplane drifted to the left and the airplane was no longer aligned with the centerline of the runway. The nose of the airplane pitched up and the stall warning horn was briefly heard, and the airplane appeared to slowly gain altitude. The airplane’s pitch angle continued to increase, and the stall warning horn sounded. Immediately thereafter, the engine rpm decreased and popping sounds consistent with a rough running engine were noted. A few seconds later the popping noises ceased, and the engine rpm returned to a higher power setting. The pitch angle continued to increase, and the stall warning horn was audible. The airplane banked left in what appeared to be a 70- to 80-degree left bank; it lost altitude and impacted terrain. The NTSB sound spectrum analysis estimated the speed of the engine to be about 1,900 rpm when the airplane passed over the runway 22 markings. After the sounds of the rough running engine, which lasted about 6 seconds, the engine speed increased to about 2,100 rpm about 9 seconds before impact, which gradually decreased to 1,700 rpm at impact. The Sharp Country Airport is a non-towered airport. It does not have an Automated Weather Observing System but does have a wind indicator located on the field. The closest aviation weather station is located 32 nautical miles away and at 1656 reported a wind from 290° at 16 knots. -
Analysis
The 80-hour pilot reported that, while attempting to land in gusty wind conditions, the wind suddenly became “super gusty” as the airplane flew over the runway numbers. The pilot performed a go-around; however, when he added throttle, the engine lost all power and due to the low altitude, he was unable to perform an engine restart. He performed a forced landing near the runway but lost control of the airplane and impacted terrain. The engine was examined, and no anomalies were detected. The left magneto could not be tested due to being waterlogged due to outside storage of the engine before the examination. The National Transportation Safety Board (NTSB) sound spectrum analysis determined that the engine was operating around 1,700 rpm at the time of impact. The airplane’s EDM-900 was downloaded, and the information plotted. The data was not time coded but did show a sharp reduction of horsepower, exhaust gas temperatures, fuel flow, and RPM, that restored briefly before dropping off, likely due to the accident. The video recovered from the accident airplane showed the airplane approaching the runway; after crossing the runway threshold, the airplane floated. There was a slight increase in engine power, and the stall warning horn sounded briefly. The airplane continued to float, and the nose of the airplane pitched up and the stall warning horn was briefly heard again. As the pitch angle continued to increase, the stall warning horn was heard. The engine rpm decreased and popping sounds consistent with a rough running engine were noted. A few seconds later the popping noises ceased, and the engine rpm returned to a higher power setting. The pitch angle continued to increase, and the stall warning was audible. The pilot lost control of the airplane as it entered a stall and impacted terrain. The sound spectrum analysis indicated that the engine ran rough for about 6 seconds, and then the engine rpm was heard increasing to about 2,100 rpm about 9 seconds before it gradually decreased to 1,700 rpm at impact. The reason for the partial loss of engine power could not be determined.
Probable cause
The partial loss of engine power during a go-around resulting in an inadvertent entry into an aerodynamic stall. Contributing to the accident was the inexperience of the low-time pilot.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
17-30A
Amateur built
false
Engines
1 Reciprocating
Registration number
N8869V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30383
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-18T22:24:14Z guid: 104829 uri: 104829 title: WPR22LA136 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104848/pdf description:
Unique identifier
104848
NTSB case number
WPR22LA136
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-26T08:50:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-04-06T01:56:50.793Z
Event type
Accident
Location
Prosser, Washington
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 26, 2022, about 0750 Pacific daylight time, a Downer Bellanca 14-19-2 (Cruisemaster), N7658B, sustained substantial damage when it was involved in an accident near Prosser, Washington. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the reason for the flight was to operate the engine at high power, to break in the piston rings after a new engine cylinder had been installed. He reported performing a thorough preflight, which included a check of the pitch trim system, during which he did not find any anomalies. Shortly after departure, and before he had reached the intended maneuvering area, he felt a mild vibration in the airframe. He was initially not concerned, because it felt like prior instances when he had encountered a fouled spark plug or bad spark plug lead. He adjusted engine power and determined that the vibrations were only present at higher power settings. He also adjusted the pitch trim but did not feel any vibration in the trim handle. He began to maneuver the airplane in a shallow descending turn when the vibrations came back, but now more pronounced, such that he could feel them through the flight control system. A few seconds later he heard a loud bang coming from the tail, followed by violent shuddering and shaking and rapid forward and aft control yoke deflections. He reduced engine power and increased back pressure on the control yoke to slow the airplane down, and when he looked back, he could see the elevator and trim tab rapidly oscillating. With limited pitch control, he began to maneuver the airplane for a forced landing by modulating engine power to a speed that minimized the vibrations. He judged the descent rate and airspeed to be too high to land, and continued to maneuver the airplane, describing the experience as closer to guiding a falling object rather than flying. He extended the landing gear, and prepared the airplane for a forced landing, and about 50 to 100 ft above ground level, decided that he was still descending too fast to land. He decided to apply engine power to control pitch attitude, and the airplane appeared to respond, such that the airplane began to flare over a field, although still at a very high airspeed. The main landing gear touched the ground, and he applied full aft pressure to the control yoke, and the airplane skipped once, touched down again, and eventually came to rest after a ground roll of what he estimated to be about 1,500 ft. Examination of the airplane revealed that the right vertical stabilizer and underside of the right horizontal stabilizer fabric skin had departed the airplane, and the left vertical stabilizer was bent about 10° in the vertical plane. The horizontal stabilizer and elevator were constructed of tubular steel structural members covered in fabric. Each elevator was held in place by a series of hinges made of metal lugs welded to the leading edge of the control tube and held in place with bolts (pins) to corresponding lugs on the horizontal stabilizer. The inboard section of the elevator was connected by a pair of similar lugs bolted to a control arm (bellcrank) in the center section of the tail (figure 1). Figure 1 – Exemplar elevator control Postaccident examination revealed that the right elevator remained attached to the horizontal stabilizer and bellcrank, and although the left elevator remained attached to the stabilizer by its hinges, the upper lug of its control tube had separated from the bellcrank (figures 2, 3). Figure 2 – Accident elevator control Figure 3 – Lug detachment from control tube The trim tab remained attached to the left elevator, but its control torque rod had separated within the support tube assembly, such that movement of the trim pushrod did not result in movement of the trim surface. The remaining components of the pitch control and trim system were intact and undamaged, and there was no looseness between the control surfaces and the flight controls in the cabin. The airplane was the subject of AD 53-16-01, which required inspection of the pitch trim tab for play at 100-hour intervals. Excessive free play had the potential to cause flutter in the pitch control system. The pilot stated that he always checked the trim tab in accordance with the AD as part of the preflight inspection, and he did not observe any play before the accident flight. Flutter is an aeroelastic phenomenon that can occur when an airplane’s natural mode of structural vibration couples with the aerodynamic forces to produce a rapid periodic motion, oscillation, or vibration. Flutter can be somewhat stable if the natural damping of the structure prevents an increase in the forces and motions. Flutter can become dynamically unstable with inadequate damping or greater speed, resulting in increasing self-excited destructive forces being applied to the structure. Flutter can range from an annoying buzz of a flight control or aerodynamic surface to a violent destructive failure of the structure in a very short period of time. Due to the high frequency of oscillation, even when flutter is on the verge of becoming catastrophic, it can still be very hard to detect. Aircraft speed, structural stiffness, and mass distribution are three inputs that govern flutter. An increase in airspeed, a reduction in structural stiffness, or a change in mass distribution can increase the susceptibility to flutter. The elevator and trim tab assembly were evaluated at the National Transportation Safety Board (NTSB) Office of Research and Engineering Materials Laboratory. Examination of the detached upper lug revealed that its weld fillet to the control tube lacked fusion and penetration, such that there was a gap between the filler and the control tube. Figure 4 – Area of detached lug on control tube Closer examination of the gaps on the control tube underneath the failed weld revealed green and light orange deposits, consistent with underlying primer and iron oxide surface rust (figure 4). The control tube also exhibited evidence of grey deposits around the failed weld, which when examined using energy-dispersive X-ray spectroscopy, revealed they were composed of aluminum oxide. The corresponding lower lug was examined, and although it had not failed, similar weld defects were observed and less than half of its welded fillet area had fused to the control tube. Examination of the trim tab control tube revealed that it had fractured at its locking bolt hole within the control arm. The fracture surfaces exhibited damage signatures consistent with overload, including rough texture and dull luster, along with chevron marks and dimpling. There was no evidence of preexisting fatigue. The airplane was manufactured in 1957. Review of Federal Aviation Administration (FAA) 337 (Major Repair and Alteration) records did not reveal any evidence of repair performed to the empennage section, and review of the available logbooks did not show any evidence of repairs to the elevators. The failed lugs appeared to be like those installed on an exemplar airplane. About 200 Cruisemaster series airplanes were made in total, all during the 1950’s. According to representatives from Bellanca Aircraft, Inc., about 45 are still flying. As a result of the NTSB Materials Laboratory findings, Bellanca performed visual examination, and dye penetrant inspections, of the elevator lug welds on 4 14-19-2 and 14-19-3 series airplanes, all of which have a similar elevator control system. Although surface corrosion commensurate with age was noted, the overall weld quality was reported as nominal, with no cracks or obvious defects observed. -
Analysis
During cruise flight the airplane lost pitch authority after a flutter event partially disabled its elevator and resulted in structural damage to the horizontal and both outboard vertical stabilizers. Although the airplane had limited pitch authority following the event, the pilot was able to successfully land the airplane in a field. The airplane was the subject of an airworthiness directive (AD) concerning play in the pitch trim system, which required inspection of the pitch trim tab for play at 100-hour intervals. The play in the pitch trim system had the potential to cause such a flutter event if not complied with. However, the airplane had just come out of its annual inspection and the pilot also examined the airplane in accordance with the AD just before flight. Additionally, no evidence of such play was observed during a postaccident examination. The pitch trim system had failed, but it appeared to be because of overload damage, likely sustained from the high oscillatory forces induced during the flutter event. Examination of the elevator revealed that the upper lug that connected the elevator pitch control tube to the elevator bellcrank had failed. The weld joints in that area exhibited a lack of fusion and penetration, creating gaps between the filler with the control arm surfaces and the lug. These gaps allowed fatigue cracks to initiate and propagate. Once the cracks had grown large enough, the remaining intact weld material fractured from overstress, leading to the separation of the lug from the control tube. The lug failure resulted in a partial disconnection of the control surface, which likely started the flutter event. This ultimately led to the failure of the pitch trim control arm, which would have exacerbated the flutter. Corrosion and primer identified at the lug fracture area indicated the surfaces had not been properly prepared before welding. Although the lower lug had not failed, it also exhibited similar evidence of gaps caused by a lack of fusion and penetration. It could not be determined if the lugs were welded at the time of the airplane’s manufacturer, more than 66 years before the accident, or during a subsequent repair.
Probable cause
An inadequately welded elevator attachment lug, which caused the elevator to partially detach from its bellcrank, resulting in flutter and structural damage.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Downer
Model
Bellanca 14-19-2
Amateur built
false
Engines
1 Reciprocating
Registration number
N7658B
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4009
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-06T01:56:50Z guid: 104848 uri: 104848 title: WPR22LA133 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104845/pdf description:
Unique identifier
104845
NTSB case number
WPR22LA133
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-26T13:00:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-30T00:59:19.55Z
Event type
Accident
Location
Mojave, California
Airport
Mojave Air and Space Port (MHV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On March 26, 2022, about 1200 Pacific daylight time, an experimental, amateur-built VariEze, N88KL, was substantially damaged when it was involved in an accident near Mojave, California. The pilot sustained minor injuries and the pilot-rated passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed from runway 26, and turned left to the south. About 500 ft above ground level (agl), the engine lost total power. As the pilot continued the left turn back toward the airport, he realized that the airplane would not reach the runway and he chose to land in open desert terrain. During the landing roll, the airplane collided with vegetation and the landing gear separated, resulting in substantial damage to the fuselage undercarriage. Postaccident examination of the airplane revealed that the air intake duct between the air filter box and the carburetor was damaged during the accident sequence and partially separated from the airplane. The ducting was about 2 inches in diameter and consistent with Sceet tubing with both an inner and outer silicone-impregnated cloth with a wire coil between the layers. The Sceet tubing was disassembled and exhibited debonding of the inner and outer layer. Oil and debris that was not consistent with the accident sequence was present between the debonded area. The separation of the inner layer was consistent with unsupported areas during a negative pressure flow during engine operation. -
Analysis
The pilot reported that, after takeoff and about 500 ft above ground level, the engine lost total power and he chose to land on the open desert terrain. During the landing roll, the airplane collided with vegetation and the landing gear separated, resulting in substantial damage to the fuselage undercarriage. Examination of the airplane revealed that the air intake duct between the air filter box and the carburetor was damaged during the accident sequence and partially separated from the airplane. The ducting was Sceet tubing that comprised wire coil encased between an inner and outer silicone-impregnated layer. The Sceet tubing was disassembled and exhibited debonding of the inner and outer layers. Oil and debris that was not consistent with the accident sequence were present in the debonded area. It is likely that the loss of engine power was due to the separation of the Sceet tubing inner layer, which then restricted airflow to the carburetor.
Probable cause
The failure of the carburetor intake Sceet tubing, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ADAMS DENNIS ALLEN
Model
VARIEZE
Amateur built
true
Engines
1 Reciprocating
Registration number
N88KL
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1644
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-30T00:59:19Z guid: 104845 uri: 104845 title: CEN22LA157 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104851/pdf description:
Unique identifier
104851
NTSB case number
CEN22LA157
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-26T17:14:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-04-02T05:38:51.662Z
Event type
Accident
Location
Rayville, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On March 26, 2022, about 1614 central daylight time, an Air Tractor AT-401, N9192E, was substantially damaged when it was involved in an accident near Rayville, Louisiana. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported that he was making the final agricultural spray passes on a field when the airplane engine began to “spit and sputter and miss”. He exited the field and climbed over trees and power transmission lines when the engine again started running abnormally. He examined the area for a safe place to land and the engine stopped producing power. He noted that the engine restarted and stopped two or three times as he maneuvered for landing. After touching down in a field, the airplane went over an embankment alongside a water-filled ditch. After it touched down on the opposite side of the ditch, the right wing struck an irrigation unit, the airplane turned sideways, and then nosed over, resulting in substantial damage to both wings. During a telephone interview, the pilot reported that when the engine lost power he cycled the magnetos, actuated the wobble pump, and performed other troubleshooting checks, but he didn’t have much time. He noted that the engine acted like it ran out of fuel, but he had just fueled before the accident load. He noted that there was fuel on board and that the airplane had fuel pressure and he had checked the magnetos. He said that this was the 14th load of the day, and the airplane was running well. He remembered that the pretakeoff magneto check showed only 50 rpm drop on one and 60 on the other. When the engine stopped producing power, it “just quit and there wasn’t anything [he] could do about it”. He said they had been fueling the airplane every 2 loads and reiterated that they had fueled just before the accident load. Postaccident examination confirmed engine rotation and valvetrain continuity. All cylinders except for the No. 8 cylinder produced suction and compression during propeller rotation. Removal of the No. 8 cylinder did not reveal any anomalies. Examination of the carburetor and airplane fuel system did not reveal any anomalies, and all engine controls were operational. Flight control continuity was confirmed. The recovery crew reported that there was only a trace of fuel removed from the airplane when it was recovered from the accident site. The pilot’s son, who was present immediately after the accident, reported that fuel was draining from the right-wing tank vent and that he used a pair of pliers to pinch the tube shut and taped it. He also reported that during recovery, the recovery crew had three 30-gallon white plastic drums and that after draining fuel, two of the drums were full and the third was partially full. -
Analysis
The pilot reported that during an agricultural spray pass the engine began to run abnormally. As he climbed over powerlines and trees, he looked for a place to land. The engine subsequently stopped producing any power. During the event, the engine started and stopped producing power two or three times. After touching down in a field, the airplane went over an embankment, the right wing struck an irrigation unit, and the airplane ultimately nosed over, resulting in substantial damage to both wings. The recovery crew reported that there was only a trace of fuel recovered from the airplane. However, the pilot’s son refuted this information, stating that fuel was draining from the airplane’s right fuel tank vent immediately after the accident and that the recovery crew drained more than 60 gallons of fuel from the airplane when it was recovered. Postaccident examination of the airplane, including the engine and airframe fuel system, revealed no anomalies. Based on the available information, the reason for the loss of engine power could not be determined.
Probable cause
A loss of engine power for a reason that could not be determined based on available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-401
Amateur built
false
Engines
1 Reciprocating
Registration number
N9192E
Operator
COLLINSTON AIR SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
401-0906
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-02T05:38:51Z guid: 104851 uri: 104851 title: ERA22LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104833/pdf description:
Unique identifier
104833
NTSB case number
ERA22LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-27T12:30:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-03-30T22:30:06.937Z
Event type
Accident
Location
Sparta, Tennessee
Airport
Upper Cumberland Regional Airport (SRB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On March 27, 2022, about 1130 central daylight time, a Cessna 172, N8431U, was substantially damaged when it was involved in an accident near Sparta, Tennessee. The student pilot and flight instructor were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   According to the instructor, the student pilot was practicing touch-and-go landings. They heard a “pop” sound as the airplane touched down. The student pilot initiated a go-around and then informed the instructor that the left main landing gear (LMLG) had separated from the airplane. They flew for about 2.5 hours to reduce the airplane’s fuel load before attempting to land with the fractured LMLG. The landing was uneventful, and the airplane came to a stop on the runway. According to the instructor, the LMLG struck the horizontal stabilizer when it separated, resulting in substantial damage. The LMLG spring strut was examined by the National Transportation Safety Board Materials Laboratory. The LMLG spring strut fractured where the step bracket was affixed to the spring strut. The step bracket was tack welded to the spring strut. No epoxy adhesive was present on the faying surfaces of the step bracket or spring strut. According to the Cessna service manual, step brackets can only be affixed to the spring strut using an approved epoxy adhesive on abrasively blasted surfaces; welding on the spring strut is not permitted. The Materials Laboratory examination also found a fatigue crack that initiated at a tack weld between the step bracket and the spring strut and propagated to a length of about 0.2 inches. The fatigue crack led to an overstress fracture during the accident flight. -
Analysis
During a touch-and-go landing, the student pilot and flight instructor heard a pop sound as they touched down. The student pilot initiated a go-around and then informed the instructor that the left main landing gear (LMLG) had separated from the airplane. They flew for about 2.5 hours to reduce the airplane’s fuel load before attempting to land with the fractured LMLG. The landing was uneventful and the airplane came to a stop on the runway. According to the instructor the LMLG struck the horizontal stabilizer when it separated, resulting in substantial damage. Examination of the left main landing gear spring strut revealed that the step bracket was tack welded onto the spring strut. According to the airplane manufacturer, step brackets can only be affixed to the spring strut using an approved epoxy adhesive; welding on the spring strut is not permitted. This improper maintenance resulted in a fatigue crack and the failure of the gear during the accident flight due to overstress.
Probable cause
Maintenance personnel’s failure to properly affix left main landing gear components, which led to the failure of the left main landing gear during the accident flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N8431U
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17252331
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-30T22:30:06Z guid: 104833 uri: 104833 title: ERA22LA172 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104857/pdf description:
Unique identifier
104857
NTSB case number
ERA22LA172
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-29T16:00:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-03-30T15:44:19.987Z
Event type
Accident
Location
Melbourne, Florida
Airport
Melbourne Orlando International (MLB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 29, 2022, at 1500 eastern daylight time, a Piper PA-28, N5067W, was substantially damaged when it was involved in an accident near Melbourne Orlando International Airport (MLB), Melbourne, Florida. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The pilot reported that he was hired to perform a pre-buy inspection of the airplane, then fly it to New Jersey to the new owner. He and his friend arrived a few days before the accident flight and he performed a pre-buy inspection. He noted that the cylinders had been replaced and was told by the seller that the break-in for the new cylinders was not completed. The pilot further stated that he “knew that it was going to be a risky flight home,” but decided to proceed. On the day of the accident, he took off and circled the airport several times and climbed the airplane to 7,000 ft mean sea level. He stated that everything looked and ran well, so he decided to proceed to New Jersey. About 20 miles northwest of MLB, he noticed that the engine was running rough and the oil pressure was low. He notified air traffic control and turned back to MLB to land. The roughness increased and the engine started vibrating, so he reduced the power to 1,500 rpm. The engine continued to run rough, so he shut the engine down and thought he could glide to runway 9R at MLB. Once he realized that the airplane would not make the runway, he maneuvered for landing in a parking lot. The pilot could not recall much after that point, but thought that the airplane may have collided with a telephone pole. According to a Federal Aviation Administration inspector, the airplane impacted telephone wires and came to rest inverted in a parking lot. Both wings sustained substantial damage. Examination of the engine revealed that the crankshaft would rotate approximately 90° before it came to a hard stop with a metal “clunk” sound. Cylinder Nos. 2 and 3 were removed for an internal examination of the engine, which revealed fractured connecting rods on each cylinder. The No. 2 connecting rod was found fractured with its bottom cap heavily damaged and flat in shape, laying below the engine crankshaft along with its corresponding bearings. The No. 3 connecting rod was found fractured similar to the No. 2, but both the connecting rod end and crankshaft journal exhibited a dark color, and remnants of its bearing were dark and smeared on the connecting rod end and cap. The No. 3 crankshaft journal was found pitted and displayed coloration consistent with presence of corrosion and smeared bearing material. -
Analysis
The pilot/mechanic was hired to perform a pre-buy inspection of the airplane and then fly it cross-county to the new owner. During the inspection, he noted that the cylinders had been replaced and was told by the seller that the break-in for the new cylinders was not completed. The pilot stated that he “knew that it was going to be a risky flight home,” but decided to proceed with the flight. Observing no anomalies, he departed on course, and about 45 minutes into the flight, he noticed that the engine was running rough and the oil pressure was low. He notified air traffic control and turned back to the nearest airport to land. The engine continued to run rough, so he shut the engine down and thought he could glide to the runway. Once he realized that the airplane would not reach the runway, he maneuvered to land in a parking lot, during which the airplane impacted telephone wires and came to rest inverted. Postaccident examination of the engine revealed that the No. 3 crankshaft journal bearing was pitted and smeared, and that two of the engine’s connecting rods had fractured. The condition of the bearing likely blocked the passage of oil through the engine, resulting in oil starvation that would have led to increased heat and ultimately the observed connecting rod failure.
Probable cause
A loss of engine power due to oil starvation as a result of the failure of the No. 3 crankshaft journal bearing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28
Amateur built
false
Engines
1 Reciprocating
Registration number
N5067W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
28-76
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-30T15:44:19Z guid: 104857 uri: 104857 title: WPR22LA138 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104861/pdf description:
Unique identifier
104861
NTSB case number
WPR22LA138
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-30T14:30:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-04-27T20:21:21.515Z
Event type
Accident
Location
Tucson, Arizona
Airport
Ryan Field Airport (RYN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On March 30, 2022, about 1330 mountain standard time, an experimental amateur-built Cozy Mark IV, airplane, N294MV, was substantially damaged when it was involved in an accident near Tucson, Arizona. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during the base turn to final, while descending at idle power, he noticed that the alternator indicator light was flashing and that there were no indications of engine rpm or manifold pressure. He further reported that there was no roughness or abnormal noise associated with the loss of power. The pilot immediately switched fuel tanks, confirmed that the boost pump was on, and noticed that the propeller was not windmilling. He attempted to restart the engine but was unsuccessful. Subsequently, the airplane impacted trees about 1,000 ft short of the runway threshold and sustained substantial damage to both wings. Postaccident examination of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. However, examination of the fuel system revealed a clogged fuel filter on the left fuel line from the left fuel tank to the engine. The fuel filter on the right fuel line also had contamination but was only partially clogged. The pilot stated that he had the left fuel tank selected at the time of the accident and normally selects it while flying in the traffic pattern. A sample of the material that clogged the fuel filter was sent to the National Transportation Safety Board Materials Laboratory for analysis along with samples of two types of foams and uncured sealant material used in building the airplane for comparison. Spectrum analysis of the clogging material determined that its spectrum was consistent with an epoxide. A spectral library search found matches to several epoxy resins and sealants. The material sample did not match any of the samples submitted for comparison including the uncured sealant sample. However, the clogging material was noted to have cured based on its appearance and the similarities to the spectral matches found in the library search. -
Analysis
During a local flight, the pilot was maneuvering the amateur-built experimental airplane to final approach in the traffic pattern when the engine lost total power. The pilot noticed that the propeller was not windmilling and attempted to restart the engine but was unsuccessful. Subsequently, the airplane impacted trees about 1,000 ft short of the runway threshold and sustained substantial damage to both wings. Postaccident examination of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. However, examination of the fuel system revealed a clogged fuel filter on the left fuel line and a partially clogged fuel filter on the right fuel line. The pilot stated that he had the left fuel tank selected at the time of the accident. Laboratory spectrum analysis determined the material clogging the fuel filters was consistent with an epoxide used in resins and sealants. Although the spectrum of the clogging material did not match that of an uncured sample of the sealant used during manufacture of the airplane, this was likely due to the cured state of the clogging material. The epoxide likely deteriorated, with the fragments becoming loose and clogging the fuel filters.
Probable cause
The total loss of engine power during an approach due to clogged fuel filters, which resulted from an epoxide sealant used in manufacture of the airplane deteriorating and clogging the fuel filter.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROBINSON MICHAEL E
Model
COZY MARK IV
Amateur built
true
Engines
1 Reciprocating
Registration number
N294MV
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0394
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-27T20:21:21Z guid: 104861 uri: 104861 title: CEN22LA163 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104865/pdf description:
Unique identifier
104865
NTSB case number
CEN22LA163
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-31T10:38:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-03-31T20:45:50.612Z
Event type
Accident
Location
Crowell, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
FAA Advisory Circular AC 90-109A, Transition to Unfamiliar Aircraft, classified the Kitfox series of airplanes as, “nontraditional and/or unfamiliar airplane systems operation” and stated that this type of airplane has “engine, avionics, fuel systems, etc. that require operational practices that are outside the normal procedures utilized in standard category airplanes.” The AC further stated: Unlike type-certificated airplanes, many experimental airplanes do not have extensive pilot’s operating handbooks (POH) or other documentation outlining the unique nature of the systems or controls installed in that particular airplane. This places the burden on the pilot to become familiar with the specific systems and controls in the airplane. Flying the airplane with a previous operator, a knowledgeable flight instructor, or the original builder, prior to operating the airplane solo will help the pilot understand the reasons why the installed controls are the way they are and what operational characteristics they have. This will also guard against any unusual handling characteristics that may arise from application of a control or system that may catch the pilot off-guard. The FAA Airplane Flying Handbook, FAA-H-8083-3A, discusses aerodynamic stall awareness. This document states in part: The key to stall awareness is the pilot's ability to visualize the wing's angle of attack in any particular circumstance, and thereby be able to estimate his/her margin of safety above stall. This is a learned skill that must be acquired early in flight training and carried through the pilot's entire flying career. The pilot must understand and appreciate factors such as airspeed, pitch attitude, load factor, relative wind, power setting, and airplane configuration in order to develop a reasonably accurate mental picture of the wing's angle of attack at any particular time. It is essential to flight safety that a pilot take into consideration this visualization of the wing's angle of attack prior to entering any flight maneuver. - A review of Federal Aviation Administration (FAA) and Transport Canada information found that the experimental airplane was built from a kit by an individual in Canada. The construction of the airplane was completed in May 2020. The accident pilot purchased the airplane in October 2020. A Transport Canada airworthiness certificate was issued for the airplane in September 2020, as an “amateur-built” airplane. A FAA airworthiness certificate for the airplane was not located. The airplane’s maintenance records were not available for review. It was undetermined if the airplane was equipped with a stall warning system or an angle of attack indicator. A historical photograph of the airplane showed that it was equipped with vortex generators on the wings, which lower the stall speed of an airplane. - On March 31, 2022, about 0938 central daylight time, an experimental Kitfox Series 7 airplane, N789RB, was destroyed when it was involved in an accident near Crowell, Texas. The private pilot and the student pilot-rated passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The brother of the pilot, who was also the father of the passenger observed the accident flight. The purpose of the flight was for the pilot to show the passenger the airplane. The airplane departed from a dirt strip at the pilot’s residence in Crowell around 0900. The pilot was seated in the left seat and the passenger was seated in the right seat. The airplane took off and flew over Crowell. The airplane then returned to the dirt strip and flew slow over the strip to the northwest. The airplane climbed out to the left and was about 650 ft off the ground when the airplane “stalled,” the left wing dropped, and the nose went straight down. The airplane impacted rolling prairie and was destroyed by a postimpact fire. The witness reported that the pilot was flying “low and slow,” the airplane “stalled,” the pilot lost control while in flight, and there was no altitude for recovery. He additionally reported that the engine was working fine during the entire flight and there was nothing mechanically wrong with the engine. - Pilot The pilot had reported having had a heart attack, coronary artery stent placement, and bypass surgery to the FAA, as well as the use of pravastatin to lower his cholesterol. According to the autopsy report, the cause of death was blunt force trauma and the manner of death was accident. The pilot was noted to be hypertensive and had moderate to severe atherosclerotic heart disease. No other significant disease was identified. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified ethanol at 0.012 gm/dl in cavity blood but none in urine; acetone and N-propanol were also identified in cavity blood but not in urine. Famotidine was detected in both specimens. Gabapentin was identified at 1872 ng/ml in cavity blood and 107,020 ng/ml in urine; diphenhydramine was not found in cavity blood but was found in urine; cetirizine was found in cavity blood at 31 ng/ml and in urine at 492 ng/ml; hydroxyzine was found at 10 ng/ml in cavity blood and 22 ng/ml in urine; norchlorcylizine was found at 35 ng/ml in cavity blood and detected in urine and finally alpha-hydroxyalprazolam was not detected in cavity blood but was found in urine. Passenger The student pilot-rated passenger had reported having no chronic medical conditions and no use of medications to the FAA. According to the autopsy report, the cause of death was blunt force trauma and the manner of death was accident. No significant natural disease was identified. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory did not identify any tested-for substances. - At the time of the accident, the witness reported the temperature was about 70°F, the wind was from the northwest, the wind speed was about 8-9 mph with no gusts, and the visibility was clear. - The airplane came to rest upright on private property in a rural area, at 1,528 ft above mean sea level. The airplane was consumed by a postimpact fire. All the major structural components of the airframe were found at the accident site. Flight control continuity was established throughout the airplane. The airframe fuel system and the cockpit area were destroyed by the fire. Airframe-to-engine control continuity was established. The engine sustained impact and fire damage. The engine case was mostly intact, while most of the engine accessories were damaged from the impact and fire. The composite, three-bladed propeller was thermally damaged and displayed fracture damage consistent with the engine producing power at the time of impact. Examination of the airframe and engine at the accident site revealed no anomalies that would have precluded normal operation. -
Analysis
The pilot of the experimental, amateur-built airplane was performing a slow speed low pass over an unpaved airstrip when he initiated a climb to the left. A witness reported that, when the airplane was about 650 ft above the ground, it “stalled,” the left wing dropped, and the nose went straight down. He additionally reported that the engine was running throughout the flight. The airplane was consumed by a postcrash fire; however, examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Autopsy of the pilot revealed significant coronary artery disease and a variety of medications that cause significant depression of the central nervous system, including four sedating antihistamines. Some of these medications were found only at very low levels, but the only specimens available were in cavity blood, which may not represent levels in antemortem intravascular blood or be directly related to effects. The reason for the pilot’s concomitant use of antihistamines was unknown, as are the potential effects of using them in combination, including any hangover or withdrawal effects. Therefore, whether effects from the pilot’s use of multiple sedating medications contributed to the circumstances of this accident could not be determined. Based on the available evidence, it is likely that the pilot exceeded the airplane’s critical angle of attack during low-level flight, which resulted in an aerodynamic stall and loss of control at an altitude too low to allow for recovery.
Probable cause
The pilot's exceedance of the airplane's critical angle of attack during low-level flight, which resulted in an aerodynamic stall and loss of control at an altitude too low to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Kitfox
Model
7
Amateur built
true
Engines
1 Reciprocating
Registration number
N789RB
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
KA08016119
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-03-31T20:45:50Z guid: 104865 uri: 104865 title: CEN22LA164 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104866/pdf description:
Unique identifier
104866
NTSB case number
CEN22LA164
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-31T12:00:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2022-04-12T23:25:04.919Z
Event type
Accident
Location
Kerrville, Texas
Airport
Kerrville Municipal Airport (ERV)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On March 31, 2022, about 1100 central daylight time, a Mooney M20E airplane, N21BS, was substantially damaged when it was involved in an accident near Kerrville, Texas. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   After a local flight, the airplane landed at the Kerrville Municipal Airport (ERV). A witness saw the airplane taxi at a high speed, and it seemed to be out of control. The witness saw the airplane taxi over a grass-covered area and then onto the ramp. The airplane struck the empennage of a parked airplane (a Rockwell Commander, N25CE). The left wing of the Mooney became wedged underneath the empennage of the Rockewell Commander. Airport personnel responded and discovered that the unresponsive pilot was slumped over the flight controls. Medical personnel based on the airport began CPR, but the pilot did not respond. The pilot was transported to a hospital where he was declared deceased.   The airplane’s left wing sustained substantial damage. Examination of the airplane’s flight control and brake systems did not reveal any anomalies that would have precluded normal operations. The engine exhaust system was found normal and intact. The Commander’s right horizontal stabilizer also sustained substantial damage. The pilot’s most recent Basic Med certificate was dated August 18, 2020. His third-class medical certificate expired in 2018. His most recent third-class medical examination was on August 31, 2016. During this examination, the pilot reported that he was taking medications for high cholesterol, high blood pressure, and low thyroid function. An autopsy on the pilot was performed by the Travis County Medical Examiner, Austin, Texas. The cause death was atherosclerotic and hypertensive cardiovascular disease in association with obesity, and the manner of death was natural. Toxicology testing performed by the Travis County medical examiner’s office was positive for the high blood pressure medication amlodipine in the pilot’s femoral blood. This substance is generally considered non-impairing. Toxicology testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences laboratory detected amlodipine and propafenone in the pilot’s heart blood and liver tissue. Propafenone is used to treat life-threatening irregular heartbeats; the medication itself can cause a new irregular heartbeat and increase the risk of death. The use of propafenone would require FAA review and approval. -
Analysis
After a local flight, the airplane landed, and a witness saw the airplane taxi over a grass-covered area and then onto the ramp at a higher-than-normal speed. The airplane struck a parked airplane, and the left wing became wedged underneath the empennage of the parked airplane. Airport personnel responded and discovered that the pilot was slumped over the flight controls and unresponsive. Emergency responders attempted CPR, but the pilot did not recover and was transported to a hospital where he was declared deceased. The airplane’s left wing sustained substantial damage. Examination of the airplane’s flight control, brake systems, and related systems did not reveal any mechanical anomalies that would have precluded normal operations. The pilot’s cause of death was atherosclerotic and hypertensive cardiovascular disease in association with obesity; the manner of death was reported as natural. There was significant cardiovascular disease identified by the autopsy without evidence of significant trauma. His cardiovascular conditions placed him at increased risk for a sudden cardiac event. Given the medical findings and the circumstances of this accident, it is likely that the pilot’s incapacitation from a sudden cardiac event caused the accident.
Probable cause
The pilot’s sudden cardiac event, which resulted in incapacitation, uncontrolled taxi after landing, and collision with a stationary parked airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20E
Amateur built
false
Engines
1 Reciprocating
Registration number
N21BS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21-1173
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-12T23:25:04Z guid: 104866 uri: 104866 title: ENG22LA049 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106762/pdf description:
Unique identifier
106762
NTSB case number
ENG22LA049
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-03-31T20:05:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Last updated
2023-03-06T23:59:28.107Z
Event type
Incident
Location
Riyadh, Saudi Arabia
Weather conditions
Unknown
Injuries
null fatal, null serious, null minor
Factual narrative
On March 31, 2022, at 19:05 universal coordinate time (UTC), a Bombardier Global 7500 Business Jet, registration number 9H-VIG, powered by two General Electric (GE) Aviation Passport 20-19BB1A turbofan engine and operated by Vistajet, experienced a right (No. 2) engine fire during the takeoff climb from the King Khalid International Airport, Riyadh, Kingdom of Saudi Arabia (OERK). After the right engine fire warning annunciated, the pilots disengaged the autothrottles and retarded the right engine throttle to idle. When the right engine throttle was reduced, the fire warning annunciation ceased. With the fire warning annunciation out, the pilots incrementally increased the right throttle and the fire warning annunciated again. The pilots shutdown the right engine, performed an in-flight air turn back to OERK, and made an uneventful landing with no injuries reported. Post-landing inspection of the right engine by GE on-wing support in the Kingdom of Saudi Arabia revealed indications of an undercowl fire and potential fuel leak locations (Photo 1 and 2). Photo 1: Sooting Damage Photo courtesy of GE Photo 2: Fuel Manifold B-nut Wetted at Top of Engine – Possible Leak Source Photo courtesy of GE The Kingdom of Saudi Arabia Aviation Investigation Bureau (AIB) informed the NTSB of this event on April 14, 2022, and the investigation was ultimately delegated to the NTSB. Due to the similarities with an on-going NTSB investigation (ENG22LA020), a joint Powerplant Group Chair Factual Report was created to document the findings for these two events. The engine has 18 fuel nozzles and fuel is provided to the fuel nozzles by two fuel manifolds mounted on the outside of the combustion case (Figure 1). Figure 1: Fuel Nozzle and Fuel Manifold Diagram Figure courtesy of GE (modified by NTSB) The engine was shipped back to GE Cincinnati to be evaluated. At fuel nozzle locations Nos. 12, 14, 16, and 18, the fuel manifold b-nut connections appeared shiny and lacked sooting and were thought to be possible leak locations. A leak check using nitrogen at pressures well below normal and takeoff operational engine fuel pressures was attempted but no leak was produced in the fuel system. A torque check of all the fuel nozzle-to-fuel manifold b-nut connects found that five had very low torque values, less than 200 inch-pounds, when compared to the other b-nut connection locations and the required installation torque of 285 inch-pounds nominal. One of the five low torque locations was fuel nozzle No. 18. All the other fuel manifold b-nut connection torque values were within the expected ranged. After all the fuel manifold b-nuts were loosened, an attempt was made to retighten them by hand. Several fuel manifold b-nuts on the left fuel manifold could not be run down using normal force. Loosening of the fuel nozzle attachment bolts at those locations enabled the fuel manifold b-nuts to be retightened freely by hand onto the fuel nozzle threads. This was indicative of a slight misalignment between the fuel nozzle and the fuel manifold. Fuel nozzle No. 18 male bullnose sealing surface exhibited galling along with and elliptical and intermediate contact marks, indicative of misalignment contact with the fuel manifold female ferrule sealing surface. There were also signs of contaminants (hard particles) on the fuel nozzle male bullnose sealing surface in the form of craters, indentations, and imbedded material on the sealing surface, along with diagonally orientated abrasive material marks/material removal consistent with what appears to be previous repair (Photo 3). According to GE, there was no record of a repair operation being performed on this specific nozzle at the fuel nozzle manufacturer or at the engine assembly site which would account for the observed abrasive material removal; therefore, GE concluded that this possible repair may have occurred sometime during engine assembly. The engine manual does not allow for any nicks or scratches but does allow for blending. However, blending is only allowed in the circumferential direction for conical/cylindrical parts; the blend/abrasive material removal marks on fuel nozzle No. 18 male bullnose sealing surface were in the diagonal direction along the axis of the part. Therefore, the observed blending in the area would be inconsistent with the engine manual blending instructions. Photo 3: No. 18 FN Male Bullnose with Abrasive Marks and Particle Impression Photo courtesy of GE (modified by NTSB) Only the fuel nozzle No. 18 male bullnose sealing surface showed evidence of rework/repair; however, hard particle damage was also observed on the male bullnose seal surfaces of fuel nozzles Nos. 12, 13, and 16 (Photo 4). GE was unable to confirm the source of the contaminates. Photo 4: High Magnification of Similar Shaped Debris Damage on Fuel Nozzle Male Bullnose Sealing Surface on Nos. 13 and 16 Photo courtesy of GE (modified by NTSB) During the investigation into the Palm Beach and Riyadh fuel manifold leaks event, two additional engines were found to have fuel manifold b-nut connection leaks; those were discovered during inspections performed by Bombardier in response to the Palm Beach and Riyadh events. The two fuel manifold leak engines found by Bombardier did not show any evidence of an undercowl fire. GE performed similar leak, torque, and alignment checks on all those engines along with visual examination of the fuel nozzle and fuel manifold sealing surfaces to determine if there were common causes/anomalies for all the observed fuel manifold leaks. Additionally, GE conducted a series of acceptance test procedure engine runs, developmental engine runs, and component static rig tests to: 1) better understand the effects of fuel nozzle-to-fuel manifold pigtail misalignment, 2) gather assembly and operational loads/stresses on the fuel manifolds under a variety of installation sequence scenarios, 3) validate and develop fuel manifold and fuel nozzle installation best practices and procedures, 4) gather operational data on torque (clamp) relaxation on the fuel manifold b-nut connections, and 5) develop methods to minimize the amount of relaxation experienced in operation. Based on all the data gathered from the event engines, the test engines, and component rig tests, several cumulative factors were found to have contributed to the fuel manifold leaks. Fuel manifold pigtail and fuel nozzle dimensional variation, combined with a given assembly sequence, can create potential misalignment between fuel manifold female ferrule and fuel nozzle male bullnose sealing surfaces, resulting in high resistance in the threads, low effective clamping force, and a false (high) torque reading. This low effective clamped connection can relax/loosen during engine operation as the manifold geometry normalizes and the connection shifts. All the leaking fuel manifold b-nut connections were found on those connections with lower than expected torque values. Since no fuel leaks occurred during the development engine tests, and leaks could be induced and stopped with slight variations in torque during the component rig tests, GE concluded that multiple factors can be present to create a leak and they are false (low) torques due to misalignment, higher than anticipated assembly loads due to dimensional variation, and poor/distressed sealing surface condition. Several corrective actions were taken by GE and the Federal Aviation Administration to address and mitigate the risk of GE Passport 20-19BB1A engines fuel manifold leaks. GE issued service bulletins to borescope the engine compartment for signs of an undercowl fuel leak or fire damage (72-00-0141-00A-930A-D-001), and to retorque the fuel manifold b-nut connections as well as the fuel manifold-to-fuel manifold b-nut connection (72-00-0142-00A-930A-D-001); the Federal Aviation Administration followed up with Airworthiness Directive AD 2022-13-12 requiring a visual inspection of the core compartment, a retorque of the core compartment coupling nuts, a ground power assurance check, and a follow-up borescope inspection to ensure that there were no leaks before the airplane was returned to service. GE reviewed the fuel manifold and fuel nozzle installation and assembly procedures and made several changes to provide more specific guidance. The changes focused on eliminating possible ambiguities in the written procedures and to minimize any misalignments or unintended installation loads based on the results from the static rig and engine tests. In addition, feedback from the assembly mechanics were included to improve the overall effectiveness of the proposed installation and assembly changes. GE issued a “change in design” to finalize and clarify the optimum fuel nozzle and fuel manifold installation and assembly procedure using the best practices developed during testing. -
Analysis
Post-event inspection of a GE Aviation Passport 20-19BB1A turbofan engine found light sooting aft of the fuel nozzles, along with minor thermal damage to an air duct thermal sleeve consistent with an undercowl engine fire. This corroborates the pilot’s reportA lot of info in factual of pilot's actions but I don't see a pilot statement in the docket. Where did the info come from? of an in-flight engine fire during takeoff climb and during the throttle increases to troubleshoot the fire warning. The engine was removed and sent to GE for evaluation and a fuel system leak check was performed but the source/location of the fuel leak could not be identified. At several fuel nozzle locations, Nos. 12, 14, 16 and 18, the fuel nozzle pigtail-to-fuel manifold b-nut connections were shiny, lacked sooting, and were thought to be possible leak locations. The fuel pressure and nitrogen check pressure used during the leak tests were well below the fuel pressure the engine experienced during the event and were determined to be insufficient to replicate the fuel leak. A torque check of all the fuel manifold b-nut connections found five locations, all located on the left fuel manifold, which had very low torque values, less than 200 inch-pounds, when compared to the other b-nut connection locations and the required installation torque of 285 inch-pounds nominal. Two of the five - Nos. 16 and 18 - were identified as possible leak sources during the initial examination. Detailed analysis of the fuel nozzle No. 18 pigtail-to-fuel manifold b-nut connection revealed evidence of fuel manifold outer diameter surface galling and elliptical and intermediate contact marks indicative of misalignment contact with the fuel manifold female ferrule sealing surface and signs of contaminants and imbedded material (hard particles) on the fuel nozzle male bullnose sealing surface; no other b-nut connection location exhibited this type of surface distress. The source of the hard particle damage could not be positively identified but the observed diagonally orientated abrasive material marks/material removal was consistent with what appears to be a previous repair; there is no record of a repair operation being performed on this specific nozzle. Since the post-event fuel system leak checks performed by GE could not induce a fuel leak, the exact location/source of the fuel leak could not be determined by testing and observations. However, the combination of low fuel manifold b-nut torque, misalignment between fuel nozzle No. 18 pigtail-to-fuel manifold b-nut connection and sealing surface distress created the conditions, and sealing surface distress created the conditions by which there was insufficient sealing allowing fuel to leak during high engine power and high fuel pressures. No other fuel nozzle locations had this combination of factors that would have allowed a fuel leak.
Probable cause
An in-flight engine fire resulted from a fuel leak from fuel nozzle No. 18 pigtail-to-fuel manifold b-nut connection that contacted hot engine parts and ignited. Contributing to the manifold fuel leak was the misalignment between fuel manifold female ferrule and fuel nozzle male bullnose sealing surfaces coupled with distress of the ferrule sealing surface.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOMBARDIER
Model
Global 7500
Amateur built
false
Engines
2 Turbo fan
Registration number
9H-VIG
Operator
VistaJet Ltd
Second pilot present
true
Flight conducted under
Non-U.S., commercial
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
70086
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-03-06T23:59:28Z guid: 106762 uri: 106762 title: ENG22LA020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104937/pdf description:
Unique identifier
104937
NTSB case number
ENG22LA020
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-03T10:06:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Last updated
2023-03-09T22:05:42.769Z
Event type
Incident
Location
West Palm Beach, Florida
Airport
Palm Beach International (PBI)
Weather conditions
Unknown
Injuries
null fatal, null serious, null minor
Factual narrative
On April 3, 2022, at 09:06 eastern standard time, a Bombardier Global 7500 Business Jet, registration number N63RP, powered by two General Electric (GE) Aviation Passport 20-19BB1A turbofan engines and operated by Wing Aviation Charter Services LLC, experienced a left (No. 1) engine fire during takeoff climb from the Palm Beach International Airport (PBI), West Palm Beach, Florida. After the left engine fire warning was annunciated, the pilots reduced power and leveled off at 4,000 feet above ground level (AGL) at which time the fire warning annunciation ceased. The pilots notified air traffic control (ATC) that the fire warning was intermittent, and they were going to proceed with the planned flight. A subsequent climb with the engines at high power resulted in the left engine fire warning to annunciate again. The pilots performed an in-flight turn back to PBI and made an uneventful landing with no injuries reported to the three crew members and 15 passengers on board. The incident flight was a 14 Code of Federal Regulations (CFR) Part 135 non-scheduled domestic passenger flight from PBI to Teterboro airport (TEB), Teterboro, New Jersey. Post-event engine inspection found light thermal distress on the outside of the engine core compartment near the top of the engine from the 10:00 to 11:00 o’clock position, aft looking forward, in the vicinity of the fuel manifolds and the fuel nozzles. Localized discoloration was observed on the inside of the core cowls consistent with the general location of fuel nozzle No. 16 and a thermally distressed engine air duct sleeve (Photo 1). At fuel nozzle No. 16, the fuel nozzle-to-fuel manifold b-nut connection appeared shiny and lacked the sooting that neighboring fuel nozzle-to-fuel manifold b-nut connections exhibited. Photo 1: Possible Fuel and Thermal Impingement locations Photo courtesy of GE (modified by NTSB) The engine has 18 fuel nozzles and fuel is provided to the fuel nozzles by two fuel manifolds mounted on the outside of the combustion case (Figure 1). Figure 1: Fuel Nozzle and Fuel Manifold Diagram Figure courtesy of GE (modified by NTSB) The engine was shipped to the GE Peebles Test Operations facility in Peebles, Ohio, to perform a series of leak checks, torque checks, and alignment checks. A nitrogen check, using soapy liquid at all the fuel manifold b-nut connections was conducted and no leaks were found. A torque check of all the fuel nozzle-to-fuel manifold b-nut connections found that four had very low torque values, less than 200 inch-pounds, when compared to the other b-nut connection locations and the required installation torque of 285 inch-pounds nominal. One of the four low torque locations was fuel nozzle No. 16. All the other fuel manifold b-nut connection torque values were within the expected ranged. After completing the on-engine checks, the fuel manifolds and fuel nozzles were removed and shipped to the GE failure analysis laboratory in Cincinnati, Ohio for additional component evaluation. Detailed examination of the fuel nozzle No. 16 location revealed: 1) galling on the outer diameter of the fuel manifold ferrule sealing surface consistent with the b-nut running onto the tube outer diameter (Photo 2), 2) signs of galling and grooving on the fuel manifold female ferrule inner conical sealing surface that mates with the fuel nozzle male bullnose sealing surface, and 3) elliptical and intermittent contact marks around the fuel nozzle male bullnose conical surface consistent with misalignment contact with the fuel manifold female ferrule; the wear mark was not in the same plane around the entire surface (Photo 3). According to GE, this observed female ferrule sealing surface damage is indicative of misalignment and relative movement within the connection due to high load and low cycle contact and not vibratory wear. Visual examination found no other fuel manifold b-nut connections or fuel nozzle male bullnoses exhibiting similar ferrule sealing surface damage. Photo 2: Fuel Manifold Ferrule Damage at Fuel Nozzle No. 16 Location Photo courtesy of GE (modified by NTSB) Photo 3: Elliptical Contact Pattern on the Fuel Nozzle Male Bullnose Sealing Surface Photo courtesy of GE (modified by NTSB) Several days prior to this event, on March 31, 2022, a Bombardier Global 7500 Business Jet, registration number 9H-VIG, operated by Vistajet, experienced a right (No. 2) engine fire during the takeoff climb from the King Khalid International Airport, Riyadh, Kingdom of Saudi Arabia (OERK). After the right engine fire warning annunciated, the pilots disengaged the autothrottles and retarded the right engine throttle to idle. When the right engine throttle was deduced, the fire warning annunciation ceased. With the fire warning annunciation out, the pilots incrementally increased the right throttle and the fire warning annunciated again. The pilots shutdown the right engine, performed an in-flight air turn back to OERK, and made an uneventful landing with no injuries reported. Post-landing inspection of the right engine by GE on-wing support in the Kingdom of Saudi Arabia revealed indications of an undercowl fire and potential fuel leak locations; NTSB investigation ENG22LA049. The Kingdom of Saudi Arabian Aviation Investigation Bureau (AIB) informed the NTSB of the event on April 14, 2022, and the investigation was ultimately delegated to the NTSB. Due to the similarities with an on-going NTSB investigation (ENG22LA020), a joint Powerplant Group Chair Factual Report was created to document the findings for these two events. During the investigation into the Palm Beach and Riyadh fuel manifold leak events, two additional engines were found to have fuel manifold b-nut connection leaks; those were discovered during inspections performed by Bombardier in response to the Palm Beach and Riyadh events. The two fuel manifold leak engines found by Bombardier did not show any evidence of an undercowl fire. GE performed similar leak, torque, and alignment checks on all those engines along with visual examination of the fuel nozzle and fuel manifold sealing surfaces to determine if there were common causes/anomalies for all the observed fuel manifold leaks. Additionally, GE conducted a series of acceptance test procedure engine runs, developmental engine runs, and component static rig tests to: 1) better understand the effects of fuel nozzle-to-fuel manifold pigtail misalignment, 2) gather assembly and operational loads/stresses on the fuel manifolds under a variety of installation sequence scenarios, 3) validate and develop fuel manifold and fuel nozzle installation best practices and procedures, 4) gather operational data on torque (clamp) relaxation on the fuel manifold b-nut connections, and 5) develop methods to minimize the amount of relaxation experienced in operation. Based on all the data gathered from the event engines, the test engines, and component rig tests, several cumulative factors were found to have contributed to the fuel manifold leaks. Fuel manifold pigtail and fuel nozzle dimensional variation, combined with a given assembly sequence, can create potential misalignment between fuel manifold female ferrule and fuel nozzle male bullnose sealing surfaces, resulting in high resistance in the threads, low effective clamping force, and a false (high) torque reading. This low effective clamped connection can relax/loosen during engine operation as the manifold geometry normalizes and the connection shifts. All the leaking fuel manifold b-nut connections were found on those connections with lower than expected torque values. Since no fuel leaks occurred during the developmental engine tests, and leaks could be induced and stopped with slight variations in torque during the component rig tests, GE concluded that multiple factors can be present to create a leak and they are false (low) torques due to misalignment, higher than anticipated assembly loads due to dimensional variation, and poor/distressed sealing surface condition. Several corrective actions were taken by GE and the Federal Aviation Administration to address and mitigate the risk of GE Passport 20-19BB1A engines fuel manifold leaks. GE issued service bulletins to borescope the engine compartment for signs of an undercowl fuel leak or fire damage (72-00-0141-00A-930A-D-001), and to retorque the fuel manifold b-nut connections as well as the fuel manifold-to-fuel manifold b-nut connection (72-00-0142-00A-930A-D-001); the Federal Aviation Administration followed up with Airworthiness Directive AD 2022-13-12 requiring a visual inspection of the core compartment, a retorque of the core compartment coupling nuts, a ground power assurance check, and a follow-up borescope inspection to ensure that there were no leaks before the airplane was returned to service. GE reviewed the fuel manifold and fuel nozzle installation and assembly procedures and made several changes to provide more specific guidance. The changes focused on eliminating possible ambiguities in the written procedures and to minimize any misalignments or unintended installation loads based on the results from the static rig and engine tests. In addition, feedback from the assembly mechanics were included to improve the overall effectiveness of the proposed installation and assembly changes. GE issued a “change in design” to finalize and clarify the optimum fuel nozzle and fuel manifold installation and assembly procedure using the best practices developed during testing. -
Analysis
Post-event inspection of a GE Aviation Passport 20-19BB1A turbofan engine found light thermal distress on the outside of the engine core compartment near the top of the engine from the 10:00 to 11:00 o’clock position, aft looking forward, and localized discoloration on the inside of the core cowls in the general location of fuel nozzle No. 16 location consistent with an undercowl engine fire. This corroborates the pilot’s report of an in-flight engine fire during takeoff climb. The fuel nozzle No. 16 location appeared shiny, lacked the sooting that neighboring fuel nozzle pigtail-to-fuel manifold b-nut connections exhibited; therefore, it was considered a possible fuel leak location. The engine was removed and sent to GE for evaluation; a fuel system leak check was performed but the source/location of the fuel leak could not be identified. The fuel pressure and nitrogen check pressure used during the leak tests were well below the fuel pressure the engine experienced during the event and was determined to be insufficient to replicate the leak. A torque check of all the fuel manifold b-nut connections found four locations, all located on the left fuel manifold, which had very low torque values, less than 200 inch-pounds, when compared to the other b-nut connection locations and the required installation torque of 285 inch-pounds nominal. One of the four low torque locations was fuel nozzle No. 16 that was identified as a possible leak source during the initial examination. Detailed analysis of the fuel nozzle No. 16 pigtail-to-fuel manifold b-nut connection revealed evidence of galling and intermediate contact marks consistent with and indicative of misalignment and relative movement within the connection; none of the other low torque b-nut connection locations exhibited this type of surface distress. Since the post-event fuel system leak checks performed by GE could not induce a fuel leak, the exact location/source of the fuel leak could not be determined by testing and observations. However, the combination of low torque, misalignment between fuel nozzle No. 16 pigtail-to-fuel manifold b-nut connection, and sealing surface distress created the conditions by which there was insufficient sealing allowing fuel to leak during high engine power and high fuel pressures. No other fuel nozzle locations had this combination of factors that would have allowed a fuel leak.
Probable cause
An in-flight engine fire resulted from a fuel leak from fuel nozzle No. 16 pigtail-to-fuel manifold b-nut connection that contacted hot engine parts and ignited. Contributing to the manifold fuel leak was the misalignment between fuel manifold female ferrule and fuel nozzle male bullnose sealing surfaces coupled with distress of the ferrule sealing surface.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOMBARDIER INC
Model
BD-700-2A12
Amateur built
false
Engines
2 Turbo fan
Registration number
N63RP
Operator
MIRASOL SKY LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
70079
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-03-09T22:05:42Z guid: 104937 uri: 104937 title: WPR22LA142 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104892/pdf description:
Unique identifier
104892
NTSB case number
WPR22LA142
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-03T14:10:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-04-05T23:37:09.259Z
Event type
Accident
Location
Jean, Nevada
Airport
Jean Airport (0L7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On April 03, 2022, at 1310 Pacific daylight time, a Sonerai II L, N333BM, sustained substantial damage when it was involved in an accident near Jean, Nevada. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he departed from Kingman, Arizona, with the intention of landing at his home airport in North Las Vegas, Nevada. Before the flight, he added 3.8 gallons of fuel, but did not know the total amount of fuel on board at the time of departure. While en route, the pilot opted to divert to Jean, Nevada, because of the gusty wind conditions in Kingman. During the flight, he noted that there were strong headwinds but thought he had adequate fuel for the flight. When arriving in the proximately of Jean, the pilot made a low pass over the airport to evaluate the wind conditions. While maneuvering to land on runway 20, the engine sustained a loss of power. The pilot was unable to maintain altitude and the airplane collided with the desert terrain about 0.5 miles north of the approach end of the runway. The Clark County Fire Department responded to the accident site. Fire department personnel stated that a visual examination of the fuel quantity indicator showed the fuel tank was empty. This was confirmed by opening the fuel cap, visually examining the inside of the tank, and then inserting a dipstick. The airplane's fuel system was a gravity-fed design where fuel flowed from an aluminum 10-gallon tank mounted in front of the instrument panel. Inside the tank there was a finger screen at the outlet and at the top of the tank was a vent output port. The port connected to a T-fitting where one clear plastic tube was routed to the instrument panel and back to the bottom of the tank. On the tube was a series of different colored tie-raps that served a fuel quantity indicator for the pilot (see Figure 1 below). The other tube on the T-fitting was routed to the bottom of the airplane and functioned as a vent. From the fuel tanks, the fuel was routed to a fuel shutoff valve and then through several fittings through the firewall to a gascolator (mounted on the engine-side of the firewall). The fuel would then continue to a fuel injector unit, where it was routed from the inlet through an orifice to the air inlet. From the inlet, the fuel-air mixture continued into the intake manifold and into each cylinder. A majority of the fuel pipe fittings had Teflon tape on the threads. Figure 1. Fuel System A postaccident examination revealed that there was no fuel onboard the airplane. The entire system remained un-breached except where the gascolator drain was compromised. The gascolator was clean and no debris was in the screen. The tapered fuel needle remained in the fuel orifice and the throttle slide was in a partially open position, consistent with near full throttle. During a postaccident examination, investigators achieved manual rotation of the crankshaft by rotation of the remaining propeller blades. Valvetrain continuity was observed, with equal lift action at each rocker assembly; oil was found in the rocker box areas on all cylinders. Investigators removed the upper spark plugs of all cylinders and they were light gray/white in color, consistent with lean to normal engine operation. A borescope examination of the cylinders revealed no foreign object damage, no evidence of detonation, and no indication of excessive oil consumption. The exhaust manifold pipes showed white residue consistent with a lean mixture. The magneto timing was consistent with normal operation. The upper spark plugs were reattached to their respective lead and rotation of the crankshaft resulted in a visible spark at each plug; the impulse couplings were audible during rotations. -
Analysis
The pilot stated that he added 3.8 gallons of fuel before departure but did not know the total amount of fuel on board. While en route, the pilot diverted to another airport due to strong headwinds. After passing over the airport and assessing the landing conditions, the engine sustained a loss of power. The pilot was unable to maintain altitude and the airplane collided with the desert terrain adjacent to the runway. A postaccident examination of the engine and fuel system revealed no evidence of a pre-impact mechanical malfunction or failure. First responders stated that a visual examination of the fuel quantity indicator showed the fuel tank was empty. This was confirmed by opening the fuel cap, visually examining the inside of the tank, and then inserting a dipstick. Although the 10-gallon fuel tank was not breached during the accident, the gascolator drain sustained damage. Due to the damage of the gascolator, it is unknown if fuel leaked out of the system following the accident. Therefore, it could not be definitively determined if the loss of power was a result of fuel exhaustion, but no other anomalies could be found.
Probable cause
A reported loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BARBER ROBERT L
Model
SONERAI II L
Amateur built
true
Engines
1 Reciprocating
Registration number
N333BM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-05T23:37:09Z guid: 104892 uri: 104892 title: CEN22LA165 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104883/pdf description:
Unique identifier
104883
NTSB case number
CEN22LA165
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-03T18:55:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-04-04T23:36:28.877Z
Event type
Accident
Location
Calhan, Colorado
Airport
Meadow Lake Airport (KFLY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On April 3, 2022, about 1755 mountain daylight time, a Piper PA-28-235, N9119W, sustained substantial damage when it was involved in an accident near Calhan, Colorado. The pilot and two passengers sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he had texted his girlfriend, who was waiting for him at the destination airport, to inquire about wind conditions. She sent him a photo of a rag in her hand that was not moving, so he assumed the wind was calm. Upon arrival at the airport, the reported wind was from 220° at 10 knots, gusting to 20 knots. As he approached runway 15, he chose to fly a faster approach speed to allow for a quicker go-around, if needed. He stated that as he touched down, a gust of wind pushed the airplane off the runway toward the hangar. Although he knew he impacted ground signs, he attempted a go-around, but was unable to avoid the hangar in front of him and impacted it with the left wing. The pilot later stated that he was unable to maintain control of the airplane during the landing and go-around attempt. Video surveillance of the accident showed the airplane cross the runway threshold and remain airborne until past the first taxiway and appeared to touchdown near the second taxiway before it bounced. It then exited the left side of the runway into a ditch, where the landing gear impacted a sign. The airplane then pitched up, consistent with an attempted go-around, and impacted a building. The airplane sustained substantial damage to the fuselage and both wings. Examination of the wreckage revealed that the left wing was separated from the airplane, consistent with impact forces, and the aileron cable exhibited a broomstraw, or frayed, appearance consistent with an overload separation. The fuselage and right wing were impact damaged, which precluded movement of the remaining flight controls. -
Analysis
The pilot reported that, upon arrival at the destination airport, the reported wind was from 220° at 10 knots gusting to 20 knots. He chose to fly a faster approach speed for landing on runway 15. He stated that, as the airplane touched down, a gust of wind pushed the airplane off the runway toward a hangar. Although he knew he impacted ground signs, he attempted a go-around, but was unable to avoid the hangar in front of him and impacted it with the left wing. The airplane sustained substantial damage to the wing and fuselage. Examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. The pilot stated that he was unable to maintain control of the airplane during the landing and attempted go-around.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Registration number
N9119W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-10732
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-04T23:36:28Z guid: 104883 uri: 104883 title: ERA22LA186 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104925/pdf description:
Unique identifier
104925
NTSB case number
ERA22LA186
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-07T14:10:00Z
Publication date
2023-05-03T04:00:00Z
Report type
Final
Last updated
2022-05-03T18:12:26.925Z
Event type
Accident
Location
Mountain City, Tennessee
Airport
Johnson County Airport (6A4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On April 7, 2022, about 1310 eastern daylight time, an experimental amateur-built Arion Lightning LS-1, N6688S, was substantially damaged when it was involved in an accident near Mountain City, Tennessee. The commercial pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot/owner stated that prior to flight, the airplane was completely filled with fuel, and he performed a preflight inspection with no anomalies noted. The airplane departed on runway 24 at Johnson County Airport (6A4), Mountain City, Tennessee. Runway 24 is a 4,498 ft long asphalt runway. The engine was at full power and the pilot lifted off at 53 knots, but the engine experienced a partial loss of power several seconds later at 70 knots, about midfield. The pilot was not sure that he could land on the remaining runway and immediately turned the right fuel tank to on and the engine rpm increased significantly. Within seconds, the engine lost total power and he elected to keep the airplane on the runway heading to clear several obstacles at the end of the runway. The pilot attempted a forced landing in a field but had to pull-up to clear a fence. The airplane subsequently landed hard in the field and collided with a creek bed, resulting in substantial damage to the forward fuselage. The pilot added that in retrospect, he should have rejected the takeoff during the first loss of engine power. Additionally, the airplane had experienced one other total loss of engine power a few months prior to the accident. At that time, the pilot was in cruise flight when the engine lost power; however, the propeller kept windmilling and he was able to restore power. He does not remember everything that he did to restore power, but he remembered switching fuel tanks He immediately brought the airplane to the kit manufacturer for troubleshooting; however, the cause of the power loss was never determined. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the right wing and fuselage. Adequate fuel remained onboard and was drained by first responders due to a potential environmental hazard. The inspector observed that the fuel bowl was about three-fourths full of fuel and the fuel was absent of visible contamination. He checked the air intake, and it was free of obstructions. Additionally, the propeller rotated without any binding. The wreckage was further examined following its recovery to the airport, by the airport manager and a mechanic with an inspection authorization. The electric boost pump switch in the cockpit was noted in the off position; however, the pilot stated that it was on for takeoff and after impact, he moved the fuel selector, master switch, and fuel pump switch to off. Disassembly of the engine driven fuel pump revealed that the diaphragm return spring on the engine side of the diaphragm was corroded. One end of the spring, where it sat against the steel plate on the diaphragm, was rusted completely away leaving an abrupt sharp point. Examination of the electric boost pump revealed its electrical wire was disconnected from the cockpit pump switch and the pump switch’s spade connector was loose. When the wire was reconnected, the spade connector had to be wiggled to get the pump to activate. Once the pump activated, it pumped 4 psi, which was in the range for normal engine operation. The airplane was assembled from a kit in 2012. Its most recent annual condition inspection was completed on August 16, 2021. At that time, the airframe and engine had accumulated 233 hours since new. The airplane flew an additional 15 hours from the time of the most recent inspection until the accident. The previous owner also built the airplane. The accident pilot stated that he was never able to get the fuel pressure sensor connected properly to the Dynon primary flight display (PFD). As such, fuel pressure was not displayed to the pilot. Additionally, fuel pressure data recorded by the Dynon was erroneous. Data from the PFD were successfully downloaded and plotted; however, the fuel pressure parameter was considered unreliable. Many of the recorded values during the accident flight and previous flight ranged from 0.1 to 0.9 psi, which would not support engine operation. The engine manufacturer published a 3.0 psi as nominal for normal engine operation. -
Analysis
The amateur-built airplane was assembled from a kit about 10 years prior to the accident and had only been flown about 250 hours during those 10 years. After performing a preflight inspection and noting no anomalies, the pilot proceeded to take off from a 4,498-ft-long asphalt runway. During takeoff, the engine experienced a partial loss of power at 70 knots, about midfield. The pilot was not sure that he could land on the remaining runway and immediately turned the right fuel tank to on and the engine rpm increased significantly. Within seconds, the engine lost total power, and the pilot elected to keep the airplane on the runway heading to clear several obstacles at the end of the runway. The pilot attempted a forced landing in a field but pulled up to clear a fence. The airplane subsequently landed hard in the field and collided with a creek bed. The pilot stated that, in retrospect, he should have rejected the takeoff during the initial partial loss of engine power. Examination of the wreckage revealed that the diaphragm return spring on the engine side of the diaphragm was corroded. Additionally, the electric boost pump’s electrical wire was disconnected from the cockpit pump switch and the pump switch’s spade connector was loose. When the wire was reconnected, the spade connector had to be wiggled to get the pump to activate. Once activated, it pumped normally. Given this information, it is likely neither fuel pump was able to provide adequate fuel flow to the engine to sustain normal operation during the takeoff.
Probable cause
A total loss of engine power due to intermittent operation of both the engine-driven fuel pump and the electric boost pump. Contributing was the pilot’s delay in rejecting the takeoff, after the initial loss of engine power, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HENRY L BERRIER JR
Model
ARION LIGHTNING LS-1
Amateur built
true
Engines
1 Reciprocating
Registration number
N6688S
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
131
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-03T18:12:26Z guid: 104925 uri: 104925 title: RRD22LR008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104918/pdf description:
Unique identifier
104918
NTSB case number
RRD22LR008
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-10T02:00:00Z
Publication date
2023-07-03T04:00:00Z
Report type
Final
Event type
Accident
Location
Boston, Massachusetts
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the April 10, 2022, passenger fatality was a short circuit in the passenger door interlock circuit on the accident railcar that enabled propulsion on train 1034 with the door obstructed by a passenger, causing the passenger to be dragged along the platform.
Has safety recommendations
false

Vehicle 1

Railroad name
MBTA
Equipment type
Commuter train-pulling
Train name
Redline Train
Train type
FTA regulated transit
Total cars
6
Findings
creator: NTSB last-modified: 2023-07-03T04:00:00Z guid: 104918 uri: 104918 title: ANC22LA028 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104935/pdf description:
Unique identifier
104935
NTSB case number
ANC22LA028
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-10T14:20:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-04-27T22:38:36.943Z
Event type
Accident
Location
Chugiak, Alaska
Airport
Birchwood (PABV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 10, 2022, about 1320 Alaska standard time, a Cessna 172H airplane, N8020L, sustained substantial damage when it was involved in an accident near Birchwood, Alaska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was landing his tricycle-gear-equipped airplane. Upon touchdown on the asphalt runway, the airplane veered abruptly to the right. He attempted to correct to no avail. The airplane exited the runway, impacted a snowbank, and nosed over, resulting in substantial damage to the vertical stabilizer, rudder, and wings. Examination of the nose landing gear system revealed no pre-accident mechanical malfunctions or failures that would have precluded normal operation. An examination of the landing surface revealed tire witness marks consistent with the airplane touching down on the left main tire in a left-wing-low attitude. The right main tire did not contact the ground until after the airplane had departed the runway surface. -
Analysis
The pilot reported that, upon touchdown on the asphalt runway, the airplane veered abruptly to the right. The airplane exited the runway, impacted a snowbank, and nosed over, resulting in substantial damage to the vertical stabilizer, rudder, and wings. Examination of the nose landing gear system revealed no pre-accident mechanical malfunctions or failures that would have precluded normal operation. An examination of the landing surface revealed tire witness marks consistent with the airplane touching down in a left-wing-low attitude and evidence that the right main tire did not contact the ground until after the airplane had departed the runway. Based on the tire witness marks and the lack of preaccident mechanical malfunctions with the airplane, the circumstances of the accident are consistent with the pilot’s failure to maintain directional control during the landing roll.
Probable cause
The pilot’s failure to maintain directional control while landing, which resulted in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172H
Amateur built
false
Engines
1 Reciprocating
Registration number
N8020L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17256220
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-27T22:38:36Z guid: 104935 uri: 104935 title: ERA22LA188 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104936/pdf description:
Unique identifier
104936
NTSB case number
ERA22LA188
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-12T18:05:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-04-15T04:57:58.04Z
Event type
Accident
Location
Calhoun, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
According to the pilot, he repositioned the helicopter within the landing zone after landing to use its full length for the planned departure. As he applied takeoff power, the pilot inadvertently climbed the helicopter into wires above the main rotor blades. The pilot subsequently reduced power and attempted a run-on landing to an adjacent road, but the main rotor struck a building. The helicopter rolled on its side and was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from wires during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N426DB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
13514
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-15T04:57:58Z guid: 104936 uri: 104936 title: WPR22LA158 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104966/pdf description:
Unique identifier
104966
NTSB case number
WPR22LA158
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-13T12:36:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-04-26T02:11:22.507Z
Event type
Accident
Location
Eastsound, Washington
Airport
ORCAS ISLAND (ORS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 13, 2022, about 1145 Pacific daylight time, an experimental amateur-built Europa XS Mono airplane, N194XS, was substantially damaged when it was involved in an accident near Eastsound, Washington. The pilot was not injured. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that, at the completion of a maintenance flight, while on downwind for runway 34, he reduced the airspeed and lowered the landing gear and flaps, which used a single control lever. He stated that he had to “wrestle” with the lever to get it in the “locked” position, and while doing so the engine lost all power. The pilot extended the downwind leg so he could attempt to restart the engine; however, unable to restore engine power, he turned toward the runway. The pilot realized he would not make it to the runway and the airplane impacted trees about 2,000 ft south of the runway threshold, which resulted in substantial damage to the fuselage. The pilot later reported, after simulating the accident sequence in the airplane, that he may have inadvertently closed one or both rocker switches that controlled the ECU, ignition coils, or fuel igniters. He stated that when he moved the control stick forward to counteract nose high attitude from lowing the flaps, it would have been possible to close the rocker switch controlling the ECU, “an action which results in an immediate engine stoppage.” -
Analysis
The pilot reported that he reduced airspeed and lowered the landing gear and flaps while on downwind for the runway. The landing gear and flaps used a single control lever, which he had to “wrestle” with to get into the “locked” position. While he attempted to lower the landing gear and flaps the engine lost all power. He extended the downwind leg so he could attempt to restart the engine. Unable to restore engine power, he turned toward the runway and the airplane impacted trees short of the runway threshold. The pilot later reported, after simulating the accident sequence in the airplane, that while extending the flaps and landing gear, he likely inadvertently closed, or turned off, a switch that controls the engine control unit (ECU), an action which results in an immediate engine stoppage.”
Probable cause
The pilot inadvertently shut off the engine control unit, which resulted in the engine turning off before the runway landing was attained.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EUROPA
Model
XS Mono
Amateur built
true
Engines
1 Reciprocating
Registration number
N194XS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
A-194
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-26T02:11:22Z guid: 104966 uri: 104966 title: ERA22LA198 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104979/pdf description:
Unique identifier
104979
NTSB case number
ERA22LA198
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-13T15:15:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-04-26T17:31:50.507Z
Event type
Accident
Location
Selma, Alabama
Airport
Craig Field Airport (SEM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 13, 2022, about 1415 central daylight time, a Cessna 310Q, N7733Q, was substantially damaged when it was involved in an accident near Selma, Alabama. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, immediately after takeoff, he needed to use significant left rudder to maintain directional control. After observing the engine monitors and noting that both engines were producing power, he held full left aileron and rudder input to maintain level flight and instructed the pilot-rated passenger to adjust the throttles to turn the airplane back to the airport for a precautionary landing. They were able to maneuver the airplane to land on the airport property, landing hard in the grass at a 45° angle to the runway. The nose landing gear fractured during landing. Examination of the airplane by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also reported that the accident flight was the first flight after the airplane had been painted, and that the flight controls had been removed for the painting. Numerous placards were missing or obscured by paint, and painter’s tape was still attached in some areas. The rudder trim system was found to be significantly out of rig, and the inspectors were unable to move the rudder trim tab to the neutral position. The pilot was unable to provide any maintenance records relating to the rudder removal and reinstallation or a subsequent weight and balance check/adjustment. Although the pilot indicated that he performed the preflight checklist before takeoff, he stated that he may not have checked the control trims that are part of that checklist. -
Analysis
The pilot reported that airplane had been painted and the rudder reinstalled before the accident flight. He stated that immediately after takeoff he noticed that he needed to use significant left rudder to maintain directional control. He executed a precautionary landing on the airport property, landing hard in the grass at a 45° angle to the runway. The fuselage sustained substantial damage and the nose landing gear fractured during the landing. Postaccident examination of the airplane revealed that the rudder trim system was significantly out of rig. The pilot was unable to provide any maintenance records relating to the rudder removal and reinstallation. It is likely that the rudder and/or its trim system was installed incorrectly following the airplane’s repainting, which resulted in the pilot’s difficulty maintaining directional control and inability to make a normal landing on the runway. Although the pilot indicated that he performed the preflight checklist before takeoff, he stated that he may not have checked the control trims that are part of that checklist. It is likely that, had the pilot completed a preflight control check before the flight, he would have identified the improperly rigged rudder trim system.
Probable cause
The failure of maintenance personnel to properly rig the rudder trim system after reinstallation and pilot’s inadequate preflight inspection after recent maintenance, which resulted in an inability to adequately maintain directional control during the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310
Amateur built
false
Engines
2 Reciprocating
Registration number
N7733Q
Operator
JUPITER FLIGHT SERVICE AND INVESTING LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310Q0233
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-26T17:31:50Z guid: 104979 uri: 104979 title: DCA22FM015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104946/pdf description:
Unique identifier
104946
NTSB case number
DCA22FM015
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-04-14T05:30:00Z
Publication date
2023-07-26T04:00:00Z
Report type
Final
Last updated
2023-07-11T04:00:00Z
Event type
Accident
Location
La Porte, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the tugboat George M and the containership MSC Aquarius was the George M mate’s attempt to make up bow to bow while the tugboat and containership were transiting at a speed that was excessive for the advanced harbor-assist maneuver. Contributing to the casualty was the George M mate’s lack of experience operating the tugboat.
Has safety recommendations
false

Vehicle 1

Callsign
368130610
Vessel name
George M
Vessel type
Towing/Barge
IMO number
9905095
Maritime Mobile Service Identity
WDL4355
Port of registry
Houston
Classification society
ABS
Flag state
USA
Findings

Vehicle 2

Callsign
5BJC5
Vessel name
MSC Aquarius
Vessel type
Cargo
IMO number
9262704
Maritime Mobile Service Identity
209716000
Port of registry
Limassol
Classification society
RINA
Flag state
CY
Findings
creator: Coast Guard last-modified: 2023-07-11T04:00:00Z guid: 104946 uri: 104946 title: WPR22LA180 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105093/pdf description:
Unique identifier
105093
NTSB case number
WPR22LA180
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-15T06:30:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-05-24T19:51:57.14Z
Event type
Accident
Location
Benson, Arizona
Airport
BENSON (31AZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 15, 2022, about 0530 mountain standard time, a Piper PA-24-400 airplane, N8493P, was substantially damaged when it was involved in an accident near Benson Municipal Airport (E95), Benson, Arizona. The pilot was not injured. The airplane was as operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was approaching E95 to land when a departing helicopter reported deer near the runway. The pilot stated that he “turned on the landing lights, dropped the gear and started [his] approach to runway 10.” He did not see any deer activity and proceeded to land. Upon landing, the airplane began to shake and then stopped with its belly on the runway and the main landing gear partially extended. The nose gear was not visible due to the airplane’s resting position on the runway. According to personnel who recovered the airplane, the landing gear switch was in the down position at recovery. When the airplane was lifted off the runway, the landing gear remained in a partially extended position and did not operate when power was applied to the airplane and the landing gear switch was manipulated. The landing gear was subsequently lowered and locked into position when the emergency gear system was used. The airplane sustained substantial damage to the skins, frames, and stringers on the belly of the fuselage. During a postaccident examination, the airplane was placed on jack stands for an operational check of the landing gear system. The landing gear motor circuit breaker was found popped. The circuit breaker was reset, and the landing gear was subsequently cycled multiple times, with the landing gear being raised and lowered using the airplane’s electrical power and the landing gear switch. The gear position indicator lights operated normally when the gear changed positions. No damage was noted to the main landing gear wheels or gear doors or the nosewheel. Abrasion damage was noted to the face of both nose gear doors, consistent with the doors being closed during landing. The landing gear was extended to about the position that was observed during recovery. Both the nosewheel and nose gear doors extended about 5 inches below the fuselage. No preimpact anomalies were noted during the examination that would have precluded normal operation of the landing gear. -
Analysis
According to the pilot, he was approaching the airport to land when a departing helicopter reported deer near the runway. The pilot stated that he turned on the landing lights, lowered the landing gear, and flew the approach. He did not see any deer activity and proceeded to land. Upon landing, the airplane began to shake, and the airplane stopped on the runway. The airplane came to rest on its belly and with the main landing gear partially extended. The nose gear was not visible due to the airplane’s resting position on the runway. The landing gear switch was found in the down position, and the gear motor circuit breaker was found popped. The airplane sustained substantial damage to the skins, frames, and stringers on the belly of the fuselage. During postaccident examination of the airplane, the popped gear motor circuit breaker was reset, and the landing gear was cycled up and down successfully using airplane power. No anomalies were noted with the landing gear system. Examination of the underside of the airplane revealed no damage to the main landing gear, wheels, or main gear doors. Examination of the nose gear showed abrasion damage to the face of the nose gear doors. The lack of damage to the main landing gear assemblies and the damage to the face of the nose gear doors was consistent with the gear being in the up position when the airplane touched down on the runway. Even though the pilot stated that he lowered the gear on approach, the evidence is consistent with the pilot failing to lower the gear on approach likely due to distraction from the report of deer near the runway. The gear motor circuit breaker popped because the landing gear switch was likely moved to the down position sometime after the airplane touched down while movement of the landing gear was restricted.
Probable cause
The pilot’s failure to lower the landing gear on approach due to distraction.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-400
Amateur built
false
Engines
1 Reciprocating
Registration number
N8493P
Operator
SONORAN SUNRISE INC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
26-73
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-24T19:51:57Z guid: 105093 uri: 105093 title: ANC22FA030 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104949/pdf description:
Unique identifier
104949
NTSB case number
ANC22FA030
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-15T09:37:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-04-25T20:53:40.05Z
Event type
Accident
Location
Gila Bend, Arizona
Airport
Gila Bend Municipal Airport (E63)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On April 15, 2022, about 0837 mountain standard time, a Robinson R22 helicopter, N7516G, sustained substantial damage when it was involved in an accident near Gila Bend, Arizona. The student pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight initiated at the Chandler Municipal Airport (CHD), Chandler, Arizona at about 0757. The flight was intended to be a solo cross-country flight to the Gila Bend Municipal Airport (E63), Gila Bend, Arizona. A witness located about 1/2 mile west of the accident site reported that the helicopter “came directly down.” He stated that before the impact the rotor blades on the helicopter were rotating; however, he was unable to hear the engine of the helicopter because he was operating heavy equipment. The helicopter impacted the terrain about 212 ft from the end of the runway, slid, and came to rest about 181 ft from the approach end of runway 22 at E63, and 52 ft left of runway centerline. The ground scars indicated the helicopter impacted on about a 180° heading and continued to travel on about a 210° heading before coming to rest on its right side with the nose of the helicopter heading about 096°. - The helicopter sustained upward crushing on the underside of the fuselage and the engine compartment, the landing gear skids were displaced in multiple pieces, and all major components of the helicopter were located at the scene. A postaccident examination revealed that the braided shielding around the governor motor power cable had been repaired with heat shrink for shielding. The governor motor was placed on a test bench and functioned as designed with the heat shrink repair in place. The heat shrink was removed, and it was noted that the braided shield had been worn away or removed and there was a small area where bare wire was visible through the shielding. The engine crankshaft was rotated, and engine continuity was established. Thumb compression was obtained on all cylinders. The magnetos were placed on a test bench and both produced spark at all leads. Internal examination of the cylinders with a lighted borescope showed normal coloration with no evidence of foreign object ingestion, and no evidence of detonation. About 15 gallons of fuel were removed from the fuel bladders. The fuel was free of contaminates. The blue main rotor blade, serial number 3363, was bent upward at about 99 inches on the span with chordwise scoring and scratching on the tip. The red main rotor blade, serial number 3107, was bowed downward about 58 inches at the span. The clutch assembly spun freely and operated as designed in the locked and freewheeled directions. The drive belts were displaced from their grooves from impact with no abnormal wear noted. The main rotor mast rotated freely through 360°. Flight control continuity was established for all flight controls. -
Analysis
The solo student pilot was conducting a cross-country flight when it impacted the terrain 212 ft before the approach end of the runway at the destination airport. The helicopter then slid about 30 ft and came to rest on its right side. A witness located about 1/2 mile west of the accident site reported seeing the helicopter go down and stated that the rotor blades were rotating before the impact. Postaccident airframe and engine examinations revealed no evidence of any preimpact mechanical failures or malfunctions that would have precluded normal operation. Given the upright orientation of the wreckage at impact, the significant damage to the underside of the fuselage, engine and skids, damage to the main rotor blades, coupled with the witness statement, were all consistent with a loss of control and a subsequent uncontrolled descent that resulted in the collision with terrain.
Probable cause
The student pilot’s failure to maintain control during the landing approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N7516G
Operator
Quantum Helicopters
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
3513
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-25T20:53:40Z guid: 104949 uri: 104949 title: ERA22FA189 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104950/pdf description:
Unique identifier
104950
NTSB case number
ERA22FA189
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-16T14:15:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-04-20T19:31:52.009Z
Event type
Accident
Location
JACKSONVILLE, Florida
Airport
Herlong Rec Airport (HEG)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On April 16, 2022, about 1315 eastern daylight time, a Schleicher ASW-19B glider, N19KW, was substantially damaged when it was involved in an accident near Jacksonville, Florida. The private pilot was fatally injured. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the tow pilot, shortly after becoming airborne, he observed the glider in his rearview mirror. He stated that the glider climbed above the tow airplane, then descended, then climbed again. As the tow pilot was reaching for his tow release handle to release the glider, he heard the glider pilot say “release” over the radio. The tow pilot immediately entered a right turn at an altitude of about 250 ft above ground level (agl). He could not immediately see the glider; however, a few seconds later, he saw the glider in the trees adjacent to the runway. The pilot of another airplane, who had just released parachute jumpers, was descending through 9,000 ft agl directly over the airport and could see the tow plane and glider taking off. The witness said that when the glider became airborne it pitched up about 30 to 40°, and he could see the entire nose of the glider. He said the glider stalled and nosed over before it entered a secondary stall and pitched up again. He heard the glider pilot on the common traffic advisory frequency yelling at the tow pilot to “take it easy…something is not right,” followed by the sound of the tow “release” mechanism. The glider then made a left “knife-edge” turn about 200 ft agl. The glider continued in a descending left turn. The left wing impacted the ground first and the tail section separated. The witness added that, right before the glider impacted the ground, the glider pilot said that he was “going down.” The glider pilot was a member of the local soaring club, and the accident was witnessed by several people on the ground. Witnesses stated that the glider made abnormal pitch oscillations before the pilot released from the tow airplane from about 100 to 150 ft agl. One witness described the glider’s takeoff as “erratic” as it climbed and descended behind the tow airplane. After release from the tow airplane, the glider entered a 30° left turn back to the airport, during which it descended and impacted the ground. One witness said the glider appeared to have no elevator authority. PILOT INFORMATION The pilot held a private pilot certificate with ratings for airplane single-engine land and glider. A review of his pilot logbook (glider only) revealed that he had accumulated a total of 324.6 flight hours in gliders, and about 320.3 hours in the accident glider at the time of his last entry on January 15, 2022. AIRCRAFT INFORMATION The Schleicher ASW 19B is a single-seat glider. The most recent annual inspection was completed on April 28, 2021, at an aircraft total time of 1,501.2 hours. WRECKAGE INFORMATION All major components of the glider were accounted for at the accident site. The glider came to rest upright in 3-to-4-ft-high brush in a wetlands area several hundred yards from the runway. The cockpit area was crushed and displaced to the right. The canopy had separated and was found forward and to the right of the main wreckage. An impact scar was observed about 6 ft behind the left wing. The outboard section of the left wing sustained impact damage and was folded over the top of the left wing but remained attached to the inboard section of the wing via control tubing. The right wing was intact and the tip came to rest against a small tree. The air brakes were extended on both wings. The glider’s tail section was partially separated at the empennage and was resting on the right horizontal stabilizer, which was bent down about 90° mid-span. The vertical and left horizontal stabilizer, rudder, and elevator were undamaged. Flight control continuity was established for all flight control surfaces to the cockpit area except for the elevator. The elevator control, which included a fixed ball joint on the base of the elevator and the elevator control tube that extended the length of the vertical stabilizer, was not connected as required by preflight flight assembly procedures. The proper function of the elevator connection was manually tested several times, and no anomalies were noted. The base of the connection clasp contained a small hole for the purpose of using a spring clip to secure the connection. No evidence of a spring clip or other securing device was found. The tow pilot reported to a Federal Aviation Administration (FAA) inspector that the pilot had trailered his glider to the airport the day of the accident and assembled the glider himself, as he had done many times before.   MEDICAL AND PATHOLOGICAL INFORMATION Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified cetirizine, trazodone, pantoprazole, carvedilol, amlodipine, tamsulosin, and losartan in the pilot’s cavity blood and urine. Cetirizine is a sedating antihistamine available over the counter, often with the name Zyrtec. Trazodone is an antidepressant that is often used off-label as a treatment for insomnia. It carries this warning about performance, “Trazodone hydrochloride may cause somnolence or sedation and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely.” Pantoprazole is used to treat heartburn and is not considered impairing. Carvedilol, amlodipine, tamsulosin, and losartan are blood pressure medications that are not generally considered impairing. ADDITIONAL INFORMATION The FAA Glider Flying Handbook (FAA-H-8083-13A), Chapter 8, Abnormal and Emergency Procedures, stated, Failure of any primary flight control system presents a serious threat to safety. The most frequent cause of control system failure is incomplete assembly of the glider in preparation for flight….Perform a positive control check with the help of a knowledgeable assistant. Do not assume that any flight surface and flight control is properly installed and connected during the post-assembly inspection. Instead, assume that every connection is suspect. Inspect and test until certain that every component is ready for flight. -
Analysis
Shortly after the tow airplane and the glider became airborne, the pilot of the glider released from the tow plane about 200 ft above ground level, then entered a left turn back toward the runway, during which the glider impacted terrain. Witnesses to the accident described the glider’s takeoff as “abnormal” and “erratic” and reported that the glider climbed above the tow plane twice before the glider pilot released from tow. Postaccident examination of the glider revealed that the elevator control was not connected as required by preflight assembly procedures, which would have resulted in the pilot’s inability to control the glider’s pitch attitude. According to the tow pilot, the glider pilot had assembled the glider by himself (as he had done many times before) on the morning of the accident. It is likely that, had the pilot completed a positive control check after assembly, he would have identified the disconnected elevator control. Toxicology testing identified two sedating drugs, cetirizine (Zyrtec) and trazodone (an antidepressant), in the pilot’s cavity blood and urine; however, the pilot’s use of these medications most likely did not contribute to the accident.
Probable cause
The pilot’s improper preflight assembly of the glider’s elevator control, which resulted in a loss of control on takeoff, and the pilot’s failure to complete a positive control check before the flight, which would have identified the disconnected elevator control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHLEICHER
Model
ASW-19B
Amateur built
false
Engines
1 None
Registration number
N19KW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
19410
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-20T19:31:52Z guid: 104950 uri: 104950 title: ERA22LA191 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104952/pdf description:
Unique identifier
104952
NTSB case number
ERA22LA191
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-16T20:52:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-04-19T21:47:04.85Z
Event type
Accident
Location
Grantsville, Maryland
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On April 16, 2022, about 1952 eastern daylight time, a Piper PA-32-260, N3618W, was substantially damaged when it was involved in an accident near Grantsville, Maryland. The pilot and two passengers received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he performed a preflight inspection with no anomalies noted, received a weather briefing, and departed Wabash Municipal Airport (IWH), Wabash, Indiana, destined for Martin State Airport (MTN) in Baltimore, Maryland, on an instrument flight rules clearance. About 2 hours into the flight, the airplane was about 11,000 ft mean sea level (msl) approaching clouds, and the pilot increased engine power and turned the pitot heat on. The airplane was “underperforming and unable to climb over the clouds.” After entering the clouds, he noticed the airspeed decreasing and the autopilot increasing the pitch of the airplane to maintain altitude. The pilot disengaged the autopilot, decreased the pitch attitude of the airplane, and noted that it was “difficult to maintain pitch control.” He examined the wings and windscreen for any signs of ice but saw none. The pilot notified air traffic control of his difficulty controlling the airplane, and they declared an emergency for him. The airplane descended out of the clouds into heavy rain. The pilot elected to perform a forced landing to a road. During the landing the airplane impacted trees and terrain, resulting in substantial damage to the fuselage, wings, and empennage. Postaccident examination of the airframe confirmed flight control continuity from the cockpit flight controls to the flight control surfaces through multiple cuts made by recovery personnel and tensile overload fractures. Engine crankshaft and valvetrain continuity were confirmed when the propeller was rotated by hand, and compression was observed on all cylinders. The cylinders were examined with a lighted borescope, and no anomalies were noted. There was no evidence found of pre-impact anomalies that would have precluded normal operation. According to the Airplane Flight Manual and an engineering drawing, the airplane was required to have a placard on the left side of the cockpit that states, “THIS AIRCRAFT APPROVED FOR NIGHT IFR NON-ICING FLIGHT WHEN EQUIPPED IN ACCORDANCE WITH FAR 91 OR FAR 135.” The placard was not located in the cockpit after the accident. Composite weather images for radar scans initiated at 1935:50, 1940:09, 1944:28, and 1948:46, respectively, indicated light to moderate precipitation along the airplane’s flight path (figure 1). The upper air sounding indicated that the freezing level was located at 5,100 ft msl, and cloud conditions were expected up to 13,000 ft msl. Figure 1 - Weather radar image for scan initiated at 1948:46 with the weather encounter location marked with a red circle. The flight track is depicted as a magenta line with black arrows pointing in the direction of travel. The National Weather Service’s Current Icing Product (CIP) and Forecast Icing Product (FIP) are intended to supplement AIRMETs and SIGMETs. The FIPs for 9,000 ft msl, 10,000 ft msl, and 11,000 ft msl indicated a 40 to 85% probability of icing from 9,000 ft msl to 11,000 ft msl over the area corresponding to the weather encounter. The FIPs indicated that the icing intensity would range from “light” to “heavy.” An AIRMET for icing conditions valid from 1700 through 2000 indicated moderate icing between the freezing level and 17,000 ft msl. A performance study was conducted using automatic dependent surveillance-broadcast (ADS-B) data to determine specific airplane performance characteristics. The study showed that during level flight above 10,000 ft msl, there were increases in drag that were also present during the final descent of the airplane. The study indicated that, at 1945, the pitch was increasing and the airspeed was decreasing, which was consistent with the pilot’s report that the autopilot was increasing the pitch to maintain altitude. Just after 1946:30, the pitch decreased, corresponding to when the pilot disconnected the autopilot and decreased the pitch attitude. The airplane began to descend 15 seconds later, and there was a marked increase in drag. At 1947, the airplane began a turn to the right; pitch again increased; but the descent continued while lift and drag increased. At that time, drag was four times higher than any other time in the flight. The airplane’s calculated airspeed slowed to near 54 knots, which was below the power off, gross weight, no flaps stall speed of 57 knots. At 1948, the angle of attack, pitch, lift, and drag all decreased suddenly; this loss of lift was consistent with an aerodynamic stall. The airplane then recovered and gained airspeed while continuing to descend. At 1951, the drag quickly increased but without an increase in lift, and the airplane began a turn to the right. At 1951:30, the lift dropped sharply without having increased during the increase in drag. This sudden loss of lift occurred at a much lower lift coefficient and angle of attack than the previous event at 1948 and at an airspeed above 100 knots, well above the airplane’s stall speed. The airplane recovered briefly before the drag began to increase again. The airplane was still slowing when the ADS-B data ended as the airplane descended below 150 ft above the terrain. The accident site was located about 2,500 ft beyond the last data point. Generally, ice accumulation on an airplane’s wings increases drag and reduces the amount of lift the wing can produce. Ice accumulation on the fuselage of an airplane also increases drag. Additionally, ice accumulation on propeller blades reduces the amount of thrust that can be produced. The pilot did not request weather information from Leidos Flight Service; however, he did request and receive a ForeFlight weather briefing at 1713 with a proposed departure time of 1725. The pilot reported that there was moderate icing forecast for the time of the flight. -
Analysis
During cruise flight above 10,000 ft mean sea level (msl) in instrument meteorological conditions (IMC), the pilot noted the airplane’s airspeed slowing and the autopilot pitching the airplane up in order to maintain altitude. After he disconnected the autopilot, the pilot had difficulty maintaining pitch control. The pilot suspected that the airplane was accumulating ice but did not see any on the wings or windscreen. A performance study using automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane descended and slowed until there was a sudden loss of lift near the airplane’s stall speed, which was consistent with an aerodynamic stall. The pilot lowered the nose, and the airplane gained airspeed while continuing to descend. About 3 minutes 30 seconds later, the airplane experienced a second sudden loss of lift at a much lower lift coefficient and higher airspeed. This second loss of lift was consistent with an accumulation of ice on the wing, which increased drag and reduced the amount of lift the wing could produce before a stall. The airplane recovered briefly before drag again began to increase. Drag continued to gradually increase until the flight descended below ADS-B coverage. According to the pilot, the airplane descended out of the clouds into heavy rain. The pilot performed a forced landing to a road. During the landing the airplane impacted trees and terrain, resulting in substantial damage to the fuselage, wings, and empennage. Based on surface weather observations, upper air sounding data, and satellite weather imagery, clouds were likely present in the accident area from 3,300 ft msl (about 400 ft above ground level) through 13,000 ft msl. In areas with precipitation, which the flight encountered, clouds likely persisted from 13,000 ft msl to near the surface. Moderate or greater icing conditions were indicated from near 6,000 ft msl through 9,500 ft msl, but icing conditions likely persisted through 13,000 ft msl near the cloud tops. Further, supercooled liquid droplets (SLD) conditions were likely present in the icing encountered by the flight. The flight was likely in IMC below 13,000 ft msl with moderate or greater icing conditions and SLD. The pilot’s reports that the airplane was underperforming, unable to climb, and that the autopilot was increasing pitch to maintain altitude were consistent with ice accumulation degrading handling. The second loss of lift event occurred at a high lift coefficient, high angle of attack, and at an airspeed lower than the airplane’s stall speed. The ice accumulation on the airplane likely made it difficult for the pilot to control airspeed and attitude, which resulted in a loss of control. Based on the ForeFlight weather briefing information that the pilot received, he should have been aware of the potential for icing conditions on the accident flight. His decision to continue the flight in an airplane not equipped for flight into known into icing conditions resulted in the accident.
Probable cause
The pilot’s decision to continue the flight into an area of moderate to heavy icing conditions, which resulted in a degradation of airplane performance and subsequent loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N3618W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-519
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-19T21:47:04Z guid: 104952 uri: 104952 title: CEN22LA181 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104987/pdf description:
Unique identifier
104987
NTSB case number
CEN22LA181
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-20T20:15:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-04-22T21:51:09.557Z
Event type
Accident
Location
Manhattan, Kansas
Airport
Smith Airport (43KS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On April 20, 2022, about 1915 central daylight time, a Cessna 172M, N9263H, was substantially damaged when it was involved in an accident at Smith Airport (43KS), Manhattan, Kansas. The pilot sustained minor injuries and the passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported flying a visual approach to a 2,800-ft turf runway that had an upslope. When the airplane was about two-thirds down the runway, at an airspeed of about 55 knots, and with its flaps extended, the pilot applied full throttle. The pilot perceived a partial loss of engine power based on lower-than-expected noise and the airplane’s inability to climb normally. The airplane descended slightly and subsequently impacted trees and fence poles off the end of the runway, which substantially damaged both wings. Postaccident examination of the engine revealed no anomalies that would have precluded normal power. The pilot stated that he did not apply carburetor heat during the visual approach. According to the Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, the airplane had a probability of encountering serious carburetor icing at glide power near the accident location. A pilot familiar with 43KS reported that the runway upslope was “deceiving and can sneak up on you” and that a creek at the departure end often produced “dead air” and a loss of lift, which demonstrated the importance of executing a flyover with excess airspeed. After the accident, the pilot stated that he should have maintained a higher airspeed during the low approach and initiated the go-around earlier. -
Analysis
The pilot flew a low approach to a turf runway with an upslope and then attempted a goaround with an airspeed of about 55 knots and the flaps extended. The pilot noted a partial loss of engine power and noted that the airplane would not climb. The airplane descended slightly and subsequently impacted trees and fence poles beyond the departure end of the runway, which damaged both wings. Postaccident examination of the airplane and engines revealed no anomalies that would have precluded normal operation. The pilot stated he did not apply carburetor heat during the approach. With the probability of serious carburetor icing at glide power, the lack of carburetor heat likely contributed to the partial loss of engine power during the go-around attempt. Another pilot familiar with the airport reported that the runway’s upslope was difficult to fly over. Because the pilot did not maintain a higher airspeed during the low approach and initiate the go-around earlier, he flew an unsuitable profile for the upsloping runway.
Probable cause
The pilot’s failure to use carburetor heat during the approach and his unsuitable flight profile for an upsloping runway, which resulted in a partial loss of engine power and an impact with terrain during an attempted go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N9263H
Operator
K S FLYING CLUB INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17266056
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-04-22T21:51:09Z guid: 104987 uri: 104987 title: ERA22LA203 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104999/pdf description:
Unique identifier
104999
NTSB case number
ERA22LA203
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-22T19:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-06-15T04:31:23.658Z
Event type
Accident
Location
Westminster, Maryland
Airport
Clearview Airpark (2W2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that he was conducting a local solo instructional flight and landing in calm wind conditions. During his first approach the airplane was “too high and fast,” and he performed a go-around. During his second approach the airplane was “a little high and fast;” however, he elected to continue the landing. The student pilot could not recall the point on the runway where the airplane touched down but knew it was “past the go-around point.” The pilot stated that the airplane carried too much speed to stop on the remaining runway. The airplane overran the departure end, continued down an embankment, nosed over, and came to rest inverted. The airplane’s vertical stabilizer was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to attain the proper touchdown point which resulted in a runway overrun.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N35571
Operator
CLEARVIEW FLYING CLUB INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17256842
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-15T04:31:23Z guid: 104999 uri: 104999 title: WPR22FA164 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104989/pdf description:
Unique identifier
104989
NTSB case number
WPR22FA164
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-23T19:48:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-04-26T21:54:17.179Z
Event type
Accident
Location
Cedar City, Utah
Airport
CEDAR CITY RGNL (CDC)
Weather conditions
Visual Meteorological Conditions
Injuries
4 fatal, 0 serious, 0 minor
Factual narrative
The weight of the airplane at the time of departure from CDC was estimated to be about 128 pounds over the maximum gross weight (2,646 pounds). Based on the airplane’s most recent weight and balance information, full fuel level (40 gallons), the reported or measured occupant weights, and no baggage. The airplane’s center of gravity (CG) was calculated using the passenger and seat locations in the most favorable position and was found to be outside of the manufacturer’s approved CG envelope. According to the performance information in the DA-40 Airplane Flight Manual and the assumed altitude and air density conditions, the airplane’s climb performance would have been about 300 ft per minute. - On April 23, 2022, about 1848 mountain daylight time, a Diamond Aircraft DA 40, N321PF, was destroyed when it was involved in an accident near Cedar City Regional Airport (CDC), Cedar City, Utah. The pilot and three passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The operator reported that the pilot rented the airplane with the intent to fly a multileg cross-county flight from his home base of Spanish Fork Municipal Airport/Woodhouse Field (SPK), Spanish Fork, Utah. The planned route of flight comprised stops at CDC and four other airports before returning to SPK. The operator stated that the airplane departed SPK on the first leg with about 40 gallons of fuel.   Recorded airport surveillance video at CDC showed that the accident airplane landed at 1615 and taxied to the self-serve fuel pumps. The pilot and passengers disembarked, and the pilot refueled the airplane, adding about 14 gallons of fuel. The pilot and passengers subsequently boarded the airplane for the next destination, Bryce Canyon Airport (BCE), Bryce Canyon City, Utah, and taxied toward the runway.    A pilot-rated witness, who was driving westbound down Cedar Canyon, reported that he observed the accident airplane flying up the canyon and over the river at an altitude of about 300 ft above ground level (agl). The witness stated that. as the airplane was about to pass over his position, the airplane turned left and then right, and its maneuvers were “quick” and “like a rocking motion.” The witness added that the propeller appeared to be under power and not windmilling.   Another witness, who was traveling near the accident site, reported that he observed the accident airplane flying on an easterly heading over the highway at an altitude of about 200 to 300 ft (agl). The witness stated that, other than being low, the airplane did not appear to be in distress. The witness also stated that that his vehicle’s windows were up, so he could not hear the airplane’s engine. After the airplane passed over the witness’ position, he looked in the mirror and saw the airplane “bank really hard to the south, back across the highway” as if the airplane “were trying to turn around in the narrow canyon.” The witness added that, at that point, the airplane’s wings were “almost completely vertical” and that the airplane “didn’t look like it had enough speed to pull off that maneuver.”    The airplane impacted mountainous terrain along the southern edge of the canyon about 7 miles southeast of CDC. A postcrash fire ensued. - The Utah Department of Health, Office of the Medical Examiner, Taylorsville, Utah, performed an autopsy of the pilot. His cause of death was blunt force injuries. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found no ethanol or drugs of abuse in the pilot’s specimens. - The calculated density altitude at the time of departure was about 6,022 ft. The calculated density altitude at the accident location and the time of the accident was 7,203 ft. - During his last Federal Aviation Administration medical examination, the pilot reported that he was 74 inches tall and weighed 215 pounds. - Examination of the accident site revealed that the airplane impacted mountainous terrain along the southern edge of a canyon about 7 miles southeast of CDC. The airplane came to rest inverted on a magnetic heading of about 289° and at an elevation of 6,583 ft mean sea level. The first identified point of contact (FIPC) was a tall tree with damaged limbs near the top of the tree. The debris path was oriented on a magnetic heading of about 294° and was about 150 ft in length from the FIPC to the main wreckage. All major structural components of the airplane were located in the debris path. The figure below shows the wreckage at the accident site. Figure. Accident site diagram. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. Postaccident examination of the airframe and engine revealed no evidence of mechanical anomalies that would have precluded normal operation. -
Analysis
Witnesses traveling near the accident site reported that they observed the accident airplane flying on an easterly heading about 200 to 300 ft above ground level. The airplane did not appear to be in distress. After the airplane passed over the witnesses’ positions, the airplane maneuvered as if the pilot were trying to turn it around. One witness stated that the airplane’s wings were almost completely vertical at that point. The airplane subsequently impacted mountainous terrain about 7 miles southeast of the departure airport. A postcrash fire ensued. Postaccident examination of the airplane revealed no evidence of a pre-existing mechanical malfunction that would have precluded normal operation. A review of the airplane’s weight and balance information showed that, at the time of departure, the airplane was about 128 pounds over the airplane’s maximum gross weight of 2,646 pounds. The airplane was also outside the approved center-of-gravity envelope. The calculated density altitude at the time of departure was about 6,022 ft. The calculated fuel use from the departure airport to the accident location was about 5 gallons. Thus, at the time of the accident, the airplane was likely about 98 pounds over the maximum gross weight. The calculated density altitude at the accident location and the time of the accident was about 7,203 ft. The calculated climb performance for the airplane, at its assumed altitude and air density conditions, would have about 300 ft per minute. The excessive airplane weight likely limited the airplane’s ability to climb in mountainous terrain.
Probable cause
The pilot’s failure to maintain obstacle clearance, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s decision to operate the airplane above its maximum gross weight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40
Amateur built
false
Engines
1 Reciprocating
Registration number
N321PF
Operator
Platinum Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
40.375
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-04-26T21:54:17Z guid: 104989 uri: 104989 title: ERA22LA200 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104991/pdf description:
Unique identifier
104991
NTSB case number
ERA22LA200
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-24T13:24:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-05-31T16:36:39.633Z
Event type
Accident
Location
Perry, Florida
Airport
Perry-Foley Airport (FPY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
According to the pilot, he topped off both wing fuel tanks about 2 weeks prior to the accident flight. The engine was ground run for about 10 minutes on the day after the fueling, after which the airplane was parked until the day of the accident flight. During the preflight inspection for the accident flight, the pilot sampled fuel from the fuel drains, but did not visually inspect the level of fuel in the fuel tanks, and assumed they were both full. About 1 hour into the flight, the engine started to “miss”, and the pilot then activated the fuel boost pump. The engine then ran normally for about 15 to 20 seconds before it began to “miss” again, until a few moments later when it lost all power. The pilot attempted to divert to a nearby airport, however during the approach he determined he would not reach the runway, and he selected a field for a forced landing. During landing the airplane struck trees, and a portion of the left wing separated about 3 ft outboard of the root. The airplane impacted terrain, came to rest inverted, and sustained additional substantial damage to the right wing, forward fuselage, horizontal stabilizer, and elevator. A Federal Aviation Administration inspector observed that both of the left wing fuel tanks were breached and that only a trace amount of fuel was found in the fractured left wing fuel line near the fuselage. The right wing fuel tanks remained intact but were inaccessible. The inspector reported, and the pilot confirmed, that there was no odor of fuel at the accident site. Following the accident, pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation prior to the accident. He concluded that although he believed the fuel tanks were full prior to departure, they likely were not, and he did not confirm the fuel level during the preflight inspection. The pilot further described that the airplane was equipped with fuel quantity gauges, however the gauges were located in the footwell for the rear seat, near but below his hips when seated in the front seat, and they were difficult to see from the front seat position. He added that the fuel quantity gauges were of limited use. Due to the wing dihedral, the gauges would indicate “full” until about 8-12 gallons had been used, and then read empty after using another 3-4 gallons. He had instead used the fuel computer/totalizer indications to reference fuel quantity. He had previously calibrated the totalizer by comparing its indications with fueling records several times and found it to be accurate. Given this information it is likely that the loss of engine power was the result of fuel exhaustion.
Probable cause
The pilot’s inadequate preflight inspection of the fuel quantity, which resulted in fuel exhaustion, a subsequent total loss of engine power, and an off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TITAN
Model
T51
Amateur built
true
Engines
1 Reciprocating
Registration number
N151CM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M18XXXCOHK0218
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-31T16:36:39Z guid: 104991 uri: 104991 title: ERA22FA207 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105004/pdf description:
Unique identifier
105004
NTSB case number
ERA22FA207
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-26T14:00:00Z
Publication date
2023-12-08T05:00:00Z
Report type
Final
Last updated
2022-05-02T19:46:59.03Z
Event type
Accident
Location
Elba, New York
Airport
Genesee County Airport (GVQ)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On April 26, 2022, at 1300 eastern daylight time, a Bell Helicopter Textron Canada, 429, N507TJ, was substantially damaged when it was involved in an accident near Elba, New York. The flight instructor and pilot receiving instruction were fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. A representative of the operator stated that the instructional flight was recurrent training being conducted by the helicopter manufacturer’s flight instructor with multiple training flights planned throughout the day; the accident flight was the second flight of the day. The first pilot who received training from the flight instructor on the morning of the accident flight stated that during their flight they entered vortex ring state (VRS) with a very high descent rate, which was confirmed by the flight data recovered from the accident helicopter. While in VRS, the pilot stated that he didn’t know why they were going so deep into VRS and that the instructor was just sitting there, “hands on his lap.” So, the pilot, feeling uncomfortable at that point, had to exit this very high descent rate on his own rather than waiting for further guidance from the instructor pilot. The helicopter was equipped with an Electronic Data Recorder (EDR) within its Display Unit (DU), also known as the Pilot Flight Display and Multi-Function Display, that recorded flight, navigation, engine, and usage parameters every half second. It was also equipped with a SKYTRAC transceiver that facilitated real-time fleet awareness, group communications, and systems performance trending and analysis. The accident flight was also recorded by automatic dependent surveillance-broadcast (ADS-B). ADS-B data, combined with the DU and SKYTRAC data sources, revealed that the accident pilot and the flight instructor departed Genesee County Airport (GVQ) Batavia, New York at 1111, and performed multiple maneuvers in the immediate vicinity of the airport before departing to the east. About 20 minutes later, the helicopter returned to the airport and performed additional maneuvers in the airport traffic pattern for about 30 minutes before again departing the traffic pattern. From about 1223 to 12:55, the pilot and instructor practiced single-engine training and dual-engine failure training with autorotations. These training maneuvers were completed about 4 minutes and 30 seconds before the accident occurred. About 12:56, the helicopter was flying over the airport and turned north. About 12:58, the helicopter was approximately 2 nm north-northeast of the airport and began a clockwise circular pattern. From 12:59:26 to 12:59:44 (18 seconds), the helicopter was operating in an envelope conducive to VRS. At 12:59:47 there were multiple abrupt control inputs; the cyclic was nearly full forward and to the left with right antitorque pedal input applied. The collective lever position was in the full down position; the airspeed was decreasing from 26 knots to 9 knots with the helicopter’s vertical descent rate increasing from -800 to -1,300 fpm. Several eyewitnesses observed and heard the helicopter flying overhead before the accident and throughout the accident sequence. One stated that he observed the helicopter “almost stationary” after it flew over, and then as it started to fly away, he heard a loud “bang”, and the helicopter began to descend out of control. An additional witness stated that the helicopter was hovering before it “fell apart” with the fuselage falling separately, and another witness stated she did not see the helicopter but heard what sounded like an engine making a “whooshing” sound, and then “three loud and rapid cracks” in succession. She further stated that she heard the helicopter impact the ground and heard the rotor blades striking the ground rapidly. AIRCRAFT INFORMATION The accident helicopter was maintained by the operator under the manufacturer’s recommended inspection program. The last entry in the helicopter’s airframe maintenance logbook was dated April 24, 2022, and reflected airframe and engine total times of 1,039.6 hours. Each engine contained an electronic engine control (EEC) and a data collection unit (DCU). Attempts were made to recover stored data within these units, but no data could be recovered from the No. 1 engine EEC and DCU due to impact damage. However, data were recovered from the No. 2 engine EEC and DCU. The recovered data showed that there were no faults or exceedances recorded during the flight. WRECKAGE AND IMPACT INFORMATION The helicopter fuselage, containing the cockpit, engine, transmission, and rotor head assembly, struck electrical distribution wires as it impacted the terrain at an elevation of about 1,220 ft msl and was oriented on a heading of about 190°. The helicopter came to rest on its left side; the fuselage impacted the ground and crushed inwards and fractured into two large sections, leaving no occupiable space in the cockpit. A small post-impact fire developed in the engine compartment but was quickly extinguished by first responders. The wreckage path was about 2,500 ft-long and oriented in a direction of 250° magnetic from the first wreckage pieces towards the main fuselage resting place. The tail boom had fractured and separated into two sections with angled fracture lines consistent with main rotor blade contact. The forward tail boom section remained attached to the upper section of the fuselage about 8 ft aft of the engine exhaust. The aft tail boom, containing the tail rotor, partial drive shaft, vertical fin, and horizontal stabilizer remained largely intact and was discovered about 390 ft on a heading of about 075° from the main wreckage. A 16-inch section of the tail rotor drive shaft cover and a partial carbon fiber tail rotor shaft was discovered 1,620 ft and a 072° heading from the main wreckage; it exhibited an angled slice line consistent with main rotor blade contact. The tail rotor remained installed on the tail rotor gearbox, which itself remained installed on the separated empennage. The four tail rotor blades did not exhibit significant damage. The tail rotor input control was manually actuated and a corresponding change of pitch for all four tail rotor blades was observed. The tail rotor pitch control tube had fractured forward of the tail rotor gearbox and exhibited multiple fractures through its normal routing through the tail boom. The tail rotor servo actuator and stability and control augmentation system (SCAS) actuator remained installed and connected to the tail rotor pitch control tube. The forward tail rotor drive shaft remained connected to the main gearbox but had fractured about midway to the fan blower shaft. The fan blower remained installed on the airframe. The forward segmented drive shaft remained attached to the fan blower shaft and was continuous through the forward snubber but had fractured near its connection to the aft segmented drive shaft and the hanger bearing; the hanger bearing was not present. The aft segmented drive shaft had fractured near its forward end and at the tail gearbox input flange. A portion of the aft snubber remained attached to its snubber mount. The tail rotor gearbox remained installed on the empennage. The tail rotor was manually rotated through several 360° rotation of the tail rotor gearbox input flange and resulted in a corresponding rotation of the tail rotor. The rotation was smooth and there were no abnormal sounds or evidence of binding or other restrictions. Examination of the flight control system consisting of the cyclic and collective push-pull tubes were traced through cuts made to facilitate recovery and overload separation damage to each of their respective servo actuators, cockpit controls, and their respective hydraulic system. The collective push-pull tube was continuous through the forward bellcrank up to the collective servo actuator. Control continuity was established between the collective servo actuator and the collective lever. The lateral cyclic push-pull tube was continuous to the forward bellcrank, to which the forward [of the two] roll SCAS actuators was attached. All the damage had features that were consistent with overload due to impact and aerodynamic forces. There was no anomalous preimpact damage or irregularity to the flight control system. Control continuity was confirmed for both collective, cyclic, and tail rotor directional control. Examination of the hydraulic system consisting of two separate and independent pressurized hydraulic systems were used to assist cyclic, collective, and antitorque flight controls. All damage was consistent with impact; there was no preimpact anomalous damage or other irregularity noted in the hydraulic modules, actuator pumps, or associated systems. Examination of all four main rotor blades, identified as ‘orange’, ‘blue’, green’, and ‘red', revealed they were separated from the main rotor head and discovered within the debris field northeast of the main wreckage. The span of all four blades were recovered. The tip ends of all four blades exhibited impact marks. The ‘red’ main rotor blade afterbody was generally whole and its leading edge did not exhibit significant fractures. On the lower surface of the ‘blue’ main rotor blade, an impact gouge was present, its location (about 89 inches from the inboard blade bolt) and size was consistent with the antenna mounted immediately aft of the engine exhaust pipes. The upper rod end of the ‘blue’, ‘orange’, ‘red’, and ‘green’ main rotor blade pitch change links (PCL) remained attached to its pitch horn but had fractured at their threaded connection to their respective PCL. The fracture on all four PCL upper rod end threads exhibited signatures consistent with overload and was deformed in the inboard direction. The lower rod ends of all four PCLs remained attached to the rotating swashplate but had fractured features consistent with overload. Three PCL bodies, ‘orange’, ‘blue’, and ‘red’, were recovered. The ‘orange’ PCL exhibited slight deformation of the link body. The ‘blue’ PCL exhibited no significant deformation. The swashplate assembly remained installed on the main rotor mast. The two rotating scissor link assemblies remained installed and attached between the rotating swashplate and the main rotor mast. All 4 rotor blades and their subcomponents were damaged by impact forces both during the initial flight breakup and through impact with the terrain. The main rotor drive system gear box remained partially attached to the airframe, with both left and right longitudinal pitch restraints separated from their respective stops. Both input driveshafts could be manually rotated counterclockwise in the freewheeling direction but could not be manually rotated in the clockwise direction, likely due to impact damage. Both engines were located within the main wreckage. The No. 1 engine’s first stage compressor blade contained one individual blade that was bent in the direction of normal rotation and the leading edge contained several indentations and marks. The other blades appeared intact and free of impact or thermal damage. The power turbine blades visible through the engine exhaust did not exhibit anomalous damage or deformation, and all blades were present. The No. 2 engine’s first stage compressor blades exhibited impact damage and gouges on their leading edges. Scrapes were present on the inner housing of the first stage compressor blades in line with the blade tip path. The power turbine blades visible through the engine exhaust did not exhibit anomalous damage or deformation, and all blades were present. Postaccident examination of both engines and their respective components revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded their normal operation. The engine switches in the cockpit located in the center below the glareshield exhibited minor deformation. The No. 1 engine switch was undamaged and functioned smoothly. It was discovered in the “OFF” position. The No. 2 engine switch was slightly bent and was discovered in the “ON” position. No pre impact anomalies were observed with the avionics or the electrical system. TESTS AND RESEARCH A vehicle performance study was conducted using parametric data for the accident flight as well as the flight immediately preceding the accident flight. A VRS envelope for the Bell 429 was calculated based on the conditions of the day and the helicopter’s estimated gross weight. The performance study determined that the helicopter had penetrated the VRS envelope on both the morning flight and the accident flight. According to airframe manufacturer’s analysis of the flight data, before entering an autorotation, the helicopter was flying a north-west heading and entered a right turn to stabilize in an eastern heading of about 100° The helicopter entered a VRS condition as evidenced by an increased sink rate and low airspeed. At 12:59:44, a longitudinal rapid forward cyclic input from 32% (aft) to 70% (fwd) was recorded and the helicopter started pitching nose down from 4.6 degrees up to -17.05 degrees nose down. This was followed a second later at 12:59:45 by a rapid aft longitudinal cyclic input to 5.75% (0% being the aft longitudinal stop, 50% being a centered cyclic and 100% being the forward longitudinal stop). The rapid cyclic input recorded would not have allowed sufficient time for the airframe attitude to adjust to the main rotor inputs from the cyclic because of the rapid aft cyclic movement (-65% in 1 second). A Vuichard exit method for VRS requires opposite side pedal to the lateral cyclic position. From the data analysis, the cyclic position was mostly aft and right while the pedal position was also to the right side before the rapid aft cyclic input. The collective position was 24.83% at the first forward cyclic input and down to 0.62% while the cyclic was quickly moved to a close to full aft position. The airframe manufacturer also conducted a blade arc study. They placed the tail rotor drive shaft cover that was recovered from the accident helicopter on an exemplar helicopter. The resulting installation and measurements showed that the main rotor blades could contact the cover at the same position as observed on the accident wreckage, and that a further result would be main rotor blade contact with an antenna and the tail rotor drive shaft. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Medical Examiner, Monroe County, New York, performed autopsies of the instructor pilot and company pilot. Both pilots’ causes of death were multiple blunt force injury and their manners of death were accidental. ADDITIONAL INFORMATION Vortex Ring State According to the FAA's Helicopter Flying Handbook (FAA-H-8083-21B), a vortex ring state "describes an aerodynamic condition in which a helicopter may be in a vertical descent with 20 percent up to maximum power applied, and little or no climb performance." The handbook also states the following: A fully developed vortex ring state is characterized by an unstable condition in which a helicopter experiences uncommanded pitch and roll oscillations, has little or no collective authority, and achieves a descent rate that may approach 6,000 feet per minute (fpm) if allowed to develop…. Situations that are conducive to a VRS condition are attempting to hover out of ground effect (OGE) without maintaining precise altitude control, and approaches, especially steep approaches, with a tailwind component. According to the airframe manufacturer’s training manual, when recovering from a VRS condition, the pilot tends first to try to stop the descent by increasing collective pitch. The traditional recovery is accomplished by increasing airspeed, and/or partially lowering collective to exit the vortex. Another method to recover from VRS, known as the Vuichard recovery technique, results in the quickest exit from VRS and requires the increase in collective to a climb power setting and the application of left pedal to maintain heading; simultaneously applying right cyclic to 20-degrees angle of bank - then back to wings level, to generate lateral movement. As soon as the advancing rotor blade reaches the upward flow of the vortex, the recovery is completed. This will be indicated by the VSI less than 300 fpm, and then apply cyclic and collective as necessary to return to the directed altitude and airspeed. Vortex Ring State Training According to the FAA's Helicopter Instructor's Handbook (FAA-H-8083-4), vortex ring state (also known as settling with power) can safely be introduced and practiced at altitudes allowing distance to recover. The handbook also states the following: Ensure the student understands that settling with power can occur as a result of attempting to descend at an excessively low airspeed in a downwind condition, or by attempting to hover OGE at a weight and density altitude greater than the helicopter's performance allows…. Recovery is accomplished by…if altitude allows, reducing collective and lowering the nose to increase forward speed. This moves a helicopter out of its downwash and into translational lift. When the helicopter is clear of the disturbed air, or downwash, confirm a forward speed indication and initiate a climb to regain the lost altitude. -
Analysis
The flight instructor was providing recurrent training to the operator’s pilots. During the first training flight of the day, a pilot who received instruction from the flight instructor described that the instructor told him to perform a vortex ring state (VRS) recovery maneuver, which the pilot accomplished, but shortly afterwards, the instructor requested that the pilot perform the maneuver again. During the second entry into VRS, the helicopter developed a very high descent rate, and the pilot was surprised when the flight instructor pilot did not intervene as the helicopter got deeper into the state. The pilot, feeling uncomfortable at that point, exited the very high descent rate on his own rather than waiting for further guidance from the instructor. The remainder of the first flight was uneventful. The second training flight of the day was the accident flight. A review of the recovered parametric data for this flight showed that the helicopter had been performing training maneuvers, and that shortly before the accident the helicopter was operating within the VRS envelope with a vertical descent rate between -800 to -1,300 feet per minute (fpm). This was consistent with the instructor directing the accident pilot to enter VRS for training purposes. Shortly thereafter, multiple abrupt control inputs were recorded, which including a forward cyclic input, followed by a nearly full-aft cyclic input within 1 second, as well as a concurrent full-down collective input with an increasing left pedal input. Based on contact signatures found on the helicopter’s main rotor blades and tailboom after the accident, it is likely that these abrupt control inputs resulted in the main rotor blades contacting the tail boom and the subsequent in-flight breakup of the helicopter. The parametric data and physical evidence observed during a postaccident examination of the wreckage revealed no evidence of any mechanical malfunctions or failures of the helicopter that would have precluded recovery from VRS. Based on this information, the reasons why the pilot(s) might have applied these abrupt control inputs could not be determined. Given the contextual commentary from the pilot of the previous training flight, it is likely the flight instructor did not provide adequate information to the accident pilot on how he would receive training for VRS, to include how they would identify, enter, and exit VRS.
Probable cause
The pilots’ inappropriate flight control inputs while in vortex ring state, which resulted in main rotor blade contact with the tail boom and a subsequent in-flight breakup. Also causal was the flight instructor’s inadequate monitoring of the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
429
Amateur built
false
Engines
2 Turbo shaft
Registration number
N507TJ
Operator
MERCY FLIGHT INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Medical flight type
Discretionary
Commercial sightseeing flight
false
Serial number
57332
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-02T19:46:59Z guid: 105004 uri: 105004 title: CEN22LA185 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105013/pdf description:
Unique identifier
105013
NTSB case number
CEN22LA185
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-28T11:40:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2022-04-29T01:11:20.327Z
Event type
Accident
Location
Syracuse, Kansas
Airport
Syracuse-Hamilton County Municipal Airport (3K3)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On April 28, 2022, about 1040 central daylight time, a Superior Culver LFA, N37888, was destroyed when it was involved in an accident near Syracuse, Kansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane had recently been rebuilt and the engine had been overhauled. The purpose of the flight was to transport the airplane from the maintenance facility to its owner in another state. Witnesses reported that after takeoff, and about 150 ft above ground level, the engine began to run rough. The pilot made a steep left turn in a nose-high attitude as if he were attempting to return to the runway. The engine continued to run rough as the left wing dropped and the airplane entered a rapid descent before impacting the ground in a nose-low attitude. The airplane was largely consumed by a post-crash fire. During a postaccident examination, flight control continuity was established to all control surfaces. The magnetos remained attached to the engine and were thermally damaged along with both ignition harnesses. The carburetor sustained impact and thermal damage. The spark plugs were removed and found to be unremarkable. No evidence of a catastrophic engine failure was present. When the temperature (66°F) and dewpoint (55°F) were plotted on a carburetor icing probability chart, the result was that the airplane was being operated in an area conducive to serious carburetor icing at glide power. (See figure 1) Figure 1: Carburetor Icing Probability Chart. Reference: Special Airworthiness Information Bulletin CE-09-35 -
Analysis
During a flight of an airplane after being rebuilt, the engine began to run rough when the airplane was about 150 ft above ground level. Witnesses observed the airplane make a steep left turn in a nose high attitude back toward the direction of the runway. The left wing subsequently dropped, and the airplane entered a rapid descent until it impacted the ground in a nose-low attitude. The airplane was largely consumed by a post-crash fire. During a postaccident examination, there were no mechanical anomalies found that would have precluded normal operation. However, the extent of the post-crash fire prevented an examination of the fuel and ignition systems. When the temperature and dewpoint were plotted on a carburetor icing probability chart, the result was that the airplane was operating in conditions that were conducive to serious carburetor icing at glide power. The investigation was unable to determine if this contributed to the engine roughness. It is likely that the pilot exceeded the critical angle of attack for the airplane as he was returning to the airport to make a precautionary landing when the engine began running rough.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack, which resulted in an inadvertent aerodynamic stall while returning to the airport following a partial loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SUPERIOR
Model
CULVER LFA
Amateur built
false
Engines
1 Reciprocating
Registration number
N37888
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
204
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-04-29T01:11:20Z guid: 105013 uri: 105013 title: DCA22FM016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105020/pdf description:
Unique identifier
105020
NTSB case number
DCA22FM016
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-04-29T20:15:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-11-16T05:00:00Z
Event type
Accident
Location
New York, New York
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the engine room fire aboard the chemical tank ship Endo Breeze was a main engine fuel injector pump replacement that was not conducted in accordance with manufacturer procedures, which resulted in a high-pressure fuel spray that ignited off the engine exhaust components.
Has safety recommendations
false

Vehicle 1

Callsign
9HA5061
Vessel name
ENDO BREEZE
Vessel type
Tanker
IMO number
9239977
Maritime Mobile Service Identity
636013575
Port of registry
Malta
Safety Management Certificate number
7439029
Classification society
DNV-GL
Flag state
MT
Findings
creator: Coast Guard last-modified: 2023-11-16T05:00:00Z guid: 105020 uri: 105020 title: CEN22LA186 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105024/pdf description:
Unique identifier
105024
NTSB case number
CEN22LA186
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-30T09:10:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-05-10T19:44:50.458Z
Event type
Accident
Location
Loogootee, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 30, 2022, about 0810 eastern daylight time, a Piper PA-32R-301 airplane, N4303P, was substantially damaged when it was involved in an accident near Loogootee, Indiana. The pilot and passenger were not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that he and a passenger departed Huntingburg Airport (HNB), Huntingburg, Indiana, and were en route to Putnam County Regional Airport (GPC), Greencastle, Indiana. About 10 minutes after departure, while in cruise flight at 3,000 ft mean sea level, the engine lost partial power. The pilot performed a forced landing to a gravel road. During the landing, the airplane’s left wing contacted a tree resulting in substantial damage. The airplane was transported to a recovery facility for further examination. After the airplane was recovered, a Federal Aviation Administration (FAA) inspector examined the engine and could not find any anomalies with the engine. An engine functional test run was conducted, and full engine rpm could not be achieved. The fuel servo and fuel flow divider were removed and sent for further examination. Testing of the fuel servo found that it could not deliver more than 22 pounds per hour of fuel, which was less than the rated specifications. Disassembly discovered that the self-locking nut (p/n 2539449) was stuck inside the top section of the plug. This resulted in the head idle spring not properly allowing fuel to flow through the ball valve. The FAA inspector was informed by the mechanic that the fuel servo was overhauled at the same time as the engine, in March 2002, at a total time of 2,011.1 hours. At the time of the accident, the airplane had accrued 4,383.3 hours. Precision Airmotive Service Bulletin PRS-97 revision 2, dated November 22, 2013, established the time between overhaul for all designated fuel system components to be the same as the engine manufacturer or 12 years, whichever occurred first. Lycoming established a time between overhaul of 1,800 hours. -
Analysis
The pilot reported that about 10 minutes after departure the engine sustained a partial loss of power. During the forced landing to a gravel road, the airplane’s left wing contacted a tree, which resulted in substantial damage. A postaccident engine test run was performed, and the engine would not produce rated power, so the fuel servo was removed for testing. Functional testing and examination of the fuel servo revealed that it would not deliver fuel to rated specifications due to a self-locking nut being stuck inside the top section of the plug. This resulted in the head idle spring not properly allowing fuel to flow through the ball valve. The engine and fuel servo had both surpassed the manufacturers’ established time between overhauls by 572 hours.
Probable cause
The inadequate maintenance and subsequent failure of an internal component in the fuel servo that prevented adequate fuel flow to the engine, which resulted in a partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA32R
Amateur built
false
Engines
1 Reciprocating
Registration number
N4303P
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-8313020
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-10T19:44:50Z guid: 105024 uri: 105024 title: CEN22LA188 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105033/pdf description:
Unique identifier
105033
NTSB case number
CEN22LA188
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-30T11:00:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-05-12T18:40:39.251Z
Event type
Accident
Location
Milwaukee, Wisconsin
Airport
General Mitchell International Airport (MKE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 30, 2022, about 1000 central daylight time, a Beech B-99 airplane, N699CZ, was substantially damaged when it was involved in an accident at General Mitchell International Airport (MKE), Milwaukee, Wisconsin. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 cargo flight. The flight originated from Baraboo/Wisconsin Dells Regional Airport (DLL), Baraboo, Wisconsin, with MKE as the intended destination. As the airplane approached MKE, the pilot was cleared by air traffic control (ATC) for the visual approach for runway 19R. He noted that the landing was “smooth given the weather conditions,” and he used normal braking to exit the runway. Upon entering the ramp area, the green right landing gear position light extinguished, and the red gear handle light illuminated. The pilot glanced over to the circuit breaker panel and noticed that the “Landing Gear Control” circuit breaker had tripped. After parking the airplane for refueling, he notified his company maintenance control group about the issue and was advised to not reposition the airplane after refueling. The pilot waited about 20 minutes for weather to clear before exiting the airplane. As he prepared to exit the airplane, the right main landing gear collapsed and the airplane’s right wing impacted the ground, resulting in substantial damage to the right wing. After the accident, it was discovered that the right landing gear drag leg support fitting, part number 50-120201-1, had broken. Further examination by the operator determined that the same part on the left landing gear was also fractured. Metallurgical examination of the separated fracture surface on the right landing gear drag leg support fitting revealed an area of fatigue in a machined radius adjacent to the center lug of the drag leg support. The remainder of the fracture exhibited features consistent with overload failure. An additional crack was found in the machined radius on the opposite side of the center lug. This portion of the part had not completely separated. Exposure of the crack revealed the existence of a fatigue crack in about the same area as the first crack, with overload signatures outside of the fatigue area. Maintenance manual excerpts for the airplane indicated that the subject part was to be cleaned and visually inspected at least every 7,500 cycles or every 5 years, whichever occurred first. If visual examination revealed a crack, it was to be verified by dye penetrant inspection. Any cracks found required replacement of the part. Maintenance records indicated that the part had accumulated 762 cycles since the last inspection 23 months prior. The operator reported that the accident airplane was maintained using an Approved Aircraft Inspection Program (AAIP) and had accumulated 35,012.9 total flight hours and 43,054 total cycles at the time of the accident. The most recent inspection of the drag leg support fitting was performed on May 11, 2020. The operator examined all the drag leg support fittings on their fleet of nine Beech B-99 airplanes, not including the accident airplane. Of the 18 drag leg support fittings examined, 14 were found to be cracked. Of the 14 cracked fittings, 11 required dye penetrant inspection to be detected; the cracks could not be detected solely by visual inspection. The operator had a previous accident (NTSB report number ERA21LA021), on October 14, 2020, involving another Beech B-99 airplane. In that accident, the right main landing gear collapsed as the airplane was taxied from the runway after landing. The drag leg support fitting was also found to have fatigue cracking in the same area of the fitting. -
Analysis
The pilot reported no difficulties during the flight or landing. While taxing the airplane after landing, the green right landing gear position indicator light extinguished, and the red gear handle light illuminated. The pilot glanced over to the circuit breaker panel and noted that the landing gear control circuit breaker had tripped. After parking the airplane for refueling, he notified his company maintenance control group about the issue and was advised to not reposition the airplane after refueling. The pilot waited about 20 minutes for weather to clear before exiting the airplane. As the pilot prepared to exit, the right main landing gear collapsed and the airplane’s right wing impacted the ground, resulting in substantial damage. Metallurgical examination of the separated fracture surface on the right landing gear drag leg support fitting revealed an area of fatigue in a machined radius adjacent to the center lug of the drag leg support. The remainder of the fracture exhibited features consistent with overload failure. An additional crack was found in the machined radius on the opposite side of the center lug. This portion of the part had not completely separated. Exposure of the crack revealed the existence of a fatigue crack in about the same area as the first crack, with overload signatures outside of the fatigue area. The airplane maintenance manual indicated that the subject part was to be cleaned and visually inspected at least every 7,500 cycles or every 5 years, whichever occurred first. Maintenance records indicated that the part had accumulated 762 cycles since the most recent inspection 23 months before the accident. After the accident, the operator examined the drag leg support fittings on their fleet of 9 other airplanes of the same model. Of the 18 fittings examined, 14 were found to be cracked. Of the 14 cracked fittings, 11 could only be detected using dye penetrant inspection, and could not be detected solely by visual inspection.
Probable cause
A right main landing gear collapse due to fatigue failure of the landing gear drag leg support fitting.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B-99
Amateur built
false
Engines
2 Turbo prop
Registration number
N699CZ
Operator
Freight Runners
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
U-10
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-12T18:40:39Z guid: 105033 uri: 105033 title: CEN22LA187 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105032/pdf description:
Unique identifier
105032
NTSB case number
CEN22LA187
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-30T14:00:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-05-04T00:43:11.173Z
Event type
Accident
Location
Fredericksburg, Texas
Airport
Gillespie County Airport (T82)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 30, 2022, about 1300 central daylight time, a North American AT-6D airplane, N29947, was substantially damaged when it was involved in an accident at Gillespie County Airport (T82), Fredericksburg, Texas. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he completed a preflight inspection and engine run-up with no anomalies noted. During the initial climb after takeoff, immediately after the landing gear was retracted, the pilot noticed white smoke from the engine cowling. A few seconds later, the engine “coughed loudly” and then lost total power. The airplane was still over the runway, and the pilot extended the landing gear, then retracted it again when he realized that insufficient runway remained for landing. The airplane landed with the right main gear extended and the left main gear partially extended, exited the runway, and collided with a runway light. The airplane sustained substantial damage to the left wing and left aileron. FAA inspectors completed an examination of the airplane and assisted the owner’s mechanics with removing the radial engine for transport. They discovered that the No. 1 cylinder was cracked all the way around the circumference. They did not observe any other anomalies during the examination. Postaccident engine examination confirmed that the No. 1 cylinder head fractured near the rear spark plug on the exhaust side. A review of the airplane maintenance records revealed that an annual inspection was completed on April 27, 2022 (3 days before the accident), at an aircraft total time (TT) of 11,694.0 hours. The previous annual inspection was completed on January 28, 2021, at 11,680.3 hours TT. A recurring FAA airworthiness directive (AD) 99-11-02, was applicable for this airplane and related to visual inspections to prevent cylinder head cracking. The AD was completed on June 29, 2017, at 11,529.3 hours TT. The AD was due to be completed again 250 hours later, at 11,779.3 hours TT. -
Analysis
The pilot stated that he completed a preflight inspection and engine run-up with no anomalies noted. During the initial climb after takeoff, immediately after retracting the landing gear, the pilot noticed white smoke from the engine cowling. A few seconds later, the engine “coughed loudly” and lost total power. The pilot landed the airplane on the remaining runway; however, the airplane exited the runway and collided with a runway light. resulting in substantial damage to the left wing and left aileron. Federal Aviation Administration (FAA) inspectors completed an examination of the airplane and assisted the owner’s mechanics with removing the engine for transport. They discovered that the No. 1 cylinder was cracked around its circumference. They did not observe any other anomalies during the examination. Postaccident engine examination confirmed that the No. 1 cylinder head fractured near the rear spark plug on the exhaust side. The mechanic noted it was likely that during the accident takeoff, the cylinder head separated due to pre-ignition or detonation stresses, which no longer allowed the push rods to operate the valves and resulted in a loss of engine power. A recurring FAA airworthiness directive (AD) was applicable for this airplane and related to visual inspections to prevent cylinder head cracking. The AD was completed 164.7 flight hours before the accident and was due to be completed again in 85.3 hours.
Probable cause
A total loss of engine power due to a failure of the No. 1 cylinder.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
AT-6D
Amateur built
false
Engines
1 Reciprocating
Registration number
N29947
Operator
CAVANAUGH FLIGHT MUSEUM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
42-85697A
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-04T00:43:11Z guid: 105032 uri: 105032 title: CEN22LA189 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105034/pdf description:
Unique identifier
105034
NTSB case number
CEN22LA189
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-04-30T14:00:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-05-03T23:05:21.719Z
Event type
Accident
Location
Blanket, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 30, 2022, about 1300 central daylight time, a Raytheon Aircraft Company A36 airplane, N47JB, sustained substantial damage when it was involved in an accident near Blanket, Texas. The pilot and passenger sustained no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the cross-country flight departed from the Majors Airport (GVT), Greenville, Texas, and was enroute to the Brownwood Regional Airport (BWD), Brownwood, Texas, via a navigational aid in Cedar Creek, Texas. During the preflight, the pilot “visibly confirmed” that there was “just over half a tank of fuel in each tank.” He reported that this amount matched the indications on the fuel gauges, which equated to 40 gallons of fuel. He reported that he decided not to “top off” the fuel tanks for the approximate one hour and twenty-minute flight. The pilot utilized the ForeFlight app for his preflight planning and the system calculated that the engine would consume about 22 gallons total for the flight. The pilot reported that the run up, enroute portion, and the descent from cruise altitude at 8,000 ft mean sea level (msl), were normal. The pilot was not able to recall what fuel tank was selected for the taxi, run up, climb out, and enroute portion of the flight. As the airplane descended to 6,000 ft msl, he cancelled the instrument flight rules clearance. When the pilot had the destination airport in sight, the engine lost power. The pilot “immediately pulled the yoke back to best glide,” selected a grass field for the landing, and began the engine out checklist. The pilot reported that he switched fuel tanks during the engine out procedure. After he completed the checklist twice, with no success at restarting the engine, he maneuvered the airplane and performed a forced landing to the field. During the forced landing, the nose gear collapsed, and the right wing sustained substantial damage. The airplane came to rest upright, and the two occupants were able to egress from the airplane without further incident. During a postaccident examination, no fuel was found in the right fuel tank and about 5.5 gallons of fuel was found in the left fuel tank (per the airframe manufacturer, 3 gallons in each fuel tank is classified as unusable). Both fuel tanks were found intact, along with the airframe and engine fuel lines. Both fuel tank caps appeared normal and were found installed properly. There was no evidence of a fuel leak or spillage on the airframe or at the accident site. There were no odors of fuel at the accident site. The fuel tank selector was found at the right fuel tank position. The fuel line to the fuel pressure regulator and the fuel injection distribution manifold was opened and there was no visible fuel found in the line. An examination of the airplane’s maintenance records revealed no evidence of uncorrected mechanical discrepancies with the airframe and engine. The airplane did not have a fuel totalizer system or an engine monitoring system onboard, nor was it required to have either system. The pilot did not have any fueling records or receipts from the last time the airplane received fuel, as the pilot received fuel from a family member, and he fueled the airplane himself. Using the information provided by the pilot, postaccident flight planning showed the engine would have consumed 21.9 gallons total for the flight. If the pilot utilized the maximum cruise speed, the engine would have consumed 22.9 gallons total for the flight. These totals do not include the required fuel reserve amounts. The Raytheon Aircraft Company A36 Pilot’s Operating Handbook/Airplane Flight Manual discusses fuel required for flight and states in part: Plan for an ample margin of fuel for any flight. The Textron Aviation Pilot Safety and Warning Supplements discusses fuel management and states in part: It is always the responsibility of the pilot-in-command to ensure sufficient fuel is available for the planned flight. A pilot should not begin a flight without determining the fuel required and verifying its presence onboard. -
Analysis
The pilot reported that he departed with “just over half a tank of fuel in each tank,” which matched the indications on the fuel gauges. He reported that he decided not to “top off” the fuel tanks for the flight of about one hour and twenty-minutes as he had about 40 gallons of fuel on board. The pilot reported that the takeoff and en route portions of the flight were normal. As the airplane descended to 6,000 ft above mean seal level, and with the destination airport in sight, the engine lost power. The pilot “immediately pulled the yoke back to best glide,” selected a grass field for the landing, and began the engine out checklist. The pilot reported that he switched fuel tanks during the engine out procedure. After he completed the checklist twice, with no success at restarting the engine, he maneuvered the airplane and performed a forced landing to a field. During the forced landing, the nose gear collapsed, and the right wing sustained substantial damage. During a postaccident examination, no fuel was found in the right fuel tank and about 5.5 gallons of fuel was found in the left fuel tank (per the airframe manufacturer, 3 gallons in each fuel tank is classified as unusable). Both fuel tanks were found intact, along with the airframe and engine fuel lines. Both fuel tank caps appeared normal and were found installed properly. There was no evidence of a fuel leak or spillage on the airframe or at the accident site. There were no odors of fuel at the accident site. The fuel tank selector was found at the right fuel tank position. The fuel line to the fuel pressure regulator and the fuel injection distribution manifold was opened and there was no visible fuel found in the line. The investigation could not determine the amount of fuel onboard before the accident flight. Based on the available evidence, it is likely the engine lost power due to the low level of fuel available in the right fuel tank due to the pilot’s improper fuel management.
Probable cause
The pilot’s failure to properly manage fuel while enroute, which resulted in a loss of engine power due to fuel starvation and a subsequent forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RAYTHEON AIRCRAFT COMPANY
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N47JB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E3207
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-03T23:05:21Z guid: 105034 uri: 105034 title: ERA22LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105026/pdf description:
Unique identifier
105026
NTSB case number
ERA22LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-01T18:05:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-05-02T21:53:33.274Z
Event type
Accident
Location
Huntsville, Alabama
Airport
Moontown Airport (3M5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On May 1, 2022, about 1705 central daylight time, an experimental amateur-built Van's Aircraft RV-7A, N1218B, was substantially damaged when it was involved in an accident near Huntsville International Airport-Carl T Jones Field (HSV), Huntsville, Alabama. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to the pilot, earlier on the day of the accident, he had flown from HSV to McKinney National Airport (TKI), Dallas, Texas. The pilot reported that he had not eaten that day but had consumed one beer while in Dallas. He recalled consuming additional alcoholic beverages in the airplane on the flight back to Huntsville but recalled nothing after the airplane crossed into Mississippi. Review of Federal Aviation Administration (FAA) flight track data revealed that the airplane was first detected about 1328 shortly after departing TKI. The airplane climbed to an altitude of about 10,500 ft mean sea level and continued on an easterly course for about 2 hours 48 minutes. Afterward, large deviations were observed in the airplane’s altitude, heading, and groundspeed data. The airplane circled right and left east of Huntsville for about 30 minutes before entering a low approach over runway 9 at Moontown Airport (3M5), Huntsville, Alabama, which was about 16 nautical miles northeast of HSV, the intended airport. The airplane then made a left 180° turn and flew west for about 8 miles before it turned back and descended again toward 3M5. The airplane impacted terrain about 600 ft short of the runway 9 threshold. The airplane came to rest inverted, and it sustained substantial damage to the wings, empennage, and fuselage. Recovery personnel reported fuel in the wing tanks at the accident site as well as opened and empty containers of alcohol. Postaccident examination of the airplane and engine revealed no preimpact anomalies that would have prevented normal operation. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected ethanol in the pilot’s hospital admission blood (0.172 gm/dL) and his urine (0.267 gm/dL). The concentration of ethanol in blood collected 3 hours after hospital admission was 0.118 gm/dL. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilot performance, even at very low levels. At blood ethanol concentrations above 0.15 gm/dL, individuals may experience significant loss of muscle control and major loss of balance. Title 14 CFR 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft “within 8 hours after the consumption of any alcoholic beverage” and “while having an alcohol concentration of 0.04 or greater in a blood or breath specimen.” -
Analysis
Review of flight track data for the personal flight showed that the airplane flew on an easterly course for about 3 hours before the airplane’s altitude, heading, and groundspeed began to deviate. The airplane overflew the intended destination airport, circled several times, and impacted terrain about 600 ft short of a private airstrip about 16 nautical miles to the northeast of the intended airport. Postaccident examination of the wreckage revealed no preimpact anomalies or malfunctions that would have precluded normal flight. The pilot stated that he had not eaten on the day of the accident, had consumed one beer before the accident flight, and had consumed additional alcoholic beverages in the airplane during the flight. The pilot recalled nothing from the last portion of the flight; however, evidence (open alcohol containers found in the wreckage) confirmed that he had consumed alcohol during the flight. Toxicology testing detected ethanol in the pilot’s blood at 0.172 gm/dL and his urine at 0.267 gm/dL. These concentrations were four to five times higher than the Federal Aviation Administration’s regulatory limit of 0.04 gm/dL; such concentrations would be impairing, and the pilot likely experienced degraded judgment and deficient coordination, psychomotor skills, perception, and attention. The airplane’s flightpath also demonstrated pilot impairment due to alcohol consumption before and during the flight. In addition, open alcohol containers were recovered in the wreckage, and the pilot admitted to consuming alcohol before and during the flight. The pilot likely experienced alcohol-related difficulties with cognitive and motor skills and was thus unable to safely manage the flight, resulting in a subsequent loss of airplane control.
Probable cause
The pilot’s impairment due to the effects of ethanol, which resulted in a loss of airplane control and an impact with terrain on approach to landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV7
Amateur built
true
Engines
1 Reciprocating
Registration number
N1218B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
72061
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-02T21:53:33Z guid: 105026 uri: 105026 title: ERA22LA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105031/pdf description:
Unique identifier
105031
NTSB case number
ERA22LA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-02T16:50:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-05-03T16:09:01.138Z
Event type
Accident
Location
Connellsville, Pennsylvania
Airport
Joseph A Hardy Connellsville Airport (VVS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On May 2, 2022, about 1550 eastern daylight time, a Cessna 414 airplane, N46TA, was substantially damaged when it was involved in an accident at Joseph A. Hardy Connellsville Airport (VVS), Connellsville, Pennsylvania. The commercial pilot sustained minor injuries, and the passenger sustained serious injuries. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a flight test. The purpose of the flight was to perform a local maintenance test flight to evaluate the autopilot’s performance. The pilot, who was also a mechanic, reported that, before the accident flight, he had removed and then reinstalled the S-TEC autopilot mode control unit in the cockpit due to a discrepancy reported on a previous flight. The pilot stated that, after a normal taxi and “complete run-up,” he initiated the takeoff for the accident flight. When the airplane reached rotation speed, he pulled back on the flight controls with one hand, but the flight controls did not move. The pilot then pulled back on the flight controls with both hands, but the flight controls still did not move. The passenger, who was also a mechanic, reported that the pilot was unable to rotate the airplane at rotation speed. The passenger recalled that the runway surface had a dip in it and that he felt a “bump” about the time that he expected rotation to occur. The pilot aborted the takeoff and applied maximum braking. The airplane was unable to stop on the remaining runway and ran off the runway and down a ravine. The airplane subsequently collided with trees, which resulted in substantial damage to the airplane fuselage and wings. The pilot reported that there was nothing “strange” with the flight controls during the run-up. The passenger recalled that the flight controls were functional before takeoff. Postaccident examination of the cockpit panel revealed that the left avionics stack included a Garmin GNS 530 GPS and a Bendix-King KX-155 navigation/communication receiver. The avionics tray on the left side that held the KX-155 unit was found stuck within the opening area of the elevator bellcrank. When the flight controls were moved forward or aft, which also moved the elevator bellcrank forward and aft, the controls would not move. The trays in the left avionics stack were found sagging downward, and the avionics units would move downward when the front of the units were pushed by hand. Further examination revealed that the bottom rearward portion of the KX-155 avionics tray was deformed and that the tray and the bellcrank displayed significant scratching and metal polishing. When the avionics tray was removed from the bellcrank movement area, the flight controls operated with a full range of movement. The avionics trays holding the GNS 530 and KX-155 equipment were secured to the sheet metal on the front of the cockpit panel, but neither avionics tray had metal straps that secured the rear or sides of the tray to the airplane’s structure of the airplane. The KX-155 avionics tray had a metal strap on its left side that was not connected to any structure of the airframe. No other avionics trays had straps connected to the airframe structure. Figure 1 shows the cockpit, elevator bellcrank and KX-155 avionics tray. Figure 2 shows a closer view of the KX155 avionics tray. Figure 1. Cockpit, avionics trays, and elevator bellcrank (Source: Federal Aviation Administration). Figure 2. Scratches found on the elevator bellcrank and KX-155 avionics tray (Source: Federal Aviation Administration). Note: The “FWD” label in the top left photograph shows where the face of the KX-155 unit was located. Review of Federal Aviation Administration airworthiness records revealed that the Garmin GNS 530 was first installed in the accident airplane in 2006. Review of the maintenance records starting in 2006 found no entries relating to the removal and reinstallation of the GNS 530 or the KX155 unit. The pilot/mechanic stated that he performed numerous inspections on the accident airplane starting in 2016. The pilot/mechanic also stated that, before the accident, he “didn’t even know to look for this” on avionics trays. Federal Aviation Administration Advisory Circular 43.13-2A, Acceptable Methods, Techniques, and Practices - Aircraft Alterations, chapter 2, Radio Installations, stated in part the following: To minimize the load on a stationary instrument panel, whenever practicable, install a support between the rear (or side) surface of the radio case and a nearby structural member of the aircraft. -
Analysis
The pilot, who was also a mechanic, had been troubleshooting an autopilot issue before the accident flight. He had removed and reinstalled the autopilot mode control unit in the cockpit panel and planned to complete a local maintenance test flight. The pilot initiated the flight, completed a normal run-up, and reported that nothing was abnormal with the flight controls. During takeoff and after reaching the airplane’s rotation speed, the pilot was unable to move the control wheel aft so that the elevator would move toward the airplane-nose-up direction. The pilot subsequently aborted the takeoff, but insufficient runway remained, and the airplane overran the runway and collided with trees. The fuselage and wings sustained substantial damage. Postaccident examination of airplane’s left-side cockpit avionics stack, which contained a GPS and radio unit, found that the avionics trays had sagged downward, resulting in the elevator bellcrank to become lodged within the lowest avionics tray. Further, the avionics trays were missing metal straps designed to secure the rear weight of the GPS and radio units to the structure of the airframe. The avionics tray and elevator bellcrank exhibited significant scraping and metal polishing, which indicated that rubbing contact between the sagging avionics tray and the elevator bellcrank had likely been occurring for some time before the accident flight. Neither the pilot nor the passenger (who was also a mechanic) reported observing any anomalies with the flight controls during the preflight run-up but did report that the airplane hit a dip in the runway as the airplane approached its the rotation speed. Thus, this movement likely moved the tray further downward and into the movement area of the elevator bellcrank. The Federal Aviation Administration had published advisory circular guidance advising mechanics to ensure that avionics units (including GPS and radio units) were properly secured with rear or side metal straps connected to a structural element on the aircraft. Review of maintenance records found no recent references to work involving the affected avionics or the securing of their avionics trays. The pilot had maintained the airplane for several years and signed off multiple annual inspections. During a postaccident interview, the pilot explained that he was not aware of the need to secure metal side or rear straps on avionics trays. Thus, because the pilot did not realize the need to properly secure the avionics trays to structural airplane elements, the trays eventually contacted the elevator bellcrank and precluded normal operation of the airplane’s pitch controls.
Probable cause
The pilot/mechanic’s failure to properly secure two airplane avionics units, which resulted in the trays supporting the units to sag downward and become lodged in the movement area of the elevator bellcrank during the accident takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
414
Amateur built
false
Engines
2 Reciprocating
Registration number
N46TA
Operator
AIR TRAVEL MANAGEMENT LLC.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
414-0466
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-03T16:09:01Z guid: 105031 uri: 105031 title: ERA22LA219 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105046/pdf description:
Unique identifier
105046
NTSB case number
ERA22LA219
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-03T11:50:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-06-15T04:39:07.97Z
Event type
Accident
Location
San Juan, Puerto Rico
Airport
LUIS MUNOZ MARIN INTL (SJU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the operator, the flight crew was conducting one engine inoperative (OEI) training as part of a check ride. While conducting an OEI instrument landing system approach, the flight crew became task-saturated and “failed to complete the approach and final checklists.” The flight crew completed the landing to the runway with the landing gear fully retracted and the airplane sustained substantial damage to the fuselage. The flight crew reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The flight crew’s failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SHORT BROS
Model
SD3-60
Amateur built
false
Engines
2 Turbo prop
Registration number
N744LG
Operator
ACC INTEGRATED SERVICES INC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
SH3744
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-15T04:39:07Z guid: 105046 uri: 105046 title: ERA22FA218 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105040/pdf description:
Unique identifier
105040
NTSB case number
ERA22FA218
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-03T18:00:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-05-17T19:12:34.101Z
Event type
Accident
Location
Altha, Florida
Airport
Calhoun County (F95)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 2 serious, 0 minor
Factual narrative
The airplane’s weight and balance at the time of the accident was reviewed. Pilot and passenger weights were obtained from autopsy and hospital records. The airplane’s weight was estimated to be 2,424 pounds, which was 224 pounds above the maximum allowable gross weight of 2,200 pounds. The center of gravity was not within the allowable operating envelope at this gross weight. One of the surviving passengers reported that the pilot did not ask him how much he weighed and that he did not observe the pilot performing a weight and balance calculation before the flight. - On May 3, 2022, about 1700 central daylight time, a Cessna 172, N6413B, was destroyed when it was involved in an accident near Calhoun County Airport (F95), Altha, Florida. The private pilot and one passenger were fatally injured, and two passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   According to the airport manager, the flight departed from runway 36 with full fuel tanks. The pilot was in the left cockpit seat and the airplane owner, who did not hold a pilot certificate, was in the right cockpit seat.   According to airport surveillance video and witness statements, the airplane lifted off and immediately attained a high angle of attack at a slow speed. The airplane proceeded northbound past the departure end of runway 36 and made a left 270° turn at a low altitude without climbing. The airplane proceeded eastbound and across the departure end of runway 36 and then descended behind a hangar. Afterward, the airplane impacted the ground, and a postcrash fire ensued. The engine was running throughout the accident flight. - An autopsy on the pilot was performed by Office of the Medical Examiner, District 14, Panama City, Florida. The pilot’s cause of death was multiple blunt traumatic and thermal injuries. Toxicological testing performed by the FAA Forensic Sciences Laboratory was negative for carboxyhemoglobin, ethanol, general drugs, and drugs of abuse. - F95 had an automated weather observing system that did not issue recorded weather data for distribution. One of the witnesses stated that he observed the airport’s windsock at the time of the accident and that the windsock indicated that the surface wind was from the west at 10 to 15 knots. A review of the airport surveillance video revealed that visual meteorological conditions prevailed. - The pilot’s logbook was not located after the accident. The pilot reported 575 hours total flight experience on his most recent Federal Aviation Administration (FAA) medical certificate application, dated January 19, 2021. - The airplane came to rest near the airport perimeter fence. The initial impact point consisted of propeller slash marks in the soil about 50 ft westnorthwest of the main wreckage. Impact marks on the ground were consistent with a nose-low, right-wing-down attitude at impact, and the wreckage was contained within a relatively compact area around the main wreckage. Most of the fuselage, including the cockpit and instrument panel, was destroyed by postaccident fire. Flight control continuity was confirmed from the flight control surfaces to the cockpit controls. The engine remained attached to the firewall, and the propeller remained attached to the engine. The mechanical flap handle was found at the 10° position. The elevator trim was found at the neutral position. During a postaccident examination of the engine, the left and right magnetos were removed for testing. The left magneto was heat damaged and would not produce a spark to any lead. Disassembly of the unit revealed internal heat damage. The right magneto produced spark on all leads when operated on a test bench. When the propeller was rotated manually, compression and suction were observed at all cylinders, and valve action was correct. Internal engine continuity was confirmed through the rear accessory drive gears. The carburetor inlet screen was clean and showed no contaminants. The examination of the engine revealed no evidence of a pre-existing mechanical malfunction or failure that would have precluded normal operation. -
Analysis
The pilot was conducting a personal flight with three passengers aboard. Witnesses and airport surveillance video revealed that the airplane took off to the north and immediately entered a nose-high attitude at slow speed while not climbing. The pilot then began a left 270° turn and crossed the departure end of the runway on an easterly heading. The airplane impacted terrain east of the runway and a postimpact fire ensued. The wreckage displayed signatures consistent with the airplane having been in an aerodynamic stall at the time of impact. Witnesses described that the engine was running during the accident flight. Postaccident examination of the airframe and engine revealed no evidence of a pre-existing mechanical failure or malfunction. Postaccident weight and balance calculations revealed that the airplane’s weight at takeoff was about 224 pounds, or nearly 10% more than the maximum allowable gross weight. One of the surviving passengers reported that the pilot did not ask for his weight and that he did not observe the pilot performing any preflight weight and balance calculation. Based on this information, it is likely that the pilot’s failure to perform weight and balance calculations resulted in the airplane taking off while overweight, which resulted in its inability to climb. Ultimately the airplane to exceed its critical angle of attack and entered an aerodynamic stall from which the pilot could not recover.
Probable cause
The pilot’s failure to perform a preflight weight and balance calculation and his operation of the flight at an excessive takeoff weight, resulting in an exceedance of the airplane’s critical angle of attack after liftoff and an aerodynamic stall from which the pilot was unable to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N6413B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
29613
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-05-17T19:12:34Z guid: 105040 uri: 105040 title: CEN22LA195 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105063/pdf description:
Unique identifier
105063
NTSB case number
CEN22LA195
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-05T22:10:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-05-16T22:34:40.922Z
Event type
Accident
Location
Denver, Colorado
Airport
Centennial Airport (APA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 5, 2022, about 2110 mountain daylight time, a Swearingen SA226-T(B), N36LC, was substantially damaged when it was involved in an accident at Centennial Airport (APA), Denver, Colorado. The captain and first officer were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight.   After six passengers disembarked at Central Nebraska Regional Airport (GRI), Grand Island, Nebraska, the captain and first officer departed from GRI without passengers. During the takeoff roll, the captain reported that the airplane accelerated slower than normal. At 60 to 80 knots, the captain “pushed in the parking brake” handle and continued the takeoff. The crew reported no anomalies on the departure or en route to APA. During the landing at APA, the airplane swerved right, and the captain was not able to maintain directional control. The airplane departed the right side of the runway, which resulted in substantial damage to the right wing. Postaccident examination revealed that the right main landing gear brakes were thermally damaged and seized. The right main landing gear tires had flat spots down to the wheel rims, consistent with no tire rotation during the landing. The left main landing gear brakes were not seized and the tires did not have flat spots. No anomalies were observed with the braking system that would have precluded normal operation. According to the flight manual, proper release of the parking brake required brake pedals to be depressed while the parking brake handle was pushed fully forward. If the parking brake handle was pushed forward without the brake pedals depressed, it was possible for the brakes to retain pressure. -
Analysis
The captain reported slower than normal acceleration during the takeoff roll. At 60 to 80 knots, the captain “pushed in the parking brake” handle and continued the takeoff. The crew reported no anomalies on the departure or while en route. While landing at the destination, the airplane swerved right and the captain lost directional control, which resulted in a runway excursion and substantial damage to the right wing. Postaccident examination revealed that the right main landing gear brakes were seized and the right main landing gear tires had flat spots down to the wheel rims, consistent with no tire rotation during landing. No preaccident anomalies were observed with the braking system that would have precluded normal operation. According to the flight manual, proper release of the parking brake required the brake pedals to be depressed while the parking brake handle was pushed fully forward. The parking brake was likely not correctly released before takeoff, which allowed the right brakes to retain pressure and led to the loss of directional control during landing.
Probable cause
The captain’s failure to ensure that the parking brake was correctly released before takeoff, which resulted in seized brakes during landing and a subsequent loss of directional control and runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SWEARINGEN
Model
SA226-T(B)
Amateur built
false
Engines
1 Turbo prop
Registration number
N36LC
Operator
Cloud Peak Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
T-387
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-16T22:34:40Z guid: 105063 uri: 105063 title: ERA22LA220 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105047/pdf description:
Unique identifier
105047
NTSB case number
ERA22LA220
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-06T09:44:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-05-17T23:57:46.174Z
Event type
Accident
Location
Tybee Island, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 6, 2022, at 0844 eastern daylight time, a Cirrus Design Corp SR22, N24LA, was substantially damaged when it was involved in an accident in the Atlantic Ocean near Tybee Island, Georgia. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.  A review of automatic dependent surveillance-broadcast (ADS-B) data and air traffic control information obtained from the Federal Aviation Administration revealed that the airplane departed runway 27 at Whiteplains Airport (SC99), Lexington, South Carolina, about 0738. The airplane turned to a southbound heading, climbed to an altitude of about 4,000 ft mean sea level (msl) and flew for about 10 nautical miles (nm). The pilot had requested and was given an approach clearance for the RNAV GPS approach to runway 17 at Barnwell Regional Airport (BNL), Barnwell, South Carolina, about 48 miles from SC99.   The air traffic controller requested that the pilot provide a position report inbound on the approach over the “FATSU” waypoint. The pilot acknowledged the request but did not report passing the waypoint. The airplane overflew runway 17 at BNL at about 2,200 ft msl and continued to fly another 113 miles on a 170° heading. The airplane crossed over the eastern coastline of Tybee Island and continued over the Atlantic Ocean for about 15 miles then began to slow and descend briefly. Then, when passing through about 1,500 ft msl, the airplane entered a left arcing descending turn with a corresponding increase in groundspeed. The last ADS-B data received was at 0844, as the airplane descended through 75 ft msl about 18 nm southeast of Tybee Island. ATC asked pilots in another airplane to check on N24LA. The pilots rocked their wings but were unable to get the accident pilot’s attention and they continued to watch as the airplane descended into the ocean. - An autopsy of the pilot was performed by the Division of Forensic Sciences, Georgia Bureau of Investigation, Coastal Regional Medical Examiner’s Office, Pooler, Georgia. The cause of death was “drowning”, and the manner of death was accidental. Toxicological testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences Laboratory detected ethanol in the pilot’s heart blood tissues. Metoprolol was detected in his heart and liver tissues; this high blood pressure medication is generally considered non-impairing. Postmortem ethanol concentrations in blood samples have been positively correlated with the number of days before body recovery at sea. The pilot reported a history of ablation for atrial fibrillation with a loop recorder implanted, for which he had received an FAA authorization for special issuance. During the time that the pilot did not report the waypoint and did not respond to ATC, there was a 7:43 minute period of tachycardia with a median heart rate of 300 beats per minute. - Postaccident examination of the recovered airframe verified flight control continuity throughout the airframe from the cockpit controls to all primary flight control surfaces.  Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot was issued instrument approach instructions from air traffic control (ATC) and instructed to report over a waypoint. The pilot did not report over the waypoint and did not respond to any subsequent ATC communications. At the request of ATC, pilots of another airplane tried to get the accident pilot’s attention but were unsuccessful. They continued alongside and watched as the airplane descended into the ocean. The pilot had a history of heart palpitations and had a loop recorder heart monitor implanted in his left upper chest. The download of the device revealed a period of tachycardia during the time the pilot was not responding to ATC. It is likely that this cardiac event caused the pilot to be incapacitated. Examination revealed there were no preimpact mechanical malfunctions or failures with the airframe or engine that would have precluded normal operation.
Probable cause
A loss of airplane control due to pilot incapacitation, which resulted in an overflight of his destination and subsequent descent into water.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N24LA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2013
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-17T23:57:46Z guid: 105047 uri: 105047 title: CEN22LA190 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105048/pdf description:
Unique identifier
105048
NTSB case number
CEN22LA190
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-06T15:18:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-08-25T22:56:45.049Z
Event type
Accident
Location
Houston, Texas
Airport
William P Hobby (HOU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 4 minor
Factual narrative
On May 6, 2022, at 1418 central daylight time, a Cessna 421 airplane, Mexican registration XB-FQS, was substantially damaged when it was involved in an accident near Houston, Texas. The pilot and three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, upon arriving at the airport’s fixed-base operator (FBO) facility, his son requested that the airplane be fueled with 70 gallons in each wing tank. They observed the airplane being fueled; several minutes later, the airplane was towed to their location at the FBO building. The pilot stated that the preflight inspection and taxi for takeoff were completed with no issues found. About halfway through the takeoff roll, the pilot thought that the airplane was “feeling weird” but was unable to stop on the remaining runway. The pilot continued with the takeoff; shortly afterward, the engines began losing power and the airplane had insufficient altitude to return to the airport. The pilot decided to execute a forced landing to a field ahead of the airplane’s flightpath. During the forced landing, the landing gear collapsed and the airplane impacted a perimeter fence. The left wing separated outboard of the engine nacelle and the airplane came to rest in a residential backyard. A postimpact fire consumed the outboard portion of the left wing. A representative of the FBO stated the pilot’s son placed the order for fuel with a front counter customer service representative. The order was noted as “70 neg each” and confirmed with the pilot’s son. The order relayed to line service was for “70 gallons each wing – negative,” indicating that a fuel additive (Prist) should not be added. The type of fuel was not discussed. The airplane was subsequently fueled with 140 total gallons of Jet A fuel without the Prist additive. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports and that, for that reason, he confirmed the order with the front desk before adding Jet A fuel to the airplane. The airplane was powered by two reciprocating engines requiring 100/100 low-lead minimum-grade aviation fuel (AVGAS). A postaccident examination by Federal Aviation Administration inspectors found that the right-wing fuel port had decals noting “100/130 Aviation Grade Min” and “AVGAS ONLY.” The decal text was faded but was clearly visible. The investigation could not determine if there were any left-wing fuel port decals because of the fire damage to the left wing. In addition, the truck used to fuel the airplane had a placard indicating “Jet A,” and an elongated fuel nozzle was installed, corresponding with Jet A fueling operations. After the accident, the FBO implemented additional communication requirements and awareness training related to aircraft fueling to prevent an incorrect fueling event from occurring. -
Analysis
The pilot reported that, before the flight, the airplane was fueled with 140 gallons of Jet A fuel. Shortly after takeoff, both engines lost total power. Because the airplane had insufficient altitude to return to the airport, the pilot executed a forced landing to a field and the left wing sustained substantial damage. A postcrash fire ensued. The investigation determined that the airplane was inadvertently fueled with Jet A fuel rather than AVGAS, which was required for the airplane’s reciprocating engines. The line service worker who fueled the airplane reported that there were no decals at the airplane fuel ports; however, postaccident examination of the airplane found that a decal specifying AVGAS was present at the right-wing fuel port. The investigation could not determine whether the same or a similar decal was present at the left-wing fuel port because the left wing was partially consumed during the postimpact fire.)
Probable cause
The fixed-base operator’s incorrect fueling of the airplane, which resulted in a total loss of power in both engines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
421
Amateur built
false
Engines
2 Reciprocating
Registration number
XB-FQS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
421C-0085
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-25T22:56:45Z guid: 105048 uri: 105048 title: ERA22LA268 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105262/pdf description:
Unique identifier
105262
NTSB case number
ERA22LA268
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-09T11:15:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Last updated
2022-07-19T16:51:11.003Z
Event type
Accident
Location
Brasstown, North Carolina
Airport
Private (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 9, 2022, about 1015 eastern daylight time, an experimental, amateur-built Escapade airplane, N86RD, was substantially damaged when it was involved in an accident at a private airport in Brasstown, North Carolina. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner of the airplane, shortly after departure from the private airport, the engine developed vibrations and an “unusual sound.” He attempted to return to the airport, which was about 8 nautical miles away. Although the engine was developing power, the engine was losing coolant and the coolant and oil temperatures were rising to excessive levels. In lieu of flying an airport traffic pattern, which would take additional time, he elected to land as soon as possible on an un-mowed portion of the airport. The nose gear collapsed during the landing, which resulted in damage to the fuselage and windscreen. The wreckage was subsequently recovered and examined by a Federal Aviation Administration (FAA) inspector. The inspector noted substantial damage to the airframe. The accident, which was reported about a month after it occurred, and the subsequent follow-up examination by the FAA, took additional time before the damage was confirmed; during which time the pilot, who was also an airframe and powerplant mechanic conducted his own examination. The pilot stated that during his examination of the experimental Viking 110 engine (Honda Derivative), it was revealed that the drive flange, also known as the engine to gearbox coupling or “spider,” located on the rear of the gearbox, had failed (Figure 1). The resulting failure threw fragments into the radiator, damaging it and resulting in coolant loss. The pilot removed the flange, which was missing one of the three drive ears. One of the ears was fractured just outside of the main splined driveshaft hole. Figure 1 Fractured flange prior to removal. The flange was installed on the engine about 134 flight hours before the accident and was accomplished by the previous owner of the airplane. A review of the engine manufacturer’s operational manuals and service bulletins revealed that this unit was in compliance with the service bulletin specific to the welding of the pins and installation. -
Analysis
Shortly after takeoff while on a local flight, the pilot, who was also the owner of the airplane, heard and felt an unusual vibration emanating from the engine. The pilot elected to return to the private airfield as the experimental automobile engine was still running. He declared an emergency as the engine was losing coolant, and the coolant and oil temperature steadily rose to very high levels. Fearing a complete engine failure, he elected to fly straight in and land on an un-mowed portion of the airport. As the airplane touched down the nose gear collapsed, causing the airplane to impact the terrain and come to a sudden stop that resulted in substantial damage to the airframe. The pilot, who was also an aircraft mechanic, examined the engine and discovered that the engine gearbox drive flange, also known as a “spider,” had failed. The three-eared flange had fractured outside of the splined driveshaft hole. The resulting failure threw parts into the radiator, puncturing it. The punctured radiator lost coolant, causing a subsequent engine over-temperature that likely would have led to a complete loss of engine power. Fearing an imminent loss of engine power, the pilot made a precautionary landing on an unimproved part of the airport.
Probable cause
The failure of the engine gearbox drive flange, which resulted in a nose gear collapse during the subsequent precautionary landing in tall grass.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WINGREN NORMAN
Model
ESCAPADE
Amateur built
true
Engines
1 Reciprocating
Registration number
N86RD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
31
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-19T16:51:11Z guid: 105262 uri: 105262 title: DCA22FM018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105056/pdf description:
Unique identifier
105056
NTSB case number
DCA22FM018
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-05-09T11:15:00Z
Publication date
2023-06-13T04:00:00Z
Report type
Final
Last updated
2023-05-26T04:00:00Z
Event type
Accident
Location
Sitka, Alaska
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the contact of the cruise ship Radiance of the Seas with the Sitka Sound Cruise Terminal pier was the master and bridge team’s overreliance on an electronic chart to identify thepier’s position relative to their planned rotation location, and the master’s misunderstanding of the clearance distances to the pier being called by the crewmember on the stern while the vessel was rotating. Contributing was the Sitka Sound Cruise Terminal not reporting the extension of the pier into the waterway to the appropriate hydrographic authority in order to update the relevant navigational chart.
Has safety recommendations
false

Vehicle 1

Callsign
C6SE7
Vessel name
Radiance of the Seas
Vessel type
Passenger
IMO number
9195195
Maritime Mobile Service Identity
311319000
Port of registry
Nassau
Classification society
DNV-GL
Flag state
BF
Findings
creator: Coast Guard last-modified: 2023-05-26T04:00:00Z guid: 105056 uri: 105056 title: CEN22LA194 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105062/pdf description:
Unique identifier
105062
NTSB case number
CEN22LA194
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-10T18:26:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-05-17T16:49:39.161Z
Event type
Accident
Location
Traverse City, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 10, 2022, about 1726 eastern daylight time, a Cessna 172S airplane, N184NW, was substantially damaged when it was involved in an accident near Cherry Capital Airport (TVC), Traverse City, Michigan. The flight instructor and the pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to Northwestern Michigan College (NMC) representatives, the pilot receiving instruction was operating the airplane as part of the college flight school program. When the flight was on a visual approach to runway 18 at TVC the engine lost total power. The flight instructor took control of the flight and made multiple attempts to restart the engine, which were unsuccessful. The flight instructor declared an emergency and executed a forced landing to a park area about 1 mile north of the runway. During the forced landing, the airplane impacted terrain and a perimeter fence. Postaccident examination of the airplane revealed substantial damage to the right wing and engine mount. Examination of the engine and fuel system revealed a loose “B” nut fitting on the fuel line between the fuel injector and fuel manifold (see the figure below). There was no visible impact damage to the “B” nut or the fitting. Figure. Loose “B” nut with fuel leaking from the fuel line (Source: Federal Aviation Administration). NMC representatives stated that the airplane had flown for about 2.7 hours since the time that the engine was installed by NMC maintenance personnel. -
Analysis
The pilot receiving instruction was on a visual approach to the runway during an instructional flight, at which time the engine lost total power. The flight instructor took control of the airplane and made multiple attempts to restart the engine, which were unsuccessful. The flight instructor declared an emergency and executed a forced landing to a park area about 1 mile north of the runway. During the forced landing, the airplane impacted terrain and a perimeter fence. Postaccident examination of the airplane revealed substantial damage to the right wing and engine mount. Examination of the engine and fuel system revealed a loose “B” nut fitting on the fuel line between the fuel injector and fuel manifold. The engine had recently been installed by maintenance personnel; the airplane had flown about 2.7 hours after the installation and before the accident. There was no visible impact damage to the “B” nut on the line or the fitting. Given this evidence, the “B” nut on the fuel line was likely not properly tightened during engine installation, which allowed the nut to loosen with normal engine vibration and allowed air to enter the system which resulted in total loss of engine power.
Probable cause
The failure of maintenance personnel to properly torque a fuel line “B” nut, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N184NW
Operator
NORTHWESTERN MICHIGAN COLLEGE
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S11085
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-17T16:49:39Z guid: 105062 uri: 105062 title: HWY22MH009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105066/pdf description:
Unique identifier
105066
NTSB case number
HWY22MH009
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-11T09:16:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-11-22T05:00:00Z
Event type
Accident
Location
Clarendon Hills, Illinois
Injuries
1 fatal, 0 serious, 4 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Clarendon Hills, Illinois, collision was the improperly licensed truck driver’s failure to manage the box truck’s power, causing the box truck to stall on the railroad, and his subsequent inability to restart the engine, causing the vehicle to block the path of the commuter train. Contributing to the collision were the motor carrier’s inadequate safety policies.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2004 International Truck
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
Metra commuter train #1242
Traffic unit type
Combination Vehicle
Units
Findings
creator: NTSB last-modified: 2023-11-22T05:00:00Z guid: 105066 uri: 105066 title: CEN22FA197 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105067/pdf description:
Unique identifier
105067
NTSB case number
CEN22FA197
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-11T13:35:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-05-12T07:58:27.39Z
Event type
Accident
Location
Broomfield, Colorado
Airport
Rocky Mountain Metro Airport (BJC)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
Low-Level Wind Shear The FAA has published Wind Shear FAA-P-8740-40. This document discusses low-level wind shear and states in part: Another type of surface obstruction—mountains—can also affect wind shear. Some airfields are close to mountain ranges, and mountain passes are close to the final approach paths. Strong surface winds blowing through these passes can cause serious localized wind shear during the approach. The real problem with such shear is that it is almost totally unpredictable in terms of magnitude or severity. A pilot can expect such shear whenever strong surface winds are present. Density Altitude The FAA has published Density Altitude FAA-P-8740-2. This document discusses density altitude and states in part: Density altitude is formally defined as “pressure altitude corrected for nonstandard temperature variations.” The formal definition of density altitude is certainly correct, but the important thing to understand is that density altitude is an indicator of aircraft performance. The term comes from the fact that the density of the air decreases with altitude. A “high” density altitude means that air density is reduced, which has an adverse impact on aircraft performance. Whether due to high altitude, high temperature, or both, reduced air density (reported in terms of density altitude) adversely affects aerodynamic performance and decreases the engine’s horsepower output. - An examination of the airplane’s maintenance records revealed no evidence of any uncorrected mechanical discrepancies with the airframe or the engine. - BJC is located near the Front Range mountain range, which is part of the Rocky Mountains. - On May 11, 2022, about 1235 mountain daylight time, a Cessna 172N airplane, N73670, was destroyed when it was involved in an accident near Broomfield, Colorado. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot was working on obtaining his commercial pilot certificate via a 14 CFR Part 141 approved course and was performing a local area flight when the accident occurred. A review of automatic dependent surveillance - broadcast data indicated that the airplane departed from the Rocky Mountain Metro Airport (BJC), Broomfield, Colorado, to the southeast and entered the traffic pattern at the Colorado Air and Space Airport (CFO), Watkins, Colorado. The pilot performed a landing at CFO and then departed to the southeast. The pilot performed flight maneuvers to the south of Bennett, Colorado, and then proceeded west to BJC. The pilot performed a touch-and-go landing to runway 12R at BJC and remained in the traffic pattern. The air traffic controller instructed the pilot to widen his downwind leg before turning base for runway 12R due to traffic landing on runway 12L. The controller then changed the landing to runway 12L and cleared the pilot to land. The pilot performed a right turn to the base leg, and after the airplane was established on final for runway 12L, it turned abruptly to the north and descended rapidly. The airplane impacted an intersection about ½ nm northwest of the approach end of runway 12L. The airplane impacted the ground and a traffic light pole and then came to rest on a sidewalk. A postimpact fire ensued and destroyed the airplane. Two witnesses, one who is a designated airworthiness representative (DAR) and the other who is a Federal Aviation Administration (FAA) aircraft certification specialist with an aerospace engineer and pilot background, observed the accident sequence while at a nearby golf course. They reported the airplane was not in an aerodynamic stall or spin. The DAR reported that the airplane appeared to be in a “gentle” left-hand turn and descent, with about 15-20° of bank. They did not observe any flight control movements, nor was there any smoke or fire coming from the airplane. They further reported that there were no abnormal engine noises and that the airplane was structurally intact while in flight. A review of local area security camera footage showed the airplane was established on final approach for runway 12L. The airplane then turned abruptly to the north before it descended rapidly and impacted the ground. - A High-Resolution Rapid Refresh model sounding identified possible low-level wind shear close to the surface near the accident site. The National Weather Service issued an Area Forecast Discussion at 1115 and stated in part: Winds will be the greatest operational impact today with VFR conditions. Winds will increase out of the southwest with speeds up to 25 kt then increase after 18z up to 32 kts for DEN and APA with BJC topping out around 25 kts. Winds will shift more westerly after 14z and be due west after 16z with gusting up to 32 kts. The estimated density altitude for BJC at the time of the accident was 8,578 ft above msl. - The pilot was enrolled at the Western Air Flight Academy, which is based at BJC. He started his training for a commercial pilot certificate on January 11, 2022. A review of the pilot’s logbook found that the pilot had received a pilot-in-command endorsement for a high-performance airplane on January 5, 2022, and he had received 5 hours of ground instruction for mountain flying and high-altitude operations. Due to the fire damage sustained to the logbook, the date for the ground instruction for mountain flying and high-altitude operations could not be determined. The pilot’s logbook also showed that he had flown in the accident airplane multiple times in the past. The pilot worked as a professional truck driver. He passed a Department of Transportation commercial driver’s license medical examination in April 2020. - The wreckage was recovered from the accident site and was transported to a salvage facility for further examination. Most of the airframe was consumed by the postimpact fire. No bird remnants were observed in the wreckage. Flight control continuity was established for all of the flight controls. The flaps were found positioned about 30° at the time of impact. There was no evidence of an asymmetric flap deployment. The engine was separated from the airframe and intact. Cylinder No.1 sustained impact damage. The propeller showed chordwise scratching on one blade. The other blade was bent, about midspan, to the rear about 90°. During the examination there were no signs of a preimpact mechanical malfunction or failure with the airframe or the engine that would have precluded normal operation. -
Analysis
Flight track data indicated that the pilot was returning to the departure airport. The pilot had flown to a nearby airport and then performed several flight maneuvers in a nearby practice area. He performed a touch and go landing and then remained in the traffic pattern. The air traffic controller instructed the pilot to widen his downwind leg, due to traffic, and changed the landing runway to the parallel runway. The pilot performed a right turn to the base leg, and after the airplane was established on final, it abruptly turned to the north and descended rapidly. The airplane impacted an intersection about ½ nautical mile (nm) northwest of the approach end of the runway. The airplane impacted the ground and a traffic light pole and came to rest on a sidewalk. A postimpact fire ensued and the airplane was destroyed. Two witnesses reported that the airplane was not in an aerodynamic stall or spin. One witness reported that the airplane appeared to be in a “gentle” left-hand turn and descent, with about 15-20° of bank. They did not observe any flight control movements, nor was there any smoke or fire from the airplane. There were no abnormal engine noises, and the airplane was structurally intact while in flight. A review of local area security camera footage showed the airplane established on final approach. The airplane then turned abruptly to the north and descended rapidly before it impacted the ground. Postaccident examination revealed no preimpact mechanical malfunctions or failures with the airframe or engine that would have precluded normal operation. A review of meteorological data showed that low-level windshear was possible. Additionally, the estimated density altitude at the airport was 8,578 ft above msl at the time of the accident. However, based on the witness statements and the security camera footage, neither windshear nor the high density altitude appeared to play a role in the airplane’s sudden departure from the approach path. The reasons for the loss of control in flight could not be determined.
Probable cause
The pilot’s failure to maintain control of the airplane for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N73670
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17267604
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-05-12T07:58:27Z guid: 105067 uri: 105067 title: ERA22LA229 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105085/pdf description:
Unique identifier
105085
NTSB case number
ERA22LA229
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-13T22:00:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-06-14T18:22:36.243Z
Event type
Accident
Location
Rochester, New York
Airport
Strong Memorial Hospital Heliport (2NY5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 13, 2022, about 2100 eastern daylight time, a Messerschmitt-Bolkow-Blohm BK117 B-2 helicopter, N370SS, was substantially damaged when it was involved in an accident at the Strong Memorial Hospital Heliport, Rochester, New York. The commercial pilot and two crewmembers were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 air ambulance flight. The pilot reported that he landed on the helipad and moved his left hand from the collective to the power levers. He said the crew was ready to go and entered the helicopter shortly after landing. Once the crew entered the helicopter and “buckled in,” the pilot moved the power levers to “fly,” turned the light switches on, and began to move the “Hat” to adjust the lights on the rooftop. The pilot stated that his right hand was in control of the cyclic when he heard a loud “bang” and noticed the rod from the wire cutter bouncing back and forth. The pilot immediately shut down the engines and the crew exited the helicopter. The pilot reported that the wind was light and variable at a velocity of about 3 mph at the time of the accident. Examination of the helicopter by a Federal Aviation Administration inspector revealed damage to the main rotor blades and the wire cutter. A rigging checkIt looks like this is documented in an email string on the OUO side. It needs to be excerpted like the other email exchange was and put onto the public side. of the flight controls was performed under the supervision of an FAA inspector, and no anomalies were noted that would have contributed accident. A static functional test of the mast moment indicator was performed, with no anomalies noted. A pre-departure test run was also performed with no anomalies. A review of the last 12-month and 100-hour maintenance inspections did not reveal evidence of any relevant maintenance to any of the helicopter’s flight control systems -
Analysis
After the pilot of the air medical helicopter landed, the medical crew boarded and he prepared the helicopter for takeoff. The pilot stated that he was adjusting a light switch while his right hand was on the cyclic control when he heard a loud “bang.” He subsequently noticed that the rod from the airframe-mounted wire cutter was bouncing back and forth. The pilot then shut down the engines and the crew exited the helicopter. A postaccident examination of the helicopter revealed substantial damage to the main rotor blades that was consistent with them having contacted the wire cutter. The examinations otherwise did not reveal evidence of any anomalies of the flight control system that would have precluded normal operation. Based on this information, while the pilot indicated that he was holding the cyclic control at the time of the event, given the damage to the helicopter and the lack of anomalous findings with the flight control system, nor the existence other external influences like substantive wind, it is likely that he inadvertently moved the cyclic, which resulted in the main rotor briefly moving into a position where it contacted the wire cutter.
Probable cause
An unintentional movement of the cyclic control before takeoff, which resulted the main rotor blades contacting the fixed wire cutter.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MESSERSCHMITT-BOLKOW-BLOHM
Model
BK 117 B-2
Amateur built
false
Engines
2 Turbo shaft
Registration number
N370SS
Operator
Mercy Flight Central
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
7133
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-14T18:22:36Z guid: 105085 uri: 105085 title: CEN22LA204 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105097/pdf description:
Unique identifier
105097
NTSB case number
CEN22LA204
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-17T17:00:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-05-19T22:54:06.199Z
Event type
Accident
Location
Denver, Colorado
Airport
Rocky Mountain Metro Airport (BJC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 17, 2022, at 1600 mountain daylight time, a Cessna T210N airplane, N210SD, sustained substantial damage when it was involved in an accident near Denver, Colorado. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he and his passenger were performing a local flight after the installation of a new GPS system. After flying for about 15 minutes, the pilot lowered the landing gear in preparation to land. The pilot observed the landing gear in an extended position via landing gear mirrors and confirmed a cockpit gear down light indication. After touchdown, the main landing gear collapsed. The airplane skidded and came to rest upright on an adjacent taxiway. According to airport surveillance video, the airplane’s landing gear appeared to be extended, and the airplane touched down uneventfully. The airplane sustained substantial damage to the left horizontal stabilizer and left elevator. Postaccident examination of the landing gear system revealed no anomalies that would have precluded normal operation. A Federal Aviation Administration inspector and a mechanic performed 10 landing gear extensions and retractions without any system anomalies noted. The cockpit landing gear light indications functioned during each gear cycle and no leaks in the system were detected. -
Analysis
The pilot and his passenger were performing a local flight after the installation of a new GPS system. After flying for about 15 minutes, the pilot lowered the landing gear in preparation to land. The pilot observed the landing gear in an extended position via landing gear mirrors and confirmed a cockpit gear down light indication. After touchdown, the main landing gear collapsed. The airplane skidded and came to rest upright on an adjacent taxiway. The airplane sustained substantial damage to the left horizontal stabilizer and left elevator. Postaccident examination of the landing gear system revealed no anomalies that would have precluded normal operation. During the examination, 10 landing gear extensions and retractions were performed without any anomalies noted with the system. The cockpit landing gear light indications functioned during each gear cycle, and no leaks in the system were detected. The reason for the main landing gear collapse could not be determined.
Probable cause
The main landing gear collapsed during landing for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N210SD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21064225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-19T22:54:06Z guid: 105097 uri: 105097 title: CEN22FA203 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105095/pdf description:
Unique identifier
105095
NTSB case number
CEN22FA203
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-17T18:51:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-05-18T07:05:00.924Z
Event type
Accident
Location
Cleburne, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s flaps-up stall speed was 70 to 72 knots with a 40° bank angle, and the flaps-up stall speed was 86 to 89 knots with a 60° bank angle. The flight instructor stated the accident airplane was “very responsive” to flight control inputs and that, during a stall, a wing would tend to “roll off abruptly.” - On May 17, 2022, about 1751 central daylight time, an American Aviation AA-1A, N6409L, was substantially damaged when it was involved in an accident near Cleburne Regional Airport (CPT), Cleburne, Texas. The student pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A review of automatic dependent surveillance-broadcast data revealed that the airplane departed CPT about 1309 and flew to Clifton Municipal Airport (7F7), Clifton, Texas. The airplane departed 7F7 with a passenger and flew to Roger M. Dreyer Memorial Airport (T20), Gonzales, Texas, to drop off equipment for oil services. The airplane was refueled at T20 and flown back to 7F7, where the passenger disembarked. About 1734, the student pilot departed 7F7 to return to CPT. About 5 miles south of CPT, the airplane made a left turn at an altitude between 200 and 300 ft above ground level and flew to the west of the student pilot’s house toward a south heading (see figure 1) at a groundspeed of about 70 knots. The airplane subsequently turned to the right at the same altitude and flew to the west of the student pilot’s house toward a north heading at a groundspeed of about 90 knots. A witness observed the airplane in a rapid descent and heard it impact the ground. Figure 1. Flight track of accident flight. - The Office of Chief Medical Examiner, Tarrant County Medical Examiner’s District, Fort Worth, Texas, performed an autopsy on the student pilot. His cause of death was multiple blunt force injuries. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected ethanol in the student pilot’s blood at 0.145 gm/dL and in his vitreous fluid at 0.187 gm/dL. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilot performance, even at very low levels. Title 14 CFR 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft “within 8 hours after the consumption of any alcoholic beverage” and “while having an alcohol concentration of 0.04 or greater in a blood or breath specimen.” - The student pilot last flew with a flight instructor on October 17, 2021. The flight instructor stated the student pilot’s cross-country training was progressing well but that the student pilot was reluctant to take the private pilot written test. The flight instructor and student pilot parted ways toward the end of 2021. The student pilot’s last training event entered in his logbook was dated November 22, 2021. The student pilot continued to record flight times in an informal maintenance log until the accident flight. - The airplane impacted an open, grassy field in a rural area in a nose-down attitude and with minimal forward momentum. The airplane came to rest upright, with both wings crushed downward (see figure 2) and the engine partially separated forward of the main wreckage. Figure 2. Airplane at accident site. All flight control surfaces were accounted for at the accident site, and flight control continuity was confirmed for the elevator, ailerons, and rudder from their respective control surfaces to the flight deck. The flaps were in the retracted position. No evidence indicated any preimpact mechanical malfunctions. Six empty mini-sized alcohol bottles (about 1.5 ounces each) were found in the glove box of the airplane’s flight deck. -
Analysis
The student pilot was returning to his home airport after making three stops to pick up and drop off equipment and a passenger. While the airplane was at low altitude about 5 miles from the student pilot’s home airport, the airplane made a left turn that was followed by a right turn near the airplane’s stall speed. The airplane rapidly descended and impacted a field in a nose-low attitude and with minimal forward momentum. The airplane came to rest upright, with both wings crushed downward and the engine partially separated and forward of the main wreckage. There was no evidence of preimpact mechanical malfunctions were observed during examinations of the engine and airframe. Six empty mini-sized alcohol bottles were found in the airplane’s glove box. In addition, the pilot’s toxicology results showed ethanol concentrations that were about five times the Federal Aviation Administration regulatory limit of 0.04 gm/dL. At such concentrations, the pilot would likely have experienced degradation of judgment and deficits in coordination, psychomotor skills, perception, and attention. The student pilot’s toxicology results indicated that he was drinking alcohol before the time of the accident. The student pilot’s decision to maneuver the airplane at a low altitude while under the influence of alcohol caused the airplane to exceed its critical angle of attack and enter a stall, resulting in a loss of control from which the student pilot could not recover.
Probable cause
The student pilot’s decision to operate the airplane after consuming alcohol, which led to an exceedance of the airplane’s critical angle of attack, an aerodynamic stall, and a subsequent loss of control at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN AVIATION
Model
AA-1A
Amateur built
false
Engines
1 Reciprocating
Registration number
N6409L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA1A-0409
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-18T07:05:00Z guid: 105095 uri: 105095 title: ERA22FA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105110/pdf description:
Unique identifier
105110
NTSB case number
ERA22FA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-20T19:42:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-05-30T18:49:10.643Z
Event type
Accident
Location
Wayne, Nebraska
Airport
Wayne Municipal Airport (LCG)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s operation manual provided a stalling speed table (Figure 2) for pilot reference. The manual also suggested that a glide speed to landing should be 65-70 MPH. Figure 2: Stall speed table provided within the airplane operating manual. Review of several videos and photographic evidence showed no sign that the flaps had been extended on the accident final approach. The video also showed the flaps were utilized for a previous landing. Per the airplane’s stall speed table, this would have resulted in a stall speed between about 49 to 40 MPH dependent upon the pilot’s application of engine power. - At the time of the accident, an airport closure and runway 31 closure Notices to Air Mission (NOTAMs) were in effect. The airport closure NOTAM was valid the day of the accident from 1700 to 1901. The runway 31 closure NOTAM was valid from May 18, 1200, through May 23, 2022, 0800. An FAA CoW had been issued to STOL Drag Events LLC from May 19 to 22 to conduct “Competition STOL Drag (Straight Line Air Race, (Non-Closed Course) at Wayne Municipal Airport, Wayne, NE. All racing will be below 100' AGL, within the defined limits of the course adjacent to Runway 05/23.” No documentation was found during the course of the investigation that showed the runway closure NOTAM was cancelled or amended. Additionally, no FAA CoW discussed the use of runway 31 or the conduct of traditional STOL demonstrations. - On May 20, 2022, about 1842 central standard time, a Cessna 140 airplane, N76075, was substantially damaged when it impacted terrain near the Wayne Municipal Airport (LCG), Wayne, Nebraska. The private pilot was fatally injured. The airplane was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. According to a representative with STOL Drag Events LLC, who was a participant organization in the 2022 Wayne County Mayday STOL Drag Races, the day before the accident the event began with short takeoff and landing drag racing (STOL Drag) training. The course was oriented to parallel runway 5-23 at LCG. On the day of the accident, additional STOL Drag training had been completed in the morning and qualifying STOL Drag races were planned for the afternoon. However, due to the northwest gusting winds, the qualifiers were postponed until the next day. After the postponement decision was made, several of the competing pilots expressed a desire to perform traditional STOL (without any drag racing component) on the grass runway 31, given the favorable headwinds. A safety briefing was held with STOL Drag representatives, FAA inspectors who were present to provide oversight of the aviation event, and pilots who planned to fly in the traditional STOL. A representative with STOL Drag informed the pilots that the flying was optional and not a part of the formal STOL Drag competition. In order to limit pattern congestion, multiple groups of 5 airplanes were organized. According to multiple witnesses and video/photographic evidence, the accident airplane was the last airplane within the third group of 5 airplanes, and each of the airplanes in that group had performed two landings without incident. During the third approach, with the accident airplane on final approach and following a Zenith STOL 701, the accident airplane descended and appeared to be lower than the airplane ahead. Subsequently, the pitch attitude increased, the airplane rolled to the right, completed a 3/4-turn right spin, and impacted terrain in a near-vertical attitude. Figure 1 depicts a series of four photographs taken by a witness during the approach and descent toward impact, with the accident airplane circled in red. Figure 1: Four photographs showing the right roll and descent. The STOL Drag representative who coordinated the traffic pattern operations over the radio, and who was standing near the runway threshold when the accident occurred, reported that about 45 seconds before the accident, he stated over the radio to the accident pilot, “lower your nose you look slow.” From his view, the accident airplane turned final approach early and appeared slow. About 15 seconds before the airplane’s roll and descent, he stated again to the accident pilot, “lower your nose.” There were no communications received from the accident pilot and none of the other pilots in the pattern were talking on the radio around the time of the accident. The pilot of the Zenith airplane who was ahead of the accident airplane on final approach reported that his approach speed on final approach was about 50 MPH. He recalled that although the wind during the approach to land was gusting, it was not any different on the accident approach than it had been during the previous two approaches. - About the time of the accident at the airport, an hourly observation reported that wind was from 290° at 15 knots, gusting to 21 knots, which was consistent with witness video that showed the movement of tall flags positioned at the runway threshold. The video showed that the gusting wind varied from about 290° to a direction nearly aligned with runway 31. - FAA Certificate of Waiver Review of the STOL Drag Events LLC. organization website found that they conducted multiple STOL Drag Racing events around the country yearly, and as of this writing, continue to conduct air race events. This was the second STOL Drag event held at LCG, with the first event occurring April 28 - May 1, 2021. In a letter from the FAA, dated April 26, 2021, and signed by the manager of the FAA Flight Standards Technical Branch (AFS-840), STOL Drag Events LLC. was qualified to be the responsible person of a STOL Drag race event and was allowed to apply for a Certificate of Waiver (CoW) using FAA Form 7711-2, Application for a Certificate of Waiver or Authorization of an Aviation Event. The letter also established that STOL Drag Events LLC was accredited to act as an air race organization. The STOL Drag Events LLC. accreditation and air racecourse approval letter were effective April 28, 2021, and valid through April 30, 2023. On April 14, 2022, the Lincoln, Nebraska FAA Flight Standards District Office (FSDO) issued a CoW to STOL Drag Events LLC. as part of the 2022 Wayne County Mayday STOL Drag aviation event. The waiver outlined specific Federal Aviation Regulations that were to be waived and noted operations authorized in accordance with operational policies submitted by STOL Drag. The FAA CoW was effective from 0900 local May 19, 2022, to 1500 May 22, 2022 and a schedule of waiver periods was outlined for the entire weekend of activities. On the day of the accident, the waiver time was scheduled from 0800 to 1900, with qualification racing scheduled as a waivered event from 1600 to 1900. A corresponding NOTAM had closed the airport until 1901, which remained published at the time of the accident, in addition to the runway 31 closure NOTAM. Review of the FAA CoW and the attached document found no authorization, operational procedure, or policies for traditional STOL operations to be conducted during the aviation event. Two specific regulations were waived as part of the CoW: 91.119(c) Minimum Safe Altitudes Federal regulation 91.119(c), minimum safe altitudes, stated in part that, except when necessary for takeoff or landing, no person may operate an aircraft below certain altitudes. Section c stated that, over other than congested areas, an altitude of 500 feet above the surface must be maintained, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure. 91.126(b)(1) Operating on or in the vicinity of an airport in Class G Airspace Federal regulation 91.1269(b)(1) required in part that pilots in class G airspace make all turns to the left in the vicinity of the airport unless specific signage or lights at the airport requires turns to the right. The accident airport had no such signage or lights that the investigation located. According to the president of STOL Drag Events LLC., wind limitations in order to conduct STOL Drag racing were a part of their National Air Race Accreditation letter, which was issued by the FAA. During the accident day, he reported that crosswind and tailwind limitations were exceeded. The FAA inspector overseeing the event reported that a 10-knot tailwind limitation had been exceeded to conduct STOL Drag racing. As part of the accreditation letter, STOL Drag Events LLC., was given the authority to conduct STOL Drag racing flight training and issue and sign air race pilot certificates for competing pilots, which was a requirement of pilots in order to fly in the races. Traditional STOL Preflight Briefing According to the president of STOL Drag Events LLC, following the postponement of the STOL Drag qualifiers, several competition pilots asked whether they could fly traditional STOL on the grass runway 31, given the favorable headwinds. About 1630, a pilot briefing was led by the STOL Drag Events LLC president. According to a statement provided by him, “STOL Drag LLC made it very clear during that briefing, with all pilots and the FAA in attendance, that this was flying at your own risk and the event was over for the day. The pilot group decided to organize a short take-off and landing practice session.” During additional interviews with the president of STOL Drag Events LLC, he reported that he stated during the pilot briefing that “STOL Drag is done for the day” and repeated that the traditional STOL flying was voluntary and not a part of any official competition. He subsequently organized four groups of five airplanes on a sheet of paper, in order to limit the number of aircraft in the traffic pattern at one time. It was his view that, if he did not help with this group organization, all of the airplanes would have attempted to fly at the same time. The accident pilot was placed in group three of four, and he was the last airplane in the group. The president of STOL Drag Events LLC reported that traditional STOL was not planned as part of the event program nor was traditional STOL commonly performed at other STOL Drag Events. He further reported that in attendance at the traditional STOL pilot briefing was the FAA inspector-in-charge (IIC), two additional FAA inspectors, and airport authority personnel. The president of STOL Drag Events LLC., reported that the FAA IIC approved traditional STOL to be conducted during the scheduled/waivered airport closure period. Additionally, he stated that the FAA IIC told him, “the waiver and the NOTAM [are] protecting you guys. yeah go fly.” The president explained that the NOTAM and waiver was valid until 1900 and that the FAA IIC was not going to allow the flight activity to go beyond 1900. Traditional STOL Operations The president of STOL Drag Events LLC coordinated the right traffic pattern operations over the radio standing near the runway threshold. The runway 31 boundaries had been altered from their normal length and width with a new white line threshold and cones (figure 3). Figure 3: Additional view of runway 31 and airplane’s arriving, about 30 seconds prior to the accident. Video of the traditional STOL operations showed individuals, one with a jacket with a “STOL Drag” logo completing measurements after STOL attempts. According to the president of STOL Drag Events LLC., “generic measurements” were being taken during the traditional STOL and the activity was not a part of any official planned competition. Witness video and photo evidence captured the accident pilot’s takeoff attempts. The video also showed the location of the crowd and car lines paralleling the runway on the airport property (figure 4). Figure 4: View of the accident airplane’s takeoff and crowd line at the aviation event. According to the president of STOL Drag Events LLC., the FAA IIC supervised the traditional STOL operations. During the traditional STOL, a representative with STOL Drag Events requested permission from the FAA IIC to continue traditional STOL past 1900 shortly before the accident occurred, however, the FAA IIC verbally denied this request. FAA Inspector-in-Charge The FAA IIC supervising the STOL Drag event reported that the aviation event was no longer taking place at the time of the accident. He reported that the 10-knot tailwind that would have been present on the 05-23 oriented racecourse was the reason that the STOL Drag racing was postponed. The FAA IIC reported that he attended the pilot briefing preceding the traditional STOL operations. He recalled that STOL Drag representatives postponed the waivered event and then they decided to conduct traditional STOL on runway 31. He could not recall agreeing or disagreeing with these decisions. The FAA IIC further added that he was asked by STOL Drag representatives shortly before the accident occurred, to continue traditional STOL operations beyond 1900 local (which was the end of the originally scheduled waiver and airport closure period), and he said no to this request. - Review of the accident pilot’s logbook revealed that he had accumulated about 310 hours of flight experience in tailwheel-equipped airplanes, with the majority of the flight experience taking place in the accident airplane. On October 16, 2021, while attending the STOL Drag Events LLC. High Sierra Fly-in event, the pilot was issued a letter from the STOL Drag Chief Flight Instructor denoting that he had satisfactorily completed the STOL Drag training course and had full permission to participate at any sanctioned STOL Drag Events LLC race event. The letter was valid for 24 months and the pilot subsequently competed in the STOL Drag racing at the High Sierra event. - The airplane came to rest about 1,600 ft from the runway 31 threshold and about 250 ft right of the extended centerline. During a postaccident examination, flight control continuity was established from the cockpit to the corresponding control surface with no preimpact anomalies noted. Fuel remained in both wings. The flap position and flap handle could not be correlated to a flap setting position due to impact-related damage. The engine had crushed rearward into the cockpit. The airspeed indicator needle was found indicating about 57 MPH and a rub mark at this speed was observed on the face of the instrument. Examination of the engine found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane was not equipped with shoulder harnesses. -
Analysis
The accident pilot had planned to participate in an aviation event that involved a form of air racing called short takeoff and landing drag racing (STOL Drag). On the day of the accident, in the afternoon, the aviation event was supposed to begin with STOL Drag qualification racing; however, the air racing was postponed to the following day due to gusting wind conditions that were oriented in an unfavorable direction relative to the orientation of the racecourse. After the postponement decision was made, several of the competing pilots expressed a desire to perform traditional STOL (without any drag racing component) on a grass runway where a more favorable, but gusty, headwind prevailed. A safety briefing was held with representatives of the event organizer, Federal Aviation Administration (FAA) inspectors who were on site to supervise the STOL Drag event, and pilots who planned to fly in the traditional STOL. A representative of the STOL Drag event organizer informed the pilots that the flying was optional, and it was not a part of the formal air race competition. To limit traffic pattern congestion, multiple groups of 5 airplanes were organized. According to witnesses and video/photographic evidence, the accident airplane was the last airplane within a group of 5, and all 5 airplanes had each performed two landings without incident. During the third approach, while the accident airplane was on final approach following a slower airplane ahead also on final approach, the accident airplane descended and appeared to be lower than the airplane ahead of it. Subsequently, the accident airplane’s pitch attitude increased, it rolled to the right, completed a 3/4-turn right spin, and impacted terrain in a near-vertical attitude. Postaccident examination of the airframe and engine found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on this information, it is likely that the accident pilot allowed the airplane to exceed its critical angle of attack while on final approach and the airplane entered an aerodynamic stall and spin at too low an altitude to successfully recover. The strong, gusting wind conditions increased the likelihood of a sudden increase in angle of attack as the pilot approached the runway at a slow speed, already operating near the airplane’s critical angle of attack. The evidence further showed that the accident pilot turned onto final approach early and, as a result, may have been altering his approach path and speed to maintain spacing behind the slower airplane ahead. If the pilot observed his airspeed decaying, given the lack of spacing ahead, adding engine power and/or increasing airspeed would only exacerbate the already close spacing with the airplane ahead. In this case, the only alternative would have been for the pilot to execute a go-around. Additionally, review of high-resolution photographs showed no evidence that the airplane’s flaps had been extended on final approach, despite having used flaps for the prior landings. Data from the airplane’s operations manual showed that extending the flaps would result in the airplane’s stall speed being about 5 mph slower, all other factors being equal. It could not be determined whether the pilot inadvertently forgot to extend the flaps during the landing attempt or had chosen not to extend them due to the gusting wind conditions. The pilot’s loss of control occurred during non-traditional traffic pattern operations, and other factors may also have contributed to the pilot’s loss of control in flight. The pilot was flying an approach in which his touchdown and landing distance would be measured and judged by spectators and fellow pilots. Regardless of whether the STOL activity being conducted at the time of the accident was part of an official competition, it is likely that the pilot’s approach was influenced by the competitive environment. The gusting wind should have resulted in the pilot increasing the airplane’s speed on final approach; however, doing so would conflict with the desire to perform a competitive STOL landing. Additionally, while the accident pilot had completed STOL Drag training and was certified to compete in STOL Drag racing, no training was required of the pilots participating in the impromptu traditional STOL operations, which was a characteristically different flight activity as compared to STOL Drag racing in which airplanes do not exit ground effect. An FAA-issued a Certificate of Waiver (CoW), outlined several exceptions to aviation regulations that were required in order to conduct the STOL Drag event. The CoW, in addition to a National Air Race Accreditation Letter and associated policies and procedures, incorporated risk mitigations that included a variety of elements, such as requirements for pilot training and certification, as well as operational wind limitations; however, these risk management controls were not present for the impromptu traditional STOL operations in which the accident pilot was participating. Had risk mitigations like those that were planned for the STOL Drag event been in place and adhered to by the event organizers and the FAA personnel present, it is possible that the accident could have been avoided.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack on final approach while conducting traditional short takeoff and landing operations in gusting wind conditions, which resulted in an aerodynamic stall and spin from which the pilot could not recover. Contributing to the accident was the competitive environment, which likely influenced the pilot’s approach speed and the subsequent loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N76075
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Air race/show
Commercial sightseeing flight
false
Serial number
10469
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-05-30T18:49:10Z guid: 105110 uri: 105110 title: ERA22LA241 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105131/pdf description:
Unique identifier
105131
NTSB case number
ERA22LA241
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-21T14:53:00Z
Publication date
2024-02-21T05:00:00Z
Report type
Final
Last updated
2022-06-02T00:45:31.617Z
Event type
Accident
Location
Lancaster, Ohio
Airport
Fairfield County Airport (LHQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 21, 2022, about 1353 eastern daylight time, an Evektor-Aerotechnik Sportstar Plus, N503RK, was substantially damaged when it was involved in an accident near Carroll, Ohio. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that his airplane had been sitting for a few months for maintenance. He stated that after a thorough external inspection, he started the engine and let it run to ensure there were no anomalies. After all engine checks were completed, he taxied to the run-up area and prepared for takeoff. After takeoff, the pilot noticed that the engine was not developing full power. He leveled off to regain airspeed and reported the engine gained about 200 rpm. Ge turned north toward the practice area, but the engine once again started to lose power. He then turned back toward the traffic pattern for the runway. While on the downwind leg, the engine “quit,” and the pilot radioed “MAYDAY.” He made a forced landing in a field adjacent to the airport. During the landing flare, the airplane landed hard and the right main and nose landing gear collapsed. Postaccident inspection of the airplane by a Federal Aviation Administration inspector revealed the right horizontal stabilizer and fuselage were buckled. An examination of the engine revealed that when Nos. 1 through 3 cylinder heads were removed the pushrod O-rings were found installed incorrectly. The O-rings were crushed, partially disintegrated, and O-ring material was found in the bore of the crankcase. The No. 4 cylinder head was removed, and the intake pushrod tube O-ring was extruding from the bore. No breaches were found in the oil or cooling system. The crankshaft would not rotate by hand. The cylinder heads were subsequently removed. The No. 4 connecting rod was separated from the crankshaft. The No. 3 piston displayed scoring and liberated pieces of the pushrod O-rings were obstructing oil ports that fed the No. 4 connecting rod bearing. A review of the maintenance logbooks for the airplane did not reveal any recent engine maintenance that would require the removal of the cylinder heads. It was noted in the maintenance logbooks that the cylinders were removed and reinstalled for repair on August 4, 2013, at a tachometer time of 480 hours. This was 8 years and 10 months and 58.8 tachometer hours prior to the accident. -
Analysis
The pilot observed a reduction in engine power shortly after takeoff. While attempting to return to the airport, the engine lost power completely while on the downwind leg of the airport traffic pattern, after which the pilot performed an off-airport landing. The airplane’s fuselage and horizontal stabilizer were substantially damaged during the landing. Postaccident examination of the engine revealed that the pushrod O-rings had been incorrectly installed. This improper installation led to the disintegration of the O-rings, and the resulting debris to blocked the oil ports to the No. 4 connecting rod bearing. The lack of oil to the bearing resulted in the failure of the connecting rod, and the subsequent total loss of engine power. The airplane’s maintenance logbooks did not document any recent engine maintenance that would have required removing the engine’s cylinder heads. The cylinders were removed and reinstalled following repair nearly 9 years, and about 58 tachometer hours, before the accident. Based on available information, it is likely that the O-rings were improperly installed during this maintenance.
Probable cause
The improper installation and subsequent failure of the pushrod O-rings, which resulted in failure of the No. 4 connecting rod due to oil starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EVEKTOR-AEROTECHNIK AS
Model
SPORTSTAR
Amateur built
true
Engines
1 Reciprocating
Registration number
N503RK
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
20050503
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-02T00:45:31Z guid: 105131 uri: 105131 title: WPR21LA368 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107076/pdf description:
Unique identifier
107076
NTSB case number
WPR21LA368
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-21T16:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-04-20T04:27:22.615Z
Event type
Accident
Location
Sacramento, California
Airport
Scheidel Ranch Airport (CA07)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during an aerial application flight, the engine lost total power. The pilot attempted to restart the engine but was unsuccessful and was forced to land in a dry plowed field. The left wing was substantially damaged. Postaccident examination of the airplane revealed that the right-side fuel tank was almost empty, and the left side fuel tank contained approximately 15 gallons of fuel. The Airplane Flight Manual for the airplane states that skidding turns below ½ tanks can transfer fuel from one tank to another, which will lead to engine flameout if one tank runs dry. Subsequently, the pilot stated that he should have completed a better visual inspection of the contents of both fuel tanks before takeoff. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-602
Amateur built
false
Engines
1 Turbo prop
Registration number
N8521V
Operator
FARM AIR FLYING SERVICE LLC
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
602-0690
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-20T04:27:22Z guid: 107076 uri: 107076 title: CEN22LA209 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105120/pdf description:
Unique identifier
105120
NTSB case number
CEN22LA209
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-21T17:30:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-05-26T22:26:13.211Z
Event type
Accident
Location
Fort Stockton, Texas
Airport
Fort Stockton - Pecos County (FST)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 21, 2022, about 1630 central daylight time, a Textron Aviation B300C airplane, N98FM, was substantially damaged when it was involved in an accident near Ft. Stockton, Texas. Neither of the two pilots were injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. The pilots were conducting landing performance testing on an unimproved, dirt runway at the time of the accident. The initial two-engine takeoffs and landings were uneventful. Subsequent testing was conducted with one engine shut down and secured, and with a 300 lb fuel imbalance as specified by the test plan. At the time of the accident landing, a 10-knot, 100° right crosswind prevailed. The wind had been variable over the course of the afternoon. The pilot flying reported the touchdown was smooth, after which the throttles were “placed into ground-fine” and maximum braking was applied. The airplane began to drift toward the right side of the runway. The pilot immediately applied left rudder and reduced braking. He subsequently “applied cautious left braking” to bring the airplane to the center of the runway without over correcting. According to the pilot, these actions were not sufficient and the right wing impacted bushes and a small tree along the right side of the runway, although the main landing gear remained on the runway. After the accident, the pilot noted that the antiskid braking system may not have been operating properly. The airplane sustained damage to the right-wing extension and winglet. Specifically, the leading edge was crushed aft, and the upper and lower wing skins were wrinkled. The lower wing skin was wrinkled aft of the spar consistent with spar damage. The airplane was equipped with a data recorder to support the flight test mission. The airframe manufacturer/operator reported that the left and right wheel speed data parameters related to the data recorder were inoperative. Wheel speed data was available to the antiskid system, which was operational during the flight. Brake pressure data revealed the left brake pressure increased after touchdown consistent with initial brake application, the right crosswind condition, and the pilot’s effort to maintain the center of the runway. About 8 seconds after initial brake application, the right brake pressure increased consistent with a maximum bilateral braking effort. In addition, the left and right brake pressures began to oscillate consistent with normal operation of the antiskid system. The pilots reported no anomalies with respect to the nose wheel steering or flight control systems. Review of the recorded data did not reveal any anomalies consistent with a malfunction of the antiskid brake system. The investigation was unable to identify any anomalies with respect to the airplane. -
Analysis
The pilots were conducting single-engine landing performance tests on an unimproved, dirt runway at the time of the accident. The pilot reported the touchdown was smooth, after which the throttles were reduced, and maximum braking was applied. The airplane began to drift toward the right side of the runway. The pilot immediately applied left rudder and reduced braking. He subsequently “applied cautious left braking” to bring the airplane to the center of the runway without over correcting. These actions were not sufficient and the right wing impacted bushes and a small tree along the right side of the runway, although the main landing gear remained on the runway. After the accident, the pilot noted that the antiskid braking system may not have been operating properly. Recorded data revealed the left brake pressure increased after touchdown consistent with the pilot’s effort to maintain the center of the runway. About 8 seconds later, the right brake pressure increased consistent with a maximum bilateral braking effort, and the left and right brake pressures began to oscillate consistent with normal operation of the antiskid system. The investigation was unable to identify any anomalies with respect to the airplane. The pilot’s efforts to maintain directional control after landing touchdown were insufficient, which allowed the right wing to drift off the right side of the runway and impact the brush and small tree. The single-engine landing and maximum braking effort in accordance with the test plan likely hindered these efforts.
Probable cause
The pilot’s failure to maintain directional control while landing with a single engine and maximum braking effort.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Textron Aviation
Model
B300C
Amateur built
false
Engines
2 Turbo prop
Registration number
N98FM
Operator
Textron Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
FM-98
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-26T22:26:13Z guid: 105120 uri: 105120 title: CEN22FA208 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105113/pdf description:
Unique identifier
105113
NTSB case number
CEN22FA208
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-22T12:49:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-05-24T07:28:38.989Z
Event type
Accident
Location
Broomfield, Colorado
Airport
Erie Municipal Airport (EIK)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Performance Study A performance study was conducted using data recovered from the primary flight and multi-function displays. Altitude, airspeed, and engine performance were compared for the accident flight and a previous flight, which operated from the same runway and about the same time of day, and which were the only two flights with data recorded after the Dynon avionics were installed. On the accident takeoff roll, engine power was slow to increase relative to the previous flight, and the airplane did not accelerate much beyond the rotation speed. The accident takeoff rate of climb was 200-300 feet per minute less than the previous flight. The airplane pitched up to over 20° during the accident takeoff, about twice the pitch attitude obtained during the previous takeoff. The airplane reached a maximum altitude of about 230 ft above ground level before pitching down, descending, and impacting the ground. Exhaust gas temperatures (EGTs) of cylinders Nos.1, 5, and 6 were 70°F, 65°F, and 130°F hotter for the accident takeoff compared to the previous takeoff, respectively, while cylinders Nos.2, 3, and 4 had similar EGT’s to the previous takeoff. The fuel flow was about 5 gallons per hour (gph) less on the accident takeoff than the previous takeoff (16 gph vs. 11 gph, or about 45% less). Fuel flow is proportional to horsepower produced by the engine. Engine RPM and manifold pressure for the two takeoffs were similar. The reason for the lower fuel flow during the accident takeoff was not conclusive. However, one possibility was that the pilot(s) leaned the mixture during the extended ground operations of more than 1 hour and subsequently forgot to enrich the mixture before takeoff. Leaning the mixture would be appropriate to avoid fouling the spark plugs. A second possibility for the lower fuel flow was carburetor ice. Carburetor ice can affect the fuel flow by disturbing the venturi effect in the carburetor throat that draws fuel into the cylinders. The result is lower fuel flows. According to Federal Aviation Administration (FAA) Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, the probability of carburetor icing during the weather conditions of the accident was serious at glide power. Rejected Takeoff Information The airplane owner’s handbook indicates a takeoff distance (which includes a climb to 50 ft) of about 1,300 ft based on the conditions of the accident. According to inflight data, the accident ground roll was about 2,300 ft. The FAA Airplane Flying Handbook (FAA-H-8083-3C) includes the following information related to a rejected takeoff: Emergency or abnormal situations can occur during a takeoff that require a pilot to reject the takeoff while still on the runway. Circumstances such as a malfunctioning powerplant, inadequate acceleration, runway incursion, or air traffic conflict may be reasons for a rejected takeoff. Prior to takeoff, the pilot should identify a point along the runway at which the airplane should be airborne. If that point is reached and the airplane is not airborne, immediate action should be taken to discontinue the takeoff. When properly planned and executed, the airplane can be stopped on the remaining runway without using extraordinary measures, such as excessive braking that may result in loss of directional control, airplane damage, and/or personal injury. The POH/AFM ground roll distances for take-off and landing added together provide a good estimate of the total runway needed to accelerate and then stop. - A review of maintenance logs revealed an avionics upgrade was completed on February 4, 2022, that included installation of a Garmin G5 and Dynon primary flight/multi-function displays. The pilot-rated passenger assisted with the avionics installation. The airplane flew about 22 hours between the time the avionics were upgraded and the time of the accident. The purpose of the accident flight included troubleshooting an avionics issue. - On May 22, 2022, about 1149 mountain daylight time, a Piper PA-32-260, N85CT, was substantially damaged when it was involved in an accident near Broomfield, Colorado. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast (ADS-B) information, the airplane departed Erie Municipal Airport (EIK) on Runway 16. About 3,000 ft from the departure end of the runway, the airplane made a left turn, descended, and impacted terrain. Figure 1. Accident Flight Track with Recorded Altitude and Indicated Airspeed Two experienced pilots who lived along the airplane’s flight path reported hearing abnormal engine noises. The first pilot, who was located about 800 ft from the departure end of Runway 16, observed the airplane fly past about 50 to 100 ft above ground level (agl). About 5 seconds later, he heard several popping noises. The second pilot was located about 1,000 ft to the west of the accident site and reported hearing a “loud carburetor cough” followed a few seconds later by a “quieter carburetor cough.” Within 10 seconds, he heard the airplane impact the ground. - An autopsy was performed on the pilot by the Office of the Coroner, Adams and Broomfield Counties, Colorado. The cause of death was multiple blunt force injuries. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory did not identify any tested-for substances. An autopsy was performed on the pilot-rated passenger by the Office of the Coroner, Adams and Broomfield Counties, Colorado. The cause of death was multiple blunt force injuries. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified tamsulosin, morphine, its metabolite hydromorphone, and dihydrocodeine in urine; However, none of these were identified in cavity blood. - The meteorological conditions were conducive to serious carburetor icing at glide power. - The airplane impacted a grassy area in a residential community. About 35 ft beyond the point of initial impact, six propeller strike marks spaced about 1 ft apart were located on a paved road. The airplane bounced and subsequently impacted a large tree about 100 ft from the propeller strike marks, which resulted in the engine and cockpit area separating from the remainder of the fuselage. Figure 2. Airplane at Accident Site All components of the airplane were observed at the accident site. Fuel was recovered from the left main, right main, and right wingtip fuel tanks, with no indications of contamination. The fuel bowl contained fuel that was free from debris or water. The electric fuel pump and fuel selector tested normally. The carburetor floats were unremarkable and carburetor inlet screen was free of debris. The electric fuel pump switch was found in the on position, and the primer pump handle was in and latched. The throttle and propeller control handles were fully forward. The mixture control knob was found extended about 1 inch out from the panel. The carburetor heat position could not be determined. Flight control cable continuity was established and the flap handle was found positioned to 10°. The pitch trim screw extension correlated to partial nose down trim. The crankshaft was rotated by hand, producing normal valve movement. Thumb compression was achieved on 5 of the 6 cylinders; however, the No.2 cylinder did not produce compression. The No.2 cylinder was removed, revealing the presence of carbon deposits between the exhaust valve and seat. Postaccident examinations revealed no evidence of a mechanical failure or malfunction that would have precluded normal operation. -
Analysis
The pilot and pilot-rated passenger conducted a personal flight that included troubleshooting an avionics issue. Following an extended taxi of longer than 1 hour, the airplane departed with a longer-than-normal ground roll and made a shallower-than-normal climb out. About ½ mile past the departure end of the runway, the airplane turned left and descended toward a road, which was a flight profile that was consistent with a forced landing attempt. The airplane impacted the road and then a large tree, which separated the engine and cockpit area from the fuselage, resulting in substantial damage. Postaccident examination of the airframe and engine did not reveal any indication of a mechanical failure or malfunction that would have precluded normal operation. Recorded data indicated engine performance during the accident takeoff was significantly lower than a previous takeoff. The engine power increased very slowly on the accident takeoff roll and fuel flow was about 45% less than the previous takeoff. The reason for the lower fuel flow during the accident takeoff could not be conclusively determined. However, one possibility was that the pilot(s) leaned the mixture during the extended ground operations of more than 1 hour and subsequently forgot to enrich the mixture before takeoff. A second possibility for the lower fuel flow was carburetor ice. The weather conditions at the time of the accident were conducive to serious carburetor icing at glide power. Carburetor ice can affect the fuel flow by disturbing the venturi effect in the carburetor throat that draws fuel into the cylinders. The result is lower fuel flows. Toxicology testing of the pilot did not identify any tested-for substances. The pilot-rated passenger’s toxicology indicated use of a number of substances; however, indications were limited to the urine and it is unlikely they were contributory to the accident. The slow acceleration and extended ground roll due to the degraded engine performance necessitated an abort that was not accomplished by the pilots. Since a purpose of the flight was troubleshooting an avionics issue, it is possible that the pilots were distracted by the avionics issue during the takeoff roll. This distraction could have led to inattention to ensuring that the fuel flow/engine performance was adequate during the takeoff roll and to abort the takeoff.
Probable cause
The pilot’s failure to abort the takeoff due to degraded engine performance. Contributing to the accident was the reduced performance of the engine, the reason for which could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N85CT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-789
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-24T07:28:38Z guid: 105113 uri: 105113 title: ERA22LA235 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105117/pdf description:
Unique identifier
105117
NTSB case number
ERA22LA235
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-22T20:52:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Last updated
2022-06-15T18:09:35.335Z
Event type
Accident
Location
Caryville, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 22, 2022, about 1952 central daylight time, a Cessna 310R airplane, N310DC, was substantially damaged when it was involved in an accident near Caryville, Florida. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot reported that preflight and ground operations were routine and normal. The day before the accident, the airplane’s fuel tanks were serviced with 47 gallons of fuel to the full capacity of 160 gallons. He departed from Northwest Florida Beaches International Airport (ECP), Panama City, Florida about 1929 with a destination of Gwinnett County Airport (LZU), Lawrenceville, Georgia. After departure, at 5,800 ft mean sea level, the left engine lost power. He initiated the emergency checklist procedures and informed air traffic control. He requested right turns only and a return to ECP. Shortly thereafter, the right engine lost power. He attempted to change to the auxiliary fuel tanks; however, there was no response from the engines. He was unable to glide to an airport, so he maintained best glide speed and performed a forced landing with the landing gear retracted to a nearby farm field. After touchdown, the airplane collided with a barbed-wire fence and came to a stop in an open farm pasture. A postcrash fire ensued, which consumed the outboard and center sections of the left wing. The pilot egressed the airplane and was met by first responders. The wreckage was recovered to a storage facility where an examination of the wreckage was performed. The right, main (tip) fuel tank was breached from ground impact and contained organic debris that was consistent with the ground around the accident site. No residual fuel was found in the tip tank. The right auxiliary tank, mounted in the right wing, contained fuel and was filled to near capacity. The fuel from the auxiliary tank was recovered; it was clean and light blue in color and contained no particulates. A small amount of water (about one teaspoon) was observed in the drained fuel. The right auxiliary fuel pump and the right transfer pump were tested; they pumped normally when powered with an electric source. All right-wing fuel lines, valves, and filters were examined for contamination and obstructions; none were found. The left-side aircraft fuel system was extensively damaged from the postaccident fire. The left, main (tip) fuel tank was destroyed by fire and no residual fuel remained. The left auxiliary tank, mounted in the left wing, contained a combination of fuel, water, and debris; it was breached during the ground impact and postaccident fire and was exposed to the elements. The fuel from the auxiliary tank was not quantified due to the damage. The left auxiliary fuel pump and the left transfer pump were not tested due to the postaccident fire damage. All surviving left-wing fuel lines, valves, and filters were examined for contamination and obstructions; none were found. Both engines were examined. Internal valve train continuity was confirmed on both engines. All top spark plugs were removed; all plugs were normal in color and wear when compared to a spark plug inspection chart. Suction and compression were observed on all cylinders when the engine crankshafts were manually rotated. Both engine-driven fuel pumps rotated freely and both pump drives were intact. All cylinder fuel injectors were removed and examined; they were clear and free of contaminants or debris. All magnetos produced spark on all leads. Residual fuel was noted inside both engine fuel distribution valves. All fuel lines on both engines were unobstructed. A lighted borescope was used to examine the inside of all 12 cylinders; the cylinder walls, piston heads, and valves were undamaged and exhibited minimal wear. Both propeller assemblies were examined. There was an absence of s-bending and twisting of the blades; however, both sets of blades exhibited leading edge polishing and chordwise scratching of the blade surfaces. Samples of fuel from the right and left auxiliary fuel tanks were tested in a laboratory for the possibility of contamination with Jet A fuel; no Jet A was found in the samples. -
Analysis
The pilot reported that preflight and ground operations were normal for the cross-country flight and all fuel tanks were filled to capacity. Several minutes after departure, at 5,800 ft mean sea level, the left engine lost power. He initiated the emergency checklist procedures and informed air traffic control. He requested right turns only and a return to the departure airport. Shortly thereafter, the right engine lost power. He attempted to change to the auxiliary fuel tanks; however, there was no response from the engines. He was unable to glide to an airport, so he maintained best glide speed and performed a forced landing with the landing gear retracted to a nearby farm field. After touchdown, the airplane collided with a barbed-wire fence and came to a stop in an open farm pasture. A postaccident fire ensued, which consumed the outboard and center sections of the left wing. An examination of the wreckage revealed no evidence of a fuel system malfunction or anomaly. Although the left-side fuel system was heavily damaged by the postaccident fire, the remaining components operated normally, and all fuel lines and filters were unobstructed. Fuel that was recovered was tested for possible contamination (misfueling) with Jet A; no Jet A was found in the fuel system. Examination of both engines revealed no malfunctions or anomalies that would have precluded normal operation. The reason for the loss of engine power on both engines was not determined.
Probable cause
An in-flight loss of engine power on both engines for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310
Amateur built
false
Engines
2 Reciprocating
Registration number
N310DC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310R0151
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-15T18:09:35Z guid: 105117 uri: 105117 title: DCA22FM019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105134/pdf description:
Unique identifier
105134
NTSB case number
DCA22FM019
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-05-23T01:30:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2023-04-24T04:00:00Z
Event type
Accident
Location
Miah Maul Shoal Light, Delaware
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire aboard the deck barge CMT Y Not 6 was the ignition of a combustible material by an undetermined source, such as sparking from shifting metallic cargo, self-heating of metallic or nonmetallic cargo, improperly prepared vehicles and appliances, or damaged lithium-ion batteries.
Has safety recommendations
false

Vehicle 1

Vessel name
CMT Y NOT 6
Vessel type
Towing/Barge
Findings

Vehicle 2

Callsign
WDJ6432
Vessel name
Daisy Mae
Vessel type
Towing/Barge
Maritime Mobile Service Identity
367797720
Port of registry
Coeymans, New York
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-04-24T04:00:00Z guid: 105134 uri: 105134 title: CEN22FA211 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105125/pdf description:
Unique identifier
105125
NTSB case number
CEN22FA211
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-24T08:00:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-05-27T01:16:04.831Z
Event type
Accident
Location
Seagraves, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The Federal Aviation Administration (FAA) publication H-8083-25A, Pilot's Handbook of Aeronautical Knowledge, stated that an aerodynamic stall results from a rapid decrease in lift caused by the separation of airflow from the wing's surface brought on by exceeding the critical angle of attack (AOA). AOA is defined as the acute angle between the chord line of the airfoil and the direction of the relative wind. An aerodynamic stall can occur when the airplane flies too slowly, or when higher wing loads are imposed due to maneuvers such as pull-ups or banked flight. According to the Federal Aviation Administration Airplane Flying Handbook (FAA-H-8083-3C): At the same gross weight, airplane configuration, CG location, power setting, and environmental conditions, a given airplane consistently stalls at the same indicated airspeed provided the airplane is at +1G (i.e., steady-state unaccelerated flight). However, the airplane can also stall at a higher indicated airspeed when the airplane is subject to an acceleration greater than +1G, such as when turning, pulling up, or other abrupt changes in flightpath. Stalls encountered any time the G-load exceeds +1G are called “accelerated maneuver stalls.” The accelerated stall would most frequently occur inadvertently during improperly executed turns, stall and spin recoveries, pullouts from steep dives, or when overshooting a base to final turn. An accelerated stall is typically demonstrated during steep turns. - On May 24, 2022, about 0700, a Piper PA-12 airplane, N78466, was destroyed when it was involved in an accident near Seagraves, Texas. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to local authorities and family acquaintances, the pilot had been flying in the local area over a period of several weeks with aspirations to become an agricultural pilot. During those weeks, the airplane had been observed by several people to be flying at low altitude while performing “ag-type maneuvers” over the fields. The airplane wreckage was located by a farmer about 1150, and there were no witnesses to the accident. - Postaccident examination of the accident site revealed that the airplane impacted terrain in a nose- and right-wing low attitude. The initial ground scar was consistent with the propeller, engine, forward fuselage, and wings. The airplane sustained substantial damage to the fuselage, wings, and empennage. The vertical stabilizer was pointed to the right, consistent with a clockwise stall/spin at impact (see Figure 1). Figure 1. Accident airplane Flight control continuity was established from the cockpit to all flight control surfaces. The engine remained partially attached to the firewall and could not be manually rotated due to damage to the engine crankcase. The propeller blades displayed forward twisting deformation. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot had been observed flying in the area over a period of several weeks at a low altitude and while performing “ag-type maneuvers” over the fields, as he aspired to become an agricultural pilot. There were no witnesses to the accident; the airplane wreckage was discovered in a field by a local farmer. Examination revealed that the airplane impacted terrain in a nose- and right-wing-low attitude, and the orientation of the wreckage was consistent with an aerodynamic stall/spin. There was no evidence of mechanical malfunctions or anomalies of the airframe or engine that would have precluded normal operation. Based on the available information, it is likely that the pilot exceeded the airplane’s critical angle of attack while maneuvering, possibly at low altitude, which resulted in an aerodynamic stall/spin, a loss of control, and impact with terrain.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack while maneuvering, which resulted in an aerodynamic stall/spin and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N78466
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-1978
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-05-27T01:16:04Z guid: 105125 uri: 105125 title: ANC22LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105132/pdf description:
Unique identifier
105132
NTSB case number
ANC22LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-24T16:10:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-05-26T01:22:33.222Z
Event type
Accident
Location
Yakutat, Alaska
Airport
Dry Bay Airport (3AK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 4 serious, 0 minor
Factual narrative
WEIGHT AND BALANCE INFORMATION As a single-engine operation, the flight was not required to have a load manifest on the airplane. The pilot stated that he had computed a weight and balance for the accident flight and recorded it on a piece of paper; however, it could not be located following the accident. At the request of the NTSB, the pilot provided documents indicating the weight of the cargo and passengers and their locations in the airplane. The first set of documents was provided on May 28, 2022, and the values and locations were not consistent with witness statements. A second set of documents was provided on June 10, 2022, that is believed to have more accurately reflected the loading of the accident flight. One passenger reported that the freight had been weighed on pallets and he assisted the pilot by handing him freight that was then loaded on the airplane. He stated there was a pallet of garbage cans that was placed near the front of the airplane, in addition to a pallet of ATV tires, wheels, and a portable sawmill head. Another passenger stated that the airplane was partially loaded when he arrived at the operator’s facility. He was not asked his weight, his bags were not weighed, and he did not see a scale. He stated that he was seated in the back of the airplane with a saw at his feet. According to the weight and balance information for the airplane dated March 15, 2017, the basic empty weight of the airplane was 4,425 lbs with a center of gravity of 141.1 inches. At the airplane’s maximum takeoff gross weight of 8,000 lbs, the center of gravity range was 135.8 inches to 152.2 inches. The airplane’s weight and balance at the time of the accident was estimated using the documentation provided by the pilot on June 10, 2022. The pilot stated that the airplane departed with about 618.8 lbs of fuel and 1,996 lbs of cargo. Assuming an average fuel burn of about 360 lbs/hr, and about 23 minutes of flight time before the accident, fuel onboard at the time of the accident was about 480.8 lbs. The gross weight of the airplane at the time of the accident, was about 7,796.8 lbs. A CG range of about 155.4 - 157.8 inches aft of datum was computed based on the two possible fuel loading extremes. The accident flight was operated under the provisions of Part 135 as an on-demand charter and was subject to the regulation’s applicable rules and the requirements set forth in the company's operations specifications (OpSpecs). Per §135.399, the operator was not allowed to operate the accident airplane without complying with "the takeoff weight limitations in the Approved Flight Manual or equivalent." The requirements of § 135.87 state, in part, that no person may carry cargo (including carry-on baggage) in an aircraft unless it is not located in a position that obstructs the access to, or the use of the aisle between the crew and the passenger compartment (see figure 2). Figure 2 - Accident airplane being loaded for the accident flight. (Source: A passenger on the accident flight) Neither Part 135 for single-engine operations nor the operator's OpSpecs require that the aircraft weight and balance be physically documented for any flight. However, according to OpSpec Paragraph A096, when determining aircraft weight and balance, the operator was authorized to use either the actual measured weights for all passengers, baggage, and cargo or the solicited weights for passengers plus 10 lbs and actual measured weights for baggage and cargo. In addition, for routine operations, the operator was required to follow the weight and balance control procedures outlined in the aircraft weight and balance section of the pilot operating handbook. Although neither Part 135 nor Yakutat Coastal Airlines’ OpSpec requires the operator to physically document the weight and balance for any flights conducted in the company's single-engine airplanes, §135.63 requires that operators using multiengine aircraft are "responsible for the preparation and accuracy of a load manifest in duplicate containing information concerning the loading of the aircraft." This load manifest must be prepared before each flight and include, among other items, the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the center of gravity location of the loaded aircraft. Further, one copy of the load manifest is to be carried in the airplane, and the operator is required to keep the records for at least 30 days. The NTSB attempted to address this single-engine exclusion with the issuance of Safety Recommendations A-89-135, A-99-61, and A-15-29, which asked the Federal Aviation Administration (FAA) to amend the record-keeping requirements of 14 CFR 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action in the above recommendations, and the NTSB classified them "Closed—Unacceptable Action" in 1990, 2014, and 2021, respectively. - On May 24, 2022, about 1510 Alaska daylight time, a de Havilland DHC-3 Turbine Otter airplane, N703TH, sustained substantial damage when it was involved in an accident near Yakutat, Alaska. The pilot and three passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 on demand charter flight. The flight, operated by Yakutat Coastal Airlines, had departed from Yakutat Airport (PAYA), Yakutat, Alaska, destined for Dry Bay Airport (3AK), Yakutat, Alaska. The pilot reported that during takeoff from PAYA, the tail came up slightly and then fell back to the runway when he attempted to raise the tail of the airplane by applying forward elevator. He thought this was unusual and attributed it to an aft-loaded airplane. The pilot applied additional nose-down trim and departed without incident. He stated that, while en route, the tail of the airplane seemed to move up and down, which he attributed to turbulence. Upon arrival at 3AK, he entered a left downwind for runway 23. At an altitude of about 600 ft, he reduced the power and extended the flaps to 10° abeam the end of the runway. He turned onto the base leg about ½ mile from the approach end of the runway and slowed the airplane to 80 mph. Turning final, he noticed the airplane seemed to pitch up, so he applied full nose-down pitch trim and extended the flaps an additional 10°. On short final, he applied full flaps, and the airplane abruptly pitched up to about a 45° angle. He stated that he applied full nose-down elevator, verified the pitch trim, and reduced the power to idle. When the airplane was about 300 ft above ground level, the airplane stalled, the left wing dropped slightly, and the airplane entered about a 45° nosedown dive. After allowing the airplane to gain airspeed, he applied full back elevator. The airplane impacted forested terrain near the approach end of runway 23 at an elevation of about 18 ft, which resulted in substantial damage to the fuselage, wings, and tail. A Garmin aera 796 was recovered from the accident site. GPS data logs for the day of the accident revealed that the airplane departed at about 1446 and after the initial climb continued southeast for about 18 minutes at GPS altitudes between 492 and 1,280 ft, with a groundspeed between 111 and 127 knots. About 2 minutes before the accident, the airplane initiated a gradual left turn to the east and entered the traffic pattern for the 3AK. For the remainder of the flight the groundspeed varied from 10 knots to 255 knots. The last fully recorded in-flight data point was at 1509, when the airplane was at a GPS altitude of 335 ft with a groundspeed of 13 kts and on a track of 56° (see figure 1). Figure 1 - Accident airplane's flight track. - The cargo was removed from the airplane following the accident without the knowledge or consent of the National Transportation Safety Board (NTSB). A postaccident examination of the airframe and engine, which included an Electronics International MVP-50T engine monitor revealed no pre-accident mechanical malfunctions or failures with the airplane, that would have precluded normal operation. Elevator control continuity was established from the control column in the control cables to the quadrant in the rear of the fuselage at fuselage station (FS) 427 to the elevator control rod to the elevators. Rudder control continuity was established from the rudder pedals to the quadrant at FS 427 to the control rod and to the rudder. . -
Analysis
The purpose of the flight was to transport three passengers and cargo. The pilot reported that, during takeoff, the airplane’s tail came up slightly lowered to the runway when he attempted to raise the tail by applying forward elevator. He stated that he thought this was unusual and attributed it to an aft-loaded airplane. He applied additional nose-down trim and departed without incident. While en route, the tail of the airplane seemed to move up and down, which the pilot attributed to turbulence. Upon arrival at his destination, the pilot entered a left downwind, reduced the power and extended the flaps to 10° abeam the end of the runway. He turned onto the base leg about ½ mile from the approach end of the runway and slowed the airplane to 80 mph. Turning final, he noticed the airplane seemed to pitch up, so he applied full nose-down pitch trim and extended the flaps an additional 10°. On short final he applied full flaps, and the airplane abruptly pitched up to about a 45° angle. He stated that he applied full nose-down elevator, verified the pitch trim, and reduced the power to idle. When the airplane was about 300 ft above ground level, the airplane stalled, the left wing dropped slightly, and the airplane entered about a 45° nose-down dive. After allowing the airplane to gain airspeed, the pilot applied full back elevator. The airplane impacted forested terrain near the approach end of runway 23 at an elevation of about 18 ft. A postaccident examination of the airframe and engine revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation. Elevator and rudder control continuity was confirmed from the cockpit to the respective control surfaces. The airplane's estimated gross weight at the time of the accident was about 7,796 lbs and the airplane's estimated center of gravity was about 3.2 to 5.6 inches beyond the approved aft limit. Maximum gross weight for the airplane is 8,000 lbs. The operator did not comply with their operations specifications and the federal regulations that required them to follow the weight and balance control procedures outlined in the aircraft weight and balance section of the pilot operating handbook and the requirement to maintain an aisle between the crew and passenger compartments. The low speed, left roll, and pitch down of the airplane is consistent with an aerodynamic stall. The additional nose down trim at takeoff, the instability of the airplane during cruise flight, the full nose down trim during the approach and rapid pitch up after the application of full flaps are all consistent with an aft center of gravity (CG) condition of sufficient magnitude that the elevator pitch down authority was insufficient to overcome the pitching moment generated by the loading and aircraft configuration. The full down (or landing) flaps exacerbated the nose-up pitching moment due to the increased downwash on the tail and aft shift of the center of pressure. For each flight in multiengine operations, Title 14 Code of Federal Regulations (CFR) 135.63(c) requires the preparation of a load manifest that includes, among other items the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the center of gravity location of the loaded aircraft; one copy of the load manifest should be carried in the airplane, and the operator is required to keep the records for at least 30 days. Single-engine operations, such as the accident flight, are excluded from this requirement. Had the pilot been required to prepare a load manifest that included the number of passengers, total weight of the loaded aircraft, the maximum allowable takeoff weight, and the center of gravity location of the loaded aircraft, he may have been more aware of the airplane’s out-of-center-of-gravity condition. The National Transportation Safety Board (NTSB) previously addressed the exclusion of single-engine operations from the Part 135 weight and balance requirements with the issuance of Safety Recommendations A-89-135, A-99-61, and A-15-29, which asked the Federal Aviation Administration (FAA) to amend the record-keeping requirements of 14 CFR 135.63(c) to apply to single-engine as well as multiengine aircraft. The FAA did not take the recommended action, and the NTSB classified Safety Recommendations A-89-135, A-99-61, and A-15-29 "Closed—Unacceptable Action" in 1990, 2014, and 2021, respectively.
Probable cause
The pilot’s failure to determine the actual weight and balance of the airplane before departure, which resulted in the airplane being operated outside of the aft center of gravity limits and the subsequent aerodynamic stall on final approach. Contributing to the accident was the Federal Aviation Administration's failure to require weight and balance documentation for 14 Code of Federal Regulations Part 135 single-engine operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
DHC-3
Amateur built
false
Engines
1 Turbo prop
Registration number
N703TH
Operator
Yakutat Coastal Airlines
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
456
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-26T01:22:33Z guid: 105132 uri: 105132 title: DCA22LA125 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105167/pdf description:
Unique identifier
105167
NTSB case number
DCA22LA125
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-25T02:10:00Z
Publication date
2023-06-16T04:00:00Z
Report type
Final
Last updated
2022-06-01T19:38:30.303Z
Event type
Accident
Location
Springfield, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
United Airlines flight 2197 experienced clear air moderate turbulence at flight level (FL) 350 while enroute to Toronto Pearson International Airport (YYZ), Toronto, Canada. The flight was a regularly scheduled passenger flight from George Bush Intercontinental Airport (IAH), Houston, Texas. As a result of the turbulence, one flight attendant experienced a serious injury to their wrist. The aircraft received no damage and continued to its destination without further incident. As stated by the first officer, dispatch remarks for this flight included a forecast for light to moderate turbulence over VORTACs BUM - JOT between FL310 - 390. The captain conducted a pre-departure briefing with the flight attendants which included the possibility of experiencing turbulence. About two hours into the flight, two flight attendants were in the last three rows of the aft cabin conducting in-flight service when light turbulence commenced. The two flight attendants decided to “bring the cart back into the galley to finish the service.” As they were pushing back into the galley, the turbulence intensified, and one of the two flight attendants asked the other to sit down in their jump seat while the other set the brake on the cart. As the flight attendant was securing the cart, the captain made an announcement asking the flight attendants to take their seats. At that time, the flight attendant who was securing the cart lost their footing and fell back where the other flight attendant had taken their seat. The seated flight attendant attempted to brace the falling flight attendant and injured their wrist. The captain stated that this instance of turbulence lasted about 15 seconds. In addition, he reported that that the seatbelt sign had been on for five minutes prior to this moderate turbulence as the aircraft flew through light turbulence earlier in the flight. The injured flight attendant was treated by an onboard doctor, and the flight proceeded to its destination without further incident. Upon arrival to Toronto, paramedics met the airplane. The flight attendant was taken for x-rays and diagnosed with a broken bone in their wrist.
Probable cause
The flight’s encounter with clear air moderate turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS INDUSTRIE
Model
A320-232
Amateur built
false
Engines
2 Turbo fan
Registration number
N483UA
Operator
United Airlines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
1586
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-06-01T19:38:30Z guid: 105167 uri: 105167 title: ERA22LA242 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105139/pdf description:
Unique identifier
105139
NTSB case number
ERA22LA242
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-25T17:00:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Last updated
2022-05-27T22:03:15.793Z
Event type
Accident
Location
Putnam Valley, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 25, 2022, about 1600 eastern daylight time, an Aeronca 7EC, N7410B, was substantially damaged when it was involved in an accident near Putnam Station, New York. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 ferry flight. The pilot reported that he had just purchased the airplane and was flying it from Saratoga Springs, New York, to Northern Lights Airport (VT46), Alburg, Vermont, for an annual inspection. During the flight, the mixture control kept “creeping out” and the pilot pushed it back in 2-3 times. The last time the mixture control moved aft, he “pushed it a little stronger,” and afterwards noted that he could no longer enrich the fuel. The engine started to backfire, “cut out,” and was losing power. Unable to regain power to the engine, he elected to execute a forced landing to a field, during which the airplane impacted a power line. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the structural tubing that connects to the firewall. The inspector’s review of the aircraft maintenance logbooks revealed that the airplane’s most recent annual inspection was in 2007. The engine and its accessories were examined under the supervision of an FAA inspector after the airplane was recovered to a hangar. The throttle and mixture controls functioned normally. The spark plugs were removed and visually examined with no anomalies noted other than postimpact oil fouling. Both magnetos were tested and produced spark at all towers. Fuel was present throughout the fuel system, including the gascolator and carburetor float bowl. About 9 gallons of fuel were drained from the left tank and about 1.5 gallons were drained from the right tank. Both wing fuel caps were tested and found to vent properly. When the left and right fuel tanks were pressurized, the right wing forward and aft vent outlets were free from obstruction; however, the right tank vent interconnect and the left tank forward and aft outlets were completely obstructed. Both fuel tanks fed into a common fuel manifold above the fuel shutoff valve. -
Analysis
The pilot had just purchased the airplane and was flying it to a maintenance facility in a neighboring state for an annual inspection. During the flight, the engine started to backfire and lose power. The pilot attempted remedial action to restore engine power; however, he was unable to regain power to the engine, and elected to execute a forced landing to a field. During the forced landing the airplane impacted a power line. Postaccident examination of the airplane revealed no anomalies with the engine that would have precluded normal operation. About 9 gallons of fuel were drained from the left tank and about 1.5 gallons were drained from the right tank, although the two fuel tanks fed a common fuel manifold above the fuel shutoff valve. When the left and right fuel tanks were pressurized, the right wing forward and aft vent outlets were free from obstruction; however, the right tank vent interconnect was obstructed and the left tank forward and aft outlets were completely obstructed. It is likely that the engine was starved of fuel due to the fuel vent obstructions, which resulted in a restriction of fuel flow.
Probable cause
A total loss of engine power during cruise flight due to fuel starvation resulting from obstructed forward and aft vent outlets in the left fuel tank.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7EC
Amateur built
false
Engines
1 Reciprocating
Registration number
N7410B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
7EC-442
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-27T22:03:15Z guid: 105139 uri: 105139 title: WPR22FA188 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105133/pdf description:
Unique identifier
105133
NTSB case number
WPR22FA188
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-25T18:50:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-03T00:28:56.361Z
Event type
Accident
Location
Show Low, Arizona
Airport
Show Low Regional Airport (SOW)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The engine was overhauled on April 29, 2016, and six new Continental 658319A1 cylinders were installed. On October 28, 2020, the pilot purchased the accident airplane. On April 26, 2021, the No. 2 cylinder was removed due to a stuck exhaust valve. The work order for the cylinder repair did not specify a reason for the stuck valve. The valve was repaired, and the cylinder was reinstalled 4 days later. At that time, the engine had accumulated 169.32 hours of tachometer time. The engine logbook contained entries for an annual inspection on September 29, 2021, and an oil change on February 19, 2022. The tachometer displayed 276.79 hours at the time of the accident. The pilot’s supervisor, who was also a pilot and had flown with the accident pilot, thought an exhaust valve also became stuck sometime between January 16 and February 27, 2022, and that the pilot had difficulty finding a mechanic to fix the stuck valve. The supervisor further stated that he explained to the pilot the procedure for resolving the stuck valve, but he did not know if the pilot attempted that procedure himself or found a mechanic to perform the work. The pilot’s supervisor also stated that, during one flight with the accident pilot, he (the supervisor) was leaning the engine when the pilot stated that he “never leaned the engine” and “didn’t need to lean the engine below 3000 feet.” The pilot indicated that he had “little or no training” on leaning the engine. - On May 25, 2022, about 1750 mountain standard time, a Cessna 172F airplane, N5532R, was substantially damaged when it was involved in an accident near Show Low Regional Airport (SOW), Show Low, Arizona. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On the morning of the accident, the pilot flew from Ak-Chin Regional Airport (A39), Maricopa, Arizona, to Falcon Field Airport (FFZ), Mesa, Arizona, to pick up the passenger and then departed for SOW. The flight arrived at SOW about 0900, and the airplane occupants spent most of the day away from the airport. A witness stated the pilot and passenger returned to the airport in the late afternoon. The witness assisted them with refueling the airplane at the self-service fuel pump and stated that both wing tanks were filled to the bottom of the filler neck. Witnesses at SOW observed the airplane attempt to take off from runway 25 about 1745. The airplane became airborne two or three times during the first attempted takeoff but did not climb very high. One witness stated that the airplane touched down, “got squirrely,” and almost departed the end of the runway. Another witness stated that the airplane slid sideways and that the engine “did not sound healthy.” Another witness stated that the engine was “sputtering.” The pilot then taxied the airplane back to the approach end of runway 25 and performed a run-up. A witness stated the engine “sounded bad” when the airplane was taxiing. The pilot then attempted a second takeoff. According to a witness who was also a pilot, the accident pilot “milked it off [the runway], set it back down, and then milked it off [the runway] again.” The witness stated that the engine was “running rich, bogged down” during the second takeoff. The airplane remained at a low altitude, began a left turn toward the downwind pattern, and then “sank.” Another witness stated that, during the left turn, the airplane descended out of sight behind a ridgeline. The airplane subsequently impacted terrain in an open field about 1 mile southwest of the departure end of runway 25. - The airplane impacted the edge of a stream in an open field. The wreckage was oriented along a 075° heading. The accident site and debris field were confined to the initial impact point. Forward of the empennage, the fuselage was bent downward. All flight control surfaces were attached to the airplane, and flight control continuity was established to the cockpit controls. The engine was pushed aft, and it protruded into the cockpit. The engine remained attached to the airframe. Engine control continuity was not established due to impact damage. The carburetor was impact separated from the engine. The mixture control at the carburetor was observed in the lean position. Valve train continuity and thumb compression/suction were obtained on all cylinders except for cylinder No. 4. Cylinder No. 4 was removed, and the exhaust valve was observed to be stuck in the open position. The magneto leads for the bottom spark plugs of cylinders Nos. 2, 4, and 6 exhibited impact damage. Both magnetos were removed, and the magneto leads were cut near the housing. The removed magnetos were rotated by hand, and spark was observed on all the leads. The bottom spark plug of cylinder No. 4 exhibited carbon buildup (see figure 1), and the cylinder contained debris (see figure 2). Figure 1. No. 4 cylinder lower spark plug (Source: Textron Aviation). Figure 2. No. 4 cylinder interior and debris (Source: Textron Aviation). The No. 4 cylinder was disassembled, and the exhaust valve stem was mostly covered in carbon buildup (see figure 3). The cylinder and associated exhaust valve components were sent to the National Transportation Safety Board (NTSB) Materials Laboratory for further examination. Figure 3. No. 4 cylinder exhaust valve. Visual examination of the exhaust valve stem found that the 0.6 to 0.7 inches of the exhaust valve stem (from the seat) exhibited deposits and that the deposits that were 0.5 inches from the seat exhibited a dark brown color with a dull luster. The other 0.1 to 0.2 inches of deposits exhibited a black color that was more reflective. Dark brown and orange-yellow deposits were present over the exhaust valve head. The deposits exhibited a flaky layered morphology that increased the overall diameter of the stem (see figure 4). Figure 4. Exhaust valve deposits. The deposits on the exhaust valve stem and valve seat surface were further examined. They showed indications of a single-chained polymer-like organic compound, consistent with deposits of unburned fuel. -
Analysis
The pilot and passenger were departing on a personal flight. Witnesses observed the airplane attempt to take off, but the takeoff was aborted, and the airplane was then taxied back to the approach end of the runway so that the pilot could perform an engine run-up. The witnesses stated that the engine was “sputtering” and “sounded bad” during the takeoff and the taxi to the runup area. The pilot subsequently attempted a second takeoff. The airplane remained at a low altitude, began a left turn toward the downwind pattern, and then “sank” out of sight behind a ridgeline before impacting terrain. A pilot witness stated that the pilot had “milked it [off the runway], set it back down, and then milked it off [the runway] again.” This witness also described the engine as “running rich, like it was bogged down” during the second takeoff. Postaccident examination of the engine found that the No. 4 engine cylinder exhaust valve was stuck due to a buildup of material that enlarged the overall diameter of the valve’s stem. Examination of the valve stem deposits showed indications of an organic compound that was consistent with deposits of unburned fuel. The stuck valve led to a partial loss of power during the accident takeoffs. The accident pilot reported to another pilot that there had been previous engine problems that had been identified as stuck valves. The accident pilot also reported that he ”never leaned the engine” and that he had littleto-no training on how to lean the engine. The partial loss of engine power that resulted from the No. 4 cylinder exhaust valve becoming stuck was likely due to the pilot's improper leaning of the engine over an extended period. Excessively rich mixtures can lead to a buildup of unburned hydrocarbons, which can foul engine components with deposits. The accident could likely have been avoided if the pilot had the airplane examined by maintenance personnel before attempting the second takeoff.
Probable cause
The pilot’s improper leaning of the engine during an extended period of time, which caused an exhaust valve to become stuck and led to the partial loss of engine power during the accident flight. Contributing to the accident was the pilot’s decision to attempt a second takeoff without having the engine further examined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172F
Amateur built
false
Engines
1 Reciprocating
Registration number
N5532R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17253113
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-03T00:28:56Z guid: 105133 uri: 105133 title: DCA22FM021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105181/pdf description:
Unique identifier
105181
NTSB case number
DCA22FM021
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-05-27T15:35:00Z
Publication date
2023-05-24T04:00:00Z
Report type
Final
Last updated
2023-05-08T04:00:00Z
Event type
Accident
Location
Seattle, Washington
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the mechanical failure of the no. 3 main engine and resulting fire aboard the offshore supply vessel Ocean Guardian was the replacement of a crankshaft main bearing with an incorrectly sized bearing during an engine overhaul due to the engine service technicians not identifying the removed bearing’s part number, which resulted in the loss of lube oil pressure in adjacent connecting rod bearings.
Has safety recommendations
false

Vehicle 1

Vessel name
Ocean Guardian
Vessel type
Offshore
IMO number
9272060
Port of registry
Seattle, WA
Classification society
DNV-GL
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-05-08T04:00:00Z guid: 105181 uri: 105181 title: ERA22LA244 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105146/pdf description:
Unique identifier
105146
NTSB case number
ERA22LA244
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-27T20:00:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-06-01T20:06:49.67Z
Event type
Accident
Location
Monongahela, Pennsylvania
Airport
Rostraver Airport (FWQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On May 27, 2022, about 1900 eastern daylight time, an Aeronca 7AC, N84583, was substantially damaged when it was involved in an accident near Monongahela, Pennsylvania. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the Federal Aviation Administration (FAA) inspector who responded to the accident site, witnesses reported that the airplane departed Rostraver Airport (FWQ), Monongahela, Pennsylvania, and was practicing touch-and-go takeoffs and landings when, after takeoff, the airplane pitched up “sharply, then went straight down.” The pilot stated that he was in the process of purchasing the airplane when the accident occurred. On the day of the accident, he performed several takeoffs and landings at another airport before flying to FWQ to get fuel. The pilot stated that he performed a few takeoffs and landings in the traffic pattern at FWQ, and “assumed” that, during the final takeoff, the airplane “got too slow and stalled.” Examination of the airplane at the accident site revealed that both wings remained attached to the fuselage, with the outboard leading edges impact damaged. The wooden propeller remained attached to the engine; one propeller blade was splintered along the entire span and the other blade was splintered about half its span. Examination of the airplane after recovery revealed continuity of the flight controls to all control surfaces. The engine was examined, and compression and suction were observed on all cylinders. Crankshaft and valvetrain continuity were confirmed when the propeller was rotated by hand. The cylinders were examined with a lighted borescope and no anomalies were noted with the piston faces, cylinder walls, or valves. The magnetos were removed and produced spark on all towers. There were no anomalies with the airplane that would have precluded normal operation before the accident. A review of the pilot’s logbooks revealed that he did not have any documented flight experience in the accident airplane make and model. The seller of the airplane stated that the accident flight was the pilot’s first flight in the accident airplane. The pilot’s tailwheel endorsement was completed on April 20, 2022, in an American Champion 7ECA Citabria; however, there was no documented flight time associated with the endorsement. -
Analysis
The pilot was conducting takeoffs and landings in the tailwheel-equipped airplane, which he had not previously flown. A witness reported that, after takeoff, the airplane pitched up “sharply, then went straight down,” consistent with an aerodynamic stall. The pilot stated that he “assumed” that, during takeoff, the airplane got too slow and stalled, which resulted in impact with trees and terrain. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation; therefore, it is likely that, during the initial climb after takeoff, the pilot failed to maintain adequate airspeed, which resulted in the exceedance of the airplane’s critical angle of attack and an aerodynamic stall.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N84583
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-3286
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-01T20:06:49Z guid: 105146 uri: 105146 title: ERA22LA246 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105149/pdf description:
Unique identifier
105149
NTSB case number
ERA22LA246
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-28T13:02:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-09-27T23:42:49.009Z
Event type
Accident
Location
Perry, Georgia
Airport
Perry-Houston County Airport (PXE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 28, 2022, about 1202 eastern daylight time, a Beech 58, N120PA, was substantially damaged when it was involved in an accident near Perry, Georgia. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot’s written statement, he was completing a short cross-country flight. While on a downwind leg of the traffic pattern at the destination airport, the pilot extended the landing gear. The subsequent touchdown was normal; however, the main landing gear collapsed during rollout. The airplane veered right and came to rest upright off the right side of the runway. A mechanic was subsequently preparing a repair estimate for the airplane and noted that the flaps were in the retracted position. When he asked the pilot about the flaps, the pilot stated that the flaps retracted uncommanded when the landing gear retracted uncommanded. Initial examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the lower fuselage. The inspector further examined the airplane in a hangar, on jacks, with external power applied. Due to impact damage, the landing gear could not be fully retracted and extended; however, he was able to partially retract and extend the landing gear to confirm electrical continuity to the landing gear system. Additionally, both weight on wheels switches tested satisfactorily. No preimpact mechanical malfunctions were identified. The inspector added that the landing gear doors were open, consistent with the landing gear being in transit at the time of impact. -
Analysis
The pilot reported that, while on a downwind leg of the airport traffic pattern at the destination airport, he extended the landing gear. The subsequent touchdown was normal; however, the main landing gear collapsed during the landing roll. Examination of the wreckage revealed that the wing flaps were retracted, and the landing gear doors were open, consistent with the airplane not being properly configured for landing and indicative of the landing gear being in transit at the time of touchdown. Functional testing of the landing gear system did not reveal any preimpact mechanical malfunctions. Based on the available information, it is likely that the pilot realized that the landing gear was retracted during the landing flare and attempted to extend the landing gear, but the airplane touched down before the gear were fully extended.
Probable cause
The pilot’s failure to properly configure the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
58
Amateur built
false
Engines
2 Reciprocating
Registration number
N120PA
Operator
Southern Sky Holdings LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TH-1658
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-27T23:42:49Z guid: 105149 uri: 105149 title: ERA22FA243 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105141/pdf description:
Unique identifier
105141
NTSB case number
ERA22FA243
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-28T15:14:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-05-30T03:29:52.897Z
Event type
Accident
Location
North Myrtle Beach, South Carolina
Airport
Grand Strand Airport (CRE)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 28, 2022, at 1414 eastern daylight time, a Piper PA-12, N4421M, sustained substantial damage when it was involved in an accident near North Myrtle Beach, South Carolina. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 banner tow flight. Witnesses standing on the flight line at Grand Strand Airport (CRE), North Myrtle Beach, South Carolina, stated that the airplane approached to pick up a banner, picked up the tow rope, pitched up, and maintained a steep angle of attack until the airplane “stalled.” The left wing dropped, and the airplane made a near-vertical descent and impacted the ground about 300 ft from the banner pick up zone. One witness reported that the airplane entered a spin prior to impact.   The owner of the banner tow company stated that the pilot was a long-term employee and most of his 15,200 hours of flying were in the accident airplane or another Piper PA-12. The accident site was located 126 ft to the right side of runway 23 and about midfield. The fuselage came to rest in a nose down, near vertical position. Both wings exhibited accordion-style crushing. Both fuel tanks were breached. Flight control continuity was established from all flight control surfaces to the flight controls. The instrument panel was located under the engine, and all instruments were impact-damaged. The engine was disassembled, and it was noted that there were no accessory drive splines installed in the engine accessory case, nor were they required to be; therefore, the engine crankshaft could not be rotated by hand. The right-side cylinders, Nos. 1 and 3, were removed to provide visual access to the internal engine components. Continuity of the crankshaft, camshaft, and valvetrain was confirmed by visual observation. The interiors of all four cylinders were examined with no anomalies noted. The magnetos were removed and sparked on all towers. Oil was present in the engine; the oil suction screen was examined, and no debris was noted. The propeller separated at the crankshaft and was buried about 2 ft in the ground. One propeller blade exhibited chordwise paint abrasion, “S” bending, and longitudinal twisting toward the blade face. The other propeller blade exhibited chordwise paint abrasion. Toxicological testing by the Federal Aviation Administration Forensic Sciences Laboratory identified ethanol at 0.016 g/dL in the pilot’s liver tissue. Ethanol was not detected in the pilot’s vitreous fluid or brain tissue. -
Analysis
The pilot of the banner tow airplane made a low approach to pick up a banner. Witnesses reported that after the tow rope was picked up, the airplane pitched up and maintained a steep angle of attack until it entered an aerodynamic stall and made a near vertical descent to impact. The airplane came to rest in a nose-down, near-vertical position about 300 ft from the banner pick up zone. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Toxicology testing detected a low level of ethanol in the pilot’s liver tissue. Some or all of the small amount of detected ethanol may have been from postmortem production. It is unlikely that ethanol effects contributed to the accident. It is likely that after the banner pickup and during initial climb, while the airplane had a high-power setting, high pitch angle, and low airspeed, the pilot exceeded the airplane’s critical angle of attack, and the airplane entered an aerodynamic stall from which recovery was not possible due to the airplane's low altitude.
Probable cause
The pilot's exceedance of the airplane's critical angle of attack, which resulted in a subsequent aerodynamic stall at an altitude that was too low for recovery.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N4421M
Operator
BARNSTORMERS AERIAL ADVERTISING LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Banner tow
Commercial sightseeing flight
false
Serial number
12-3375
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-05-30T03:29:52Z guid: 105141 uri: 105141 title: ERA22LA245 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105148/pdf description:
Unique identifier
105148
NTSB case number
ERA22LA245
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-29T10:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-06-15T04:47:49.006Z
Event type
Accident
Location
Frederick, Maryland
Airport
FREDERICK MUNI (FDK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot, who was also the owner and builder of the tailwheel equipped biplane stated that the purpose of the flight was to perform a “final check” of the airplane’s engine and operating systems. The airplane performed “properly,” and he landed “without issue.” The pilot further stated that at low speed during the landing roll, his foot “became lodged between the bulkhead and the brake” which resulted in a sudden misapplication of the brakes and a nose over event, which fractured a wing strut and substantially damaged the airplane.
Probable cause
The pilot’s inadvertent application of the brakes during the landing roll which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Van Lehn
Model
Hatz Classic
Amateur built
true
Engines
1 Reciprocating
Registration number
N85EX
Operator
VAN LEHN RICHARD GLENN
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
194
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-15T04:47:49Z guid: 105148 uri: 105148 title: ERA22LA247 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105154/pdf description:
Unique identifier
105154
NTSB case number
ERA22LA247
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-29T11:15:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-06-02T17:25:39.765Z
Event type
Accident
Location
Jacksonville, Florida
Airport
Jacksonville Executive Airport at Craig (CRG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 29, 2022, about 1015 eastern daylight time, a Cessna 150F airplane, N8919S, was substantially damaged when it was involved in an accident at Jacksonville Executive Airport (CRG), Jacksonville, Florida. The pilot was not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that he planned to remain in the traffic pattern for touch-and-go landing practice. The pilot completed the first landing of the flight and, after an uneventful landing roll, added full power for takeoff. While raising the flaps from 30°, the airplane “started pulling very hard to the left.” The pilot attempted to correct the situation with full right rudder and right brake, but the airplane continued off the runway and into grass. The pilot reduced power to idle during the runway excursion, but he was not able to control the direction of the airplane, and it nosed over, resulting in substantial damage to the wings, fuselage, and vertical stabilizer. Postaccident examination of the airplane revealed that the left steering connecting rod had fractured at its connection point on the nose landing gear (NLG). The right steering connecting rod remained connected, and the NLG sustained little-to-no damage. The NLG was found in a left-turning position and could not be moved by hand in any direction. The National Transportation Safety Board Materials Laboratory examined the steering connecting rod assembly and found that it exhibited a fractured rod end fitting. Examination of the fractured rod end fitting revealed that the threaded shank portion above the stop nut exhibited plastic deformation. Examination of the fracture surfaces of the rod end fitting revealed slant fractures consistent with overstress. The plastic deformation along with the slant fracture features were consistent with bending overstress. The figure below shows the left steering connecting rod fracture areas and a Cessna illustrated parts catalog drawing indicating these areas on the NLG. Figure - Fractured rod end fitting of the left steering connecting rod assembly. Review of the maintenance records found that, during the May 8, 2021, annual inspection, the NLG scissors were greased. No other recent maintenance entries noted work on or anomalies with the NLG. The Federal Aviation Administration’s Pilot’s Handbook of Aeronautical Knowledge, chapter 5, states in part the following about torque: To the pilot, “torque” (the left turning tendency of the airplane) is made up of four elements that cause or produce a twisting or rotating motion around at least one of the airplane’s three axes. These four elements are: 1. Torque reaction from engine and propeller 2. Corkscrewing effect of the slipstream 3. Gyroscopic action of the propeller 4. Asymmetric loading of the propeller (P-factor) -
Analysis
The pilot reported that, during a personal flight while in the traffic pattern, he applied power after the first landing to perform a touch-and-go landing. During the takeoff roll, the pilot moved the flaps from a landing to takeoff setting, at which time the airplane began pulling hard to the left. The pilot attempted to correct this movement with full right rudder and right brake, but the airplane continued off the runway and into grass. The pilot reduced power to idle during the runway excursion but was unable to control the direction of the airplane, and it nosed over. The wings, fuselage, and vertical stabilizer sustained substantial damage. The left nose landing gear (NLG) steering connecting rod had fractured at its connection point. The right steering connecting rod remained connected. Laboratory examination of the fracture surfaces of the rod end fitting revealed slant fractures consistent with overstress. The plastic deformation along with the slant fracture features were consistent with bending overstress. The NLG connecting rod had likely fractured and become disconnected during the runway excursion or noseover; the laboratory examination found that the fracture was due to a one-time instance of overload and was not the result of cumulative applications of force. Furthermore, the airplane veered to the left, which was consistent with the left-turning tendencies that would be experienced upon power application during a touch-and-go. It is possible that during the touch-and-go landing attempt, the pilot was distracted with changing the flap setting. Ultimately, he did not maintain directional control of the airplane, which resulted in its departure from the runway surface.
Probable cause
The pilot’s failure to maintain directional control during a touch-and-go landing after applying power for takeoff, which resulted in a runway excursion and noseover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N8919S
Operator
N8919S INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15062219
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-02T17:25:39Z guid: 105154 uri: 105154 title: CEN22LA227 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105189/pdf description:
Unique identifier
105189
NTSB case number
CEN22LA227
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-29T16:27:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-06-06T18:26:38.777Z
Event type
Accident
Location
Morgan, Texas
Airport
W4 Ranch Airport (84TE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On May 29, 2022, about 1527 mountain daylight time, a Piper PA-28RT-201T, N2148J, was substantially damaged when it was involved in an accident near Morgan, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while in cruise flight at 9,500 ft mean sea level (msl), he observed the throttle lever creep back and a drop in manifold pressure. The pilot descended to about 5,500 ft msl and then observed a loud rattling engine noise with strong vibrations. The pilot shut down the engine, located a nearby airport, and executed a forced landing to runway 17 at W4 Ranch Airport, Morgan, Texas. The pilot reported that he thought the airplane was too high on the downwind leg; however, after turning onto the final leg, he realized that the headwind was going to prevent him from making it to the runway. During landing, the airplane touched down short of the runway in an area of rough terrain, which resulted in substantial damage to the right wing. Examination of the No. 3 cylinder at the National Transportation Safety Board Materials Laboratory revealed the cylinder barrel had fractured in the smooth-walled region located between the cooling fins and the threaded section used for mounting the cylinder head. The fracture surface was examined with the aid of a stereomicroscope. Features were consistent with a fatigue crack that originated along the outer diameter surface of the barrel at a corrosion pit. The fracture surface near the pit exhibited radial lines and flat feathery features that were consistent with crack initiation and progression due to cyclic fatigue. The inboard-facing side of the first cylinder cooling fin and adjoining material was tinted black for about a 180° arc. The fatigue crack was in line with the center of the black tinted arc. The Continental Engine Standard Maintenance Practice Manual, Section 6-4.11.1, includes the following information for a cylinder visual inspection: Inspect the external surfaces of the cylinder head including the fins, intake and exhaust ports, top and bottom spark plug bosses and fuel nozzle bosses for cracks, exhaust flange leakage or any signs of oil, fuel, or soot leakage indicating cylinder or the head-to-barrel junction structural integrity breach. A review of maintenance records revealed the compression checks of the No. 3 cylinder were lower than the other cylinders during the last 3 annual inspections. The engine was operated about 30 hours since the last annual inspection which was performed on July 19, 2021. The mechanic did not respond to requests for an interview regarding the recent maintenance of the engine. -
Analysis
While in cruise flight, the pilot observed the manifold pressure drop, followed by a loud rattling engine noise with strong vibrations. The pilot shut down the engine and diverted toward a nearby airport. The pilot reported that he thought the airplane was too high on the downwind leg; however, after he turned the airplane onto the final leg, he realized that the headwind would prevent him from making it to the runway. The pilot performed a forced landing into rough terrain short of the runway, which resulted in substantial damage to the right wing. Postaccident examination of the No. 3 cylinder revealed the cylinder barrel was fractured between the cooling fins and the threaded section used for mounting the cylinder head. A metallurgical examination revealed a fatigue crack that originated at a corrosion pit on the outer diameter surface of the cylinder barrel. The inboard-facing side of the first cylinder cooling fin was tinted black for a 180° arc, with the center of the arc in line with the fatigue crack. Manufacturer guidance includes inspection of cylinder fins for any signs of oil or soot leakage that might indicate a cylinder or head-to-barrel junction structural integrity breach. The engine was operated about 30 hours since the last annual inspection.
Probable cause
A partial loss of engine power due to a corrosion-related fatigue crack of the No. 3 cylinder barrel.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28RT-201T
Amateur built
false
Engines
1 Reciprocating
Registration number
N2148J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7931012
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-06T18:26:38Z guid: 105189 uri: 105189 title: CEN22FA216 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105145/pdf description:
Unique identifier
105145
NTSB case number
CEN22FA216
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-30T08:48:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-06-01T20:48:13.69Z
Event type
Accident
Location
Cheyenne, Wyoming
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The airplane and engine were last inspected on February 16, 2022, which involved a condition inspection with combined 200- and 400-hour checklists. The pilot was also a mechanic and had performed engine maintenance on March 4, 2021. However, another mechanic performed the most recent inspection according to logbook entries. - A review photo documentation by the NTSB Fire & Explosion Specialist could not determine the area of the reported in-flight fire. Due to the intense post impact fire, any signature of inflight fire was likely masked. - On May 30, 2022, about 0748 mountain daylight time, an Express 2000RG airplane, N44508, was destroyed when it was involved in an accident near Cheyenne, Wyoming. The pilot was fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Radio transmissions from the pilot were recorded by Cheyenne Air Traffic Control Tower and position information was determined through automatic dependent surveillance-broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA). A performance study was conducted for the accident flight largely based on ADS-B data. The airplane departed the Cheyenne Regional Airport/Jerry Olson Field (CYS) from runway 27, about 0744, and the pilot requested a turn to the south. At 0746:39, when the airplane was about 4 miles south of the airport, the pilot radioed to the air traffic control tower and reported an engine failure. About this time, the airplane turned left with a bank angle of about 75° and reversed course back toward the airport. During this turn, the airplane’s pitch reduced from 10° nose high to 10° nose low. At 0746:53, the pilot stated he needed to determine if he could make it back to the airport. The airplane continued towards the airport and at 0747:47 the pilot informed the tower controller that he could not make the airport and he intended to land in a field. The pilot then radioed that the airplane was on fire and asked the controller to send fire-rescue. At 0748:02, the airplane turned right with a bank angle of about 75°, and the airplane’s pitch increased from 0° pitch to about 11° nose high. There were no other recorded transmission from the pilot. Video cameras from a local business captured a portion of the accident sequence which showed the airplane in a near vertical descent with a right roll. The airplane impacted a paved road within a storage facility and a fire destroyed the airplane. - An autopsy was performed on the pilot by the Regional Medical Examiner, who found the cause of death to be multiple blunt force injuries. Toxicology testing by the FAA Forensic Sciences Laboratory detected the presence of rosuvaststin, which is a prescription cholesterol medication that the pilot reported on his medical certificate application to the FAA. - The pilot’s personal logbooks were not available for review. On the pilot’s most recent application for a FAA medical certificate, dated December 7, 2021, the pilot reported accruing 12,267 total hours with 309 hours in the preceding 6 months. According to airplane registration information on file with the FAA, the pilot purchased the airplane on January 29, 2018. Using maintenance logbook entries, the pilot’s estimated time in the accident airplane was about 700 hours. - The airplane impacted a paved road within a storage facility. The initial impact point was a divot in the concrete. The wreckage path continued on a 084° heading about 15 ft into a storage locker. A postcrash fire consumed a majority of the airplane. The airplane came to rest upright. Due to impact and fire damage, the flight controls were broken in several locations. Examination of the airframe was limited due to the impact and fire damage; however, there were no preimpact anomalies noted with the remaining wreckage that would have precluded normal operations. Cockpit instrumentation was digital and largely thermally damaged. The airplane was equipped with a Dynon D10A Electronic Flight Instrument System (EFIS), which was impacted separated from the cockpit and not identified in the wreckage. The power lever appeared to be in the flight idle position and the propeller condition lever was forward towards maximum power. The fuel condition lever was found near the low idle position and the fuel shutoff valve was found in the off position; however, this may have been moved by first responders. The engine was separated from the wreckage and sent to Pratt & Whitney Canada’s facility in West Virginia. Under the auspices of the National Transportation Safety Board (NTSB), the engine was examined and no anomalies were detected during the examination. There was evidence of rotational scoring of the compressor and turbine components as well as a fracture of the propeller shaft with signatures consistent with torsional overload. -
Analysis
Shortly after departure, the pilot informed air traffic control that he had an engine failure, and the airplane entered a left turn back toward the airport. The pilot then told the controller that he was not going to be able to make it back to the airport and he was going to land in a field. The pilot then reported that he had a fire onboard the airplane. The airplane impacted the ground in a storage yard and slid into a storage unit. The airplane was destroyed by impact and fire damage. A performance study revealed that, while in the turn to the field, the airplane banked right about 75° with an increase in pitch from 0° to about 11° nose up at an altitude of about 400 ft above the ground. The airplane exceeded the critical angle of attack, entered an accelerated stall, and departed controlled flight. It is likely that due to the inflight fire and the loss of engine power, the pilot was unable to maintain control of the airplane during the last portion of the flight. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded operations; however, the examination was limited due to impact and fire damage. The reason for the reported loss of engine power could not be determined. Due to the postimpact fire, the source of ignition for the inflight fire could not be determined.
Probable cause
The pilot's inability to maintain proper airspeed and his exceedance of the airplane’s critical angle of attack while managing a loss of engine power and inflight fire, which resulted in an aerodynamic stall. Contributing factors to the accident were the loss of engine power and the in-flight fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Express
Model
2000RG
Amateur built
true
Engines
1 Turbo prop
Registration number
N44508
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0101RG
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-06-01T20:48:13Z guid: 105145 uri: 105145 title: CEN22FA217 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105150/pdf description:
Unique identifier
105150
NTSB case number
CEN22FA217
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-05-31T09:35:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-06-02T01:31:15.649Z
Event type
Accident
Location
Memphis, Tennessee
Airport
General Dewitt Spain (M01)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On May 31, 2022, at 0835 central daylight time, a Cessna 162 airplane, N162KG, was substantially damaged when it was involved in an accident near Memphis, Tennessee. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight departed the General Dewitt Spain Airport (M01), Memphis, Tennessee, at 0732 and proceeded about 16 miles northwest. The airplane remained in that vicinity for about 30 minutes, and the altitude varied from about 1,200 ft mean sea level (msl) to about 2,500 ft msl. The flight track appeared consistent with general flight maneuvers. At 0826, the pilot contacted Memphis approach and informed the controller that he was experiencing chest pains. The airplane was about 9 miles west of M01 at that time. The pilot subsequently established the airplane on an easterly course toward M01. However, at 0833, the flight track turned southbound, and the airplane entered a descent and impacted terrain. - The pilot had reported coronary artery disease, including a previous heart attack and a history of high blood pressure and high cholesterol. Records demonstrated that he was intermittently non-compliant with his medication regimen but at the time of the last medical exam, he reported he was using rosuvastatin and ezetimibe to treat his high cholesterol. According to the autopsy report issued by the Office of the Medical Examiner, West Tennessee Regional Forensic Center, the cause of death was multiple blunt force injuries and the manner of death was accident. The pilot was noted to have biventricular dilated cardiomyopathy (cardiomegaly). Stents were noted in the left anterior descending coronary artery, left circumflex coronary artery, and right coronary artery, each with “associated calcific atherosclerotic stenosis,” including > 95% stenosis of the left anterior descending, ~50% stenosis of the left circumflex, and ~75-90% stenosis of the right coronary artery. A 0.7 cm scar was noted in the posterior wall of the ventricle. Microscopic examination of the heart noted an area of “wavy myocytes” that was considered indeterminant in that it may have been due to trauma or could have been due to acute ischemic injury. Toxicology tests performed at the request of the medical examiner identified caffeine, cotinine, diphenhydramine (330 ng/ml) in heart blood. Testing of vitreous for clinical indicators were within appropriate postmortem limits. Toxicology testing performed by the Federal Aviation Administration’s Forensic Sciences Laboratory identified diphenhydramine at 496 ng/ml in heart blood and was inconclusive for ibuprofen. Both were detected in urine. Caffeine is the stimulant commonly found in coffee, black tea, and colas. Cotinine is found in tobacco and is the primary metabolite of nicotine. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. - The pilot’s logbook was not available to the National Transportation Safety Board during the course of the investigation. - The airplane impacted a soybean field about 3 miles west-southwest of M01. The airplane came to rest inverted about 90 ft from the initial ground impact. The fuselage, right wing, and vertical stabilizer were damaged during impact. Postaccident airframe and engine examinations did not reveal any preimpact anomalies. -
Analysis
After takeoff, the pilot maneuvered the airplane in the local area for about 30 minutes. He then contacted approach control and informed the controller that he was experiencing chest pains. The airplane became established on a course to return to the departure airport. However, a few minutes later, the flight track abruptly turned away from the airport. The airplane entered a descent and impacted a soybean field. The fuselage, right wing, and vertical stabilizer were damaged during impact. Postaccident airframe and engine examinations did not reveal any preimpact anomalies. The pilot had a history of coronary artery disease, including a previous heart attack, high blood pressure, and high cholesterol. Records demonstrated that he was intermittently non-compliant with his medication regimen. Considering the evidence about the pilot’s underlying severe coronary artery disease, his non-compliance with his medical regimen, likely continued use of tobacco, and reported chest pain to air traffic control, it is likely the pilot experienced an in-flight acute cardiac event, most likely cardiac ischemia, that caused the accident. The investigation could not determine if effects from his use of the sedating antihistamine diphenhydramine contributed to the accident.
Probable cause
Pilot incapacitation due to an acute cardiac event.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Cessna Aircraft Co.
Model
162
Amateur built
false
Engines
1 Reciprocating
Registration number
N162KG
Operator
Jay Air LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
16200011
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-02T01:31:15Z guid: 105150 uri: 105150 title: CEN22LA220 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105171/pdf description:
Unique identifier
105171
NTSB case number
CEN22LA220
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-01T13:15:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-14T18:23:56.572Z
Event type
Accident
Location
River Falls, Wisconsin
Airport
ST CROIX RIVIERA (6WI2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On June 1, 2022, about 1215 central daylight time, a Grumman AA-1B airplane, N6298L, was substantially damaged when it was involved in an accident near St. Croix Riviera Airport (6WI2), River Falls, Wisconsin. The student pilot sustained minor injuries, and the flight instructor sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that, during the accident flight, he and the student pilot performed two takeoffs and landings and that, on the third takeoff, the engine “quit abruptly” at an altitude of about 150 ft. The flight instructor stated that the engine appeared to have “seized instantly.” The student pilot reported that, during the initial climb after takeoff and when the airplane was about 150 to 200 ft above ground level, the engine “locked up” and lost total power. At that time, the flight instructor assumed control of the airplane and made a forced landing to a vacant field south of the airport, which was straight ahead of the departure runway. The airplane came to rest upright in the field, which resulted in substantial damage to the left outboard wing panel. Examination of the airplane at the accident scene found no fuel in the wing fuel tanks. A subsequent examination revealed that the fuel tanks were not breached and that the other fuel system components had no discrepancies. According to the accident report submitted by the flight instructor they departed with 8 gallons of fuel and were flying for about 1 hour and 15 minutes. The engine rotated freely, and compression was verified on all cylinders. Both magnetos produced spark when rotated. -
Analysis
The flight instructor and student pilot reported problems with the airplane’s engine shortly after takeoff. The flight instructor stated that the engine “quit abruptly” and “seized,” and the student pilot stated that the engine “locked up” and lost total power. The flight instructor assumed control of the airplane and made a forced landing in a field, which resulted in substantial damage to the airplane’s left wing. Postaccident examination of the airplane revealed no fuel remaining in the wing tanks and no evidence of a fuel spill. The fuel system was not compromised. According to the accident report submitted by the flight instructor they departed with 8 gallons of fuel and were flying for about 1 hour and 15 minutes. Postaccident examination revealed that the engine rotated freely, and compression was verified on all cylinders. Both magnetos produced spark when rotated. Thus, the engine likely lost power due to fuel exhaustion.
Probable cause
The student pilot’s and flight instructor’s inadequate preflight fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN AMERICAN AVN. CORP.
Model
AA-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N6298L
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA1B0098
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-14T18:23:56Z guid: 105171 uri: 105171 title: CEN22LA228 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105190/pdf description:
Unique identifier
105190
NTSB case number
CEN22LA228
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-01T18:00:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-06-06T18:33:30.075Z
Event type
Accident
Location
Allport, Arkansas
Airport
Private (None)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 1, 2022, about 1700 central daylight time, an Air Tractor AT-602 airplane, N5007R, sustained substantial damage when it was involved in an accident near Allport, Arkansas. The pilot sustained minor injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot reported he was on the 35th flight of the day and the airplane had been performing well all day with no issues noted. The airplane was refueled two flights before the accident flight and at the time of the accident each wing fuel tank was about half full of Jet A fuel. The airplane’s 6,500 lb hopper was loaded with 3,600 lbs of urea. For the accident flight, the pilot intended to fly to a rice field to apply fertilizer. Immediately after the takeoff from the private airstrip, the pilot heard a “loud pop” noise emit from the turboprop engine and he observed flames emit from the left side of the airplane. The pilot confirmed that a loss of engine power occurred, he made sure the flaps were down, and he began to scan the area to perform a forced landing. During the forced landing, the pilot reported that it felt like there was a “slight recovery” of engine power, but then the engine ceased producing power. The pilot retarded the throttle and landed on a flat field consisting of grass, dirt, and mud. During the landing, the airplane nosed over and came to rest inverted. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the left wing, the fuselage, and the empennage. Examination of the airframe established flight control continuity. Fuel was found in the fuel lines at the fuel pump, to the fuel selector, the header tank, and forward to the airframe fuel filter. The airframe fuel filter assembly on the firewall was removed and FOD of unknown origin was found between the airframe fuel filter pleats and in the fuel filter bowl. Examination of the engine revealed FOD contamination of the engine fuel filter and various fuel-wetted accessories. Bench testing of the fuel control unit, the flow divider/dump valve, and fuel nozzles indicated that they performed within expected parameters. The engine exhibited rotational contact signatures on the compressor turbine and power turbine components consistent with the engine producing power at the time of impact. The engine power output at the time of impact could not be determined. Examination of the propeller revealed no mechanical malfunctions or failures that would have prevented normal operation. Marks on the piston, cylinder, and blade damage indicated that the propeller was operating at low blade angles with low or no power at impact. Chemical testing of the FOD samples from the engine and the airframe revealed a composition consistent with an unknown, fertilizer-type material. A review of the airplane’s maintenance records revealed that the airframe fuel filter was most recently inspected and cleaned on August 12, 2021, at 1,285.5 hours Hobbs time. The accident occurred at 1,429.5 hours Hobbs time. The Air Tractor AT-602 Maintenance Manual stated that the airframe fuel filter was to be inspected and cleaned every 100 hours. Engine maintenance was performed on May 23, 2022, and the engine was successfully test run, but the associated maintenance logbook entry did not show any tasks related to the fuel system. The maintenance manual discussed cleaning the airframe fuel filter and provided a caution that stated , “if any contamination is found in either fuel filter, investigate the cause and rectify the problem.” The operator was unable to provide fuel or chemical loading records. The operator additionally reported that after the accident, the other Air Tractor AT-602 airplane that they operate did not have any mechanical issues and that both airplanes received fuel from the same fuel truck. Air Tractor published Service Letter #148, Fuel Contamination, on June 24, 1996. This document discusses fuel contamination with Air Tractor airplanes and states in part: As we all know, it is of the utmost importance to maintain a clean fuel system in your aircraft. It is also just as important to acquire clean fuel and maintain clean storage facilities. The National Agricultural Aviation Association published a Fly Safe Message, “Avoid Engine Fuel System Contamination,” on May 1, 2023. This document discusses preventing engine fuel system contamination for aerial application aircraft and states in part: Ag aircraft are subject to numerous situations that could result in contamination to the engine fuel system such as unclean fuel storage facilities, aircraft washing, loading, refueling, and maintenance; and/or operating/storing the aircraft outside in condensation/rain. Contamination could be from a variety of sources such as chemicals, debris from the aircraft and maintenance work, or dirt, dust, microbial growth, rust, sand, and water. Contamination of an engine fuel system could result in either a partial or a complete loss of engine power. Turbine engine components that could be adversely affected by contamination include the fuel control unit and the fuel nozzles. According to Federal Aviation Administration Advisory Circular 20-43, turbine engine fuel controls and pumps are more sensitive than piston engine fuel systems. Their fuel feed and pumping systems must work harder, tolerances are closer and fuel pressures are higher. Fine contaminates may block fuel supply systems and erode critical parts of engine and fuel control systems. Due to the nature of aerial application work, operators should consider increasing the inspection frequency of turbine engine fuel system components. Always follow the maintenance manual when performing your work. Consult with the airframe, the engine, and the engine accessory manufacturers on any additional service documents regarding the topic of fuel contamination. -
Analysis
The aerial application airplane was loaded with chemical for application on a rice field. Immediately after the takeoff from the private airstrip, the pilot heard a “loud pop” noise from the turboprop engine, and he observed flames emit from the left side of the airplane. During the forced landing, the pilot reported that it felt like there was a “slight recovery” of engine power, but then the engine ceased producing power. During the forced landing, the airplane nosed over and came to rest inverted, resulting in substantial damage to the left wing, the fuselage, and the empennage. Examination of the airframe revealed foreign object debris (FOD) between the airframe fuel filter pleats and in the fuel filter bowl. Examination of the engine revealed contamination of the engine fuel filter and various fuel wetted accessories. The engine exhibited rotational contact signatures on the compressor turbine and the power turbine components consistent with the engine producing power at the time of impact; however, the engine power output at the time of impact could not be determined. Marks on the piston, cylinder, and blade damage indicated the propeller was operating at low blade angles with low or no power at impact. Chemical testing of the FOD samples from the airframe and the engine revealed a composition consistent with an unknown fertilizer-type material. A review of the airplane’s maintenance records revealed that the airplane was flown about 44 hours past the manufacturer’s required fuel filter inspection interval. It is likely that contaminated fuel obstructed the engine fuel filter and was injected into the engine, which resulted in a partial loss of engine power. The source of the FOD and how it entered the fuel tanks could not be determined based on the available information. It is possible that, had the operator completed the airframe fuel filter inspection within the required interval, the contamination of the filter may have been identified.
Probable cause
A partial loss of engine power due to fuel contamination from foreign object debris. Contributing to the accident was the operator’s failure to follow the manufacturer’s required airframe fuel filter inspection interval.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-602
Amateur built
false
Engines
1 Turbo prop
Registration number
N5007R
Operator
WEBB FLYING SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
602-0501
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-06T18:33:30Z guid: 105190 uri: 105190 title: CEN22LA221 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105172/pdf description:
Unique identifier
105172
NTSB case number
CEN22LA221
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-01T21:15:00Z
Publication date
2023-07-06T04:00:00Z
Report type
Final
Last updated
2022-06-03T18:42:17.041Z
Event type
Accident
Location
Burlington, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On June 1, 2022, about 2015 central daylight time, a Cameron Z-90 balloon, N65009, was substantially damaged when it was involved in an accident near Burlington, Wisconsin. The pilot and 2 passengers were seriously injured. The balloon was operated as a Title 14 Code of Federal Regulations Part 91 other work use flight. The pilot reported he had taken off with two passengers near the Burlington Municipal Airport (BUU) and drifted southeast. About an hour into the flight, the lake effect wind moved in and the pilot looked for a place to land. The pilot selected a road east of some railroad tracks and gave the passengers a landing briefing. The pilot noted their speed was 4 mph. The pilot also noticed a slow-moving train to his left but did not think it was a factor. The pilot remembered seeing the park east of the road and contacting the train. The pilot reported being knocked unconscious and that he did not recall anything else. The engineer on the Canadian National freight train reported that he saw the balloon descending and began to slow the train as he did not know where the balloon was going. He said that he saw the balloon approach the train in his side mirror, at which time he applied the emergency brakes. The balloon then landed in the grassy area between the railroad tracks and a street. As the balloon began to lose air and become limp it started to blow toward the rail cars. The balloon envelope caught on one of the cars, 15 cars back from the engine, and the balloon was pulled off the ground. The envelope then ripped away from the basket and ascended about 200 ft into the air. None of the occupants of the train were injured. Onboard forward- and rear-facing video recordings from the freight train engine showed that the balloon descended toward a road that ran parallel to railroad tracks just east of the train. In both videos, the balloon envelope was fully inflated as it slowly descended toward the road near an electrical substation. In the rear-facing video, the pilot engaged the burners just before the balloon disappeared behind the first freight car. A witness who was at the nearby dog park reported that the balloon came over the tree line south of the dog park about 50 ft above the trees. The balloon descended as if it were going to land in the park but continued over the adjacent street toward the railroad tracks, which at the time had a train traveling northbound. The balloon landed in the grassy area between the railroad tracks and the street, and the balloon envelope became limp. The balloon then caught on one of the train cars which pulled the balloon off the ground. The envelope tore away from the basket and the three individuals in the basket fell out. A Federal Aviation Administration inspector who responded to the scene reported that witness marks showed the balloon initially touched down in the grassy area between the road and the railroad tracks, and again a second time closer to the railroad tracks. The balloon envelope caught on one of the uprights of an empty lumber car as it passed, which lifted the balloon off the ground and dragged it. The balloon basket was intact and found inverted near the railroad tracks. Both propane tanks were intact and remained secured in the basket. One fuel line was separated from one tank. The fuel line to the second tank was separated near the burner attachment end. The envelope came to rest on a road, about 80 ft north of the basket. The aluminum uprights fractured at the basket attach points. The cross tubes and burners were broken out at their attach points at the top of the uprights. The envelope sustained substantial damage to the A-blocks, carabiner attachments, and flying lines. Additionally, several panels to the envelope were ripped. Control continuity to the envelope spring top and turning vents was confirmed. Postaccident examination of the balloon showed no mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot was making an approach from the southeast to land the hot air balloon on a road that paralleled railroad tracks. A freight train was traveling northbound on the tracks at the same time. The balloon initially touched down in a grassy area east of the road, between the road and the railroad tracks. The balloon skipped normally and stopped near the railroad tracks. The balloon envelope dipped as a result of being slightly deflated for the landing and caught on one of the uprights of an empty lumber car as it passed, which lifted the balloon off the ground and dragged it. As the balloon was dragged, the uprights, envelope, burners, and fuel lines separated from the basket and the pilot and passengers were ejected. The engineer in the engine cab immediately stopped the train. The basket came to rest inverted along the east side of the railroad tracks. The envelope climbed to 200 ft. and drifted north until it cooled and came to rest on the road, about 80 ft from the basket. The pilot misjudged the landing, which placed him too close to the railroad tracks and resulted in the balloon’s envelope being caught and the balloon being dragged by the freight train as it went by.
Probable cause
The pilot’s selection of an inappropriate landing location and his failure to avoid an oncoming freight train, which resulted in the train colliding with and dragging the balloon.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
CAMERON BALLOONS
Model
Z-90
Amateur built
false
Registration number
N65009
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Scheduled flight
false
Commercial sightseeing flight
true
Serial number
6612
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-03T18:42:17Z guid: 105172 uri: 105172 title: CEN22LA251 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105267/pdf description:
Unique identifier
105267
NTSB case number
CEN22LA251
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-02T14:15:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-06-21T22:36:39.596Z
Event type
Accident
Location
Ray, Michigan
Airport
RAY COMMUNITY (57D)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 2, 2022, about 1315 eastern daylight time, an experimental, amateur-built Trojan TA16 airplane, N36YR, was substantially damaged when it was involved in an accident near Ray, Michigan. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot, who was the owner and builder of the airplane, stated that the preflight, engine run-up, and takeoff were all normal. During the departure climb, the engine surged rapidly three times and then stopped producing power. The pilot scanned the cockpit instruments and noted that the tachometer displayed 0 rpm. The pilot turned the airplane back toward the runway while attempting to restore engine power. Unable to restore engine power or reach the runway, the pilot performed a forced landing, during which the airplane collided with small trees, resulting in substantial damage to the fuselage and wings. A postaccident examination of the engine found that the pistons in cylinders Nos. 1 through 5 were seized at the bearings connecting the piston arms to the crankshaft. Those bearings displayed signatures consistent with a lack of adequate oil lubrication and cooling. Reviewed data stored in the electronic flight instrument system did not provide indications of an impending oil system malfunction. The pilot reported that he purchased the engine as a “firewall forward” package. He speculated that the engine could have benefitted from additional oil cooling, such as a secondary oil cooler. -
Analysis
The pilot, who was the builder of the experimental, amateur-built airplane, reported that shortly after takeoff the engine surged rapidly three times and then lost total power. The pilot turned the airplane back toward the airport to try to land on the runway. While maneuvering toward the airport, the pilot attempted to restore engine power, but was not successful. Unable make the runway, the pilot performed a forced landing to a rough field, during which the airplane sustained substantial damage to the fuselage and wings. A postaccident examination of the engine found that the bearings connecting the piston arms to the crankshaft were seized and displayed signatures consistent with a lack of oil lubrication and cooling. Reviewed data stored in the electronic flight instrument system did not provide indications of an impending oil system malfunction. The pilot stated that he purchased the engine as a “firewall forward” package and speculated that the engine could have benefitted from the installation of a secondary oil cooler.
Probable cause
A lack of lubrication and inadequate cooling, which resulted in internal damage to the engine and a subsequent total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Trojan
Model
TA16
Amateur built
true
Engines
1 Reciprocating
Registration number
N36YR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-21T22:36:39Z guid: 105267 uri: 105267 title: CEN22FA223 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105180/pdf description:
Unique identifier
105180
NTSB case number
CEN22FA223
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-02T18:45:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-07T05:10:41.293Z
Event type
Accident
Location
Bowling Green, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
According to the FAA Airplane Flying Handbook (FAA-H-8083-3C): At the same gross weight, airplane configuration, CG location, power setting, and environmental conditions, a given airplane will consistently stalls at the same indicated airspeed provided the airplane is at +1G (i.e., steady state unaccelerated flight). However, the airplane can also stall at a higher indicated airspeed when the airplane is subject to an acceleration greater than +1G, such as when turning, pulling up, or other abrupt changes in flightpath. Stalls encountered any time the G-load exceeds +1G are called “accelerated maneuver stalls. The accelerated stall would most frequently occur inadvertently during improperly executed turns, stall and spin recoveries, pullouts from steep dives, or when overshooting a base to final turn. An accelerated stall is typically demonstrated during steep turns. - On June 2, 2022, about 1745 central daylight time, an Aeronca 7AC, N1976E, sustained substantial damage when it was involved in an accident near Bowling Green, Missouri. The two pilots sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the airplane owner, the two pilots were planning to conduct a local flight to practice basic agricultural flight maneuvers. A witness, located in his residence about ½ mile from the accident site, reported that he saw the airplane at low altitude flying from the south to the north. The airplane then made a right turn to the east. During the turn, the right wing dropped, and the airplane nosed down toward the ground. The witness lost sight of the airplane behind some trees and located the airplane wreckage in a field adjacent to his residence. The witness stated that he had observed the airplane performing similar flight maneuvers over the nearby fields during the weeks before the accident. - The front-seat pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land, airplane single-engine sea, and instrument airplane. The rear-seat pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. - Postaccident examination of the accident site revealed that the airplane impacted the terrain in a nose- and left-wing-low attitude. The airplane sustained substantial damage to the fuselage, wings, and empennage. The left wing was separated from the fuselage by rescue personnel to facilitate recovery efforts. The vertical stabilizer and tail were twisted to the left, consistent with a counterclockwise stall/spin at the time of impact. (See Figure 1.) Figure 1. Airplane wreckage (left wing removed from fuselage by rescue personnel). Flight control continuity was established from the cockpit to all flight control surfaces. The engine remained partially attached to the firewall, and the two-bladed propeller remained attached to the engine crankshaft. The propeller blades displayed some forward twisting deformation. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
Two pilots were conducting a local flight to practice basic agricultural flight maneuvers. A witness observed the airplane enter a right turn at low altitude, during which the right wing dropped, and the airplane nosed down toward terrain and disappeared from his view. The airplane impacted terrain in a nose- and left-wing-low attitude in a field. The airplane sustained substantial damage to the fuselage, wings, and empennage. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The airplane damage was consistent with a near-vertical descent, indicative of an aerodynamic stall. It could not be determined which of the two pilots was flying the airplane at the time of the accident. The circumstances of the accident are consistent with the pilots’ failure to maintain sufficient airspeed while maneuvering, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall.
Probable cause
The pilots’ failure to maintain adequate airspeed while maneuvering, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N1976E
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-5543
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-07T05:10:41Z guid: 105180 uri: 105180 title: CEN22LA230 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105192/pdf description:
Unique identifier
105192
NTSB case number
CEN22LA230
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-02T19:03:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-06-06T21:27:49.902Z
Event type
Accident
Location
Ennis, Texas
Airport
Ennis Municipal Airport (F41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 2, 2022, about 1803 central daylight time, a Cessna 172P, N65497, was substantially damaged when it was involved in an accident near Ennis, Texas. The flight instructor and pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. While enroute to the Ennis Municipal Airport (F41), the flight instructor reported that the engine power decreased about 200 rpm on two occasions. The pilot flew an approach to Runway 16 at F41 and executed a go-around due to excess airspeed. When the throttle and carburetor heat controls were advanced to the full forward position, the engine power only increased to about 2,000 rpm. The flight instructor adjusted the mixture control and reapplied carburetor heat in an attempt to increase engine power, but the power decreased, and the flight instructor executed a forced landing to a field. During the landing roll, the flight instructor turned right to avoid cows and the airplane impacted a tree, which resulted in substantial damage to the right wing. The postaccident examination of the engine revealed normal engine continuity and no anomalies were observed with the carburetor. Four hold down studs on the No. 1 cylinder were fractured and their separated pieces were found in the bottom of the cowling. No other anomalies were observed that would have precluded normal engine operation. No impact damage occurred in the vicinity of the engine All spark plugs had signatures consistent with normal engine operation when compared to a Champion Check-a-plug chart. The weather conditions at the time of the accident were conducive to serious carburetor icing at glide power. -
Analysis
The flight instructor and pilot observed the engine power decrease about 200 rpm on two occasions while en route. The pilot flew an approach and then a go-around due to excess airspeed during the approach. When the throttle and carburetor heat controls were fully advanced, the engine power only increased to about 2,000 rpm. The flight instructor attempted to increase engine power without success. During the forced landing to a field the airplane hit a tree, which resulted in substantial damage to the right wing. Examination of the engine revealed normal engine continuity and compression was confirmed on all 4 cylinders. Several hold down studs on the No. 1 cylinder were fractured and their separated pieces were found in the bottom of the cowling. No other anomalies were observed that would have precluded normal engine operation. No impact damage occurred in the vicinity of the engine and investigators could not determine when these studs separated; however, it is unlikely that the separated studs resulted in the slight loss of engine power noted by the pilot and flight instructor. The weather conditions at the time of the accident were conducive to serious carburetor icing at glide power. The flight instructor recalled pulling the carburetor heat lever out during the approach, therefore, it is unlikely that carburetor icing resulted in the loss of engine power. Investigators were not able to determine the reason for the loss of engine power.
Probable cause
A partial loss of engine power for reasons that were undetermined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N65497
Operator
Golf Aero Flight School
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17275765
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-06T21:27:49Z guid: 105192 uri: 105192 title: CEN22LA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105201/pdf description:
Unique identifier
105201
NTSB case number
CEN22LA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-04T10:00:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-06-17T00:10:51.742Z
Event type
Accident
Location
Amarillo, Texas
Airport
Tradewind Airport (TDW)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 4, 2022, at 0900 central daylight time, a Beech A36, N9087S, was involved in an accident near Amarillo, Texas. The airplane sustained substantial damage. The pilot and pilot-rated passenger were uninjured. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot stated that during an RNAV approach to runway 35 at the destination airport, he attempted to apply full engine power when he noticed that the airspeed was decreasing. He realized that the engine lost power and he was unsuccessful in his attempts at regaining engine power. He performed a forced landing on a pasture about 2-3 miles from the airport, during which the airplane sustained substantial damage that included damage to the right wing. Postacccident examination of the airplane revealed that the left side of the engine cowl had a blue stain, consistent in color with 100 low lead aviation fuel, that extended in the aft direction. A postaccident engine run was attempted but could not be completed due to fuel leaking from the fuel control assembly. The fuel control assembly was removed from the engine for bench testing. An attempt was made to bench test the fuel control assembly, but due to fuel leaking from the control arm shaft, the bench test could not be performed. The safety wire around the fuel control assembly had a metal stamp with “TCM,” which indicated that the last assembly of the fuel control assembly was performed by Teledyne Continental Motors (TCM). Disassembly of the fuel control assembly revealed that the leak was at the mixture control arm shaft O-ring, which was intact and did not exhibit separation. The outside diameter of the O-ring was less than the diameter of the mixture control shaft. TCM records showed that in 1996 the engine and engine accessories were overhauled, which included the fuel control assembly. An engine logbook entry dated July 15, 1996, stated that the engine was installed onto the airplane. An engine logbook entry dated April 1, 2013, noted a tachometer and an engine total time of 772.0 hours. The time since major overhaul (TSMOH) was recorded as “NA.” The logbook entry stated that all work was done in accordance with the TCM IO-520 overhaul manual and that an annual inspection was performed. The entry did not state that an engine overhaul was performed. Subsequent logbook entries referenced the TSMOH of the April 1, 2013, entry. No evidence could be found to indicate that the fuel control assembly had been overhauled since 1996. TCM’s recommended time between overhaul, as stated in Continental Motors Aircraft Engine Service Information Letter SIL98-9C, was 12 years. Several sections in TCM’s Standard Practice Manual stated that the engine accessories must be overhauled at the time of engine overhaul. -
Analysis
The pilot stated that during a nonprecision instrument approach to the destination airport, he applied full engine power when he noticed that the airplane airspeed was decreasing. He realized that the engine lost power and was unsuccessful in attempts at regaining engine power. He performed a forced landing on a pasture during which the airplane sustained substantial damage that included damage to the right wing. A postaccident examination of the wreckage revealed streaks fuel on the left side of the engine cowling. An examination of the engine revealed the fuel control assembly was leaking at the mixture control shaft’s O-ring. The O-ring was intact and did not exhibit separation. However, the outside diameter of the O-ring was less than the diameter of the mixture control shaft consistent with wear. A leak within the fuel control assembly would have allowed air to enter/fuel to exit the assembly resulting in improper fuel metering and a loss of engine power. No other mechanical anomalies were noted with the airframe and engine that would have precluded normal operations. Maintenance records showed that the last overhaul of the fuel control assembly was performed during an engine overhaul in 1996. There were no subsequent records or evidence that indicated the assembly was overhauled after 1996. The engine manufacturer’s recommended time between overhaul (TBO) was 12 years. The engine manufacturer’s standard practice manual stated that engine accessories must be overhauled at the time of engine overhaul. The engine and fuel control assembly exceeded the engine manufacturer’s recommended TBO.
Probable cause
The loss of engine power due to a leak in the fuel control assembly. Contributing to the accident was the inadequate maintenance of the fuel control assembly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N9087S
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
E-1299
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-17T00:10:51Z guid: 105201 uri: 105201 title: ERA22FA257 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105184/pdf description:
Unique identifier
105184
NTSB case number
ERA22FA257
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-04T13:01:00Z
Publication date
2023-09-20T04:00:00Z
Report type
Final
Last updated
2022-06-11T18:33:25.025Z
Event type
Accident
Location
Fairfield, New Jersey
Airport
Essex County Airport (CDW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
The Bell 407 Rotorcraft Flight Manual, “Emergency and Malfunction Procedures,” section 3.5, Tail Rotor, stated the following: There is no single emergency procedure for all types of anti-torque malfunctions. One key to a pilot successfully handling a tail rotor emergency lies in the ability to quickly recognize the type of malfunction that has occurred. The manual also stated that the indications of a loss of tail rotor thrust were (1) uncontrollable yawing to the right (left side slip), (2) nose-down tucking, and (3) possible roll of fuselage. The manual noted that the “severity of initial reaction of helicopter will be affected by AIRSPEED, CG [center of gravity], power being used, and HD [density altitude].” In addition, the manual stated the following about an in-flight complete loss of tail rotor thrust: Reduce throttle to IDLE, immediately enter autorotation and maintain a minimum airspeed of 55 KIAS [knots indicated airspeed] during descent. Note: When a suitable landing site is not available, vertical fin may permit controlled flight at low power levels and sufficient airspeed. During final stages of approach, a mild flare should be executed, making sure all power to rotor is off. Maintain helicopter in a slight flare and smoothly use collective to execute a soft, slightly nose-high landing. Landing on aft portion of skids will tend to correct side drift. This technique will, in most cases, result in a run-on landing. The FAA’s Helicopter Flying Handbook, FAA-H-8083-21B, chapter 11, Helicopter Emergencies and Hazards, stated the following: An antitorque failure with a high-power setting at a low airspeed results in a severe spinning to the right. At low power settings and high airspeeds, the spin is less severe. High airspeeds tend to streamline the helicopter and keep it from spinning…. A mechanical control failure limits or prevents control of tail rotor thrust and is usually caused by a stuck or broken control rod or cable. While the tail rotor is still producing antitorque thrust, it cannot be controlled by the pilot. The amount of antitorque depends on the position at which the controls jam or fail. Once again, the techniques differ depending on the amount of tail rotor thrust, but an autorotation is generally not required. The US Army Training Circular 3-04.4, “Fundamentals of Flight,” stated the following: According to Newton’s law of action/reaction, action created by the turning rotor system causes the fuselage to react by turning in the opposite direction. The fuselage reaction to torque turning the main rotor is torque effect. Torque must be counteracted to maintain control of the aircraft; the antitorque rotor does this…. Improved rotor efficiency resulting from directional flight is translational lift. The efficiency of the hovering rotor system is improved with each knot of incoming wind gained by horizontal movement or surface wind…. In addition, the tail rotor becomes more aerodynamically efficient during the transition from hover to forward flight. As the tail rotor works in progressively less turbulent air, this improved efficiency produces more thrust, causing the nose of the aircraft to yaw left (with a main rotor turning counterclockwise) and forces the aviator to apply right pedal…in response. As a result of this investigation, the operator developed a required inspection program, which was published and amended to the General Operating Manual. The program was submitted to the appropriate FAA Certificate Holder District Office, and the manual revisions were accepted. - According to the operator, the tail rotor was installed on the day before the accident after the replacement of four feathering bearings. The director of maintenance (DOM), who performed the task, stated that he conducted the tail rotor assembly installation by laying out the parts on a maintenance cart; performing the installation procedure, including the mast nut torque application; and having a mechanic verify the mast nut torque. He then finished the installation and had another mechanic verify the work. A company pilot performed a preflight inspection of the helicopter, ground functional checks, and three consecutive maintenance runs to balance the tail rotor. The accident flight was the first flight after completion of this work.   According to the DOM, between the mast nut torque application and completion of the tail rotor assembly installation, he was “called out” to consult on two different aircraft repairs. The DOM did not recall the amount of time that elapsed before he resumed the installation work. - On June 4, 2022, about 1201 eastern daylight time, a Bell 407 GXP helicopter, N98ZA, was substantially damaged when it was involved in an accident near Fairfield, New Jersey. The commercial pilot was seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The helicopter departed Essex County Airport (CDW), Caldwell, New Jersey, about 1147 for John F. Kennedy International Airport (JFK), Queens, New York. A review of automatic dependent surveillance-broadcast (ADS-B) data showed the helicopter in a cruise profile on a southeasterly track at an altitude of about 500 ft mean sea level (msl). Air traffic control data and review of the helicopter’s Appareo Vision 1000 onboard recording system revealed that, about 1152, when the helicopter was about 2 miles south of Teterboro International Airport (TEB), Teterboro, New Jersey, the pilot stated, “what is going on here?” About 1 minute later, the pilot contacted the controller and requested to return to CDW. The controller asked the pilot if he needed assistance, and the pilot declined. The helicopter turned left and proceeded toward CDW at an altitude of about 500 ft msl and an indicated airspeed of about 85 knots. About 1155, the pilot contacted the CDW tower controller and stated that he “may need the runway.” The controller advised the pilot to report when the helicopter was 2 miles from the airport and expect runway 28 at CDW. About 1158, the pilot reported that the helicopter was 2 miles from the airport, and the controller subsequently cleared the helicopter to land “on the numbers” for runway 28. The pilot acknowledged. About this time, the helicopter’s indicated airspeed was 95 knots, and the airspeed continued to decrease as the helicopter approached CDW. About 1200, the helicopter crossed airport property with its nose slightly pitched up and an indicated airspeed that was decreasing below 65 knots. About 1201, at an altitude of 250 ft msl and with the runway visible (via the left chin bubble below the helicopter), the helicopter began yawing to the right as the indicated airspeed decreased below 35 knots. At that time, the helicopter was flying over a grass area north of and parallel to runway 28. The helicopter’s right yaw increased significantly as its airspeed decayed below 30 knots. When the helicopter was near the ground about treetop level, and an indicated airspeed of 0 knots, the right yaw ceased, and the helicopter began to yaw to the left and roll slightly to the left. The helicopter subsequently entered a rapid right yaw, pitched forward, and began to descend as the helicopter rotated right around the main rotor mast. The helicopter completed several 360° rotations before impacting terrain north of runway 28, which caused substantial damage to the fuselage and tailboom, as shown in figure 1. Figure 1. Helicopter after ground impact (Source: FAA). Airport surveillance video captured the helicopter’s approach, its alignment with the runway, and its decreasing airspeed as the nose pitched upward. The video showed that, as the helicopter slowed, its nose yawed to the right, and the helicopter became unstable and started to descend vertically while rotating around the main rotor mast. About 3 seconds into the vertical descent, the right yaw slowed and then stopped, and the helicopter rotated to its left as it descended and contacted the ground. After ground contact, the main rotor continued to turn, and the main rotor blades continued to strike the ground, shedding about 50% of the span of each blade. - In addition to his commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter, the pilot held a flight instructor certificate with the same ratings. Review of the pilot’s employee records revealed that he received 16 hours of initial ground instruction in the Bell 407 (including systems, performance planning, and emergency procedures) as well as general subjects such as meteorology and flight planning. He also received 5 hours of flight training and satisfactorily completed a Part 135 airman competency/proficiency check in the Bell 407 on May 16, 2020. The pilot demonstrated satisfactory knowledge of emergency procedures related to settling with power and tail rotor failure. - Postaccident examination revealed that the tail rotor crosshead drive plate, which was positioned behind the pitch change rod attachment nut, was not bolted to the tail rotor crosshead, as prescribed in the maintenance manual. The two attachment bolts were not present, and no remnants of any bolts were found in their threaded receptacles in the crosshead drive plate, as shown in figure 2. The threads were undamaged and showed no signs of corrosion, deformation, smearing, or cross-threading. Figure 2. Tail rotor crosshead/drive plate attachment bolt bore threads (Source: Bell Helicopters). Main rotor flight control continuity was confirmed from the cockpit to several breaks to each respective rotor blade. Tail rotor control was confirmed from the pedals to breaks to the tail rotor gearbox to the pitch control rod. Movement of the pitch change push-pull tube resulted in smooth movement of the pitch change rod; the attached tail rotor crosshead drive plate moved with the pitch change rod but moved independently of the crosshead (to which the tail rotor crosshead drive plate was no longer bolted). -
Analysis
The pilot of the helicopter was conducting a positioning flight. About 5 minutes after departure, the onboard video recorder captured him saying, “what is going on here?” The pilot subsequently contacted air traffic control and requested to return to the departure airport, but he did not declare an emergency or state that he needed assistance. Upon initial contact with the tower controller at the destination airport, the pilot stated that he “might need the runway”; several minutes later, the controller cleared the pilot to land on the runway numbers. As the helicopter approached the airport and its indicated airspeed began to decay below about 30 knots, the helicopter entered a right yaw and completed several 360° rotations around the main rotor mast before impacting terrain next to the runway, resulting in substantial damage. Postaccident examination of the helicopter revealed that the tail rotor crosshead drive plate, which was positioned behind the pitch change rod attachment nut, was not bolted to the tail rotor crosshead. The two attachment bolts were not present, and no remnants of any bolts were found in the threaded receptacles in the crosshead. The threads were undamaged and showed no signs of corrosion, deformation, smearing, or cross-threading, indicating that the attachment bolts were likely not installed. The tail rotor was installed on the day before the accident after the replacement of four feathering bearings. The operator’s director of maintenance (DOM) performed the installation and had a mechanic verify that the mast nut torque was correctly applied. After the DOM completed the installation, another mechanic verified the work. A company maintenance pilot then completed a preflight inspection of the helicopter, ground functional checks, and three consecutive maintenance runs. The accident flight was the first flight after the completion of this work. According to the DOM, between the mast nut torque application and completion of the installation, he was “called out” to consult on two different aircraft repairs. He did not recall the amount of time that had elapsed before he resumed the installation work. At some point during the installation, the DOM failed to properly secure the tail rotor crosshead drive plate. This error was subsequently not detected by the mechanic during his check of the DOM’s work, the maintenance pilot while balancing the tail rotor, or the accident pilot during the preflight check. The helicopter experienced a loss of tail rotor antitorque control due to the separation of the crosshead drive plate, but the helicopter was still controllable at speeds at or above effective translational lift. It is likely that the increased efficiency of the main and tail rotors, the streamlining effect of the fuselage, and the increased effectiveness of the vertical stabilizer at cruise speed all prevented the helicopter from entering an uncontrolled yaw while the pilot was returning to the airport. However, the increased engine power required to slow the helicopter to perform a normal approach to a hover to land on the runway numbers resulted in a torque moment that could not be overcome given the loss of tail rotor antitorque control. A run-on landing, during which the pilot would have maintained a forward speed above effective translational lift, would have afforded greater yaw stability, and thus have increased the chance for a successful landing.
Probable cause
The failure of maintenance personnel to properly secure the tail rotor crosshead drive plate and the failure of maintenance personnel, the maintenance pilot, and the accident pilot to detect the error, which led to the helicopter’s loss of tail rotor antitorque. Also causal was the pilot’s failure to maintain the helicopter’s airspeed at or above effective translational lift and perform a run-on landing, which resulted in a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N98ZA
Operator
Zip Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
54635
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-11T18:33:25Z guid: 105184 uri: 105184 title: WPR22LA204 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105221/pdf description:
Unique identifier
105221
NTSB case number
WPR22LA204
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-04T15:30:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-06-14T22:09:24.421Z
Event type
Accident
Location
Snohomish, Washington
Airport
HARVEY FLD (S43)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 4, 2022, about 1430 Pacific daylight time, a Piper PA-32-300, N561PK, was substantially damaged when it was involved in an accident near Snohomish, Washington. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that before he departed Paine Field (PAE), Everett, Washington, he did not refuel the airplane, and during his preflight inspection he strained all the fuel tanks and performed an engine runup with no issues. He then departed for a flight to Harvey Field (S43), Snohomish, Washington. He was airborne for about 10 minutes and landed on runway 15L. After landing, he exited the runway and, during his post-landing checklist, the engine “hiccuped” like it was it was losing power and then “revved up.” The pilot turned the fuel pump off and back on and the engine seemed to have “cleared up.” The pilot stated that before takeoff from S43, he performed an uneventful engine runup and elected to conduct a short-field takeoff from runway 17. As the airplane ascended through about 700 ft mean sea level, the engine began to surge, followed by a total loss of engine power. The pilot attempted to land on a nearby road; however, he realized he was unable to reach it and instead landed in an open field. During the landing roll, the airplane struck a dirt berm and became airborne briefly before it touched back down. The pilot stated that once the nose wheel landing gear settled onto the soft dirt it immediately collapsed, and the airplane came to rest nose low. The pilot further reported that before his flight from PAE, the owner of the airplane sent him a text message telling him that the fuel selector valve was on the left tip tank. The pilot said he didn’t think it was an issue; however, he could not remember if he put the selector valve on the left main fuel tank or not. He added that he could see himself switching the fuel tank position by hand, and then putting it back where it was without visually verifying the position. The owner of the airplane reported that he had about 2 or 3 gallons of fuel in the left wing tip tank before he added 4 gallons of fuel, before a performing a “mini run up” and taxiing back to his hangar at PAE. The owner estimated that the left tip tank had about 4 gallons of fuel in it. Postaccident examination of airframe revealed that all four fuel tanks were intact and undamaged. The left wing tip tank was void of any fuel, while the left main tank, right main tank, and right wing tip tank contained a significant amount of fuel. No visible damage to the airframe was observed except for the nose wheel landing gear, which was compressed aft into the firewall. Additionally, the engine mount where the nose gear attached was buckled. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot reported that he had flown about 10 minutes from one airport to another and, after landing, the engine “hiccuped” like it was it was losing power and then “revved up.” The pilot turned the fuel pump off and back on, and the engine seemed to clear up. The pilot performed an uneventful engine runup and elected to conduct a short-field takeoff. As the airplane climbed through about 700 ft mean sea level (msl), the engine began to surge, followed by a total loss of engine power. The pilot attempted to land on a nearby road; however, he realized he was unable to reach it and instead landed in an open field, which resulted in substantial damage to the engine mount. The pilot reported that before the flight, the owner of the airplane sent him a text message telling him that the fuel selector valve was on the left tip tank. The pilot didn’t believe that to be an issue; however, he could not remember if he put the selector valve on the left main fuel tank or not. The owner of the airplane estimated that the left tip tank had about 4 gallons of fuel in it when he put the airplane in the hangar. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. During the examination, the left-wing auxiliary fuel tank was found void of fuel. It’s likely that while the pilot conducted his preflight, he inadvertently positioned the fuel selector to the left wing tip tank position.
Probable cause
The total loss of engine power during takeoff due to fuel starvation and the pilot’s improper fuel tank selection and inadequate preflight inspection.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N561PK
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-7340124
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-14T22:09:24Z guid: 105221 uri: 105221 title: CEN22FA224 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105185/pdf description:
Unique identifier
105185
NTSB case number
CEN22FA224
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-05T17:30:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-16T22:59:12.376Z
Event type
Accident
Location
Midlothian, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The glider logbooks were not located during the investigation, and the date of its most recent annual inspection was not determined. - On June 5, 2022, about 1630 central daylight time, a Schweizer SGS 135C glider, N2817H, was undamaged when the pilot was found deceased after landing near Midlothian, Texas. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to members of the Texas Soaring Association (TSA), the pilot was launched via aerotow around 1500 that day. About 1700, the glider was found by another pilot as he landed at TSA Gliderport (TA11), Midlothian, Texas. The pilot was found strapped in his parachute and harness with the canopy closed despite temperatures in excess of 90°F. The glider was about 150 yards from the intended landing area in an open field. (See Figure 1.) None of the other pilots recalled hearing any landing radio calls or distress calls from the pilot. The exact time the pilot landed was not determined. Figure 1. Location of the glider as found. - An autopsy was performed on the pilot by the Southwestern Institute of Forensic Sciences at Dallas, Texas. The cause of death was aortic dissection associated with hypertensive and atherosclerotic cardiovascular disease. Blunt force injuries were also noted as contributing. The manner of death was ruled as accident. An aortic dissection is a complication of chronic high blood pressure. Constant high blood pressure and turbulent blood flow cause a tear in the inner layer of the aorta (the large blood vessel that exits the heart) and blood rushes into the layers of the aorta, splitting them. In the worst cases, as in this one, it tears through all the layers and out into the mediastinum, interrupting blood flow to the rest of the body. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified amlodipine and alfuzosin in liver; amlodipine was also identified in muscle tissue, but testing was inconclusive for alfuzosin in muscle. Testing was negative for ethanol. Amlodipine is a calcium channel blocker used to treat high blood pressure and coronary artery disease. Alfuzosin is an antagonist and is used to treat the symptoms of an enlarged prostate. - The pilot’s logbook was not located during the investigation. The pilot’s total experience in gliders could not be determined; however, he was an active member of the Texas Soaring Association and owned gliders for over 14 years. - The glider was located in an open field, as seen in Figure 2. Figure 2. Glider at the accident site. Examination of the glider did not reveal any damage or evidence of a hard landing. The flaps were found fully extended with the flap handle locked in the detent. Flight control continuity was confirmed from the cockpit controls to the flight control surfaces. Disassembly of the glider for transportation found that the LSP-1 safety pin was not installed to secure the clevis pin that connected the left aileron pushrod to the aileron idler horn. Despite being partially unseated, the clevis pin was seated adequately for operation of the aileron. (See Figure 3.) The right aileron was properly secured. No other anomalies were detected with the airframe that would have precluded normal operations. Figure 3. Aileron connection to the aileron idler horn. -
Analysis
The pilot was found deceased in the undamaged glider following a landing to a field near the airport. Postaccident examination revealed an improperly secured aileron connection; however, despite being partially unseated, the ailerons clevis pin remained seated adequately to facilitate operation of the aileron. No other anomalies were detected with the airframe that would have precluded normal operation. Autopsy revealed that the pilot’s cause of death was aortic dissection associated with hypertensive and atherosclerotic cardiovascular disease, with blunt force injury contributing.
Probable cause
The pilot’s incapacitation by an aortic dissection (natural disease).
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS135
Amateur built
false
Registration number
N2817H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
77
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-06-16T22:59:12Z guid: 105185 uri: 105185 title: HWY22FH010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105204/pdf description:
Unique identifier
105204
NTSB case number
HWY22FH010
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-06T15:45:00Z
Publication date
2024-03-01T05:00:00Z
Report type
Final
Last updated
2024-02-05T05:00:00Z
Event type
Accident
Location
Dermott, Arkansas
Injuries
5 fatal, 5 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Dermott, Arkansas, intersection crash was the failure of the bus driver to yield to the combination vehicle, likely as the result of fatigue.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2018 Starcraft Allstar medium-size bus
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2018 Freightliner truck-tractor and semi-trailer
Traffic unit type
Combination Vehicle
Units
Findings
creator: NTSB last-modified: 2024-02-05T05:00:00Z guid: 105204 uri: 105204 title: ERA22FA261 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105200/pdf description:
Unique identifier
105200
NTSB case number
ERA22FA261
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-06T17:10:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-11T01:29:38.014Z
Event type
Accident
Location
Panama City, Florida
Airport
Northwest Florida Beaches International Airport (ECP)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 1 serious, 0 minor
Factual narrative
According to the most recent annual inspection, the airplane had a tachometer time of 508.6 hours. During the annual inspection, a new avionics system was installed, which included a Dynon Skyview HDX panel display and a Dynon electronic flight instrument system. The airframe maintenance logbook indicated that the work was performed by five people, one of whom was the pilot, and was signed off by a mechanic with inspection authorization. Additionally, Federal Aviation Administration Form 337, Major Repairs and Alterations, indicated that the installation of the Dynon Skyview HDX was performed in accordance with Dynon Skyview HDX System Installation Manual, dated October 28, 2020. The installation manual stated the following: Mount the oil pressure sensor securely to the airplane’s structure using appropriate AN/MS hardware fittings, clamps, and flexible hose…. DO NOT mount the sensor directly to engine or other areas of high vibration. Always mount the sensor to the airframe structure, and connect it with flexible hose to minimize vibration effects. Mounting the sensor directly to the engine may cause sensor failure/leakage and possibly fire. According to the airplane flight log, the tachometer time on June 5, 2022, was 511.5 hours. Furthermore, on an entry dated May 25, 2022, the entry indicated that the pilot flew the airplane with “Fly Test” written next to his name. - Postaccident examination of the pavement in the parking area of the FBO revealed a trail of oil drops that led to a small puddle of oil where the airplane was initially parked. A second larger area of oil staining, measuring about 6 ft by 6 ft (as shown in figure 2), was found at the airplane’s second parking location (where the airplane had been moved by FBO personnel), which was where the pilot conducted his walk-around and loaded passengers before he started the engine for taxi and takeoff. Furthermore, there was a trail of oil leading from the spot pictured in Figure 2 toward the runway that aligned with the airplane taxiing to the runway. Figure 2 - Large oil stain on the pavement where airplane was located at engine start. - On June 6, 2022, about 1610 central daylight time, a Piper PA-28RT-201, N160LL, was substantially damaged when it was involved in an accident near Northwest Florida Beaches International Airport (ECP), Panama City, Florida. The pilot and one passenger were fatally injured, and another passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On the morning of the accident, the pilot and passengers arrived at ECP, and the pilot parked the airplane on a local fixed-base operator (FBO) ramp about 0941. About 1100, the FBO moved the airplane to another location on the ramp because the pilot and passengers were not returning until later in the day. A review of the data downloaded from an onboard avionics system revealed that during the flight to ECP, the oil pressure initially stabilized at 89 pounds per square inch (psi) and decreased gradually as oil temperature increased. Immediately before takeoff power was set, the oil pressure had reduced to about 50 psi. The oil pressure remained steady at 80 psi during the flight. After landing, the oil pressure ranged between 50 and 70 psi (depending on the engine power setting). A review of security camera video revealed that the pilot returned to the airplane about 1530. He opened the baggage compartment, entered and exited the cockpit multiple times, walked around the front of the airplane, and stopped in front of each wing until the two passengers arrived about 1541. During these 11 minutes, he did not appear to spend any appreciable time inspecting the airplane’s engine or the ground below it. About 1551, the airplane exited the FBO ramp and taxied to runway 34. Onboard avionics system data showed that immediately after the engine was started for the accident flight, the oil pressure stabilized at about 67 psi. The oil pressure gradually decreased as the oil temperature increased and continued decreasing as the aircraft taxied to the runway. Immediately before takeoff, the oil pressure had reduced to about 10 psi. When the engine was advanced to takeoff power, the oil pressure dropped to 4 psi. According to automatic dependent system broadcast (ADS-B) data, the airplane began the takeoff roll about 1606 and reached a peak altitude of about 1,200 ft mean sea level (msl). According to summary of air traffic control communications, the pilot declared an emergency about 1609. ADS-B data showed that the airplane began to descend, made a 180° left turn, and then continued to descend until it impacted trees and terrain about 1.7 miles from the runway threshold. The ADS-B data ended about 190 ft before the main wreckage; figure 1 shows the airplane’s flight track. Figure 1 - ADS-B data showing the accident flight track. - According to the pilot’s logbook, on May 25, 2022, the pilot performed a flight that the logbook described as “TEST ARROW”. - The airplane came to rest upright in an area of dense brush at an elevation of 25 ft. All major components of the airplane were located near the main wreckage. Multiple tree branches located along the debris path exhibited black paint transfer and were cut at 45° angles. Flight control cable continuity was established from the cockpit to the flight control surfaces. Oil was noted along the bottom right side of the fuselage. The three-blade propeller remained attached to the engine. The spinner was impact damaged, all blades remained attached to the hub, and one of the blades exhibited chordwise scratching. Postaccident examination of the engine revealed a breach of the crankcase near the No. 4 cylinder. The engine was disassembled, and continuity of the crankshaft was confirmed. No anomalies were noted on the main journals of the crankshaft. The No. 4 connecting rod journal exhibited thermal damage, and bearing material was found welded/smeared to the crankshaft journal. The No. 4 connecting rod cap, connecting rod bolts, and bearing pieces were found in the oil sump along with other metallic debris and a trace amount of oil. The oil drain plug remained seated and safety wired to the oil sump. The oil pump rotated freely by hand. The oil pump was disassembled, and no scoring was noted on the oil pump gears or the housing. The oil pressure sensor was separated from the engine. The sensor’s rigid copper line was fractured at the fitting to the accessory section of the crankcase, as shown in figure 3. Figure 3. Fractured oil pressure sensor line. The rigid copper line and oil pressure sensor were examined by the National Transportation Safety Board Materials Laboratory. The examination revealed that most of the fracture occurred on a flat plane perpendicular to the tube axis, and a darker region with a smooth curving boundary was observed at one side identified as the origin area, as shown in figure 4. The figure also shows that fatigue features emanated from the origin area and extended to the boundary approximately indicated with dashed lines. The remainder of the fracture surface showed a change in fracture plane with dimple features on the fracture surface; those features were consistent with ductile overstress fracture of the remaining ligament of the tube wall. Figure 4. Oil pressure sensor line fracture surface after cleaning. The dashed lines indicate the approximate fatigue boundary from the origin area, which is indicated with a bracket. -
Analysis
The pilot was conducting a personal flight with two passengers aboard. Security camera video revealed that when the pilot arrived at the airplane prior to initiating the flight, he did not perform a complete preflight inspection, which should have included at least a cursory examination of the airplane’s engine and a check of the ground below it. Shortly after departure, the pilot declared an emergency, and the airplane made a 180° left turn back toward the airport. The airplane descended and impacted terrain about 1.7 miles from the runway threshold. Postaccident examination of the engine revealed that the crankcase was breached near the No. 4 cylinder. Also, the No. 4 connecting rod journal exhibited thermal damage and bearing material was found welded/smeared to the crankshaft journal. The No. 4 connecting rod cap, connecting rod bolts, and bearing pieces were found in the oil sump along with other metallic debris and a trace amount of oil. Examination of the oil system revealed that the oil pressure sensor was separated from the engine. The sensor’s rigid copper line was fractured at the fitting to the accessory section of the crankcase. The propeller exhibited chordwise scratching and angle-cut tree branches in the vicinity of the wreckage, which were indications that the engine did not lose total power. Examination of the rigid oil pressure line revealed that it fractured due to high-cycle fatigue. This was likely from excessive vibration due to insufficient support of the oil pressure sensor and rigid line. The oil pressure sensor, which was part of the avionics system, was installed about 3 flight hours before the accident. The installation manual for the avionics system stated that a flexible line should be used to install the oil pressure sensor in order to minimize vibration effects. Instead, a rigid line was installed, which would have been more susceptible to the effects of vibration, including high-cycle fatigue failure. Oil staining observed on the ramp area where the airplane was parked before the flight, a trail of oil leading from the parking area to the runway, and the oil observed on the airframe exterior at the accident site all suggest that the airplane was actively leaking oil both before and during the accident flight. Based on all available information, it is likely that the oil pressure sensor line fractured during the flight before the accident flight, which resulted in oil leaking from the engine. This oil leak ultimately resulted in oil starvation and loss of engine power during the departure from, and the pilot’s attempted return to the airport. Had the pilot noted and investigated the source of the oil leakage during the preflight inspection, he might have taken appropriate corrective action and avoided the accident.
Probable cause
Maintenance personnel’s failure to follow the avionics installation guidance for the oil pressure sensor, which resulted in the high-cycle fatigue failure of an line, oil starvation, and the subsequent loss of engine power. Contributing to the accident was the pilot’s failure to perform an adequate preflight inspection of the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28RT-201
Amateur built
false
Engines
1 Reciprocating
Registration number
N160LL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7918157
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-11T01:29:38Z guid: 105200 uri: 105200 title: ERA22FA262 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105205/pdf description:
Unique identifier
105205
NTSB case number
ERA22FA262
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-07T10:40:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-09T19:08:14.935Z
Event type
Accident
Location
Greenville, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On June 7, 2022, about 0940 eastern daylight time, an Enstrom F28F helicopter, N600TA, was substantially damaged when it was involved in an accident near Greenville, Ohio. The private pilot and the passenger (a student pilot) were fatally injured. The flight was conducted as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot owned the helicopter, which was used for agricultural spraying on his family farm. The helicopter was based at a private hangar facility in Greenville. According to a Federal Aviation Administration (FAA) inspector, who visited the facility after the accident, the pilot and the passenger were observed on surveillance video departing the facility at 0925. The spray equipment had been removed from the helicopter. Several witnesses saw the helicopter flying in the local area at an altitude between 500 and 1,000 ft mean sea level. About 0940, law enforcement received a 911 call that the helicopter had crashed in the driveway of the pilot’s residence, which was about 3 miles from the hangar facility. There were no eyewitnesses or video of the accident. The pilot was not in contact with air traffic control, and no flight plan had been filed. A search for air traffic control radar data revealed no radar data was captured for the flight. Automatic dependent surveillance-broadcast (ADS-B) flight tracking equipment was installed on the helicopter, but no tracking data was captured for the accident flight. The helicopter was equipped with a DynaNav DynaFlight 3 navigational system; however, it was not being used during the accident flight and no flight data was recorded. According to the pilot’s flight instructor, who also flew spraying operations in the accident helicopter, he said the pilot had planned to fly to the Warren County Airport (I68), Lebanon, Ohio, later that day to drop the helicopter off for scheduled maintenance. The passenger was going to drive down and pick him up after he dropped off the helicopter. The instructor was not sure why the pilot and passenger were operating the helicopter at their home that morning. PILOT INFORMATION The pilot held a private pilot certificate for rotorcraft-helicopter. His last FAA third-class medical was issued on January 7, 2020. A review of the pilot's flight logbook revealed his last entry was on December 14, 2021. According to the pilot’s father, the pilot was in the process of obtaining his commercial pilot certificate. As such, he could not legally conduct any agricultural flights for hire. However, he would fly the helicopter to/from Lebanon, Ohio, for maintenance, which helped accrue flight hours. The father said the reason there was no flight time logged in the pilot’s logbook from December 2021 to the date of the accident was most likely due to maintenance (they were awaiting parts from the helicopter manufacturer, who had recently filed for bankruptcy) and because they were busy with regular farming operations during that time. The passenger held a student pilot certificate. Her last FAA third-class medical was issued on March 22, 2022. A review of the passenger’s logbook revealed that she had a total of 24 flight hours (all dual instruction in the accident helicopter). The last flight she and her instructor logged was on December 19, 2021. WRECKAGE DESCRIPTION The helicopter came to rest upright, with the skids fully spread, on a magnetic heading of about 245°. A postaccident fire consumed the aft cockpit area to the forward tail boom area, including the engine and both fiberglass fuel tanks. All three main rotor blades remained secured to the main rotor head. The No.1 and No. 2 blades were undamaged, and the No. 3 blade, which came to rest above the postaccident fire, was partially delaminated and exhibited heat damage. There were no ground scars or impact marks observed around the main wreckage, consistent with the helicopter making a near-vertical descent. The helicopter struck a ½-inch coaxial cable that ran between the street and the home as it descended before it impacted the ground. The cable was severed and laying on the ground to the left and right of the main wreckage. One end of the cable was frayed and part of the black outer jacket of the cable was scraped away. Material from the cable was smeared on the leading edge of the No. 2 main rotor blade from the tip to about 88-inches inboard. The main rotor blades were manually rotated and continuity to the tail rotor was free and smooth. The tail rotor gear box was intact, and one tail rotor blade was bent about 90 degrees. The other blade sustained minor damage. The tail rotor guard was broken in two sections and found about 20-30 ft behind the main wreckage, along with a cargo door. The cockpit area was crushed downward, but the instrument panel was intact and undamaged. The wind/glareshield was shattered and numerous pieces of plexiglass were sitting on the ground in front of the nose of the helicopter. Both the left and right seat structures were crushed downwards. The on/off fuel shut off valve handle in the cockpit was bent downwards and the fuel selector valve was found in the “on” position. Both sets of flight controls were installed in the helicopter and moved in sync (interconnected) with each other when manually moved. Breaks in the flight control system were observed that appeared consistent with fire and impact damage in the aft cockpit area. Flight control continuity for each cyclic, the collective pitch controls, and the anti-torque pedals was traced from the controls to their respective control surfaces. The pilot’s flight instructor said he flew the helicopter about a week before the accident. He said the helicopter “flew better than ever”, and he was looking forward to flying it again during the regular ag-spraying season. The flight instructor also said that the dual controls were not installed when he flew the helicopter that weekend, and they are not normally installed when conducting ag spraying operations. The engine sustained extensive fire damage and the accessory case was heavily burned. The engine was removed from the airframe, and the valve covers and top spark plugs were removed from all four cylinders. Manual rotation of the crankshaft produced strong compression on the No. 1 and No. 3 cylinders, and weak compression on the No. 2 and No. 4 cylinders. Valvetrain continuity was also observed on all four cylinders. An internal inspection of the No. 2 and No. 4 cylinders with a lighted borescope revealed that both intake and exhaust valves were properly seating. These cylinders were removed, and no anomalies were noted that would have contributed to the low compression. The piston rings were unremarkable on each piston. The No. 4 outer exhaust valve spring was found broken, but there were no indications that it would have contributed to an engine issue. The oil sump screen was removed and absent of debris. The single-drive dual magneto remained attached to the accessory case, and the case had partially burned away exposing the driveshaft. When the engine was rotated, this drive was observed rotating. The ignition leads were consumed in the postaccident fire. Due to fire damage, the magneto could not be tested. The fuel injector nozzles were removed and exhibited a light amount of debris. The flow divider was intact, but the diaphragm sustained heat damage. The helicopter was equipped with an Electronics International TC-1P engine monitor; however, this model monitor had no recording capability, and no engine data was recorded. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. The testing detected ketamine in the pilot’s heart blood, hospital blood, and urine; norketamine in his heart blood, hospital blood, and urine; fentanyl in his heart blood and urine; norfentanyl in his heart blood and urine; and midazolam in his urine. Sevoflurane was detected in the pilot’s hospital blood. The generally non-impairing medications albuterol, lidocaine, and trimethoprim were detected in the pilot’s heart blood and urine. Post-accident medical records showed that all of these medications were administered post-accident. Toxicology testing of the passenger detected diphenhydramine in her heart blood and liver. -
Analysis
The pilot and the passenger departed on a local flight in their helicopter and about 15 minutes later, the helicopter impacted the driveway at their residence. There were no witnesses to the accident and it could not be determined why they were operating the helicopter near their home. Impact marks at the accident site were consistent with the helicopter impacting the ground hard in a near-vertical descent. A postimpact fire consumed the aft cockpit area to the forward tail boom area, including the engine and both fuel tanks. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunction or failure that would have precluded normal operation. Based on available information, the reason the helicopter impacted terrain could not be determined.
Probable cause
An impact with terrain for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ENSTROM
Model
F28
Amateur built
false
Engines
1 Reciprocating
Registration number
N600TA
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
704
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-09T19:08:14Z guid: 105205 uri: 105205 title: DCA22FM022 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105208/pdf description:
Unique identifier
105208
NTSB case number
DCA22FM022
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-06-07T13:04:00Z
Publication date
2023-10-24T04:00:00Z
Report type
Final
Last updated
2023-09-29T04:00:00Z
Event type
Accident
Location
Norfolk, Virginia
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The NTSB determines the fire aboard the Spirit of Norfolk was likely the ignition of combustible material stored near the exhaust piping from the operating port generator. Contributing to the severity of the fire was the lack of a firedetection and fixed fire extinguishing system in the engine room. Also contributing to the severity were ineffective communications between the unified command and Engine Room Fire Aboard Passenger Vessel Spirit of Norfolk firefighting teams that led to the fire attack team opening the engine room door, allowing the fire to spread.
Has safety recommendations
true

Vehicle 1

Callsign
WDJ2746
Vessel name
Spirit of Norfolk
Vessel type
Passenger
IMO number
8861618
Port of registry
Norfolk, VA
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-09-29T04:00:00Z guid: 105208 uri: 105208 title: CEN22LA237 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105215/pdf description:
Unique identifier
105215
NTSB case number
CEN22LA237
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-07T15:15:00Z
Publication date
2023-12-06T05:00:00Z
Report type
Final
Last updated
2022-06-22T20:36:04.564Z
Event type
Accident
Location
Fort Worth, Texas
Airport
FORT WORTH MEACHAM INTL (FTW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 7, 2022, about 1415 central daylight time, a Piper PA-28-161 airplane, N8283V, was substantially damaged when it was involved in an accident near Fort Worth, Texas. The student pilot was not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. The solo student pilot returned from a cross-country flight and planned on practicing touch-and-go landings. After the first touch-and-go landing to runway 17, when the airplane was about 100 ft above ground level, the airplane’s engine stopped producing power. The student pilot performed a forced landing straight ahead. During the landing, the airplane’s left wing contacted a tree and separated resulting in substantial damage. A Federal Aviation Administration (FAA) inspector responded to the accident site and examined the airplane. He found that the fuel selector was selected to the left fuel tank, which was about half full of fuel. The right fuel tank was empty. The student pilot reported to the FAA inspector that the fuel selector was on the right tank when the engine stopped producing power. The student pilot stated the selector was moved to the left tank position when the airplane was being secured after the accident. -
Analysis
The student pilot was practicing a touch-and-go landing following a cross-country flight when the accident occurred. During the takeoff portion of the touch and go, at an altitude of 100 ft above the runway, the engine stopped producing power. The student pilot performed a forced landing and the left wing collided with a tree and separated which resulted in substantial damage. A postaccident examination of the airplane found the right fuel tank was empty and the left fuel tank was about ½ full of fuel. The student pilot reported the right fuel tank was selected when the engine lost power. It is likely that the engine lost power when it was starved of fuel.
Probable cause
The student pilot’s inadequate fuel management that resulted in a loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N8283V
Operator
Delta Qualiflight Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-8116065
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-22T20:36:04Z guid: 105215 uri: 105215 title: ANC22LA042 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105265/pdf description:
Unique identifier
105265
NTSB case number
ANC22LA042
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-08T00:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-07-01T01:04:57.098Z
Event type
Accident
Location
Chisana, Alaska
Airport
Chisana Airport (CZN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of a twin-engine, turbine-powered airplane was landing at a remote, rough, soft, turf and grass covered airstrip at the completion of a Part 135 cargo flight. He said that after an uneventful touchdown, as the airplane’s landing roll slowed, the right main landing gear wheel and the nose wheel contacted an area of soft, muddy terrain. The airplane’s nose wheel collapsed, and it subsequently folded under the fuselage. The airplane sustained substantial damage to the fuselage. The pilot reported no mechanical problems that would have precluded normal operations.
Probable cause
The pilot’s selection of an unsuitable landing site, which resulted in the nosewheel collapsing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SHORT BROS. & HARLAND
Model
SC7
Amateur built
false
Engines
2 Turbo prop
Registration number
N731E
Operator
Viking Air LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
SH-1853
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-01T01:04:57Z guid: 105265 uri: 105265 title: DCA22LA126 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105216/pdf description:
Unique identifier
105216
NTSB case number
DCA22LA126
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-08T05:15:00Z
Publication date
2023-08-03T04:00:00Z
Report type
Final
Last updated
2022-07-11T20:53:34.554Z
Event type
Incident
Location
Tulsa, Oklahoma
Airport
Tulsa International Airport (TUL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
Air Traffic Control Information: There were two controllers on duty at the time of the incident with one in the tower and one on break. All radar and tower positions were combined to the ground control/ clearance delivery position in the tower. This staffing was the normal mid-shift “TRACAB” configuration, with the controller in-charge position also combined and providing oversight at the time of the incident. During her interview, the tower controller said she categorized the traffic complexity and volume as being 1 on a scale of 1-5 (5 being high). In a recount of the events, she stated the incident flight had come in from the south, she confirmed they had the current ATIS, and were assigned runway 18L. She then assigned FedEx 1170 a northbound heading and at 6,000 feet, amended their altitude and pointed out the field 10 miles south of their position. The crew reported the field in sight, and she cleared them to land. She then diverted her attention from FedEx 1170 to provide taxi instructions to an unrelated aircraft being repositioned for maintenance. The tower controller said she conducted a visual sweep of the runway when she initially cleared FedEx 1170 for the approach and to land but admitted she did not look back at the aircraft again. The last time she observed the aircraft on the radar was when it was on a “dogleg” turn to base. FedEx 1170 landed, and the pilot advised they had landed on the wrong runway. Once the pilot reported their position, the tower controller provided taxi instructions from runway 18R. - Tulsa International Airport was located about 5 miles northeast of Tulsa, Oklahoma, with a field elevation of 677.5 ft above mean sea level (msl). The airport was owned by the City of Tulsa and was serviced by an FAA ATC tower that was in operation 24-hours a day. The ATC tower was in operation at the time of the incident. Approach radar services were provided by Tulsa Approach control. At the time of the incident, TUL, had three paved runway surfaces designated as 18L/36R, 18R/36L, and 8/26. The intended landing runway 18L was 10,000 ft long and 150 ft wide, with precision instrument markings. It had high-intensity edge lights, centerline lights, a 4-light PAPI on the left side of the runway, and medium intensity approach lighting system (MALSR) approach lights. The actual landing runway 18R was 6,101 ft long and 150 ft wide with precision instrument markings and a 600-foot displaced threshold. It had high-intensity edge lights, a 4-light PAPI located on the left side of the runway, and runway end identifier lights. Figure 2: Tulsa International Airport 10-9 Airport Diagram. (Source: Jeppesen) - The NTSB Vehicle Recorder Division received a Smiths Industries (P/N: 175497-01-01, S/N: 0000638) combination flight data and cockpit voice recorder. The recorder was in good condition and the data were extracted normally from the recorder. The flight data recording contained approximately 26.38 hours of data. The event flight was the last flight of the recording, and its duration was approximately 40 minutes. This model cockpit voice recorder records a minimum of 120 minutes of digital audio stored on solid state memory modules. Four channels are recorded: one channel for each flight crew member, one channel for a cockpit observer, and one channel for the cockpit area microphone. All four channels had good to excellent quality audio and a transcript was created of the audio associated with the entirety of the incident flight. - The incident flight crew began the day’s pairing in Ontario, California with a report time of 1850 Pacific daylight time (2050 Central daylight time (CDT)). Their first flight of the evening was from Ontario International Airport, Ontario, California to Fort Worth Alliance Airport (AFW), Fort Worth, Texas. The flight arrived at AFW about 0030 CDT. After postflight procedures each crewmember procured a crew rest room. According to the first officer, he was able to get about 30 minutes of rest prior to preparing for the next flight, which was the incident flight. The captain reported that he attempted to obtain rest, however, he “couldn’t get to sleep.” However, the captain added that he would not have flown fatigued, and he did not feel tired on the incident flight. The crew reconvened in the preflight briefing room, where they reviewed notices to air mission (NOTAMs) and the weather. Then, they proceeded to the airplane where they conducted preflight checks. About 0330, the flight pushed back from the parking position, taxied out to the runway, and departed AFW for the less than one-hour flight to TUL. The captain was the pilot flying and the first officer was the pilot monitoring. The flight climbed to an enroute altitude of flight level 310 at 0349 and began their descent 2 minutes later. The first officer stated that at the start of the descent, he obtained the current TUL weather and performance data for the landing. He then proceeded to set up the frequencies for the ILS. Additionally, they created a waypoint about 30 miles from the airport as they wanted to be at 11,000 feet (ft) at that waypoint. The captain briefed the anticipated visual approach, backed up by the ILS, and landing to runway 18L, which included the frequency for the ILS, the Vref speed of 123 knots, and the approach lights for runway 18L. He also briefed that they would not use the autobrakes, as he wanted to “roll long” as the parking location was at the south end of runway 18L. The flight was transferred from the Federal Aviation Administration (FAA) Air Route Traffic Control Center to the FAA TUL approach controller about 10,000 ft and were issued a heading of 360°, which routed the flight west of the airport. According to the flight crew, the flight was in instrument meteorological conditions at the time. The flight was given a further descent and then exited the base of the clouds. The first officer reported that when the flight exited the clouds, he could not see the runway but did visually acquire the TUL airport beacon and said it “looked like a normal downwind.” The captain reported that after exiting the clouds he could see the lights for runway 8/26 and that they were “normal.” The flight crew extended the centerline for runway 18L in their flight management system, which displayed the extended centerline on their ND in the cockpit. Additionally, the first officer verified that the frequency for the ILS 18L was correct and, when the captain requested, extended the flaps to one. The approach controller asked, and the crew verified that they had the airport in sight. The flight was cleared for the visual approach to runway 18L and cleared to land runway 18L. The captain commanded the autopilot to start the turn to the right and the first officer set 2,400 ft into the altitude preselector, the altitude for the final approach fix as published on the ILS 18L approach chart. During the turn to final about 0410, the captain stated they disengaged the autopilot, extended the flaps to 5, and subsequently configured the airplane for landing which included extending flaps to 30, lowering the landing gear, and conducting the before landing checklist. According to the FO, while on final approach, the aircraft appeared low visually and he brought that to the captain’s attention. He further explained that the glideslope appeared to be “normal” however, the PAPI lights indicated they were below the runway’s glidepath. Additionally, he stated that the deviation bar on his HSI was deflected to the left; however, during the incident flight he did not bring that to the captain’s awareness. The captain adjusted the descent rate of the airplane to place the airplane on the visual glideslope as indicated by the PAPI. About a 2.8 mile final and about 800 feet above ground level, the RAAS callout “Approaching 18R” was recorded on the CVR, however this occurred simultaneously with communications in the cockpit and neither crew member acknowledged or recalled this call out. The captain stated that initially the HUD was showing “slightly off to the left.” However, he transitioned visually to what the PAPI lights were indicating for his vertical alignment with the runway and was more focused on that. The flight touched down about 0413 on runway 18R and the RAAS subsequently announced there was 3,000 ft of runway remaining. The captain stated during a post incident interview, that he applied the brakes and “came on them harder initially because he was confused.” After slowing the airplane, the captain asked the FO “are we on the correct runway?” and then stated, “we landed on the right [hand] runway.” After informing the controller that they had landed on runway 18R, the controller provided taxi instructions to the ramp. - FedEx’s 757 Aircraft Systems Manual, “Warning Systems” provided, in part, the following information on RAAS: “RAAS is a software enhancement hosted within the EGPWS unit to provide aural advisories to assist flight crew awareness of airplane position during ground operations, approach to landing, and go-around. The airports in the RAAS airport database include details for every runway on the airport. The following RAAS characteristics must be considered: · RAAS voice annunciations are based upon RAAS database runway details NOT the runway intended or planned. · The voice annunciations do NOT take into account airplane performance factors such as airplane weight, wind, runway condition, slope, air temperature, or airport altitude. · Voice annunciations do not ensure that a runway is inappropriate for takeoff or landing nor does the absence of voice annunciations ensure that a runway is appropriate for takeoff or landing. o Advisories do not ensure that the aircraft will land on the identified runway nor imply that the aircraft can or cannot be safely landed, stopped, or taken off, from a runway. They also do not ensure that the aircraft will, or can be, stopped before hold lines, the runway edges or the runway end. o The absence of advisories does not necessarily imply that the aircraft is approaching a surface other than a runway. · Flight crew is responsible to use other means available to ensure correct runway selection and the performance calculations are accurate for the conditions. · The design of RAAS does not include knowledge of ATC clearance or flight crew intent, and therefore factors such as clearance misunderstandings, incorrect or inappropriate clearances cannot necessarily be mitigated by use of RAAS. Figure 5: Voice annunciations during approach, landing, go-around, and rejected takeoff (RTO) on RAAS airports. (Source: FedEx) · The following four routine advisories are intended to enhance aircraft position awareness and reduce the risk of a runway incursion: o Approaching Runway (on ground) o On Runway (on ground) o Approaching Runway (in air) o Distance Remaining (landing and rollout advisory) …” FedEx Fatigue Risk Management Program (FRMP): According to the FedEx flight operations manager, their FRMP was focused on predictive, proactive, and reactive risk modeling and it was done in collaboration with ALPA. FedEx fatigue software used the Karolinska Sleepiness Scale on a 1-9 scaled rating. ALPA used both the KSS and the PVT to calculate a SAFTE-FAST score and the resulting scores were compared. Potential pairings were reviewed at least 6 weeks prior to schedule. A KSS score of 7 or higher typically indicated the pairing needed further review and was a high risk. When a high risk KSS pairing was noted, it was discussed by the Fatigue Event Review Committee which then worked with scheduling to resolve the issue with the pairing. The incident flight score was a KSS of 6.39, PVT of 9, and SAFTI-FAST of 76.0%, and these scores incorporated the assumption that the crew would nap during their hub-turns. FedEx did not publish KSS pairing scores and they did not provide the scores or the napping assumption associated with the pairings to the crew. Crews were provided accommodations at many of their hubs. Rooms were temperature and light controlled, and a wake-up call was provided on request. If a crew member felt he or she was too fatigued to proceed with a flight, he or she could make a call to the duty officer who would take one of three mitigative paths: 1) that leg of the pairing would slip to allow the opportunity for more rest; 2) another crew member could be dispatched to take the flight instead; or 3) the flight would be cancelled. If a crew member called in fatigued, it resulted in a mandatory fatigue report and a forfeiture of sick leave hours. A review would be conducted to determine if the crew member’s lost hours would be returned to his or her sick bank. The FRMP manager said that they averaged 35-40 fatigue calls a month. The FRMP was kept on file for two years, was approved by the FAA, and went through an internal auditing process routinely. The interim human factors and training manager at FedEx provided an overview of the company’s fatigue training. Crew members received a training manual that included a section dedicated to fatigue. The section discussed conditions that produce fatigue, the effects of fatigue, identified how fatigue might manifest, and provided mitigation techniques for combatting fatigue. The course used a combination of power point, case study and a training manual to facilitate training. Crew members received fatigue training at their new-hire indoctrination, at alternating 18- and 36-month training cycles, and during upgrade training. The FedEx flight operations manager stated that the biomathematical software used to assess trip pairings assumed that a 30-minute nap was to be taken in hub-turns lasting 2 ½ hours or more. This assumption was not conveyed to flight crews. - The incident flight crew consisted of a captain and first officer. Both crewmembers stated that this pairing was the first time they had flown with each other. Captain: The captain was 57-years-old and held an Airline Transport Pilot (ATP) certificate with a rating for airplane single-engine land and multiengine-land, and type ratings on the A310, B-707, B-720, B-757, B-767 which included limitations of B-757, B-767, A-310 Circling approach – visual meteorological conditions (VMC) Only, and English Proficient. He held an FAA first-class medical certificate dated January 27, 2022, with limitation of must wear corrective lenses. At the time of the incident, he was based at Memphis International Airport (MEM), Memphis, Tennessee. The captain held over 10,000 hours of total flight experience, 790 of which were as a captain in the B757. During the interview with the captain, he stated that he had flown into TUL “at least a hundred times” and the most recent was about two weeks prior to the incident. The captain’s account of his sleep in the 72 hours preceding the incident starts the evening of June 5, therefore it is unknown at what time he awoke that morning. He obtained approximately seven hours of sleep, followed by a six-hour period of wakefulness, a two-hour nap, another six-hour period of wakefulness, and a final four-and-a-half-hour period of rest prior to the 0225 crew show on June 7. Following that flight, he slept for approximately five hours. The captain did not have another period of rest before the incident flight. He was awake for approximately 15 hours and 30 minutes prior to the incident occurring. First Officer: The FO was 50-years-old and held an ATP certificate with a rating for multi-engine land, single-engine land, rotorcraft-helicopter, instrument helicopter, instrument powered-lift, powered-lift, and type ratings in the A-320, B-757, B-767, with limitations of English Proficient and A-320, B-757, B-767 Circling approach – visual meteorological conditions (VMC) Only . He held an FAA first-class medical certificate dated May 24, 2022, with no medical restrictions. At the time of the incident, he was based at MEM. The FO held about 4,500 hours of total flight time, 739 of which was as a first officer in the B757. The first officer stated during his interview that it was his second time operating into TUL since his employment began with FedEx 2 years earlier. The FO’s account of his sleep in the 72 hours preceding the incident starts the evening of June 5, therefore it is unknown at what time he awoke that morning. The longest period of rest was the evening of June 5 to the morning of June 6 where the FO recorded approximately nine hours of sleep. This was followed by a period of wakefulness for approximately 12 hours. A four-hour nap followed and was prior to the 0225 crew show time on June 7. After that flight, the FO recorded another seven hours of sleep, interrupted by a lunch break. The next crew show time was approximately three hours later. Following that flight, the FO took a short, ½ hour nap before the last crew show at 0226 for the incident flight. He was awake for approximately 12 hours since his last prolonged period of rest, and three hours since his nap, prior to the incident occurring. - Operational Factors/Human Performance Group Simulator Evaluation: The Operational Factors/Human Performance group conducted a simulator evaluation in one of the operator’s B757 simulators. During the evaluation, the simulator was placed on a right downwind leg west of the airport for an approach to runway 18R and 18L. The simulator navigation was programed in accordance with the operator’s policies and procedures provided for an ILS to runway 18L. During the visual approach to runway 18R the PFD (figure 3) and HUD (figure 4), indicated that the aircraft was to the right of course and below the glideslope. Figure 3. Simulator PFD as viewed approaching runway 18R. (yellow labels added for clarity) Several approaches were made to runway 18R and 18L. In these approaches the RAAS annunciated approaching the runway the airplane was aligned with, irrespective of the ILS frequency that was selected. One item that was noted during the approach to runway 18R was the Enhanced Ground Proximity Warning System (EGPWS) “glideslope” audible warning was annunciated approximately 13 times. The crew interviews and CVR did not indicate these warnings annunciated on the incident flight. On approaches to 18R the flight mode annunciator indicated the glideslope was captured but the localizer (LOC) was still illuminated in the armed (white) mode indicating it had not captured. Figure 4 shows the HUD display from the operator’s panel in a FedEx B-757 simulator. The depiction was consistent with that shown on the captain’s HUD in the simulator. The image in figure 4 was taken while the simulator was in right turn from base to final for runway 18R. The identifier IDWE located in the lower left side of the display is associated with the identifier for the runway 18L localizer. The course deviation indicator for the localizer is on the left side of the horizontal situation indicator at the bottom of the display. The course deviation indicator and offset between the flight path indicator and command indicator show that the target runway is further to the left than the aircraft’s actual path. Figure 4. HUD display from the operator’s panel in the FedEx B-757 simulator. (blue labels added for clarity) -
Analysis
As the Federal Express (FedEx) flight 1170 flight crew approached the Tulsa International Airport (TUL), they mis-identified runway 18R as runway 18L and continued their approach and landing on runway 18R. After touchdown and hearing the “3000 feet remaining” call from the automated runway awareness and advisory system (RAAS), the captain recognized they had landed on the incorrect runway, applied heavy braking and was able to exit the runway at the final taxiway. Figure 1. Final approach screenshot illustrating flight alignment with runway 18R. Available Cues As the flight was in visual meteorological conditions, there were available visual cues external to the airplane, to distinguish the runways from one another in their lighting, configurations, and the surrounding environments. These differences were all salient visual cues that should have enabled the flight crew to distinguish one runway from the other in visual meteorological conditions. The flight deck provided both pilots with a primary flight display (PFD) and navigation display (ND), while only the captain had a heads up display (HUD) to aid in monitoring the progress of the flight. The first officer (FO) told investigators that the electronic glideslope on the PFDs and HUD which was set for 18L looked “normal” however he was concerned about their alignment with the visual glideslope (18R precision approach path indicator (PAPI)). The FO failed to realize that ultimately the airplane was showing “low” on the visual glideslope because of the parallel runways’ displaced thresholds. Cognitive Phenomena The flightdeck visual cues that were perceived by the flight crew were 1) the horizontal situation indicator (HSI) deviation bar being off to the left on the FO’s PFD; and 2) the captain’s HUD localizer being off to the left. It was FedEx policy to back up all approaches with the instrument landing system (ILS), however the flight crew appeared to discount the information their instruments were providing in favor of the view they had of the runway and understanding of their circumstances. The flight crew focused on their flightpath and decent rate for the runway they had already visually acquired, and the multiple visual cues that they were misaligned were not recognized. Once they took manual control of the airplane and adjusted to the desired precision approach path, the flight crew proceeded with the landing without engaging in further confirming acts. This behavior is consistent with the psychological phenomenon of plan continuation bias which is the unwillingness to deviate from a previously determined course of action, despite the arrival of circumstances precipitating the need for a change. Once a plan is committed to, it becomes increasingly difficult for stimuli or changing conditions to be recognized. Plan continuation bias is exacerbated by fatigue. In this incident, the flight crew was working within the window of circadian low and under circadian disruption. While the captain, who was the pilot flying, stated that he was not fatigued during the incident flight, he had been awake for more than 15 hours prior to the incident occurring and was likely experiencing fatigue due to chronic and acute sleep debt due to limited sleep in the days preceding the incident. The flight crews lack of recognition of their error was likely affected by fatigue, plan continuation bias, and their inability to perceive and efficiently integrate available information. Operator Fatigue Risk Management When creating flight schedules FedEx determines the potential risk for fatigue for each pairing by using the Karolinska Sleepiness Scale (KSS) on a 1-9 scaled rating. In evaluating the pairings FedEx also collaborates with the Airline Pilots Association (ALPA) who uses SAFTE-FAST which incorporates both the KSS and the Psychomotor Vigilance Test (PVT) on a scale of 1-100% (100% being peak wakefulness). The resulting scores are then compared. A KSS score of 7 or higher, or a SAFTE-FAST score of 70% or lower, typically indicated the pairing was of high risk and needed further review. The FedEx assessment of the incident flight pairing was a KSS of 6.39 and the score was established using the assumption that the flight crew would nap during their hub-turns. The ALPA assessment of the pairing was a 76.0% SAFTE-FAST score which also incorporates the nap assumption. FedEx did not publish KSS pairing scores, nor did they provide the scores (including the 30-minute nap assumption) to the flight crew. FedEx crews were expected to nap on a hub turn but were not told that a nap is expected or why that expectation exists. When asked why they adopted this policy, FedEx fatigue risk management program (FRMP) manager expressed concern over overburdening flight crews with additional information. The manager stated that FedEx feels that notifying flight crews of the pairing fatigue score, and what assumptions are factored into the obtaining of that score, is unnecessary and that FedEx’s current training program effectively addresses flight crew expectations and what fatigue mitigations are available. In this incident, the captain chose to abandon his nap attempt during the hub turn when he was unable to fall asleep. After about 30 minutes he decided to prepare for the next phase of his schedule. In failing to obtain a nap during the hub-turn, the captain unwittingly increased his fatigue score from within limits to high risk (7.4) on the KSS. Air Traffic Control (ATC) ATC awareness of the traffic approaching the airport provides an additional barrier to trap and correct errors, such as aircraft misalignment during landing. The tower controller’s failure to monitor the flight throughout the duration of its progress resulted in a missed opportunity to notify the crew and correct the misalignment before landing. Expectation bias occurs when a person hears or sees something or behaves in a way based on what he or she expects rather than what is actually occurring. Past experience or repetition can exacerbate this issue. In this incident, the controller had a reasonable expectation that the flight — a late night/early morning operation recurrent to TUL — would approach and land on the assigned runway. Consequently, she directed her attention away from the flight to other tasks. Because she was not monitoring the flight, she was unable to confirm its alignment on the correct runway nor was she able to provide corrective action to prevent the wrong surface event.
Probable cause
The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight after issuing a landing clearance.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
757-236
Amateur built
false
Engines
2 Turbo fan
Registration number
N949FD
Operator
Federal Express Corporation
Flight conducted under
Part 121: Air carrier
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
25060
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-07-11T20:53:34Z guid: 105216 uri: 105216 title: CEN22LA250 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105266/pdf description:
Unique identifier
105266
NTSB case number
CEN22LA250
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-08T12:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-06-16T01:32:16.815Z
Event type
Incident
Location
Evansville, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 8, 2022, about 1100 central daylight time, a Beech 58 airplane, N78KL, sustained minor damage when it was involved in an incident near Evansville, Indiana. The pilot and four passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that no anomalies were noted during the preflight inspection of the airplane. The airplane departed from Kirk Field Airport (PGR), Paragould, Arkansas, with a destination of James M. Cox Dayton International Airport (DAY), Dayton, Ohio. When the airplane was about 1 hour into the flight, while at an altitude of about 9,000 ft mean sea level and an airspeed of about 180 knots, the pilot heard a “boom” noise. The airframe began vibrating, and the airplane yawed to the left. The pilot contacted approach control and reported that he needed to land the airplane immediately. The pilot was directed to divert to Evansville Regional Airport (EVV), Evansville, Indiana. The pilot then reduced the power on the right engine and maneuvered the airplane for landing on runway 18 at EVV. The pilot was able to land the airplane without incident. After the pilot exited the airplane, he noticed that one of the aluminum propeller blades on the left engine had separated about mid-span. The separated blade segment was not recovered. No other damage was observed on the propeller, engine, or airframe. The airplane had two Hartzell Propeller model HC-C4YF-2E/FC7063Q propellers that each had four blades. The propellers were installed on the airplane via Federal Aviation Administration (FAA) Supplemental Type Certificate SA1762SO on November 12, 2002. The fractured blade was manufactured on September 6, 2000. Airplane registration records indicate that the airplane was sold on May 13, 2021. The airplane’s previous 100-hour inspection, completed before the airplane was sold, occurred on December 17, 2020, when the propeller had accumulated 1,097 hours of time since overhaul (TSO). The most recent 100hour inspection of the propeller occurred on January 10, 2022, when the propeller had accumulated 1,172 hours of TSO. The propeller had accumulated 1,200 hours of TSO at the time of the incident. The fractured blade (design number FC7063Q and serial number J51843) was removed from its hub and was provided to the National Transportation Safety Board Materials Laboratory for further examination. The examination of the fracture surface revealed signatures consistent with high-cycle fatigue failure. The blade fractured was about 16.9 inches from the blade butt. The deice boot was severed at the fracture and was partially debonded on both the camber and face sides. The fatigue origin area was coincident with an area of damage that was covered with a thick black paint that had a slightly different composition than the thinner layer of black paint on the rest of the blade. No evidence indicated any repair in the area of the damage. The pilot reported that he was not aware of any paint work performed on the blades or any previous propeller blade impacts. The mechanic who performed the most recent 100-hour inspection reported that he performed a visual examination of the blades and recalled that only normal damage was observed on the blades, such as small nicks, which he dressed. He did not remember if he did any paint work on the blades. FAA Advisory Circular 20-37E, Aircraft Propeller Maintenance, discusses propeller blade failures and states in part the following: A propeller is one of the most highly stressed components on an aircraft. During normal operation, 10 to 25 tons of centrifugal force pull the blades from the hub while the blades are bending and flexing due to thrust and torque loads and engine, aerodynamic and gyroscopic vibratory loads. A properly maintained propeller is designed to perform normally under these loads, but when propeller components are damaged by corrosion, stone nicks, ground strikes, etc., an additional unintended stress concentration is imposed, and the design margin of safety may not be adequate. The result is excessive stress and the propeller may fail. Additional causes of overstress conditions are exposure to overspeed conditions, other object strikes, unauthorized alterations, engine problems, worn engine vibration dampers, lightning strike, etc. Most mechanical damage takes the form of sharp-edged nicks and scratches created by the displacement of material from the blade surface and corrosion that forms pits and other defects in the blade surface. This small-scale damage tends to concentrate stress in the affected area and eventually, these high-stress areas may develop cracks. As a crack propagates, the stress becomes increasingly concentrated, increasing the crack growth rate. The growing crack may result in blade failure. Many types of damage cause propellers to fail or become unairworthy. FAA data on propeller failures indicates that the majority of failures occur in the blade at the tip region, usually within several inches from the tip and often due to a crack initiator such as a pit, nick, or gouge. However, a blade failure can occur along any portion of a blade, including the mid-blade, shank, and hub, particularly when nicks, scratches, corrosion, and cracks are present. Therefore, during propeller inspection and routine maintenance, it is important to inspect the entire blade. FAA Special Airworthiness Bulletin NE-08-22, Propeller Search Inspection (General Visual Inspection), discusses cosmetic repairs and states in part the following: For exposed aluminum surfaces, an exposed defect can be inspected while a hidden defect cannot be inspected. A cosmetic repair that creates a hidden defect in an exposed surface is an unacceptable practice. -
Analysis
The airplane was about 1 hour into the cross-country flight when the pilot heard a “boom” noise. The airframe began vibrating, and the airplane yawed to the left. The pilot contacted approach control and stated that he needed to land the airplane immediately. The pilot was directed to divert, and he landed the airplane without incident. After exiting the airplane, the pilot noticed that one of the aluminum propeller blades on the left engine had separated about midspan, resulting in minor damage. The “boom” that the pilot heard was likely the blade separating in flight. Examination of the fracture surface revealed signatures consistent with high-cycle fatigue failure. The fatigue origin area was coincident with an area of damage that was covered with a thick black paint. The paint had a slightly different composition than the thinner layer of black paint on the rest of the blade. No evidence indicated any repair in the area of the damage and investigators were unable to determine when the damage was painted. Although the investigation could not determine, based on the available evidence for this incident, when the damage that led to the fracture occurred, or when the damage was painted, it is likely the damaged area was present at the airplane’s most recent 100-hour inspection, which occurred 28 hours before the incident. The presence of the black paint could have made it difficult to detect the damage during the mechanic’s visual inspection of the blade surface during the airplane’s most recent 100-hour inspection. Had the damage been detected during the 100-hr inspection it should have triggered maintenance of the propeller blade. The damage was also hidden but detectable during the preflight inspection conducted by the pilot before the accident flight. Had the damage been detected by the pilot, it should have triggered further examination and maintenance of the propeller blade.
Probable cause
The failure of the propeller blade due to high-cycle fatigue that originated from damage that occurred at an unknown time. Contributing to the accident was the failure to identify the damage before the accident flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
58
Amateur built
false
Engines
2 Reciprocating
Registration number
N78KL
Operator
NEA INDUSTRIAL LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TH-1578
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2022-06-16T01:32:16Z guid: 105266 uri: 105266 title: ANC22LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105232/pdf description:
Unique identifier
105232
NTSB case number
ANC22LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-08T12:34:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-06-10T01:57:06.142Z
Event type
Accident
Location
Kodiak, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 8, 2022, about 1134 Alaska daylight time, a Cessna U206F, N592KB, was substantially damaged when it was involved in an accident 65 miles west-northwest of Kodiak, Alaska. The pilot and four passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 air tour flight. According to the pilot, the airplane that he was flying was the fourth company airplane to land at a remote beach site, known as Hallo Bay, as part of a bear viewing flight. The pilot set up for a landing on the same tracks as the three preceding company airplanes. During the landing, the left main landing gear wheel touched down first, followed by the right main landing gear wheel. When the right wheel touched down, the pilot heard a “pop” sound and the airplane veered to the right. The airplane slowly came to rest upright about 150 ft from the initial touchdown location (see figure 1). The pilot reported that small leaves and seaweed debris were present in the landing area and that no large debris was noted. Figure 1. Accident airplane in its resting location (Source: K Bay Air). Postaccident examination of the airplane revealed substantial damage to the left wing and right horizontal stabilizer. The right main landing gear leg was fractured near the wheel attachment fitting and displayed fatigue signatures (see figure 2.). Figure 2. Fractured right main landing gear leg (Source: K Bay Air). A review of the airplane’s records revealed that, in July 2019, the main landing gear legs were removed and repaired per the manufacturer’s service manual. Between the time of repair and the accident, the main landing gear legs accumulated about 875 hours and about 200 beach/off-airport landings. Metallurgical examination of the fractured landing gear leg by the National Transportation Safety Board’s Materials Laboratory found that the gear leg, which was composed of hardened alloy steel, had fractured through the cross-section, perpendicular to the longitudinal direction. River patterns on the fracture surface emanated from an area consistent with the start of the fracture sequence. A closer view of the area revealed several thumbnail-shaped cracks with a large, vertically orientated ratchet mark on the fracture surface. The cracks exhibited crack arrest marks, consistent with crack propagation, and ratchet marks, consistent with multiple crack initiation sites. The end of the largest thumbnail crack on the fracture surface exhibited fatigue striations, consistent with fatigue crack propagation. The rest of the fracture surface exhibited dimpled rupture, consistent with overstress fracture. The crack initiation sites contained iron oxides with elements typical of salt and marine environments. The fatigue crack initiation site near the larger ratchet mark contained a corrosion pit. These features indicated that the gear leg fractured due to the stress concentration of fatigue cracks that had propagated inward from the lower surface of the leg. The fatigue cracks initiated from corrosion pits in an area of the leg without paint and primer. -
Analysis
The airplane was the fourth air tour company airplane to land at a remote beach site as part of a bear viewing flight. The pilot set up for a landing on the same tracks as the three previous company airplanes. During the landing, the left main landing gear wheel touched down first, followed by the right main landing gear wheel. When the right wheel touched down, the pilot heard a “pop” sound and the airplane veered to the right. The airplane slowly came to rest upright and sustained substantial damage to the left wing and right horizontal stabilizer. Postaccident examination revealed that the right main landing gear leg was fractured near the wheel attachment fitting. Materials laboratory examination of the right main landing gear leg revealed that the gear leg fractured during landing due to fatigue cracks that initiated from localized corrosion pitting. The area of the fatigue cracks which was absent paint and primer, contained many elements typical of salt corrosion in a marine environment. Repeated abrasive wear from landings on rough terrain or runway asphalt had likely removed the protective coatings in the area of the fatigue cracks.
Probable cause
The failure of the right main landing gear leg due to fatigue cracks that initiated from corrosion pitting.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
U206F
Amateur built
false
Engines
1 Reciprocating
Registration number
N592KB
Operator
K Bay Air LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Aerial observation
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
true
Serial number
U20601770
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-10T01:57:06Z guid: 105232 uri: 105232 title: ANC22FA041 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105233/pdf description:
Unique identifier
105233
NTSB case number
ANC22FA041
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-08T18:26:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-06-10T03:13:58.067Z
Event type
Accident
Location
Kalea, Hawaii
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 3 minor
Factual narrative
Postaccident Actions On December 1, 2022, based on the findings of this investigation, the NTSB issued four urgent safety recommendations (two each to the Federal Aviation Administration [FAA] and Transport Canada [TC]). These recommendations (A-22-28 through -31) asked both regulators to require operators of Bell 407 helicopters to conduct 1) an immediate torque check of the tail boom attachment hardware and visual inspection of the tail boom attachment fittings for evidence of cracks and fractures and to report findings to the respective regulator and 2) subsequent torque checks and visual inspections at an interval significantly less than the currently required 300-hour interval until the causal factors that led to the separation of the upper-left attachment hardware (this accident) could be determined. On December 8, 2022, Bell issued Alert Service Bulletin (ASB) 407-22-128 for a one-time torque check and inspection of the tail boom attachment hardware and fittings as well as reporting (to Bell) the findings from these actions. Subsequently, TCCA issued Airworthiness Directive (AD) CF-2022-68 on December 15, 2022, effective December 29, 2022, and the FAA issued AD 2022-27-08 on December 28, 2022, effective January 12, 2023. Both ADs required accomplishment of the Bell ASB though with compliance times that did not ensure immediate action as recommended (as of the publishing of this report, A-22-28 to the FAA is classified Closed—Unacceptable Action and A-22-30 to TC is classified Open—Unacceptable Response). Neither AD required any further action subsequent to the one-time inspection, which was not responsive to the NTSB’s recommendation for recurring checks and inspections (as of the publishing of this report, A-22-29 to the FAA and A-22-31 to TC are classified Open—Unacceptable Response). On March 28, 2023, Bell provided the NTSB, FAA, and TCCA with a summary of the reported responses to the aforementioned actions. The Bell 407 worldwide fleet, inclusive of all series, was estimated at 1,546 helicopters. As of March 10, 2023, Bell had received a total of 554 responses, 14 of which reported anomalous findings. According to Bell, none of the anomalous findings involved a fractured bolt or a gross loss of torque, but several failed the torque check near their required torque value. Of the reported anomalous findings for attachment hardware torque, two were at the upper-left location, none were at the upper-right location, nine were at the lower-left location, and four were at the lower-right location. Of the total results of the reported movement of the fasteners, none were characterized as significantly below installation torque. For structural damage found on the attachment fittings, there was one report each for the upper-left and upper-right locations. On January 12, 2024, TCCA informed the NTSB of an additional occurrence of a fractured upper-left tail boom attachment bolt that was discovered during a 300-hour torque check. For further information, reference NTSB investigation ENG23LA045. - Airframe Structure Description The helicopter fuselage was composed of three primary structural assemblies: the forward fuselage, the intermediate fuselage, and the tail boom. The intermediate fuselage begins at the rear of the passenger compartment and extends to the front of the tail boom. The aft portion of the intermediate fuselage is referred to as the aft fuselage. Four aft fuselage longerons—upper-left, upper-right, lower-left, and lower-right—are attached to the aft fuselage bulkhead. The tail boom is installed to the intermediate fuselage with fasteners (bolts, washers, and nuts) to connect the four aft fuselage longerons to four corresponding longerons located at the forward end of the tail boom. According to Bell, the tail rotor thrust produces tension loads on the two left attachment points and compression loads on the two right attachment points. The weight of the tail boom as well as aerodynamic forces from the horizontal stabilizer applies tension loads on the two upper attachment points and compression loads on the two lower attachment points. As a result, the upper-left tail boom attachment point has the highest tension loading of the four attachment points. The lower-left attachment point carries the next highest load, followed by the upper-right and the lower-right attachment points. Helicopter Maintenance Records A review of the accident helicopter’s maintenance records revealed that the most recent 300-hour torque check of the tail boom attachment fasteners was completed on May 4, 2022, at a total airframe time of 22,891.4 flight hours. On June 6, 2022, 2 days before the accident, the helicopter had a total airframe time of 23,005.6 flight hours (114.2 flight hours since the torque check), 30,490 total flight cycles, and no additional maintenance had been conducted to the attachment fasteners since the torque check. The tail boom (part number [P/N] 407-030-801-205D and serial number BP-1598) was installed on August 23, 2009, at a total airframe time of 5,780.0 hours. The tail boom was last removed and reinstalled on July 3, 2014, to facilitate longeron and frame repairs. According to the work order, a repair station assisted the operator accomplishing Bell TB 407-12-96 Revision A (Rev A). The subject of TB 407-12-96 Rev A was the installation of a redesigned aft fuselage upper-left longeron assembly. TB 407-07-78, dated September 19, 2007, introduced an improved machined aft fuselage bulkhead, P/N 407-030-027-101. This was the P/N of the bulkhead installed on the accident helicopter. A later bulletin, TB 407-07-78 Rev A, issued In August 2020, introduced a new aft fuselage bulkhead that had a reinforced inside flange in the upper left area. The helicopter record list contained no entries regarding TBs 407-07-78 and 407-12-96. Bell Technical Bulletins for the Aft Fuselage Bell TBs 407-07-78 and 407-12-96 Rev A utilize an aluminum drill plate, manufactured locally in accordance with instructions provided in both TBs, to verify the location and planar alignment between the four tail boom attachment fittings and their bolt holes. Within TB 407-12-96 Rev A, before the final installation of the upper-left longeron and aft fuselage bulkhead to the aft fuselage, Step 23, a note recommends installation of the new improved machined aft fuselage bulkhead per TB 407-07-78. Additionally, this note states it is acceptable to reinstall the existing sheet metal aft fuselage bulkhead. Bell TB 407-07-78 provides instructions in three parts for the installation of the new improved machined aft fuselage bulkhead. Part I contains instructions for the removal of the aft fuselage bulkhead and positional verification of the longeron fittings. Part II contains instructions for the installation of the bulkhead using existing pilot holes on the bulkhead and is considered the preferred method of installation. Part III contains instructions for drilling new pilot holes in the bulkhead (the existing pilot holes are not used). Part III is considered the alternate method for installing the bulkhead. A note within TB 407-07-78, before Step 10, which accomplishes the final ream for the upper-left bolt hole, states not to drill the upper left upper longeron/fitting hole at this point if the aft fuselage bulkhead installation is accomplished in conjunction with the installation of a replacement upper-left longeron per TBs 407-12-96 or 407-17-125. According to TB 407-07-78, the new aft fuselage bulkhead is initially secured to the four longeron fittings and the drill plate via four 3/16-inch diameter bolts that are torqued to 50 inch-pounds. At the four bolt hole locations, bushings are used to fill the gap between the 3/16-inch diameter bolt and the larger diameter bolt holes of the longeron fittings and the drill plate. According to TB 407-12-96 Rev A, after removal of the existing longeron and a first-fit installation of the new upper-left longeron, the drill plate is temporarily secured to the upper-right, lower-left, and lower-right longeron fittings using the existing fasteners and torqued to 50 inch-pounds. The new upper-left longeron, whose fitting has a 3/16-inch diameter pilot hole, is secured to the drill plate using a 3/16-inch diameter bolt. Unlike TB 407-07-78, TB 407-12-96 does not specify instructions to use bushings for the installation of the 3/16-inch diameter bolt to secure the upper-left longeron to the drill plate. After securing the new upper-left longeron to the drill plate, the instruction states to verify that no gap exists between the longeron assembly and the drill plate and/or the spacer. A note preceding this step states that it is acceptable to hold the new upper-left longeron to the drill plate using a C-clamp until it is completely riveted to the fuselage. The last step in Part I of TB 407-07-78 is to verify the four longeron fittings are in plane within 0.002 inches. A drill plate is attached to the four longeron fittings using the existing hardware that is torqued to 50 inch-pounds. The TB instructs that a gap check should be conducted between the drill plate and the aft face of each longeron fitting. If a gap is more than 0.002 inches on only one longeron fitting, the affected longeron must be replaced before the installation of the new aft fuselage bulkhead. If a gap is more than 0.002 inches on more than one longeron fitting, the affected longerons must be replaced, which requires installing the helicopter on a Bell-approved fuselage fixture. According to TB 407-12-96 Rev A, before the installation of rivets for the upper-left longeron and aft fuselage bulkhead, sealant should be applied to these items. Specifically Step 23 of TB 407-12-96 Rev A, states the following: Apply a coat of sealant (C-251) to faying surfaces of longeron assembly (2), aft fuselage bulkhead (6), the splices joining affected bulkhead sections and if needed the shims made in Step 20 before installing in place with drill plate (8). Secure longeron assembly (2) and bulkhead (6) with applicable rivets wet with sealant (C-251). Do not install rivets common to oil cooler fairing retainers (1, 2, Figure 2), the side skin panel (16, Figure 7) and the top skin (1, Figure 6) at this time, but secure any applicable shims made earlier with clecos. According to Bell, if TB 407-07-78 is to be accomplished in conjunction with TB 407-12-96, then the aft fuselage bulkhead would be installed immediately before Step 23 of TB 407-12-96. Additionally, according to Bell the engineering drawing for the aft fuselage bulkhead installation does not require sealant between the contact surfaces of the aft fuselage bulkhead and the upper-left longeron. In TB 407-07-78, both Parts II and III contain instructions to apply sealant to the faying surfaces of the shim and aft fuselage bulkhead. - On June 8, 2022, about 1726 Hawaii-Aleutian standard time, a Bell 407 helicopter, N402SH, sustained substantial damage when it was involved in an accident near Kalea, Hawaii. The pilot and two passengers sustained serious injuries, and three passengers sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 on-demand air tour flight. According to the operator, Paradise Helicopters, about 1701, the helicopter departed the company base at Ellison Onizuka Kona International Airport at Keahole (PHKO), Kona, Hawaii, to the south for an air tour flight around the island. Automatic dependent surveillance-broadcast and company flight track data showed the helicopter traveled southeast toward an area known as South Point. The pilot stated that the first part of the flight was normal. About 35 minutes into the flight, at an altitude of 1,500 ft agl and an airspeed of 130 knots, the helicopter experienced a violent upset, followed by an uncontrolled spin (yaw) to the right. A passenger, seated in the aft-left forward-facing seat, reported that as the helicopter continued to spin she observed something fall off the helicopter; however, she was not able to identify the specific part. The pilot communicated two mayday calls and attempted to recover helicopter control as it continued to spin uncontrollably and rapidly descend. The helicopter subsequently impacted a lava field and came to rest on its left side (see figure 1). After the impact, about 1728, a passenger placed an emergency call to report that the helicopter had crashed. Simultaneously, the US Coast Guard Honolulu Joint Rescue Coordination Center received an emergency locator transmitter alert and initiated search and rescue operations. Figure 1. Main wreckage in a lava field. - As a result of the accident, the operator elected to replace the tail boom attachment hardware on their remaining five Bell 407 helicopters as a precautionary measure. The operator performed a torque check of all installed attachment hardware and reported no evidence of anomalous torque values or damage of the attachment hardware after their removal. In addition, the operator performed an eddy-current nondestructive inspection on the aft fuselage longerons as another precautionary measure. The inspections found crack indications on two helicopters. On one helicopter, the crack indications were identified on the aft faying surface of the lower-left longeron at the bolt hole and within the bolt hole of the upper-left longeron. On the other helicopter, the crack indications were identified on the outboard surface of the outboard longitudinal channel of the upper-right longeron, on the inboard surface of the outboard longitudinal channel of the upper-left longeron, and on the lower surface of the outboard longitudinal channel of the upper-left longeron. According to Bell, there was one reported previous occurrence of a fractured tail boom attachment bolt. Metallography of the fractured bolt found multiple-origin fatigue cracking through about 2/3 of the fracture cross-section, with the remainder of the fracture cross-section in overload. The location of the fracture on the bolt was estimated to be co-located with the aft face of the aft fuselage bulkhead. The fractured bolt was found during a 300-hour recurring torque check. The Bell Field Investigations Lab report that documented the fractured attachment bolt stated that the operator observed a gap between the aft fuselage bulkhead and the upper-left longeron as well as misalignment of the upper-left longeron bolt hole and a work aid to locate the aft fuselage longeron bolt holes. Since the bolt had been installed, four 300-hour recurring torque checks were performed, with the upper-left bolt found fractured during the fourth check; about 297 flight hours had elapsed since the last torque check. Based on information provided by the operator, the upper-left longeron was replaced about 1,163 flight hours and 24 months before the detection of the fractured upper-left attachment bolt. According to Bell, there was one reported occurrence of fatigue cracking of the aft fuselage lower-left longeron (on the radius that is adjacent to the bolt hole). The operator provided the Bell Field Investigations Lab with the lower-left longeron for examination. The fatigue crack was found on the forward face of the lower-left longeron attachment fitting (opposite the face that contacts the aft fuselage bulkhead). Metallography of the lower-left longeron found the fatigue origin was located at a corrosion pit within the lower-left longeron transition radius to the attachment bolt fitting. Other corrosion pits were found near the origin location. According to the Field Investigations Lab report, the occurrence helicopter had an airframe total time of 5,310 hours at the time the crack was discovered. - A National Transportation Safety Board (NTSB) examination of the accident site revealed the tail boom came to rest about 762 ft northeast of the main wreckage, which consisted of the fuselage, engine, and main rotor system. The tail boom separated from the aft fuselage at the tail boom attach point (see figures 2 and 3). The upper-left attachment fitting fastener was not present and the lower-left attachment fitting was fractured and displayed fatigue signatures. The fasteners for the lower-left, lower-right, and upper-right attachment fittings were present. Figure 2. Tail boom at accident site with the four attachment fittings annotated. Figure 3. Aft fuselage at the accident site with the four longeron locations annotated. Postaccident examination of the helicopter’s rotor system, flight control system, and engine revealed no malfunctions or failures that would have occurred before the tail boom separation. Portions of the tail boom structure, aft fuselage structure, attachment fittings and fasteners were retained for further examination by the NTSB’s Materials Laboratory. Disassembly of the Fractured Fittings Significant deformation was observed throughout the tail boom-to-aft fuselage attachment structure. Examination of the upper-right, lower-left, and lower-right attachment hardware assemblies found their installation consistent with the requirements of the Bell 407 maintenance manual. Additionally, there was no evidence of corrosion preventative compound (CPC) on the exposed threads. Measurement of the attachment hardware torque found the upper-right and lower-right assemblies was greater than the specified lower torque limit. The lower-right fitting was fractured adjacent to the attachment bolt; the fracture surfaces exhibited signatures of overload. Once the bolts were disassembled from their respective fittings, the washers, nuts, and shank portion of the bolts were inspected for evidence of CPC. The countersunk washer under the head portion of the bolts, shank portion of the bolts, washers adjacent to the nuts, and shank portion of each bolt were covered with CPC. Small amounts of CPC were transferred to the threads as the washers were removed from the bolts. The forward face of the fuselage frame in the area of the upper-left fitting contained a black paste-like deposit, consistent with CPC that was exposed to the environment and engine exhaust, whereas the areas that corresponded to the remaining fittings exhibited clean CPC. The aft face of the fuselage frame in the area of the upper-left fitting and the mating forward face of the tail boom bulkhead showed evidence of fretting. Evidence of sealant was noted on the faying surface between the aft fuselage bulkhead and upper-left longeron aft face. Upper-Left Fitting The upper-left fitting remained attached to the longeron on the upper fuselage structure and showed no evidence of a crack or fracture. Examination of the bolt hole revealed evidence of circumferential gouge and impression marks to include fretting, black and brown deposits consistent with iron oxide, and corrosion pits. The marks were more severe on one side of the hole, and the fretting and pitting corrosion was not uniform around the hole circumference. Lower-Left Fitting Examination of the lower-left fitting revealed the fracture face contained evidence of crack arrest marks typical of fatigue cracking that emanated from two separate areas, identified as O1 and O2 (see figure 4). Scanning electron microscope examination revealed that fatigue crack O1 emanated from multiple origins at the outer surface at an area that was located slightly forward of the inner transition radius of the diagonal wall member portion of the fitting. The fatigue origin contained no evidence of pitting corrosion. Fatigue propagation was down and through the wall then extended to the right of the fitting. The 1-inch fatigue crack contained alternating fatigue crack and overstress features. Figure 4. Fractured lower left fitting showing fatigue cracking indicated by brackets “O1” and “O2”. Fatigue crack O2 emanated from a corrosion pit at the outer surface in an area slightly forward of the inner transition radius near the upper right end of the fitting. The fatigue crack propagated through the wall and then extended down where it intersected the left edge of fatigue crack O1. The 0.75-inch fatigue crack region contained alternating fatigue crack and overstress features. The bolt hole showed evidence of severe spiral gouge marks and fine spiral scratches. The spiral gouge marks did not extend all around the bore. Upper-Right and Lower-Right Fittings The fracture faces of both the upper-right and lower-right fittings exhibited a rough texture on slanted planes consistent with overstress separation. The lower-right fitting showed evidence of severe spiral gouge marks and fine spiral scratches. The spiral gouge marks did not extend all around the bore. The upper-right fitting showed a circumferential gouge mark, fine circumferential scratches, and an isolated area of fretting. Fuselage Frame Bolt Holes The upper-left bolt hole contained circumferential gouge and impression marks. The marks were more severe on one side of the hole. The remaining bolt holes in the fuselage frame showed no evidence of circumferential gouge marks or impressions. The attachment bolts for the fittings were specified as NAS627 bolts. This specification indicated the hardness of a bolt was to be between 39 and 43 on the Rockwell C hardness scale (HRC). Rockwell hardness testing produced hardness values that were within the specified range for the upper-right and lower-left bolts; the hardness value for the lower-right bolt exceeded the upper limit by one hardness point (measuring 44 HRC). The material grade for the bolts complied with those specified by NAS627. The grip length and diameter of the bolts were within the specified ranges, and the washer inner and outer diameters were within specified range. -
Analysis
The pilot reported the first part of the air tour flight around the island was normal. About 35 minutes into the flight, during cruise flight at 1,500 ft above ground level (agl), the helicopter experienced a violent upset, followed by an uncontrolled spin to the right. The helicopter entered a rapid descent, its airspeed decreased, and it continued to spin uncontrollably. The pilot attempted to recover control of the helicopter, but it impacted a lava field and came to rest on its left side. Postaccident examination of the helicopter revealed the tail boom separated in flight. Further examination revealed there were no malfunctions or failures with the rotor systems, flight control systems, and engine before the tail boom separation. Examination of the tail boom revealed the upper-left tail boom attachment bolt was not present in the wreckage and was not found. Circumferential gouge and impression marks within the upper-left attachment bolt holes indicated the bolt was installed before the accident but that it had fractured and migrated out. After the bolt fractured, the structural load increased on the remaining three tail boom attachment points. As a result, multiple origin fatigue cracks, as well as fatigue cracking originating from a single corrosion pit, initiated on the lower-left attachment fitting. Once the fatigue cracks grew to a critical length, all three remaining attachment fittings failed in overload, resulting in the tail boom separation. The examined tail boom attachment fittings and attachment hardware met manufacturing requirements, which were not a factor in this accident. Due to the missing upper-left attachment hardware, the fracture mode and the duration of crack growth of the upper-left bolt could not be determined. The presence of sealant at the faying surface between the upper-left longeron and aft fuselage bulkhead indicated there was a small gap between those two structures. This gap was likely introduced during the replacement of the upper-left longeron and aft fuselage bulkhead, per manufacturer technical bulletins (TB), about 8,050 flight hours before the accident. The manufacturer reported a previous occurrence (on a different Bell 407) of a fractured upper-left attachment bolt that was attributed to abnormal loading of the bolt due to a gap and misalignment between the upper-left longeron and aft fuselage bulkhead. Similarly, the gap between the two structures on the accident helicopter likely applied abnormal loads on the upper-left attachment bolt that, over time, resulted in crack initiation on the bolt shank and the subsequent bolt failure. Due to structural deformation caused by the accident, it could not be determined if any axial misalignment was present between the upper-left longeron, the aft fuselage bulkhead, and the tail boom. A 300-hour recurring inspection, which included a torque check of the four tail boom attachment bolts and visual inspection of the fittings, occurred about 114 flight hours before the accident and resulted in no anomalous findings. It is unlikely the bolt had fractured or had a crack of sufficient size to fail during this last torque check. Therefore, it is likely the upper-left attachment point continued to carry load during the last 300-hour torque check and that the multiple-origin fatigue cracking on the lower-left attachment fitting had not yet initiated. However, it is possible that the fatigue crack had already initiated from the single corrosion pit on the lower-left attachment fitting at the time of the last 300-hour recurring inspection, but that it was too small to visually detect. In summary, examination of the wreckage revealed the accident occurred due to the in-flight separation of the tail boom during cruise flight, which resulted in the pilot’s inability to control the helicopter. The tail boom separated due to the abnormal loading and fracture of the upper-left longeron attachment hardware. The presence of a gap between the upper-left longeron and the aft fuselage bulkhead, introduced during the accomplishment of manufacturer technical bulletins, likely led to the hardware failure.
Probable cause
The in-flight separation of the tail boom as a result of abnormal loading and fracture of the upper-left tail boom attachment bolt due to a gap between the upper-left longeron and aft fuselage bulkhead.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N402SH
Operator
K&S HELICOPTERS INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Aerial observation
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
true
Serial number
53118
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-10T03:13:58Z guid: 105233 uri: 105233 title: WPR22LA217 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105290/pdf description:
Unique identifier
105290
NTSB case number
WPR22LA217
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-09T12:45:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-06-26T21:00:58.428Z
Event type
Accident
Location
McCall, Idaho
Airport
MC CALL MUNI (MYL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 9, 2022, about 1145 mountain daylights time, a Cub Crafters, CC19-215, N61KT, was substantially damaged when it was involved in an accident near McCall, Idaho. The pilot and flight instructor were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot of a tailwheel airplane reported that, while attending a backcountry flying course, he had completed several off-airport landings with a flight instructor before returning to McCall Municipal Airport (KMYL), McCall, Idaho. During the landing roll to runway 34, while applying brakes, the left brake “flopped” under his foot with no pressure and the airplane veered to the right. The pilot was unable to maintain control of the airplane and it traveled off the side of the runway and down an embankment, where the left wing and tail contacted the down-sloping terrain. The pilot was then able to taxi the airplane back to the ramp. Postaccident examination by a Federal Aviation Administration inspector revealed that the left brake line near the caliper was separated and the left wing and elevator were substantially damaged. The brake caliper and brake line components from the left main landing gear were sent to National Transportation Safety Board Materials Laboratory, Washington, DC, for examination. The brake line 45° fitting at the lower side of the caliper was fractured. Examination of the fracture surface revealed characteristics consistent with a ductile overstress fracture. Additionally, a sliding contact mark was observed on the lower surface of the caliper aft of the fitting. The surface within the contact mark was smeared and exhibited a deformation pattern consistent with contacting an object moving forward relative to the brake caliper. An additional contact mark was also observed on the aft side of the fitting adjacent to the sliding contact mark on the caliper. -
Analysis
The pilot reported that he was attending a backcountry flying course and had conducted several off-airport landings on various backcountry airstrips prior to returning to the destination airport. During the landing roll, the left brake “flopped” under his foot with no pressure and the airplane veered to the right. The airplane exited the right side of the runway and traveled down an embankment, where the left wing and tail contacted the down-sloping terrain. Examination of the brake caliper and brake line components revealed that the brake line fitting had fracture separated. A contact mark was observed on the brake caliper aft of the fitting. Metallurgical examination of the fracture surfaces on the brake line fitting revealed that it had fractured due to overstress. It is likely that, while operating on an unimproved surface, the brake line fitting struck an object that fractured the fitting. The loss of functionality in the left brake caused the loss of directional control during the subsequent landing.
Probable cause
A loss of directional control during the landing roll due to a fractured brake line fitting on the brake caliper.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUB CRAFTERS INC
Model
CC19-215
Amateur built
false
Engines
1 Reciprocating
Registration number
N61KT
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
CC19-0058
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-26T21:00:58Z guid: 105290 uri: 105290 title: CEN22FA240 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105236/pdf description:
Unique identifier
105236
NTSB case number
CEN22FA240
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-09T18:37:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-06-24T22:05:56.954Z
Event type
Accident
Location
Rifle, Colorado
Airport
RIFLE GARFIELD COUNTY (RIL)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The accident glider was a single-seat, mid-wing glider with an engine and propeller combination that could be retracted into the fuselage. The engine provided the glider with self-launch capability. The glider had a wingspan of 59 ft, and a gross weight of 1,320 lbs. The glider was registered to the pilot. The operating limitations for the glider listed a requirement that it undergo a condition inspection within the preceding 12 months. During the investigation, maintenance records for the glider were not available. - On June 9, 2022, at 1737 mountain daylight time, a HPH SPOL SRO Glasflugel 304MS powered glider, N249SD, was destroyed when it was involved in an accident at the Rifle Garfield County Airport (RIL), Rifle, Colorado. The pilot was fatally injured. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance – broadcast (ADS-B) flight tracking the flight originated about 1200 from RIL. The glider proceeded in a generally westward direction for about 160 miles before turning back eastward. At 1712, the glider was about 45 miles north of RIL at 14,300 ft mean sea level (msl), when it turned to the south toward RIL. At 1735, the glider was about 2 miles west of RIL at 7,600 ft msl when it began a left turn onto a downwind traffic pattern leg for runway 26. The published field elevation for RIL was 5,337 ft msl. When the glider was on the downwind leg, about abeam the midfield location, it began descending rapidly. The descent rate during the last 47 seconds of the flight was calculated to be more than 1,600 ft/min. The RIL airport was an uncontrolled airport and communications were conducted on a common traffic advisory frequency (CTAF). CTAF at RIL was recorded and copies of the communications were provided for the investigation. On the recording, the pilot of the accident glider reported “heavy sink going for left downwind two six”. There was no time index on the CTAF recording provided. A video surveillance recording from RIL captured the accident. The camera was positioned about 1,000 ft east and 400 ft north of the runway 26 approach threshold. The camera was positioned to capture the approach end of runway 26 with the center of the view oriented about 150 degrees magnetic. In the video, the glider can be seen descending in a left-wing-low attitude and striking the ground at time index 1737:49. During this portion of the flight, the glider appeared to travel in a northeasterly direction consistent with the ADS-B track data. About the time the glider descended, a dust cloud appeared in the background travelling in the same direction as the glider, consistent with a strong tailwind. The surveillance video provided showed virga forming in the clouds above the airport about 12 minutes after the accident. The 1753 surface weather observation at RIL recorded wind from 290° at 5 kts, gusting to 16 kts. The remarks section of the observation noted a peak wind from 190° at 43 kts, which occurred at 1739. Weather radar animations showed a dissipating rain shower cell move from west to east-southeast across the area along with areas of virga noted in the airport surveillance and Federal Aviation Administration (FAA) weather camera imagery. Airport surveillance and FAA weather surveillance video both showed blowing dust from 1735 to 1739 across the airport, indicative of strong winds. The upper air sounding for the area indicated the potential for surface wind speeds up to 67 knots due to a downdraft, outflow boundary, or gust front. The RIL terminal area forecast before departure did not indicate a chance of precipitation or rain showers for the accident site. However, by 1358 it was updated to include the potential for convective activity at RIL through 1800. It is unknown if the accident pilot had access to updated weather information during the accident flight. - On June 10, 2022, an autopsy was performed on behalf of the Garfield County Coroner’s Office, Silt, Colorado. The cause of death was listed as multiple blunt force injuries. Toxicology testing performed by the FAA Civil Aerospace Medical Institute was negative for substances in the screening profile. - The accident site was located on airport property about 1,000 ft and 140° from the approach end of runway 26. The distance and direction from the initial impact point to the main wreckage was about 170 ft and 10°, consistent with a left base leg for the airport traffic pattern. The forward fuselage exhibited extensive crushing damage. The tail surfaces were separated from the fuselage and located in the immediate vicinity of the main wreckage. The right wing was predominately intact with little damage except for separation of the outboard removable wing panel, which was found next to the wing. The left-wing root structure remained attached to the fuselage. The left wing was separated from the root section about 2 ft outboard of the fuselage and was found inverted next to the fuselage. The inboard structure exhibited delamination due to impact. The outboard removable panel was separated and found in the vicinity of the main wreckage. The horizontal tail was separated from the fin and broken about mid-span. The right elevator was still attached, and the left was separated and found in the vicinity of the main wreckage. The fuselage was broken at the leading edge of the vertical tail. The rudder was intact and still attached. Postaccident examination of the glider and its control system did not reveal any preimpact failures or malfunctions that would have precluded normal operation. -
Analysis
As the pilot maneuvered the glider in the airport traffic pattern, he radioed that he experienced a heavy sink rate. Shortly thereafter, the glider impacted the ground on airport property. Airport and weather surveillance cameras recorded blowing dust indicating gusting wind. Further meteorological reports supported the possibility of wind speeds up to 67 knots due to a downdraft, outflow boundary, or gust front. Airport surveillance video showed the glider descend in a left wing low, nose low attitude before it struck the ground. About the same time a dust cloud was seen on the video travelling the same direction as the glider, indicating a tailwind. Postaccident examination of the glider did not reveal any mechanical malfunctions or failures that would have precluded normal operation. The examination also revealed that the glider’s retractable engine was stowed within the aft fuselage and was not available to enhance the glider’s climb capability. The accident occurred at the end of a flight that exceeded 5 hours in duration, and it is unknown if the pilot had access to or had received updated weather information during the flight. The terminal area forecast before departure did not indicate a chance of precipitation or rain showers for the accident site. However, about 4 hours before the accident it was updated to include the potential for convective activity. Based on the available evidence, the glider entered an area with weather conditions that included downdrafts and wind gusts, that the pilot could not overcome before the glider impacted the ground.
Probable cause
The glider’s encounter with gusting tailwind and downdraft conditions that the pilot was unable to overcome.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
HPH SPOL SRO
Model
GLASFLUGEL 304 MS
Amateur built
false
Engines
1 Reciprocating
Registration number
N249SD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
110-MS
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-06-24T22:05:56Z guid: 105236 uri: 105236 title: ERA22LA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105240/pdf description:
Unique identifier
105240
NTSB case number
ERA22LA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-11T13:07:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-07-12T17:11:38.714Z
Event type
Accident
Location
Stockbridge, Georgia
Airport
BERRY HILL (7GA7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On June 11, 2022, at 1207 eastern daylight time, a Piper PA-23-180, N3477P, was substantially damaged when it was involved in an accident near Stockbridge, Georgia. The private pilot and pilot-rated passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated he had just purchased the airplane and that it had just undergone an annual inspection. The purpose of the accident flight was for the pilot and the airplane’s previous owner to fly to Covington, Georgia. According to the pilot he conducted a preflight inspection of the airplane and noted no anomalies. The pilot reported that fuel was drained from the main and cross feed fuel lines and was “clean with no water”. He also noted that the fuel was bluish in color similar to 100 low-lead aviation fuel. The pilot stated (and a review of fuel receipts confirmed) that he purchased 43 gallons of 100 low-lead aviation fuel before the flight. The fueler reported the fuel supply was tested twice with negative results for water contamination. After completing an engine run-up with no anomalies noted, the pilot stated he positioned the airplane as far back on the runway as possible, held the brakes, and applied full power. He stated that he “looked at the engine instruments and all were within the green and producing power,” so he released the brakes for takeoff. After takeoff, the airplane started to shake and yaw to the right, and the pilot believed that the right engine had lost power. The pilot applied left rudder to correct and noted the airspeed was below the placarded blue line airspeed (best rate of climb airspeed for single-engine operation), so he decreased the airplane’s pitch attitude to gain airspeed. He stated, “the airplane was a hand full,” and the pilot then told the pilot-rated passenger to take the controls. The pilot-rated passenger told the pilot to “feather the right engine” and the pilot reported seeing the propeller stop. The pilot-rated passenger then attempted to return to the airport. The airplane impacted trees, resulting in substantial damage to the fuselage, both wings, both horizontal stabilizers and elevators, and the vertical stabilizer and rudder. The pilot and pilot-rated passenger were seriously injured. A witness reported that upon arriving on scene he smelled a “chemical or fuel like odor in the air.” Postaccident examination of the airplane was performed under the oversight of a Federal Aviation Administration (FAA) inspector. The inspector reported that all the airplane’s fuel bladders were breached, absent of fuel, and subsequently were unable to be tested for contamination. The fuel selectors were both found positioned to their respective main fuel tank positions, and the cables that connected the selector levers to the selector valves could not be examined due to impact damage. A postaccident examination of the left engine found there was continuity of the engine crankshaft to the rear accessory drive gears and valvetrain when the crankshaft was rotated by hand. Compression and suction were observed from all four cylinders. No anomalies were noted on the interior of any of the cylinders when examined with a lighted borescope. The induction air box was partially crushed, and the exhaust system was examined with no obstructions noted. Both magnetos remained attached to the engine and produced a spark on all leads when the input drive was rotated by hand. The spark plugs electrodes exhibited normal wear and the No. 1 upper and Nos. 2 and 4 lower spark plugs were oil soaked. The carburetor remained attached to the oil sump and the fuel line from the engine-driven fuel pump to the carburetor was impact separated from the pump but remained attached to the carburetor. The throttle and mixture control cables remained attached to their respective control arms. The carburetor heat control cable was impact-separated from the air box control arm. No liquid was observed in the carburetor float bowl. The carburetor fuel inlet screen was absent of debris and no damage was observed to other carburetor internal parts. The engine-driven fuel pump was fractured across the drive section and the pumping section was impact separated. No anomalies were noted with the engine-driven fuel pump’s internal components. No liquid was observed in the fuel pump or in the corresponding fuel lines forward of the firewall. The oil suction screen and oil filter media were absent of any debris. Postaccident examination of the left propeller found the propeller remained attached to the engine crankshaft flange and the spinner was impact damaged. The propellers were arbitrarily labeled A and B for identification purposes. Propeller blade A was bent aft about 20° about 10 inches from the tip. Blade A’s tip exhibited impact damage and spanwise scratching. Blade B was bent aft about 45° and exhibited chordwise scratching and trailing edge damage. The propeller control cable remained attached to the governor control arm. The left propeller governor was removed, the drive spline rotated freely by hand, and the governor oil screen was absent of debris. Postaccident examination of the right engine found engine crankshaft continuity to the rear accessory drive gears and valvetrain when the crankshaft was rotated using the propeller. Compression and suction were observed on all cylinders when the crankshaft was rotated. The interiors of the cylinders were examined with a lighted borescope and no anomalies were noted. The induction air box was impact crushed and the exhaust system was removed with no obstructions noted. Both magnetos remained attached to the engine and the left magneto sparked from all leads when the input drive was rotated by hand. The right magneto did not spark from any lead when the input drive was rotated by hand. Oil was observed on the right magneto distributor block, in the ignition contact points compartment, on the ignition coil, and on the coil high tension contact. The spark plugs exhibited normal wear and the Nos. 2 and 4 upper spark plugs were oil soaked. The carburetor remained attached to the engine oil sump. The aluminum fuel line from the engine-driven fuel pump to the carburetor fuel inlet fitting was impact separated from the pump but remained attached to the carburetor. The throttle control cable remained attached to the throttle control arm. The mixture control cable was impact separated from the carburetor mixture control arm. The carburetor heat control cable was impact separated from the air box control arm. No liquid was observed in the carburetor float bowl and the carburetor fuel inlet screen was absent of any debris. Heavy wear was observed to the rubber tip of the needle in the needle seat assembly. No other damage was observed to the other internal carburetor parts. The engine-driven fuel pump was fractured across the drive section and the pumping section was impact separated. No damage was observed to the pumping section’s rubber diaphragms or check valves. No liquid was observed in either the pump or the corresponding fuel lines forward of the firewall. The oil suction screen and oil filter media were absent of any debris. Postaccident examination of the right propeller found the propeller remained attached to the engine crankshaft flange and the spinner was impact damaged. The propellers were arbitrarily labeled A and B for identification purposes. No damage was noted to propeller blade A. Propeller blade B exhibited trailing edge damage. The propeller control cable remained attached to the governor control arm. The right propeller governor was removed, the drive spline rotated freely by hand, and the governor oil screen was absent of debris. At 1026, the weather reported at Hartsfield – Jackson Atlanta International Airport (ATL), Atlanta, Georgia, which was located about 15 nautical miles northwest of the accident site, included a temperature of 29°C and a dew point 17°C. The calculated relative humidity at this temperature and dewpoint was 48 percent. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." -
Analysis
The pilot had recently purchased the twin-engine airplane, and before the accident flight had completed a preflight inspection, which included sampling fuel from both main fuel tanks and cross feed lines. He started both engines and noted no anomalies during the run-up. During the initial climb the airplane started to yaw to the right and shake. He subsequently transferred control of the airplane to the pilot-rated passenger, who was the previous owner of the airplane. The pilot-rated passenger told the pilot to secure the right engine, which he did. The pilot-rated passenger then attempted to return to the airport but the airplane struck trees, resulting in substantial damage to the fuselage, both wings, the tail, and serious injuries to both occupants. Postaccident examination of both engines found no evidence of a preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane’s fuel tanks were breached during the accident sequence, and the quantity and condition of the fuel onboard the airplane could not be confirmed. The pilot reported obtaining fuel before the flight, and a witness reported smelling a fuel-like odor when he arrived at the accident site immediately after the accident. The fueler reported that the fuel supply had been tested twice with negative results for water contamination. While the temperature and dewpoint at the time of the accident were favorable for the formation of carburetor ice at glide [idle] engine power settings, given that the airplane was taking off when the loss of engine power to one engine occurred, it is not likely that carburetor icing played a role in the loss of engine power. Based on available information, the reason for the total loss of engine power for the right engine could not be determined.
Probable cause
A total loss of right engine power during initial climb for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-23
Amateur built
false
Engines
2 Reciprocating
Registration number
N3477P
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
23-1451
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-12T17:11:38Z guid: 105240 uri: 105240 title: ERA22LA270 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105270/pdf description:
Unique identifier
105270
NTSB case number
ERA22LA270
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-11T16:00:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-07-20T17:15:18.405Z
Event type
Accident
Location
Middleboro, Massachusetts
Airport
Fisher's Field (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 11, 2022, about 1500 eastern daylight time, an experimental amateur-built A Plane, N51324, was substantially damaged when it was involved in an accident near Middleboro, Massachusetts. The private pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot stated that earlier that day he drained each wing fuel tank, added 6 gallons of fuel/oil equally divided into each wing fuel tank, and checked the vented fuel caps. He departed on an uneventful 15-minute flight and, after landing, added the remaining 2 gallons of fuel/oil. As part of his preflight check he did not find any water in the fuel tanks or from the lowest part of the fuel system, and reported a normal rpm drop during the check of the dual ignition system as part of his run-up. Prior to departure he performed a full-throttle pass on the runway with no discrepancies noted. He then taxied back to the departure end of the runway where he initiated the takeoff, noting that the engine rpm was at 6,300. After becoming airborne and at the start of a left turn, the engine began to “die out,” which he described as the engine rpm dropping to 4,000, increasing to 5,000, then decreasing to 3,000 before the engine completely lost power. At that time the airplane was 50 ft above the treetops. He glided but when the flight was 20 ft above the treetops the airplane dropped consistent with a stall/mush and descended into a tree. The airplane descended to the ground in a near-vertical, nose-low attitude that resulted in substantial damage to the right wing. He shut off the fuel before getting out of the airplane. Following recovery of the airplane, a sample of fuel taken from one of the fuel tanks contained drops of water, and the carburetor bowl was empty. There were no obstructions of the fuel supply system from each wing fuel tank to the fuel shut-off valve, which was installed about 1 ft from the in-line fuel filter. After installing a different propeller, the pilot plumbed a temporary fuel supply into the fuel filter inlet. Using the same fuel that was in the airplane’s fuel tanks at the time of the accident, the engine was started and ran using the manifold-driven pneumatic fuel pump to between 4,000 and 4,500 rpm (safety concerns prevented full-throttle application). Although a check of the dual ignition system was not performed during the postaccident engine run, the pilot reported no discrepancies. The temperature and dewpoint 8 minutes before the accident at an airport about 6 nm east-northeast from the accident site were 75°F and 50°F, respectively. A review of Federal Aviation Administration Special Airworthiness Information Bulletin (SAIB) CE-09-35, Carburetor Ice Prevention, revealed the environmental conditions about the time of the accident were favorable for serious icing at glide power. -
Analysis
The pilot was departing for a local flight after a successful engine run-up when the accident occurred. He reported that while starting a left turn the engine rpm fluctuated before the engine lost all power. While flying slightly above the trees, the airplane stall/mushed and descended into the trees, coming to rest in a nose-low attitude. Examination of the fuel supply system and postaccident operational testing of the engine using the same fuel as the time of the accident revealed no evidence of preimpact failure or malfunction. Although the airplane was operated at a low power setting shortly before takeoff in environmental conditions that were favorable for serious icing at glide power, the engine was developing near full power during the subsequent takeoff. The empty carburetor bowl found during the postaccident examination likely occurred because of fuel leakage after coming to rest. The reason for the reported loss of engine power could not be determined based on the available evidence.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BURRILL STEVEN E
Model
A PLANE
Amateur built
true
Engines
1 Reciprocating
Registration number
N51324
Operator
BURRILL STEVEN E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4101
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-20T17:15:18Z guid: 105270 uri: 105270 title: ERA22LA313 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105479/pdf description:
Unique identifier
105479
NTSB case number
ERA22LA313
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-11T16:40:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-08-09T17:13:55.805Z
Event type
Accident
Location
Indian Trail, North Carolina
Airport
GOOSE CREEK (28A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 11, 2022, at 1540 eastern daylight time, an experimental amateur-built Twinstarr gyroplane, N298RW, was substantially damaged when it was involved in an accident near Indian Trail, North Carolina. The private pilot received minor injuries. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the gyroplane belonged to a friend who had recently purchased it. As the gyroplane’s new owner did not have any experience in a gyroplane, the pilot was going to “check over the machine and possibly do a short test flight to insure everything was functional and safe,” before the owner began training in the gyroplane. The pilot reported running the engine multiple times on the ground and completing multiple taxi tests to check the brakes and steering mechanism. The pilot was satisfied that everything appeared functional, and the gyroplane was safe to attempt a flight. He planned to take off, climb to traffic pattern altitude, fly a traffic pattern, and land. The pilot reported (and a video of the takeoff taken by a witness confirmed) that shortly after takeoff the engine sustained a total loss of engine power. The pilot attempted to return to the airport but was unsuccessful. The gyroplane struck powerlines and subsequently impacted the ground, resulting in substantial damage to the fuselage, tail section, and main rotor. The pilot reported that before the flight he had added 5 gallons of fuel for a total amount of fuel onboard of 10 gallons. He reported that the fuel pump was “running,” and the magnetos were in the on position when the loss of power occurred. Three days after the accident the pilot returned to the wreckage to check the fuel system and found a large piece of debris blocking a majority of the fuel filter inlet (see figure). Another larger piece of debris that was similar in color and texture was found in the fuel tank underneath the fuel quantity sending unit. Photographs showed that the large piece of debris in the fuel tank and the piece of debris found in the fuel filter inlet appeared consistent with silicone sealant residue found on the fuel quantity sending unit. Figure. Photograph from the pilot of foreign debris blocking a majority of the fuel filter inlet. -
Analysis
The pilot was taking the gyroplane on a short test flight. After adding fuel, the pilot ran the engine multiple times on the ground and completed multiple taxi tests to check the brakes and steering mechanism. The pilot was satisfied that everything was functional and decided to attempt a flight in the airport traffic pattern. Shortly after takeoff the engine lost power. The pilot attempted to return to the airport, but the gyroplane impacted powerlines and the ground, resulting in substantial damage. During a postaccident examination of the wreckage, the pilot found that there was a large piece of debris obstructing a majority of the fuel filter inlet. Another large piece of debris was observed in the fuel tank. All the debris found were consistent in color and texture with silicone sealant used on the fuel quantity sending unit. Based on this information, it is likely that the sealant debris found in the fuel filter inlet obstructed the flow of fuel to the engine and resulted in the total loss of engine power.
Probable cause
A blockage of the fuel filter inlet by a piece of debris, which resulted in fuel starvation and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
Whittridge
Model
Twinstarr
Amateur built
true
Engines
1 Reciprocating
Registration number
N298RW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TS97015
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-09T17:13:55Z guid: 105479 uri: 105479 title: ERA22LA267 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105254/pdf description:
Unique identifier
105254
NTSB case number
ERA22LA267
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-13T18:15:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2023-01-19T05:35:02.183Z
Event type
Accident
Location
Bluffton, Ohio
Airport
BLUFFTON (5G7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
On the day of the accident, the student pilot performed four takeoffs and landings with his flight instructor before he was cleared by the instructor for his second solo traffic pattern flight. The student pilot reported that upon touching down on the third solo landing the airplane was blown across the runway by a sudden crosswind, and he decided to abort the landing. The student pilot described that after applying full power and beginning to climb the airplane encountered an aerodynamic stall. Airport surveillance video confirmed that during the climb, the airplane was in a nose high pitch attitude and at relatively slow ground speed before it descended to the ground in a left turn. The airplane impacted a field to the left of the runway resulting in substantial damage to the fuselage, both wings and the vertical stabilizer. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s loss of control during climb after an aborted landing, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N78755
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17257747
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-19T05:35:02Z guid: 105254 uri: 105254 title: DCA22FM024 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105268/pdf description:
Unique identifier
105268
NTSB case number
DCA22FM024
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-06-15T04:00:00Z
Publication date
2023-09-07T04:00:00Z
Report type
Final
Last updated
2023-08-24T04:00:00Z
Event type
Accident
Location
Freshwater Bayou, Louisiana
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the capsizing and sinking of the crane barge Ambition was the barge owner’s lack of hull inspection and maintenance, and not conducting permanent repairs, which resulted in the failure of the hull and subsequent flooding. Contributing was likely downflooding through an open deck hatch due to the tow operator’s failure to ensure adherence to its procedures for barge watertight integrity before getting underway, despite being aware of deficiencies with the watertight integrity of the barge.
Has safety recommendations
false

Vehicle 1

Vessel name
Ambition
Vessel type
Towing/Barge
Port of registry
Lake Charles, LA
Flag state
USA
Findings

Vehicle 2

Callsign
WDF7145
Vessel name
Karen Koby
Vessel type
Towing/Barge
Maritime Mobile Service Identity
367481540
Port of registry
Cut Off, LA
Classification society
ABS
Flag state
USA
Findings

Vehicle 3

Vessel name
GD962 (Port Barge)
Vessel type
Towing/Barge
Port of registry
Caruthersville, MO
Flag state
USA
Findings

Vehicle 4

Vessel name
GD983 (Starboard Barge)
Vessel type
Towing/Barge
Port of registry
Caruthersville, MO
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-08-24T04:00:00Z guid: 105268 uri: 105268 title: HWY22FH012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105968/pdf description:
Unique identifier
105968
NTSB case number
HWY22FH012
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T00:58:00Z
Publication date
2023-12-19T05:00:00Z
Report type
Final
Event type
Occurrence
Location
Indianapolis, Indiana
Injuries
null fatal, null serious, null minor
Probable cause
The PC was not determined for this case.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2015 Complete Coach Works Zero Emission Propulsion System (CCW–ZEPS), battery-electric-powered transit bus
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2023-12-19T05:00:00Z guid: 105968 uri: 105968 title: CEN22LA252 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105271/pdf description:
Unique identifier
105271
NTSB case number
CEN22LA252
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T09:30:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2022-06-21T18:13:54.445Z
Event type
Accident
Location
Weslaco, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 16, 2022, about 0830 central daylight time, a Meyers 200A airplane, N489C, was substantially damaged when it was involved in an accident near Mid Valley Airport (TXW), Weslaco, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he intended to complete a cross-country flight to Florida and had about 65 gallons of fuel onboard before departure. After departing from TXW, he entered the left traffic pattern to overfly the runway before proceeding to the northeast. While on the downwind leg, the engine sustained a total loss of power and the propeller continued to windmill. As he turned toward the airport, he extended the airplane’s landing gear because he believed the airplane would reach the runway. However, the additional drag of the extended landing gear increased the airplane’s descent rate and the airplane descended into an area of trees short of the runway. The airplane collided with trees and came to rest vertically with the tail resting on a tree (Figure 1). Witnesses converged on the accident site and assisted the pilot’s egress from the airplane. Figure 1. Accident airplane nose down in a field and against a tree (Courtesy of Texas DPS). Postaccident examination of the airplane revealed substantial damage to the engine mounts, forward fuselage, and both wings. The header fuel tank contained fuel. The gascolator had very little fuel and did not reveal signs of damage to the unit or the nearby structure. The gascolator butterfly valve did not appear to have any damage or evidence of dislocation from impact. There was still fuel in all the fuel tanks except the left inboard main tank, which was breached during the accident and was the only noticeable damage to the airframe fuel system. The fuel selector valve worked as designed and with no obstructions noted when air was blown through each tank selection. The fuel lines appeared new and were free of any restrictions. Fuel was observed in the fuel lines connected to the auxiliary fuel pump. The fuel lines were impact separated at the firewall due to the accident sequence. The induction air box and associated air filter were in place and not obstructed. The engine was mostly separated from the firewall mounts and the propeller separated from the engine. All oil and fuel lines were intact and secured. The crankcase and cylinders were intact with minimal damage. All engine accessories remained intact and attached at their respective mounts. The magnetos, ignition wires, and spark plugs operated as designed and produced spark when tested as an assembly. The crankshaft rotated without anomalies via the propeller flange. Suction and compression were obtained from each cylinder. All fuel lines to the engine-driven fuel pump, fuel servo, fuel manifold, and fuel injectors were intact and secure. The fuel servo screen was clear. The fuel servo’s throttle plate moved when the throttle arm was actuated from stop-to-stop and all control linkages were intact and secure. The mixture arm moved from stop-to-stop. The fuel manifold was undamaged and in place with no debris or anomalies noted. All fuel injectors were free of obstructions. The oil filter was intact. The oil filter element was free of metallic debris and contaminants and the oil color appeared normal. The examination did not reveal any preaccident mechanical malfunction or anomalies that would have precluded normal operation. -
Analysis
The pilot reported that he intended to complete a cross-country flight and the airplane had about 65 gallons of fuel onboard. After takeoff, he entered the left traffic pattern to overfly the runway before departing the area. While on the downwind leg, the engine sustained a total loss of power and the propeller continued to windmill. As he turned toward the airport, he extended the airplane’s landing gear because he believed the airplane would reach the runway. However, the additional drag of the extended landing gear increased the airplane’s descent rate and the airplane descended into an area of trees short of the runway. The airplane collided with trees and came to rest vertically with the tail resting on a tree. The engine mounts, forward fuselage, and both wings were substantially damaged during the accident. Postaccident examination of the airplane revealed that there was adequate fuel available, and no mechanical malfunctions or anomalies with the airframe or engine that would have precluded normal operation were identified. The reason for the loss of engine power could not be determined based on available information.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MEYERS INDUSTRIES INC
Model
200A
Amateur built
false
Engines
1 Reciprocating
Registration number
N489C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
254
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-21T18:13:54Z guid: 105271 uri: 105271 title: CEN22LA256 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105284/pdf description:
Unique identifier
105284
NTSB case number
CEN22LA256
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T10:15:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-06-21T19:39:31.802Z
Event type
Accident
Location
Madison, Mississippi
Airport
Bruce Campbell Field Airport (MBO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 16, 2022, about 0915 central daylight time, a Bellanca 17-30A, N39880, was substantially damaged when it was involved in an accident at Bruce Campbell Field Airport (MBO), Madison, Mississippi. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. After departing from MBO, the pilot noticed smoke in the cabin and returned to land. While taxiing, the smoke worsened, and the pilot stopped the airplane and shut down the engine. The pilot and passenger egressed and observed a fire on the right side of the engine compartment. The passenger used a fire extinguisher but was not able to stop the fire. The fire department arrived and extinguished the fire. The airplane sustained substantial damage to the forward fuselage. Postaccident examination revealed the right-side exhaust system was fractured between the muffler and tailpipe. The muffler and tailpipe assemblies were sent to the National Transportation Safety Board Materials Laboratory, which determined that the aft ball tube (part of the muffler assembly) had separated from the muffler body and remained attached to the tailpipe. The outer surface of the ball tube exhibited rubbing in the regions where it lapped the tailpipe clamping assembly and the muffler. The forward end of the ball tube was found to have cut back material in one region and raised up material in another region, with both regions exhibiting rubbing features. The features on the ball tube were consistent with failure of a repair weld. Areas of the ball tube had a gray and/or red appearance, which was consistent of an oxide film that formed from repeated exposure to hot exhaust gases. In 2007, Alexandria Aircraft, the holder of the Bellanca 17-30A type certificate, issued a service letter, B-110, regarding inspection of the 17-30A exhaust system (which also applied to other Bellanca models). Subsequently, the Federal Aviation Administration (FAA) issued an AD 2008-05-11, which made the service letter a mandatory requirement. The service letter requires the inspection of the weld joints of the muffler for cracks. The first inspection is within 25 hours, with recurring inspections every 50 hours. If/when a crack is found, the owner has three options for remediation: 1) Replace the muffler and tailpipe assemblies with new, redesigned parts. 2) Send the muffler and tailpipe assemblies to Bellanca/AALLC FAA Repair Station BNXR512X for reconditioning, which results in a functionally similar part as the new, redesigned parts. 3) “Recondition or repair the defective left and/or right muffler and tailpipe assembly(ies) to their original configuration using FAA approved methods and materials. See FAA Advisory Circular 43.13-1: Acceptable Methods, Techniques and Practices – Aircraft Inspection and Repair.” A maintenance record of the weld repair was not available to the investigation. Maintenance records show that AD-2008-05-11 was complied with at the last annual inspection dated May 20, 2022, at an aircraft total time of 2543.5 hours. According to the owner, the accident occurred about 10 flight hours following the annual inspection. The mechanic who performed the last annual inspection stated that he hadn’t noticed anything that “stuck out” with the exhaust system. He was familiar with the accident and remarked that it was very difficult to view the location where the fracture occurred. He reported he didn’t used a borescope to assist viewing internal welds and was not familiar with the service letter requirement to spray the outside of the muffler with a penetrating oil to assist with identifying cracks. The Alexandria Aircraft Service Letter B-110 inspection includes the following procedure: Spray the outside of the muffler at the riser and ball joint attachment welds with a penetrating oil. If there is a crack around the riser or the ball joint the penetrating oil will quickly move thru crack and a wet spot will appear inside the muffler. -
Analysis
The pilot noticed smoke in the cockpit while on departure. He returned to land and when the smoke worsened during taxi, he stopped the airplane and shut down the engine. The pilot and passenger egressed the airplane and observed a fire in the engine compartment. They were not able to put out the fire with a fire extinguisher. The airplane sustained substantial damage to the forward fuselage. Postaccident examination revealed the right-side exhaust system was fractured between the muffler and tailpipe. The investigation determined that a crack in the weld joining the aft ball tube to the aft muffler flange had previously failed, and a weld repair had been performed. Metallurgical examination determined that the repair weld had failed, allowing hot exhaust gases to escape onto the surrounding engine compartment components. Maintenance records show the Airworthiness Directive (AD) calling for the repair weld to be inspected was complied with during the last annual inspection, just under a month and about 10 flight hours before the accident. The mechanic that completed the inspection was not aware of the AD requirement to spray the outside of the muffler with a penetrating oil to check for cracks, which most likely would have identified the muffler weld issue prior to the failure.
Probable cause
The failure of a muffler weld due to inadequate maintenance, which resulted in a fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
17-30A
Amateur built
false
Engines
1 Reciprocating
Registration number
N39880
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
73-30551
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-21T19:39:31Z guid: 105284 uri: 105284 title: WPR22LA219 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105292/pdf description:
Unique identifier
105292
NTSB case number
WPR22LA219
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T12:28:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-06-22T00:47:39.593Z
Event type
Accident
Location
Davis, California
Airport
UNIVERSITY (EDU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 16, 2022, about 1128 Pacific daylights time, a Cessna, TR182, N756EG, was destroyed when it was involved in an accident near Davis, California. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that after conducting an uneventful engine run-up, he taxied to runway 17 at the University Airport, Davis (EDU), California, for departure. During the takeoff climb, at an altitude of about 100 ft above ground level (agl), he observed smoke coming from the instrument panel. As the airplane reached an altitude of about 200 ft agl, flames were emitting from the pilot’s rudder pedal area, followed by a partial loss of engine power. The airplane had enough altitude to clear the trees near the departure end of the runway and the pilot made a forced landing in a tomato field. During the landing rollout, the airplane nosed over and came to rest inverted. Review of the on-scene photographs provided by the Federal Aviation Administration showed that the airplane had sustained impact damage and had been destroyed by the inflight and postaccident fires. The National Transportation Safety Board conducted a subsequent examination that revealed that the firewall along with the engine, engine mount, and nose landing gear had separated as one unit from the fuselage structure. The engine accessory case had sustained thermal damage; the initiating source of the fire could not be determined due to the amount of thermal damage. -
Analysis
According to the pilot, he conducted an uneventful engine run-up and taxi to the runway for departure. During the initial takeoff climb he observed smoke emanating from the instrument panel, followed by flames radiating from the rudder pedal area and followed by a partial loss of engine power. The airplane had enough altitude to clear the trees near the departure end of the runway; the pilot then made a forced landing on a tomato field. During the landing rollout, the airplane nosed over and came to rest inverted. The fire subsequently destroyed the airplane. The thermal damage to the engine’s accessories case and firewall suggests that the fire originated near the rear of the engine. However, destruction of the airframe precluded determination of the reason for the in-flight fire.
Probable cause
An in-flight fire during the initial takeoff climb for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
TR182
Amateur built
false
Engines
1 Reciprocating
Registration number
N756EG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
R18201049
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-06-22T00:47:39Z guid: 105292 uri: 105292 title: CEN22LA253 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105272/pdf description:
Unique identifier
105272
NTSB case number
CEN22LA253
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T15:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-06-24T22:17:30.625Z
Event type
Accident
Location
Austin, Texas
Airport
AUSTIN-BERGSTROM INTL (AUS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 16, 2022, about 1400 central daylight time, a Cessna T206H, N52854, was substantially damaged when it was involved in an accident near Austin, Texas. The pilot was seriously injured. The airplane was operated as a public use flight. The pilot reported that the accident flight was the first flight following a 100-hour maintenance inspection. The pilot departed from the Austin-Bergstrom International Airport (AUS), Austin, Texas, and shortly after takeoff reported to air traffic control that there was smoke in the cockpit and he wanted to return to AUS. Shortly thereafter, the smoke increased, and the pilot was not able to see his instrument panel. He attempted to increase engine power and discovered that the engine had stopped producing power. After opening the airplane’s side windows, he could see a body of water below him and ditched the airplane into Lady Bird Lake, near Austin. Postaccident examination revealed that the V-band exhaust coupling securing the turbocharger exhaust fractured. The General Aviation Joint Steering Committee issued a “Best Practices Guide for Maintaining Exhaust System Turbocharger to Tailpipe v-band Couplings / Clamps”, which recommended life limits for the various styles of clamps including a 500-hour life limit on spot welded v-band couplings such as the failed coupling from the accident airplane. Figure 1. Photo of failed V-band exhaust coupling. The Federal Aviation Administration issued a Special Airworthiness Information Bulletin (SAIB), CE-18-07, on December 14, 2017, which described several accidents that resulted from v-band clamp failures. The SAIB recommended detailed inspections of v-band exhaust couplings be performed at 100-hour intervals. It also identified areas of concern and locations on the v-band exhaust couplings for focused inspection. In April 2018, the General Aviation Joint Steering Committee issued a “Best Practices Guide for Maintaining Exhaust System Turbocharger to Tailpipe V-band Couplings / Clamps”, which went into further detail concerning the various designs of exhaust system couplings, and inspection of those couplings. The guide also recommended life limits for the various styles of clamps including a 500-hour life limit on spot welded v-band couplings such as the failed coupling from the accident airplane. According to maintenance records, the airplane’s most recent annual inspection was completed on December 13, 2021, and indicated that an exhaust system inspection was included in the inspection process. A 100-hour inspection was completed on June 15, 2022, and indicated that an exhaust system inspection had been performed. Neither entry specifically noted inspection of the v-band exhaust couplings and the investigation was unable to determine if a specific inspection of the v-band clamp was accomplished. The total time in service of the clamp was not determined. -
Analysis
The pilot reported that shortly after takeoff he experienced smoke in the cockpit. The pilot reported to air traffic control that he wanted to return to the airport; however, the amount of smoke continued to increase and the engine stopped producing power. The pilot opened the side windows and located a lake below him into which he ditched the airplane. Postaccident examination revealed that the v-band clamp securing the turbocharger exhaust fractured and allowed hot exhaust gas to blow over the accessory section of the engine. The hot exhaust gases caused damage to several components, resulting in a fire and total loss of engine power. The Federal Aviation Administration issued a Special Airworthiness Information Bulletin (SAIB), CE-18-07, recommending detailed inspections of v-band exhaust couplings be performed at 100-hour intervals. The accident occurred on the first flight following a 100-hr inspection that indicated an examination of the exhaust system. The investigation did not determine the total time in service of the clamp or whether a specific examination of the v-band clamp was accomplished.
Probable cause
A total loss of engine power due to an engine fire that resulted from failure of the turbocharger exhaust clamp, which allowed hot exhaust gases to damage other vital engine components.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T206H
Amateur built
false
Engines
1 Reciprocating
Registration number
N52854
Operator
TEXAS PARKS AND WILDLIFE DEPT
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft - state
Commercial sightseeing flight
false
Serial number
T20608939
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-24T22:17:30Z guid: 105272 uri: 105272 title: DCA22LA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105273/pdf description:
Unique identifier
105273
NTSB case number
DCA22LA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T15:20:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-06-21T17:30:27.812Z
Event type
Accident
Location
Chicago, Illinois
Airport
CHICAGO O'HARE INTL (ORD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Cape Air’s pilot reported that while waiting to depart, the tower cleared their flight to line up and wait at the N5 intersection, advising “traffic on the roll” on runway 28R. As the accident airplane approached the hold short line, the right wing was lifted, and the right landing gear was raised off the ground causing the left wingtip to contact the ground. Cape Air’s pilot corrected the airplane to a normal attitude, exited the runway at EE intersection and returned to the fixed base operator (FBO). The airplane sustained substantial damage to the left forward wing spar. Figure 1. Google Earth imagery of the locations of the accident airplane and departing airplane at the time of the upset. ADS-B data showed the upset occurred about 28 seconds after a preceding Boeing 737 (B737) had crossed the same hold short line. At the time of the upset, shown in Figure 1, the B737 had just completed the turn on to the runway centerline and begun increasing thrust for takeoff.
Probable cause
The accident airplane encountered jet blast from a departing Boeing 737.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
COSTRUZIONI AERONAUTICHE TECNA
Model
P2012 TRAVELLER
Amateur built
false
Engines
2 Reciprocating
Registration number
N833CA
Operator
Hyannis Air Service, Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
014/US
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-21T17:30:27Z guid: 105273 uri: 105273 title: ERA22LA274 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105281/pdf description:
Unique identifier
105281
NTSB case number
ERA22LA274
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-16T18:45:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-27T18:20:45.055Z
Event type
Accident
Location
Brevard, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On June 16, 2022, about 1745 eastern daylight time, a Cessna 172M, N5064H, was substantially damaged when it was involved in an accident near Brevard, North Carolina. The pilot and the two passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the airplane was flying over a camp so that a passenger could drop candy from the airplane. The pilot stated that the airplane was “a couple hundred feet” above the trees in slow flight. The next thing that the pilot remembered was waking up in a hospital. According to one of the passengers, after the candy drop, the airplane flew around the camp so that photographs could be taken. The passenger stated that the airplane was descending and that he made a comment to the pilot about getting close to the treetops and needing to apply power and pull up. The pilot stated that the pilot said something similar to, “I’m working on it.” The passenger recalled that the airplane hit some trees and that he woke up next to the airplane on the ground. He also stated the engine was operating normally. A GoPro video camera was found at the accident site and was sent to the National Transportation Safety Board’s Vehicle Recorders Division, Washington, DC, for download. The camera contained multiple short videos and still pictures of the accident flight. The 8-minute 42-second stitch of the accident image sequence showed the airplane maneuvering at a low altitude and high bank angles. The airplane made multiple passes over a clearing in the tree canopy, and the passenger in the right front seat made motions consistent with dropping objects out of the airplane over the clearing. The airplane continued to maneuver at high bank angles and a low altitude until the airplane impacted terrain. Postaccident examination of the airplane revealed that the tail section had partially separated from the fuselage and that the wing had separated from the fuselage, resulting in substantial damage. All instrument panel components had dislodged from their housings and were scattered around the cabin. Further examination of the airplane revealed that the left wing remained fastened to its attachment points to the fuselage. The leading edge exhibited aft diagonal buckling/crushing from the wing root to the pitot tube. Just inboard of the pitot tube, the leading edge exhibited a tree impact mark that was about 8 inches in diameter. Approximately midspan, the leading edge exhibited a tree impact mark that was about 1.5 inches in diameter. The right wing remained fastened to its attachment points to the fuselage. About 3 ft 5 inches from the wing tip, the leading edge exhibited a tree impact mark that was about 4 inches in diameter. The right horizontal stabilizer was separated about 6 inches outboard from its attachment points. The elevator and trim tab remained attached to the horizontal stabilizer rear spar, which had separated from the rest of the horizontal stabilizer. Continuity of all primary flight control cables were confirmed from the cockpit to their respective flight control surface. The engine remained attached to the firewall and front section of the fuselage. The propeller remained attached to the engine, and tree bark was noted in the spinner dome, which was bent. Both propeller blades exhibited bent tips, and one blade had S-shaped bending. Both magnetos had separated from the engine. The magnetos were spun with an electric drill and produced sparks on all leads. The top spark plugs exhibited normal wear. Thumb compression and suction were established on all cylinders when the propeller was rotated by hand. Engine continuity was established through the engine and accessory case. A lighted boroscope was used to examine the cylinders, pistons, and valves. The carburetor was disassembled, and no anomalies were noted. Examination of the airframe and engine revealed no evidence of mechanical malfunctions that would have precluded normal operation. -
Analysis
The pilot and two passengers were flying at low altitudes over a camp and dropping candy from the airplane. The pilot recalled that the airplane was “a couple hundred feet” above the trees in slow flight; the next thing that the pilot remembered was waking up in a hospital. During the flight, one of the passengers commented to the pilot that the airplane was getting close to the treetops and that he needed to apply power and pull up. The pilot stated something similar to, “I’m working on it.” The passenger recalled that the airplane hit trees and that he woke up next to the airplane. He also stated that the engine was operating normally. Postaccident examination of the airplane revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation. An onboard image recording from a camera found at the accident site revealed that the airplane was maneuvering at a low altitude and high bank angles until the airplane impacted terrain. Given the passenger’s recollections and the onboard image recording evidence, the pilot allowed the airplane to sink below the level of the treetops while conducting high bank angles at a low altitude.
Probable cause
The pilot’s failure to maintain altitude while maneuvering the airplane at a low altitude, which resulted in impact with trees and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N5064H
Operator
FRANKLIN AIR SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17265325
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-27T18:20:45Z guid: 105281 uri: 105281 title: DCA22LA135 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105317/pdf description:
Unique identifier
105317
NTSB case number
DCA22LA135
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-17T23:30:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-07-01T21:21:08.561Z
Event type
Accident
Location
New York, New York
Airport
John F kennedy International (KJFK)
Weather conditions
Visual Meteorological Conditions
Injuries
null fatal, null serious, null minor
Analysis
The flight crew of F-GSPQ, an Air France B777-200ER, operating as Air France flight 008, had stopped with the parking brake set while waiting for the gate personnel to finish preparing gate 9 to receive their flight at Terminal 1, at John F. Kennedy International Airport (KJFK), when their airplane was struck by an ITA Airways A330-202 that was taxiing past. The Boeing 777 airplane received substantial damage to the right-hand elevator. The Airbus airplane only received scratches on the left winglet. The Air France crew said that their company procedure to enter gate 9 is to stop and wait for a tow. There were no ground marshalling crew present when they arrived, so they stopped, shut down the engines, and waited about 10 to 15 minutes for a tow to arrive. About the time the tug arrived, the crew said they felt the airplane move due to a “hard connection”, but they were unaware of an airplane passing behind at that time. After the airplane was parked at the gate and passengers had disembarked, maintenance informed the flight crew of damage to the elevator, and it was determined to be from the ITA Airways A330 that had passed behind. The Air France flight crew said they tried to contact the Air Traffic Control Tower to stop the ITA Airways flight, but the conversation was lengthy, and the ITA Airways flight 611 took off without receiving timely notification of the collision. The ITA Airways crew said they noted an Air France Boeing 777 entering at gate 9, a safe distance away, where it stopped awaiting a tow to parking. The ITA Airways crew further stated that after engine start, they were cleared to taxi via Taxiway N, Taxiway B, Taxiway G, cross runway 22L, and via taxiway Z to join the queue for takeoff on runway 31L. They said that during the taxi at no time was there any indication that they had impacted an airplane. After takeoff, while climbing out at 3,000 feet, the ITA Airways crew received a radio call from JFK Tower asking if they had impacted an airplane, and if they had any damage. The crew said they then conducted visual, and systems checks, and checked with the cabin crew. No abnormalities were observed. Upon reaching FL300 the ITA Airways flight crew said they received a second radio call from Air Traffic Control. After contacting their company, and having ruled out any problems with the airplane, a decision was made for the ITA Airways flight to continue to Leonardo Da Vinci International Airport (FCO). After an uneventful flight and landing, an inspection revealed a longitudinal abrasion throughout its length on the upper part of the left winglet consistent with the winglet contacting an object.
Probable cause
The ITA Airways flightcrew’s misperception of the distance to maintain separation and safely pass the stopped Air France airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A330
Amateur built
false
Engines
2 Turbo fan
Registration number
EI-EJL
Operator
ITALIA TRASPORTO AEREO SPA(ITA Airways)
Second pilot present
true
Flight conducted under
Part 129: Foreign
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
1283
Damage level
Minor
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
BOEING
Model
777
Amateur built
false
Engines
2 Turbo fan
Registration number
F-GSPQ
Operator
Air France
Second pilot present
true
Flight conducted under
Part 129: Foreign
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
28682
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-01T21:21:08Z guid: 105317 uri: 105317 title: WPR22FA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105274/pdf description:
Unique identifier
105274
NTSB case number
WPR22FA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-18T07:55:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-25T02:32:13.67Z
Event type
Accident
Location
Buckeye, Arizona
Airport
Buckeye Municipal Airport (KBXK)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The Federal Aviation Administration Airplane Flying Handbook (FAA-H-8083-3C) states the following regarding standard airport traffic patterns: - The traffic pattern altitude is usually 1,000 feet above the elevation of the airport surface. - The downwind leg is a course flown parallel to the landing runway, but in a direction opposite to the intended landing direction. This leg is flown approximately 1/2 to 1 mile out from the landing runway and at the specified traffic pattern altitude. - Pattern altitude is maintained until at least abeam the approach end of the landing runway. At this point, the pilot should reduce power and begin a descent. The pilot should continue the downwind leg past a point abeam the approach end of the runway to a point approximately 45° from the approach end of the runway, and make a medium-bank turn onto the base leg. Pilots should consider tailwinds and not descend too much on the downwind in order to have sufficient altitude to continue the descent on the base leg. - The base leg is the transitional part of the traffic pattern between the downwind leg and the final approach leg. Depending on the wind condition, the pilot should establish the base leg at a sufficient distance from the approach end of the landing runway to permit a gradual descent to the intended touchdown point. While on the base leg, the ground track of the airplane is perpendicular to the extended centerline of the landing runway. Stall Speeds The airplane’s gross weight at the time of the accident was not determined. Estimated gross weight using a generic empty weight for an E-35 airplane (1791 lbs), 17 gallons of fuel (102 lbs), no baggage, and the reported weights of both occupants (463 lbs) resulted in a gross weight estimate between 2,300-2,400 pounds. According the aircraft performance charts, the no-flap stall speeds (indicated airspeed) for the airplane are as follows: 2300 lbs 2400 lbs Level 54 kts 55 kts 30° Bank 58 kts 59 kts 45° Bank 65 kts 66 kts The flap DOWN stall speeds (indicated airspeed) for the airplane are as follows: 2300 lbs 2400 lbs Level 46 47 30° Bank 50 51 45° Bank 55 56 The pilot’s operating handbook (POH) Before Landing checklist, step 7, states “Flaps – Down.” - The student pilot purchased the airplane January 25, 2019. The airplane was equipped with a dual yoke. - On June 18, 2022, at 0655 mountain standard time, a Beech E-35, N13AR, was destroyed when it was involved in an accident near Buckeye, Arizona. The student pilot and flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. A review of the automated dependent surveillance-broadcast (ADS-B) flight data revealed that the airplane departed from the Glendale Municipal Airport (GEU), Glendale, Arizona, its home base, at approximately 0625. Following a normal takeoff from runway 19, the pilot conducted maneuvers predominantly to the south before altering his course westward towards Buckeye Municipal Airport (BKX). About 20 minutes later, the airplane passed to the south of BKX, subsequently executing a right turn to adopt a northward heading. Approximately 5 miles north of BKX, the airplane initiated a descending 270° left turn, followed by a right turn as it continued on a southbound trajectory indicative of a direct approach towards runway 17 at BKX (Figure 1). The airplane executed a low approach, reaching an altitude of approximately 200 feet above ground level (AGL) before initiating a level right turn near the midpoint of runway 17. The airplane proceeded beyond a parallel runway heading toward the downwind leg and then began angling toward runway 17, maintaining an altitude of about 200 feet AGL and a speed between 63-68 knots. The last recorded ADS-B data point occurred at 0654, at which point it recorded the airplane was approximately 0.43 miles west-northwest from the threshold of runway 17 (Figure 2). The airport (BKX) was equipped with a VirTower traffic monitoring system. An image of the airplane’s flight path in the traffic pattern was recovered that mostly mirrored the flight path generated by the ADS-B data (Figure 3). The VirTower flight path continued past the last recorded ADS-B point and showed the airplane made a right turn and maintained a heading of about 030° before the flight track ended near the accident location bearing 313° and .22 miles from the approach end of runway 17. A postimpact fire occurred that destroyed the airplane. There were no witnesses to the accident and there were no recorded communications from the airplane while it operated in the BKX traffic pattern. Figure 1 – Traffic Pattern Flight Path Figure 2 – Final Flight Path Figure 3 – Traffic Pattern Flight Path (VirTower Generated) - Student Pilot The Maricopa County Office of the Medical Examiner performed the student pilot’s autopsy. According to the autopsy report, his cause of death was blunt force injuries and his manner of death was accident. His heart was described as enlarged, with a slightly dilated shape. His heart weight was 625 grams (upper limit of normal is roughly 570 grams for a male of body weight 270 pounds), his left cardiac ventricular wall thickness was 1.5 cm (normal is roughly 0.9 cm to 1.6 cm), his right cardiac ventricular wall thickness was 0.3 cm (normal is roughly 0.2 cm to 0.6 cm), and his cardiac intraventricular septal thickness was 1.4 cm (normal is roughly 0.9 to 1.8 cm). His right coronary artery had up to 25% narrowing by plaque. Visual examination of his heart was otherwise unremarkable for natural disease. The remainder of his autopsy did not identify other significant natural disease. His reported weight at his last flight physical dated January 31, 2022 was 270 pounds. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the student pilot. Phentermine was detected in cavity blood and urine. Phentermine is a prescription weight loss medication. It is the most frequently prescribed medication for weight loss in the United States. It is a Schedule IV controlled substance under federal law, with some potential for abuse. It may sometimes be associated with adverse cardiovascular effects including increased blood pressure, rapid or irregular heartbeat, or heart attack. Side effects of phentermine may include insomnia, nervousness, and dizziness. Uncommonly, more extreme side effects such as psychosis may occur. The drug typically carries a warning that it may impair the ability to engage in potentially hazardous activities such as operating machinery or driving a motor vehicle. The FAA considers phentermine to be a “do not issue/do not fly” medication. Flight Instructor The Maricopa County Office of the Medical Examiner performed the pilot’s autopsy. According to the pilot’s autopsy report, his cause of death was blunt force and thermal injuries, and his manner of death was accident. His autopsy did not identify any significant natural disease. His reported weight at his last flight physical dated December 13, 2019, was 193 pounds. The flight instructor initially survived the accident and was transported to a hospital for treatment. During treatment he received blood and plasma under massive transfusion protocols. Because the pilot received a large amount of donated blood products before his death, toxicological results in his postmortem specimens were not considered useful for this investigation, as donated blood may contain drugs. The screening routinely performed on donated blood does not test for drugs. - The flight instructor’s logbooks were not located during the investigation and his experience in the make and model of aircraft could not be determined. The student pilot’s logbook contained only one entry indicating the student pilot had operated the airplane prior to the accident. The entry stated the student pilot and the flight instructor attempted to fly together in the accident airplane on June 11, 2022. The entry indicated the student pilot logged 0.5 hours of dual instruction received. The entry also stated “Flight with intention of taking off, lost coms holding short.” The entry was signed by the flight instructor. - The airplane impacted flat, sparsely vegetated desert terrain. Impact marks on the ground were consistent with the airplane hitting the ground in a nose- and left-wing-low attitude. A propeller cut mark was observed in the dirt near the engine impact point. Postimpact fire consumed most of the airplane fuselage, cockpit, and inboard portions of the wings. Both wing leading edges exhibited aft crushing damage perpendicular to the leading edge, with the left wing being crushed further aft. The fuselage and cockpit from the firewall aft to about two feet forward of the empennage was consumed by postimpact fire. Cockpit instrumentation, switches, and controls were mostly destroyed by fire. Flight control continuity was verified to all control surfaces from the cockpit. The left and right flaps were in the retracted position and the position of the flap control handle could not be determined. All landing gear were in the extended position. Both propeller blades exhibited leading edge polishing and chordwise scratches. One blade was bent aft about 45° near the midpoint of the blade and was loose on the hub. The second blade was bent aft about 80° about 1/3 the length of the blade outward from the hub. Engine continuity, cylinder compression, and valvetrain continuity were verified by rotating the propeller by hand. The top spark plugs were removed and exhibited normal burn signatures. No preimpact mechanical anomalies were noted with the engine or airframe during post-accident examination. -
Analysis
The flight instructor and student pilot departed the airport where the airplane was based and proceeded to another airport, flying a flight profile consistent with flight training. They flew one straight-in approach to a low approach over the runway, about 200 ft above ground level (AGL). Following the low approach, the airplane made a right turn to downwind about midway down the runway. The airplane did not climb during the turn or after it was established on downwind. It remained 200-300 ft AGL and maintained airspeed at or near the 45° bank no-flap stall speed. The airplane then angled towards the extended runway centerline and began a turn to final shortly after passing abeam the runway threshold. The airplane subsequently impacted terrain in the turn and short of the runway. A postimpact fire ensued and the airplane was destroyed. There were no witnesses to the accident. The airplane impacted terrain in a near-vertical and left-wing-low attitude, consistent with impact following a stall. Postaccident examination of the wreckage and engine revealed no preimpact anomalies and damage to the propeller blades was consistent with the engine producing power at the time of impact. The flaps were found in the retracted position, contrary to normal landing procedures that specify the flaps should be extended. The student pilot had heart disease and had used a medication that increased his risk of having a sudden impairing or incapacitating cardiac event such as arrhythmia or heart attack. There is no autopsy evidence that such an event occurred, although such an event does not reliably leave autopsy evidence if it occurs just before death. Operational evidence in this case makes a sudden medical event involving the student pilot unlikely. Had such an event occurred with the student pilot flying, the flight instructor would have been available to assist in maintaining airplane control. Additionally, the airplane’s flight path prior to the accident indicates the airplane was being flown in a controlled manner. Due to the limitations of the instructor’s toxicological testing, the results of that testing cannot be reliably interpreted. Thus, there is insufficient toxicological evidence to determine whether the instructor had used any substances that were potentially impairing or indicative of potentially impairing underlying conditions. The airplane was flown in a non-standard traffic pattern at an unusually low altitude that positioned the airplane closer to the runway than normal during the final turn. Additionally, the airplane flaps were found in the retracted position. It could not be determined why the non-standard traffic pattern was flown or why the flaps were retracted, but both conditions increased the susceptibility of an accelerated stall during the turn to final. It was not determined which pilot was manipulating the controls at the time of the accident, but the evidence indicates the pilot flying maneuvered the airplane such that an accelerated stall occurred. The flight instructor was responsible for the safe operation of the airplane, but he did not ensure proper airspeed or bank control during the turn to final.
Probable cause
The pilots’ failure to climb and complete a normal traffic pattern after making a low approach and their failure to extend the flaps for reasons that could not be determined, and the flight instructor’s failure to ensure adequate airspeed and bank control during the turn to final approach, which resulted in an accelerated stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
E35
Amateur built
false
Engines
1 Reciprocating
Registration number
N13AR
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
D-3885
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-06-25T02:32:13Z guid: 105274 uri: 105274 title: CEN22LA255 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105283/pdf description:
Unique identifier
105283
NTSB case number
CEN22LA255
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-18T10:45:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2022-06-28T16:57:54.638Z
Event type
Accident
Location
Stillwater, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 18, 2022, about 0945 central daylight time, a Mooney M20E airplane, N5895Q, sustained substantial damage when it was involved in an accident near Stillwater, Oklahoma. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot reported that, about 20 to 25 minutes after departure and while in cruise flight at an altitude of about 4,500 ft mean sea level, the airplane lost partial engine power. The power had been set to 2,400 rpm and 24 inches of manifold pressure, which decreased to 2,000 rpm and between 11 and 12 inches of manifold pressure. The pilot manipulated the throttle control, but the engine did not respond. He moved the fuel selector through all positions while also moving the throttle, but the engine still did not respond. Because the airplane was unable to maintain level flight, the pilot elected to conduct a forced landing to a highway. As the airplane was about to land, the pilot became focused on avoiding a vehicle and failed to extend the landing gear. The airplane touched down “very softly” with the gear up, and the pilot turned the airplane slightly to the left to keep the propeller from impacting the vehicle, which resulted in the left wing impacting a road barrier and substantial damage to the wing. A postaccident examination revealed no anomalies with the engine control system, and throttle control continuity was established from the cockpit controls to the engine. The engine cowling was removed, and the induction air coupling was found wrapped in gray tape (see figure 1). When the tape was removed, separations were visible on the top and bottom at the flange on the inboard side. The inside of the coupling was examined, and the lower portion appeared to be permanently deformed in a manner consistent with compression (see figure 2). Figure 1. Induction coupling with gray tape. Figure 2. View from inside the induction coupling The pilot reported that the airplane’s tachometer time at the time of the accident was about 4,489 hours. According to the maintenance logbooks, the airplane’s most recent annual inspection, in accordance with Title 14 CFR Part 43 Appendix D, was performed on June 11, 2021, at a tachometer time of about 4,429 hours. The airframe and powerplant mechanic with inspection authorization who completed that annual inspection also completed the airplane’s two previous annual inspections. Those inspections were performed on November 11, 2018, and December 7, 2019, when the airplane’s tachometer time was about 4,380 and 4,396 hours, respectively. The maintenance entry dated November 11, 2018, noted “installed new Brackett induction air filter.” No other entries in the maintenance logbooks were associated with the induction air filter or coupling. Multiple attempts to contact the mechanic were made with no success. As a result, the investigation could not determine when the tape was applied to the induction coupling. According to Title 14 Part 43 Appendix D, during an annual inspection, lines, hoses, and clamps should be checked “for leaks, improper condition and looseness” and all systems should be checked for “improper installation, poor general condition, defects, and insecure attachment.” -
Analysis
The pilot reported that, during cruise flight, the engine lost partial power, which necessitated an emergency landing on a highway. During the landing, the airplane impacted a road barrier, which resulted in substantial damage to the left wing. During a postaccident examination, the induction air coupling was found wrapped in gray tape. When the tape was removed, separations were visible on the top and bottom at the flange on the inboard side. The top and bottom separations likely reduced the rigidity of the coupling when the engine was operating. Examination of the inside of the coupling showed that the lower portion appeared to be permanently deformed in a manner similar to compression. Therefore, because of the reduction in the coupling’s rigidity, the coupling had likely closed due to suction from the engine, which impeded airflow. Tape should not have been applied as a fix for the induction coupling separations. The investigation could not determine when the coupling separations appeared or the tape was applied, but those events had likely caused the permanent deformation to the coupling. The airframe and powerplant mechanic, who performed annual inspections for the airplane during the 3 years before the accident. should not have allowed the airplane to return to service with the tape applied and the coupling deformed.
Probable cause
The inadequate maintenance and inspection of the engine induction air coupling, which impeded airflow to the engine and resulted in the subsequent partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20E
Amateur built
false
Engines
1 Reciprocating
Registration number
N5895Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
812
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-28T16:57:54Z guid: 105283 uri: 105283 title: ERA22LA282 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105310/pdf description:
Unique identifier
105310
NTSB case number
ERA22LA282
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-18T18:30:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-14T18:09:49.055Z
Event type
Accident
Location
Jasper, Georgia
Airport
Pickens County (JZP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 18, 2022, about 1730 eastern daylight time, a Cessna 414, N414HF, was substantially damaged when it was involved in an accident near Jasper, Georgia. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.   The pilot reported that after touchdown on runway 34 the left main landing gear collapsed. The airplane skidded to the left, departed the runway surface, and struck a taxiway sign. The pilot also reported that he had “3 green” indications before touchdown, and the landing was “smooth and straight.”   An inspector with the Federal Aviation Administration (FAA) responded to the accident site and examined the wreckage. The inspector reported that the left wing sustained substantial damage to the lower structure. The landing gear was collapsed, and the left main landing gear torque tube was fractured.   After recovery of the wreckage to the ramp, maintenance personal removed the fractured torque tube, and it was forwarded to the National Transportation Safety Board Materials Laboratory for further examination. The examination revealed the presence of multiple fatigue cracks near the weld between the boss arm and the tube body. The opposite-facing fatigue cracks propagated inward from the outer and inner surfaces, consistent with reverse bending at this location. The cracks initiated from multiple crack initiation sites. Cessna Multi-engine Service Bulletin (SB) MEB09-2, dated May 11, 2009, addressed the issue of main landing gear torque tube failure. The service bulletin stated that noncompliance could result in fatigue failure of the torque tube. The SB required replacement of the tube at 4,000 hours of time in service. According to the owner, the airplane total time was 5,000 hours, and the torque tube was original to the airplane. The service bulletin was not included in an FAA Airworthiness Directive. An FAA fact sheet titled “Service Bulletins and the Aircraft Owner,” stated in part: “Are Service Bulletins Mandatory? The short answer is – it depends. If you are operating your aircraft under 14 CFR part 91, a service bulletin is advisory, and compliance is not mandatory unless it is included in an Airworthiness Directive. Keep in mind that even when a service bulletin is not mandatory, you should always pay attention to it as a means to ensure your safety….” -
Analysis
After touchdown on the runway, the airplane’s left main landing gear collapsed. The airplane skidded to the left, departed the runway surface, and struck a taxiway sign. The left wing was substantially damaged. Postaccident examination revealed that the left main landing gear torque tube had fractured, which resulted in the gear collapse. Further examination of the torque tube revealed that it failed from fatigue cracks that originated in multiple locations. A service bulletin issued by the airplane’s manufacturer required replacement of the torque tube at 4,000 hours time in service to prevent fatigue failure of the torque tube; however, the airplane had accrued about 5,000 hours total time, and the tube was original to the airplane. While compliance with the service bulletin was not mandatory, replacement of torque tube would have likely prevented the accident.
Probable cause
The failure of the owner to comply with a service bulletin, which resulted in the failure of the left main landing gear torque tube due to fatigue cracking.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
414
Amateur built
false
Engines
2 Reciprocating
Registration number
N414HF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
414-0389
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-14T18:09:49Z guid: 105310 uri: 105310 title: CEN22LA260 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105304/pdf description:
Unique identifier
105304
NTSB case number
CEN22LA260
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-19T11:30:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-29T04:10:12.008Z
Event type
Accident
Location
Union, Nebraska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 19, 2022, about 1030 central daylight time, a Smith Miniplane DSA-1, N208C, was substantially damaged when it was involved in an accident near Union, Nebraska. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, while cruising about 1,000 ft above ground level, the engine lost power. He landed the airplane into a wooded area, which resulted in substantial damage to both wings, the empennage, and fuselage. Post-accident examination revealed that no fuel was present in the fuel line from the engine-driven pump to the carburetor. The carburetor bowl was completely dry and clean, with a small amount of fuel in the accelerator pump cavity. The fuel tank was empty when viewed with a borescope, and the fuel selector valve was in the open position. No anomalies were noted with the fuel cap vent, filler neck, carburetor, cylinders, magnetos, or the engine’s mechanical continuity. The airplane was not equipped with a fuel quantity gauge. -
Analysis
The pilot reported that, while in cruise flight about 1,000 ft above ground level, the engine began running rough. The pilot subsequently made a forced landing into a wooded area, which resulted in substantial damage to the airplane. Postaccident examination revealed that no fuel was present in the fuel line from the engine-driven pump to the carburetor. The carburetor bowl was completely dry, and the fuel tank was empty when viewed with a borescope. No anomalies were observed with the fuel cap vent, filler neck, carburetor, engine cylinders, magnetos, or the engine’s mechanical continuity. Based on the available evidence, it is likely that the airplane’s fuel supply was exhausted due to the pilot’s inadequate fuel planning, leading to a loss of engine power and forced landing. The airplane was not equipped with a fuel quantity gauge, which likely contributed to the pilot’s lack of awareness of the airplane’s low fuel state.
Probable cause
The pilot’s inadequate fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SMITH MINIPLANE
Model
DSA-1
Amateur built
true
Engines
1 Reciprocating
Registration number
N208C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
GY-DSA-100
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-29T04:10:12Z guid: 105304 uri: 105304 title: ERA22LA293 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105385/pdf description:
Unique identifier
105385
NTSB case number
ERA22LA293
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-19T13:00:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-07-26T04:19:00.846Z
Event type
Accident
Location
Seminole, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot he was conducting some pleasure flying and sightseeing in a float-equipped airplane. He flew over a lake and decided to do a touch-and-go landing on the lake. He said while on final approach the wind shifted and the left wing “dropped.” The wing contacted the water and the airplane spun to the left. The right front float collided with the water and the airplane landed on the tail. The pilot taxied to the shore and noticed the damage to the horizontal stabilizer. An examination by a Federal Aviation Administration inspector confirmed substantial damage to the right horizontal stabilizer and rudder. The pilot reported that there was no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane during landing flare.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CRAWFORD JAMES R
Model
MU-582 DRIFTER
Amateur built
true
Engines
1 Reciprocating
Registration number
N2628E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
14752
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-26T04:19:00Z guid: 105385 uri: 105385 title: ERA22LA272 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105279/pdf description:
Unique identifier
105279
NTSB case number
ERA22LA272
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-19T14:04:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2022-06-23T16:58:09.818Z
Event type
Accident
Location
Monongahela, Pennsylvania
Airport
ROSTRAVER (FWQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 19, 2022, at 1304 eastern daylight time, a Cessna 414, N1996G, was substantially damaged when it was involved in an accident near Monongahela, Pennsylvania. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. In a written statement, the pilot stated that the preflight, run-up, taxi, and en route portion of the flight revealed no anomalies with the performance and handling of the airplane. On final approach for runway 26 at Rostraver Airport (FWQ), Monongahela, Pennsylvania, the pilot stated that she “had a little wind shear (-15 knots).” She adjusted the airplane’s reference landing speed (Vref) on final approach to Vref plus 10 knots, so the wind shear was “no issue.” The pilot performed the landing flare 500 ft beyond the landing threshold. A wind gust “took” the airplane up and it touched down about 1,000 ft beyond the threshold of the 4,002 ft-long runway. Upon touchdown, the pilot applied the brakes but “nothing happened,” despite hard application. According to the pilot, “Power was off, flaps up, so, I pull the mixtures, still on the brakes, fuel off, and hope I’ll be slow to make the last exit.” The pilot stated that she attempted to “ground loop” the airplane at the departure end of the runway without success, and ultimately guided the airplane to the left, avoiding lights and other infrastructure. The airplane transitioned onto the grass apron, descended an embankment, and came to rest upright with substantial damage to the nose and right wing. The airplane’s most recent annual inspection was completed on June 10, 2021, at 6,349.5 total aircraft hours. The airplane was examined at FWQ by an investigator from Textron Aviation and a Federal Aviation Administration safety inspector. The brake units (rotors and stators) of the main landing gears were examined and the left main landing gear brake cylinder and pressure plate were disassembled with no anomalies noted. The right main landing gear brake unit remained installed on the landing gear, but the brake hose had been cut by recovery personnel. The cockpit carpet and panels as well as an exterior access panel just aft of the nose landing gear bay were removed and revealed hydraulic (brake) fluid in the area. The nut that secured the 45° fitting to the 90° fitting of the brake hose at the pilot’s right brake master cylinder was loose. The hose was removed, inspected, and found to be a different, yet authorized substitute for the line specified in the Cessna parts catalogue. The line was reinstalled, tightened, and the system was pressurized with compressed air, which revealed no leaks. Fig. 1 – Extract from Cessna Illustrated Parts Catalogue A summary of brake work performed over the 10 years before to the accident revealed the following: · 10-15-12 – (2) 111417-4S0520 Brake Lines, LH and RH new parts installed. · 03-03-17 – Tightened and cleaned around LH gear well brake line elbow. Ops check shows no leaks. Installed new LH and RH brake linings (SPS6606600 (x16)) · 03-06-18 – Serviced LH brake reservoir with 5606, and bleed LH MLG brakes as required, leak check good. · 05-04-18 – Replaced all brake linings, P/N 066-06600 (x16). Performed run in, ops. check good. Applied spiral wrap to LH brake hose from master cylinder to parking brake. · 09-14-20 – Bled both brakes IAW AMM Ch. 4-112. Ops check good. Installed 8 new brake linings. 4 ea. P/N 066-06600 on OB of LH and RH wheels IAW AMM 4-60A. According to the Cessna Model 414 Service Manual, the service interval for “Brake System Plumbing – Inspect for leaks, hoses for bulges and deterioration…” was after the airplane’s first 100 hours, and then “Every 200 hours” and “Every 12 [months]” thereafter. The most recent annual inspection was performed 12 months, 9 days, and 126.1 aircraft hours before the accident. According to Federal Aviation Regulations: An aircraft inspected and approved on any day of a calendar month will become due for inspection on the last day of the same month, 12 calendar-months later. However, the owner/operator/program manager of an aircraft may have annual inspections performed at any interval that does not exceed the maximum of 12 calendar-months between inspections, as specified by § 91.409(a)(1). -
Analysis
According to the pilot, she performed the approach at the airplane’s reference landing speed (Vref) plus 10 knots. The airspeed adjustment and the gusting conditions resulted in a touchdown 1,000 ft beyond the touchdown zone on a 4,002 ft-long runway. The pilot applied the brakes with no response, ultimately guiding the airplane to the left at the departure end to avoid lights and other infrastructure. The airplane traveled into the runway’s grass apron, descended an embankment, and came to rest upright with substantial damage to the nose and right wing. The cockpit carpet and panels, as well as an exterior access panel just aft of the nose landing gear bay, were removed and revealed hydraulic (brake) fluid in the area. The nut that secured the 45° fitting to the 90° fitting of the brake hose at the pilot’s right brake master cylinder was found to be loose. According to the airplane’s Service Manual, the service interval for “Brake System Plumbing – Inspect for leaks, hoses for bulges and deterioration…” was after the airplane’s first 100 hours, and then “Every 200 hours” and “Every 12 [months]” thereafter. The most recent annual inspection was performed 12 months, 9 days, and 126.1 aircraft hours before the accident. While the airplane was 9 days past the manufacturer’s recommended inspection interval, the inspection required by regulations was not due for 3 weeks.
Probable cause
Loss of braking authority due to a loosened brake line fitting for reasons that could not be determined, which resulted in a runway overrun.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
414
Amateur built
false
Engines
2 Reciprocating
Registration number
N1996G
Operator
ERTEL CAIOLINN CHELSEA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
414-0603
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-23T16:58:09Z guid: 105279 uri: 105279 title: ERA22LA276 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105300/pdf description:
Unique identifier
105300
NTSB case number
ERA22LA276
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-20T14:15:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-07-08T16:01:52.098Z
Event type
Accident
Location
LAURINBURG, North Carolina
Airport
LAURINBURG-MAXTON AIRPORT (MEB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 20, 2022, about 1315 eastern daylight time, a Piper PA-28-180 airplane, N9676J, was substantially damaged when it was involved in an accident near Laurinburg, North Carolina. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he arrived at Raleigh Executive Jetport (TTA), Sanford, North Carolina, following a long cross-country flight. He believed that, upon landing, the airplane contained about 10 total gallons of fuel (5 gallons each in the left and right tanks), which was consistent with his observation of the fuel gauges. He departed TTA shortly after 1300 for Lumberton Regional Airport (LBT), Lumberton, North Carolina, with an intermediate fuel stop planned at Laurinburg/Maxton Airport (MEB), Maxton, North Carolina. The fuel was out of service at LBT, which necessitated the fuel stop at MEB. The pilot reported that, shortly after takeoff from TTA, the fuel gauges settled below 5 gallons per tank, and about 15 to 20 miles north of MEB, the engine began to sputter. He switched tanks from the right tank to the left, and power returned to normal momentarily. At this point, he began navigating directly to runway 23 at MEB and announced over the common traffic advisory frequency that he would be performing a straight-in approach for landing. About 3 miles from the runway, the engine sputtered again, and the pilot switched the fuel selector back to the right tank. Subsequently, the engine lost all power, but the propeller continued to windmill. The loss of power occurred at 2,700 ft mean sea level (about 2,400 ft above ground level) and the pilot assessed that he could not make the runway at MEB. He subsequently maneuvered to a small service road and made an off-airport landing. During the landing roll, the left wing impacted a metal object, which caused the airplane to veer into a chain link fence adjacent to the road. The left wing sustained substantial damage. A Federal Aviation Administration inspector examined the airplane and engine several days after the accident. The right tank contained less than 1 cup of fuel. No areas of possible fuel leakage were observed. Less than 1/2 gallon of fuel was discovered in the left tank; however, a fuel leak was observed at the left wing root. The fuel drained was free of debris. During a postaccident test run, the engine started and produced normal power during a runup after about 4 gallons of fuel was added to the right tank. The right fuel gauge displayed an accurate measurement with this added fuel. The pilot reported after the accident that he believed the loss of power was due to a “loss of fuel.” He further added that he should have added fuel at TTA and that he was “over trustful” of the fuel gauges. -
Analysis
The pilot reported that he conducted a long cross-country flight and landed with 10 gallons of fuel between the two wing fuel tanks. He subsequently departed without refueling and about 15 to 20 miles from his destination, the engine began to sputter. The pilot switched the fuel selector to the left tank, which momentarily resolved the partial loss of engine power, but the engine again sputtered when the airplane was about 3 miles from the destination. The pilot switched the fuel selector back to the right tank, after which the engine lost total power. He determined that the airplane had insufficient altitude to reach the runway, so he completed a forced landing on a road, during which the airplane struck an object, resulting in substantial damage to the left wing. The right fuel tank was found nearly empty, and the tank was intact with no areas of fuel leakage observed. The left tank contained less than 1/2 gallon of fuel; however, a fuel leak was observed at the wing root as a result of impact-related damage, and the fuel was measured several days after the accident. Therefore, the exact quantity of fuel that remained in the left wing tank at the time of the accident could not be determined. Postaccident testing of the engine found that it produced normal power after fuel was added to the right tank. Although the investigation could not determine the total fuel remaining in the left tank due to damage sustained in the accident, it is likely that the pilot exhausted the airplane’s total fuel supply during the approach to landing. The pilot reported that he should have refueled before departing on the accident flight and that he was “over trustful” of the fuel gauges.
Probable cause
The pilot’s decision to depart with insufficient fuel onboard, which resulted in a total loss of engine power due to fuel exhaustion on final approach for landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N9676J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-3846
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-08T16:01:52Z guid: 105300 uri: 105300 title: ERA22LA277 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105301/pdf description:
Unique identifier
105301
NTSB case number
ERA22LA277
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-20T16:50:00Z
Publication date
2023-11-08T05:00:00Z
Report type
Final
Last updated
2022-06-27T17:45:03.648Z
Event type
Accident
Location
Wilmington, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 20, 2022, about 1550 eastern daylight time, an experimental Hawker Hunter MK.58, N337AX, was substantially damaged when it impacted the Atlantic Ocean about 40 miles southeast of Wilmington, North Carolina. The commercial pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 public use flight. According to the operator, while performing an exercise with the US Navy, the airplane experienced a partial loss of engine power at flight level 240. Specifically, the rpm reduced and stabilized to about 5,000. The pilot knew that 6,800 to 7,200 rpm would be required to maintain altitude and return to an airport. After two unsuccessful attempts to restore engine power, the pilot ejected from the airplane at 3,000 ft mean sea level. The pilot was subsequently rescued by a nearby fishing vessel; however, he suffered a serious back injury during the ejection. The fuel system was examined at a maintenance facility after the wreckage was recovered from the ocean. The examination revealed that a bearing failed in the high-pressure fuel pump governor, which prevented pump output pressure from increasing above 850 psi; the operating range limit was between 1900 to 2200 psi. -
Analysis
The vintage military jet was being operated under an experimental certificate. The airplane experienced a partial loss of engine power over an ocean at flight level 240. Specifically, the engine rpm reduced and stabilized to about 5,000. The pilot knew that 6,800 to 7,200 rpm would be required to maintain altitude and return to an airport. After two unsuccessful attempts to restore engine power, the pilot ejected at 3,000 ft mean sea level. The fuel system was examined at a maintenance facility after the wreckage was recovered from the ocean. The examination revealed that a bearing failed in the high-pressure fuel pump governor, which prevented pump output pressure from increasing above 850 pounds per square inch (psi); the operating range limit was between 1,900 to 2,200 psi.
Probable cause
A bearing failure in the high-pressure fuel pump, which resulted in a partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HAWKER
Model
HUNTER
Amateur built
false
Engines
1 Turbo jet
Registration number
N337AX
Operator
Airborne Tactical Advantage Company
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft
Commercial sightseeing flight
false
Serial number
41H-697456
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-27T17:45:03Z guid: 105301 uri: 105301 title: DCA22LA133 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105303/pdf description:
Unique identifier
105303
NTSB case number
DCA22LA133
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-21T10:45:00Z
Publication date
2023-08-03T04:00:00Z
Report type
Final
Last updated
2022-07-01T20:53:02.725Z
Event type
Incident
Location
Pittsburgh, Pennsylvania
Airport
Pittsburgh International Airport (KPIT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
Runway Awareness and Advisory System The United Airlines 737 Flight Manual stated that the runway awareness and advisory system (RAAS), an enhancement to the ground proximity warning system (GPWS), provides aural callouts and visual alerts on the navigation display to assist pilots with situational awareness during ground operations, approaches to landing, and go-arounds. RAAS required the following conditions for proper operation: • terrain and airport runway database is in the GPWS computer, • aircraft is approaching an airport in the RAAS airport runway database, and • GPS and other required signals are available with an accuracy that meets minimum requirements. When enabled, RAAS callouts operate without any required action from the pilots. Visual display of RAAS callouts and alerts on the navigation display requires the selection of the terrain feature. Audible alerts associated with an approach and landing included “caution taxiway,” which would sound if an airplane aligned with a taxiway when the airplane was at an altitude between 150 and 250 ft agl. United Airlines selected, as part of its option package for RAAS, to disable the airborne alerts that announces the runway that a company flight was approaching to minimize any distractions while on final approach and maintain a “quiet cockpit” environment. Federal Aviation Administration Order 7110.65Z Federal Aviation Administration Order 7110.65Z prescribed air traffic control procedures and phraseology for use by air traffic control personnel. The order required controllers to be familiar with the provisions in the order that pertained to their operational responsibilities. The order stated that, if a controller becomes aware that an aircraft is aligned with the wrong surface, the controller should “inform the pilot” and either “issue control instructions/clearances” or “if time permits, verify the pilot is aligned with the correct runway” and “issue control instructions/clearances as necessary. In addition, the order allows controllers “to exercise their best judgment if they encounter situations not covered by [the order].” - The airplane was equipped with a General Electric Aviation (GE) FMC system, which interfaced with other airplane systems to support lateral, vertical, and time-based navigation guidance. The FMC system comprised two computers and two control display units. Both computers were removed from the airplane and sent to the manufacturer for evaluation. Data obtained from the computers showed that the dual blanking of the FMC displays was caused by a dual FMC reset that occurred during the descent into PIT. GE stated that this reset was consistent with a known software exception (problem) related to a vector/discontinuity combination followed by a waypoint with a “required navigation Performance.” This problem was introduced in a version of the Boeing 737 flight management system software that included refinements to GE’s earth model. The software exception occurred in the air and resulted in a “numeric error” exception in the earth model. The FMC manufacturer developed a procedural workaround, and the error was corrected in the subsequent version of the software. Boeing issued a service bulletin about the software update in May 2022. - At the time of the incident, PIT had four paved landing surfaces for airplanes: 10R/28L, 10C/28C, 10L/28R, and 14/32. Runway 10R/28L was 11,500 ft long and 200 ft wide, and runway 28L was serviced by a four-light PAPI on the left side of the runway and a medium-intensity approach light system with runway alignment indicator lights. Runway 10C/28C was 10,775 ft long and 150 ft wide and was serviced by a four-light PAPI located on the left side of the runway and runway centerline lights. The centerline of runway 28C was about 1,200 ft from the centerline of runway 28L. The distance from the air traffic control tower to the runway 28C threshold was about 7,500 ft. - The Federal Aviation Administration (FAA) Airport Traffic Control Tower (ATCT) was in operation at the time of the incident. According to the FAA, the flight established communication with the local controller approximately 6.5 miles east of the airport. The flight crew advised the controller they were on a visual approach to runway 28C, and the controller cleared the flight to land on runway 28C. According to radar data, on an approximately 6-mile final, the flight joined the final for runway 28L. About 2-mile final the flight crew requested verification of their clearance to land runway 28C. The controller advised of mowers in the vicinity and cleared the flight to land on runway 28C. The controller subsequently observed the flight had lined up with runway 28L. The controller exercised their best judgment, as allowed in FAA Job Order 7110.65Z, that for the safety of the flight that it was best to allow the flight to land on runway 28L Given their low altitude and noting there were no airplanes or vehicles on or near runway 28L, he decided not to issue a go-around to the flight. The traffic volume was classified as being “light with routine complexity” and no other aircraft or vehicles were on runway 28L. The air traffic control tower was located about 1 1/2 miles from the approach end of runways 28L and 28C. - The FDR was found to be in good condition, and the data were extracted normally from the recorder. The FDR recording contained about 27 hours of data. The FDR data showed that, at 0940:17, parameters sourced from the FMC began to show an error pattern consistent with the FDR not receiving data from the FMC ARINC data bus. According to Boeing, the fault condition must be present for at least four successive data points for it to be annunciated in the output data frame recorded on the FDR. On the basis of the sampling rate of the affected parameters, the data loss condition began at 0940:13. The error pattern in the FMC-sourced data continued for about 13 seconds, at which time it transitioned to a no computed data error pattern. That error pattern continued for about 6 seconds, and the FDR began receiving valid data again at 0940:36. The FMC “valid” parameter was in the VALID state for the entire flight. - On June 21, 2022, about 0945 eastern daylight time (EDT), United Airlines flight 2627, a Boeing 737-9 MAX, N37513, was cleared for a visual approach to land on runway 28C at Pittsburgh International Airport (PIT), Pittsburgh, Pennsylvania, but the flight crew landed on runway 28L instead. None of the 174 occupants aboard the airplane were injured, and the airplane was not damaged. The regularly scheduled passenger flight was operating under the provisions of Title 14 Code of Federal Regulation Part 121 from Chicago O’Hare International Airport (ORD), Chicago, Illinois, to PIT. The flight crew reported that the incident flight was the first leg on the first day of a 3-day trip. The captain was the pilot flying, and the first officer was the pilot monitoring. Before the flight, the crew reviewed and accepted the operational flight plan to PIT, which indicated an arrival on runway 28L. Flight data recorder (FDR) data showed that the airplane departed ORD about 0845 EDT (0745 local time) and that the autopilot was engaged shortly after takeoff until shortly before the final approach to PIT. The flight crewmembers reported that, before the airplane began its descent into the terminal area, they obtained automatic terminal information service (ATIS) information for PIT via the airplane’s aircraft communication addressing and reporting system (ACARS). Per the ATIS information, they briefed the JESEY4 area navigation (RNAV) arrival. and the first officer programmed the flight management computers (FMC) for the RNAV approach to runway 28C. The flight crew made initial contact with PIT approach control when the airplane was about 25 miles northwest of the airport. The approach controller told the flight crew to expect a visual approach to runway 32. The flight crew retrieved landing data for runway 32, briefed the approach, and programmed and loaded the FMC with the instrument landing system (ILS) approach to runway 32 to back up the planned visual approach. The controller subsequently offered the crewmembers radar vectors for the visual approach to runway 28C, which they accepted. The captain selected “heading select” on the autopilot and flew the assigned heading while the first officer programmed the FMC for the RNAV approach to runway 28C. The flight crew established communication with the tower controller when the airplane was about 6.5 miles east of the airport. The crew advised the tower controller about the visual approach to runway 28C, and the controller cleared the airplane to land. According to the crew, the airplane turned from the downwind to the base leg for the runway at an altitude of about 4,000 ft mean sea level (msl), which would allow the airplane to join the final approach for the runway about 2 miles east of the SUPPR waypoint. The flight crew told the controller that the airport was in sight, and the controller cleared the airplane for the visual approach to runway 28C. During a postincident interview, the captain stated that he visually acquired the precision approach path indicator (PAPI) when the airplane was about 6.5 miles away from the airport. (The captain was using the PAPI for vertical guidance because runway 28C had no ILS. Runways 28C and 28L had PAPI lights associated with the runway, and both sets of PAPI lights were located on the left side of their respective runway.) The captain requested that the first officer extend the virtual centerline of the approach from the SUPPR waypoint, at which time the first officer announced that both FMC control displays had blanked; thus, only the “ACARS” prompt was showing and available on the menu page of the FMC display units. According to FDR data, the FMC blanking occurred at 0940:13 (as discussed further in the Flight Recorders section), after which lateral and vertical guidance on the MAX display system was unavailable. The captain reported that, at the time of the screen blanking, the PAPI lights were still in sight and that he continued the visual approach to the airport. The captain disconnected the autopilot and autothrottle at 0942:07 when the airplane was at an altitude of about 2,300 ft above ground level (agl). The flight crew stated that the FMCs came back on when the airplane was between 700 and 1,000 ft agl, but no approach guidance was displayed. The captain stated that, at that time, he could see the airport and the PAPI lights, and that he continued to the airport visually. About 2 miles from the runway threshold, the first officer contacted the tower controller to confirm that the airplane was cleared to land on runway 28C, and the controller provided confirmation. The airplane then aligned with and landed on runway 28L instead of runway 28C at 0944:42 and subsequently turned right to exit the runway. The figure below is a Google Earth screenshot that is overlaid with automatic dependent surveillance-broadcast ground tracks showing the incident flight aligned with and landing on runway 28L. During another postincident interview, the tower controller stated that, after he cleared the airplane to land on runway 28C (when the airplane was on a 2-mile final), he observed that the flight crew had aligned the airplane with runway 28L instead of runway 28C. The controller decided that, given the airplane’s altitude, it would be appropriate for the airplane to land on runway 28L. The controller decided not to issue a go-around instruction given that no airplanes or vehicles were on or near runway 28L. The PIT air traffic manager reported that, at the time of the incident, the traffic volume was “light with routine complexity.” -
Analysis
This analysis discusses the incorrect runway landing at Pittsburgh International Airport involving United Airlines flight 2627. The airplane had been cleared to land on runway 28C, but the flight crew aligned the airplane with and landed on parallel runway 28L. The flight crewmembers reported that, before beginning the descent into the terminal area, the first officer (the pilot monitoring) programmed the flight management computer (FMC) for the area navigation (RNAV) approach to runway 28C. During the descent, the crew was instructed twice by PIT approach control to change the landing runway. The crew was first instructed to expect a visual approach to runway 32; a short time later, the crew was provided vectors for the visual approach to runway 28C. Once on the base leg of the approach, the crew reported that the airport was in sight, and the controller cleared the airplane for the visual approach to runway 28C. The captain (the pilot flying) stated he visually acquired the precision approach path indicator (PAPI) lights. Runways 28C and 28L both had PAPI lights located on the left side of the respective runway. The captain stated that he observed one set of PAPI lights, which he thought were associated with runway 28C. The captain requested that the first officer extend the centerline of the approach from the next waypoint, at which time the first officer reported that both FMC control display units had blanked, taking away the backup lateral and vertical navigational guidance to runway 28C. Although the PAPI lights provided vertical guidance, the first officer attempted to diagnose and restore the FMC's lateral guidance, which created a distraction at a critical phase of the flight that reduced the crew’s opportunity to ensure correct runway alignment. A postincident review of FMC data showed that the FMCs experienced a dual reset when the airplane was at an altitude of about 4,000 ft (3,350 ft above ground level). The FMCs rebooted and began transmitting valid data 23 seconds later when the airplane was about 3,128 ft above ground level, about 4 minutes away from touchdown. While on final approach, the crew requested that the controller confirm that the airplane was cleared to land on runway 28C; the controller provided this confirmation. However, at some point afterward, the controller observed that the airplane was aligned with runway 28L. After verifying that no conflicting traffic existed, the controller decided to allow the flight to continue and land on runway 28L rather than issue a go-around instruction at a low altitude. This flexibility is permitted by Federal Aviation Administration Order 7110.65Z, which allows controllers to exercise their best judgment if they encounter situations not covered by the order. The flight crew subsequently aligned the airplane with and landed on parallel runway 28L, which was located about 1,200 ft to the left of intended runway 28C. Because runway 28L and runway 28C were closely located, it would have been challenging for the controller to have visually detected the misalignment. The crew stated that, after the airplane landed, the first officer rechecked the automatic terminal information service broadcast, and they thought that it indicated that the PAPI lights for runway 28L were out of service. However, a review of the broadcast revealed that the PAPI lights for runway 10L were out of service. The dual FMC reset was due to an issue with the system’s software, which was known before the incident. A fix was identified and released about 1 month before the incident. The dual blanking of the FMC control display units did not cause the flight crew to align the airplane with and land on the wrong runway given that the airplane was operating in visual meteorological conditions and the flight was cleared for the visual approach to runway 28C. Although the incident airplane had a runway awareness and advisory system (RAAS) installed in the cockpit, the operator did not select the option to provide crews with an aural alert for the runway that the airplane would be approaching in flight. If the operator had selected this option, the system would have alerted the incident flight crew that the airplane was aligned with a runway that was not consistent with the landing clearance provided by air traffic control, which might have precluded the wrong runway landing.
Probable cause
The flightcrew’s misidentification of the intended landing runway, which resulted in approach to and landing on the wrong runway. Contributing to the incident was the distraction caused by the dual reset of the flight management computer displays.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-9
Amateur built
false
Engines
2 Turbo fan
Registration number
N37513
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
64494
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-07-01T20:53:02Z guid: 105303 uri: 105303 title: ERA22LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105367/pdf description:
Unique identifier
105367
NTSB case number
ERA22LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-21T14:55:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-06T19:37:01.225Z
Event type
Accident
Location
Canandaigua, New York
Airport
Canandaigua Airport (IUA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 21, 2022, about 1355 eastern daylight time, an experimental amateur-built Lightning airplane, N51TM, was involved in an accident near Canandaigua, New York. The private pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations part 91 personal flight. According to recorded audio from the Canandaigua Airport (IUA) common traffic advisory frequency, about 1347, the pilot advised he was taxiing to runway 31. About 7 minutes later, he made a mostly unintelligible comment that included a reference to runway 31, consistent with announcing his takeoff. A witness who was located about 350 ft northeast of the accident site reported seeing the airplane to the west of his position flying about 20 ft above a wheat field. The airplane disappeared over a hill. He went to the top of the hill, saw that the airplane had crashed in the field, and contacted law enforcement. The pilot reported that he extricated himself from the cockpit and was airlifted to a hospital after sustaining serious injuries during the accident. The pilot’s wife reported that her husband’s only recollections of the accident were that he thought the field was flat but encountered a bump during the landing roll and that he turned off the fuel selector valve after the accident. He passed away more than 30 days after the accident. The accident site was located about 3,170 ft north-northwest from the departure end of runway 31. Examination of the accident site by a Federal Aviation Administration (FAA) airworthiness inspector revealed the airplane came to rest upright with the nose landing gear collapsed; the airplane sustained minor damage. An engine monitor and portable GPS receiver were retained by NTSB for further examination; however, neither device contained any data associated with the accident flight. The airplane was recovered and secured in the pilot’s hangar for further examination. Postaccident examination of the airplane by an FAA airworthiness inspector revealed adequate fuel in both wing fuel tanks; no contaminants were noted. An odor of fuel in the cockpit was associated with the left fuel supply line that separated from the fuel selector due to impact damage. During activation of the auxiliary fuel pump, a fuel smell was noted, but visual examination of the engine compartment could not identify the source. During a subsequent attempt to start the engine following activation of the auxiliary fuel pump, the flexible fuel hose from the gascolator to the engine-driven fuel pump separated from the outlet fitting of the gascolator. Inspection of the hose and clamp revealed the screw used to tighten the hose clamp was tight to turn, but the hose was not tight on the barbed fitting. The hose was tightly secured to the fitting by the inspector. The engine was started with the fuel selector positioned to the right fuel tank and operated normally when the throttle was advanced to partial power. At idle, the engine operated rough and lost power; this was attributed to the choke being partially on. Full power or prolonged engine operation was not possible due to the impact-damaged propeller blades. According to maintenance records, the airplane’s last condition inspection was performed about 8 months and 14 operating hours before the accident. During the inspection, the pilot, who was the builder of the airplane, reportedly replaced a fuel line associated with the auxiliary fuel pump in the cockpit. A representative of the airplane designer reported that a loose fuel hose at the outlet of the gascolator could introduce air into the fuel supply being delivered to the engine-driven fuel pump; this condition could result in reduced fuel flow and reduced engine power. No determination could be made based on the available evidence as to the reason for the off-airport landing executed by the pilot. -
Analysis
Shortly after takeoff, the experimental amateur-built airplane was seen by a witness near the accident site flying about 20 ft above a wheat field. The pilot performed an off-airport landing in the field, which resulted in the nose landing gear collapsing. The pilot sustained serious injuries, and his only recollections of the accident were that he thought the field was flat but encountered a bump during the landing and that he shut off the fuel selector after the accident. The pilot passed away more than 30 days after the accident. Postaccident examination of the airplane revealed an adequate supply of fuel in both fuel tanks with no contaminants found. No discrepancies were noted during a visual inspection of the engine compartment, but during an attempt to start the engine following activation of the auxiliary fuel pump, a fuel hose from the gascolator to the engine-driven fuel pump separated from the outlet fitting of the gascolator due to inadequate clamping force. The hose was re-installed onto the fitting, and the engine was started and found to operate normally at low power; a full-power engine run was not performed due to impact-damaged propeller blades. While the airplane designer reported that a loose fuel hose at the outlet of the gascolator could introduce air into the fuel supply, it could not be determined whether this condition existed prior to, or was a result of the impact, and the reason the pilot performed an off-airport landing shortly after takeoff could not be determined.
Probable cause
The pilot’s performance of an off-airport landing shortly after takeoff for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MANTELL ALLAN T
Model
LIGHTNING
Amateur built
true
Engines
1 Reciprocating
Registration number
N51TM
Operator
MANTELL ALLAN T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
9
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2022-07-06T19:37:01Z guid: 105367 uri: 105367 title: ERA22LA309 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105469/pdf description:
Unique identifier
105469
NTSB case number
ERA22LA309
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-22T14:48:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-18T21:23:39.002Z
Event type
Accident
Location
Lancaster, Ohio
Airport
Fairfield County Airport (LHQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 22, 2022, about 1348 eastern daylight time, a Cessna 172M, N9556H, was substantially damaged when it was involved in an accident near Lancaster, Ohio. The private pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he performed a preflight inspection of the airplane and confirmed that the fuel tanks were full and absent of contamination, but he did not check the airframe fuel strainer. He reported no discrepancies during the engine run-up before takeoff. After takeoff, he turned onto the crosswind and then onto the downwind legs of the airport traffic pattern, flying on the downwind leg between 1,600 and 1,700 ft mean sea level (msl). While flying between 1,600 and 1,650 ft msl, he applied carburetor heat and then adjusted the engine rpm to 2,000. Abeam the approach end of runway 28, he reduced engine power to 1,700 rpm, extended the flaps to 10°, and heard radio calls from several other aircraft announcing they were transitioning the area. After turning onto the base leg of the airport traffic pattern, he noticed that his sight picture was “not right” and he could see the propeller blades rotating. He turned onto the final approach leg of the airport traffic pattern and, with the engine not developing power, he determined that the airplane would not reach the runway. He declared an emergency on the common traffic advisory frequency and noted a soybean field was located under the approach path. The airplane subsequently impacted about 2 ft below the top of a ditch and came to rest inverted. Examination of the airframe and engine was performed by a Federal Aviation Administration airworthiness inspector following recovery. Structural damage to the fuselage, left wing, and aft empennage was noted. Examination of the engine revealed crankshaft, camshaft, and valvetrain continuity. No evidence of preimpact failure or malfunction was noted of the air induction, ignition, or exhaust systems. No fuel contamination was noted in the right fuel tank, but because of the resting position of the airplane, no fuel was remaining in the left fuel tank. Both fuel tank caps were vented, and there was no issue with the airframe fuel vent system. The standpipe of the airframe fuel strainer was noted to have some of the black coating separated, exposing the base material, which was corroded. Black particles were noted in the fuel drained from the airframe fuel strainer and also the carburetor bowl. Additionally, the carburetor fuel inlet screen was blocked on the end opposite of the inlet by “fibrous material.” Examination of each wing fuel tank strainer revealed very slight amount of “fibrous material.” The carburetor heat control operated satisfactorily. Damage to the propeller precluded operational testing of the engine. Review of the maintenance records revealed the airplane’s last 100-hour inspection was performed on May 26, 2022. The airplane had accrued about 44 hours at the time of the accident since the inspection. An aviation weather surface observation report taken at the accident airport about 5 minutes after the accident reported the temperature and dew point to be 93°F and 73° F, respectively. According to FAA Special Airworthiness Information Bulletin (SAIB) CE-09-35 – Carburetor Icing Prevention, those environmental conditions were favorable for icing at glide and cruise power settings. -
Analysis
The pilot departed and remained in the airport traffic pattern. While on the downwind leg, he applied carburetor heat then reduced power to 2,000 rpm. Abeam the approach end of the runway, he reduced power further, then turned onto the base leg, where he recognized that the engine had lost power. After turning onto final approach and realizing that the airplane would not reach the runway, he performed an off-airport landing in a field, resulting in nose-over and substantial damage to the left wing, fuselage, and aft empennage. Postaccident examination of the engine revealed no evidence of preimpact failure or malfunction of the powertrain, ignition, air induction, exhaust, or carburetor heat systems. Although there was fuel contamination (particulates) found in the carburetor and airframe fuel strainer, and fibrous material inside the carburetor inlet screen, the amount and location of the contamination likely existed at the time of takeoff and the pilot did not report a loss of engine power until being at a reduced power setting on the base leg of the airport traffic pattern. Reported weather conditions were conducive to the formation of carburetor icing at glide and cruise power. Although the pilot reported that he applied carburetor heat before reducing engine power while on the downwind leg of the traffic pattern, it is likely that the ice accumulated to the degree that the carburetor heat was insufficient at the partial power setting to melt the ice that had accrued, resulting in a partial loss of engine power.
Probable cause
A partial loss of engine power due to the formation of carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N9556H
Operator
Sundowner Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17266227
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-18T21:23:39Z guid: 105469 uri: 105469 title: CEN22LA283 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105347/pdf description:
Unique identifier
105347
NTSB case number
CEN22LA283
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-24T09:48:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-06-30T23:34:14.54Z
Event type
Accident
Location
Bulverde, Texas
Airport
BULVERDE AIRPARK (1T8)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 24, 2022, about 0848 central daylight time, an Osprey II airplane, N10236, was substantially damaged when it was involved in an accident near Bulverde, Texas. There were no injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane was not fueled on the day of the accident and had last been fueled a week before. The fuel tanks were about ½ full with about 6 gallons in each of the 2 tanks. He sampled the fuel tanks and observed no contaminants. The engine start and run-up were normal, and he proceeded to runway 16 at the Bulverde Airpark (1TT8) for takeoff. The engine operated normally during the takeoff roll. Shortly after rotation, the engine sounded quieter, and the rpms fluctuated between 2,300 - 2,500 rpm. An engine speed of 2,600 rpm was normal for takeoff. He retracted the landing gear, which helped the climb a little, but the engine power continued to deteriorate. No engine roughness was felt at this time. The airplane was placed at the best angle for climb, about 70 mph. As the airplane cleared the 35-ft-tall trees at the end of the runway, the engine rpm was about 2,100 - 2,300 rpm and some roughness was now felt. The airplane would not climb, and the pilot selected a field and landed the airplane with the retractable landing gear in the retracted position. Before touchdown, the mixture was leaned to shutoff and the throttle was closed. After touchdown on the hull, as the airplane slowed, the right wing settled to the ground and the right-wing sponson struck the ground. The airplane incurred substantial to the right wing and fuselage during the forced landing. Postaccident examination of the airplane revealed that the fiberglass fuel tanks contained a considerable amount of contamination and the resin system appeared to be deteriorating. The resin system used in construction was believed to be polyester resin, which was not compatible with automotive fuel. The pilot/owner was not the original builder and had only used 100 low lead aviation gasoline since purchasing the airplane, but he could not say if previous owners had used automotive gasoline. The baffling in the tanks prevented visual inspection with the tanks mounted in the airplane and removal was not possible, requiring disassembly of the wings. The pilot noted that when he first purchased the airplane the gascolator had debris and after the accident it had some debris in it as well. Examination of the engine confirmed compression on all cylinders. Although ignition was not verified during the examination, the pilot reported that during the accident flight the engine never stopped running, indicating that the ignition system was operating during the event. The air temperature about the time of the accident was 80° F and the dew point was 70° F. The Federal Aviation Administration’s Carburetor Icing Probability Graph indicates that, under those conditions, the airplane encountered a serious risk of carburetor icing at glide power. -
Analysis
The pilot reported that the amphibious airplane’s engine gradually lost partial power shortly after takeoff and he was unable to maintain altitude. He performed a forced landing in a field with the retractable landing gear in the retracted position. After touchdown on the hull, as the airplane slowed, the right wing settled to the ground and the right-wing sponson struck the ground. The airplane incurred substantial damage to the right wing and fuselage during the forced landing. Postaccident examination of the airplane revealed that the fiberglass fuel tanks of the airplane had debris and deterioration. The resin used in construction of the fuel tanks was not compatible with automotive gasoline. The pilot/owner had never used automotive gasoline but could not attest to what previous owners had used. Further examination did not reveal any other preimpact anomalies with the engine that would have precluded normal operations. Although there was a potential for carburetor icing at glide power, based on the available evidence and that the airplane was taking off at the time of the accident, the engine likely lost power due to fuel starvation caused by debris obstructing the fuel outlet port of the fuel tank.
Probable cause
A loss of engine power due to fuel starvation due to a blockage of the fuel tank outlet port.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
OSPREY
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N10236
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
289
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-30T23:34:14Z guid: 105347 uri: 105347 title: ERA22LA294 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105387/pdf description:
Unique identifier
105387
NTSB case number
ERA22LA294
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-24T15:25:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-27T16:13:39.255Z
Event type
Accident
Location
Hartford, Kentucky
Airport
Ohio County (JDQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 24, 2022, about 1425 central daylight time, a Bücker BU-133, N1940H, was substantially damaged when it was involved in an accident near Hartford, Kentucky. The private pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   Witnesses reported that the pilot refueled the airplane and started the engine with the assistance of a mechanic, who hand-propped the engine. After engine start, the pilot taxied for departure. The airplane became airborne about 1,000 ft down the 5,000-ft-long runway and immediately pitched up into a nose-high attitude with little increase in altitude. The witnesses also reported that the engine ran smoothly during the entire event. As the airplane passed the departure end of the runway, it made a slight right turn, followed by a sharp turn to the left, back toward the runway. The airplane stalled, the nose dropped, and the airplane impacted the ground. First responders assisted the pilot out of the wreckage and he was transported to a local hospital for treatment.   An inspector with the Federal Aviation Administration (FAA) responded to the accident site and examined the wreckage. The airplane crashed in an open, grassy area about 400 ft past the departure end of the runway. The left wing and forward fuselage sustained substantial damage. There was no fire. Continuity was established from all flight control surfaces to the cockpit controls. The elevator trim was found in the neutral position. The FAA reported that, due to his injuries, the pilot had no recollection of the event. -
Analysis
Witnesses reported that, during takeoff, the airplane became airborne about 1,000 ft down the 5,000-ft-long runway and immediately pitched up to a nose-high attitude with little increase in altitude. The witnesses also reported that the engine ran smoothly during the entire event. As the airplane passed the departure end of the runway, it made a slight right turn, followed by a sharp turn to the left back toward the runway. During the left turn, the nose dropped, and the airplane impacted the ground past the end of the runway in a left-wing-low attitude. Examination of the airplane revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation. Given the witness statements and the lack of mechanical anomalies, it is likely that the pilot exceeded the airplane’s critical angle of attack while attempting to return to the airport during the initial climb, which resulted in an aerodynamic stall, loss of control, and impact with terrain.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall during an attempted return to the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Bucker
Model
BU-133
Amateur built
false
Engines
1 Reciprocating
Registration number
N1940H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
37
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-27T16:13:39Z guid: 105387 uri: 105387 title: CEN22LA289 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105358/pdf description:
Unique identifier
105358
NTSB case number
CEN22LA289
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-24T16:18:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-06-27T17:48:28.246Z
Event type
Accident
Location
Monee, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On June 24, 2022, about 1518 central daylight time, a Glasair II FT airplane, N350CP, was substantially damaged when it was involved in an accident near Monee, Illinois. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot was conducting power-off aerodynamic stall recoveries about 3,000 ft msl. The pilot reported that the first three stall recoveries were unremarkable. However, before the fourth stall, the airplane’s deceleration rate and pitch attitude were greater than the previous three stall entries. The airplane snapped to the left and rolled inverted. It continued to roll and settled into an upright left spin with a relatively flat nose-down pitch attitude between 10° and 20°. Multiple attempts to recover from the spin were not successful. The airplane made about 6 complete rotations before it impacted the terrain. The airplane sustained substantial damage to both wings, the fuselage, and the empennage. The pilot reported no malfunctions or failures associated with the airplane before the accident. He noted that initiating recovery at the first indication of the stall might have prevented the loss of control. -
Analysis
The pilot was conducting power-off aerodynamic stall recoveries about 3,000 ft mean sea level (msl) at the time of the accident. The first three stall recoveries were unremarkable. However, before the fourth stall, the airplane’s deceleration rate and pitch attitude were greater than the previous three stall entries. The airplane snapped to the left and rolled inverted. It continued to roll and settled into an upright left spin with a relatively flat nose-down pitch attitude between 10° and 20°. Multiple attempts to recover from the spin were not successful. The airplane made about 6 complete rotations before it impacted the terrain. The airplane sustained substantial damage to both wings, the fuselage, and the empennage. The pilot reported no malfunctions or failures associated with the airplane before the accident. He noted that initiating recovery at the first indication of the stall might have prevented the loss of control.
Probable cause
The pilot’s in-flight loss of control while practicing aerodynamic stall recoveries.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Glasair
Model
II FT
Amateur built
true
Engines
1 Reciprocating
Registration number
N350CP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1008
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-06-27T17:48:28Z guid: 105358 uri: 105358 title: ERA22LA292 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105383/pdf description:
Unique identifier
105383
NTSB case number
ERA22LA292
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-25T11:20:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-08-18T17:39:35.187Z
Event type
Accident
Location
New Market, Virginia
Airport
Franwood Farms Inc Airport (9VA4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 25, 2022, about 1020 eastern daylight time, a Luscombe 8A, N77863, was substantially damaged when it was involved in an accident near New Market, Virginia. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was attempting to take off from a 1,550-ft long, upsloping turf airstrip. At the time of the accident, the prevailing wind was a 3-knot left-quartering headwind, and the ambient temperature was 80°F. The pilot added that, as the airplane lifted off, the engine sputtered for about 3 seconds. The airplane did not gain enough altitude and the right main landing gear and right horizontal stabilizer impacted the top of a 4.5-ft high fence located about 60 ft from the departure end of the runway. The airplane then settled into a field on the other side of the fence and, during the landing roll, the right main landing gear impacted a groundhog hole and collapsed. Initial examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the right horizontal stabilizer. Additional examination of the engine was planned following recovery of the wreckage from the field; however, the pilot did not respond to subsequent requests regarding the disposition of the engine for examination. He also was unable to produce maintenance and pilot logbooks for examination. The airplane was manufactured in 1946 and its Owner’s Handbook indicated, “Take-Off Distance – 625 feet on a hard turf surface.” More recent publications listed a takeoff ground roll of 1,050 ft; however, none of the data accounted for an upsloping turf runway, ambient temperature of 80°F, or distance to clear a 4.5-ft obstacle. -
Analysis
The pilot of the vintage tailwheel airplane was attempting a takeoff from an uphill 1,550-ft-long turf airstrip, with a 3-knot left-quartering headwind and in an 80° F ambient temperature. The airplane lifted off at the end of the airstrip; however, the right main landing gear and right horizontal stabilizer impacted the top of a 4.5-ft high fence. The airplane then settled into a field on the other side of the fence and during the landing roll, the right main gear impacted a groundhog hole and collapsed. Initial examination of the wreckage revealed substantial damage to the right horizontal stabilizer. The pilot reported that the engine sputtered for about 3 seconds before collision with the fence and additional examination of the engine was planned following recovery of the wreckage from the field; however, the pilot did not respond to subsequent requests regarding the disposition of the engine for examination. He also was unable to produce maintenance and pilot logbooks for examination. Whether an engine anomaly may have contributed to the accident could not be determined. Review of the airplane’s owner’s handbook revealed a published takeoff distance of 625 ft on a hard turf surface. More recent publications listed a takeoff ground roll of 1,050 ft; however, none of the data accounted for performance considerations such as an upsloping turf runway, high ambient temperatures, or distance to clear obstacles.
Probable cause
Impact with a fence during an attempted takeoff from a short, uphill turf airstrip.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LUSCOMBE
Model
8
Amateur built
false
Engines
1 Reciprocating
Registration number
N77863
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3590
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-18T17:39:35Z guid: 105383 uri: 105383 title: ERA22LA306 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105454/pdf description:
Unique identifier
105454
NTSB case number
ERA22LA306
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-25T11:20:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-07-13T18:53:44.415Z
Event type
Accident
Location
New Shoreham, Rhode Island
Airport
BLOCK ISLAND STATE (BID)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing flare the airplane “floated more than I expected.” After touching down and seeing he did not have much runway remaining, the pilot applied toe braking, and realized he would not be able to stop before the end of the runway. Instead, he elected to turn to the right exiting the runway into a grassy area and subsequently struck a taxiway sign resulting in substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to attain a proper touchdown point, resulting in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24
Amateur built
false
Engines
1 Reciprocating
Registration number
N7883P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-3111
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-13T18:53:44Z guid: 105454 uri: 105454 title: ERA22LA291 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105375/pdf description:
Unique identifier
105375
NTSB case number
ERA22LA291
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-26T15:10:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-08T16:03:00.312Z
Event type
Accident
Location
Warm Springs, Georgia
Airport
Roosevelt Memorial Airport (5A9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On June 26, 2022, about 1410 eastern daylight time, a Piper PA-24-250 airplane, N14FC, was substantially damaged when it was involved in an accident near Warm Springs, Georgia. The private pilot and passenger sustained serious injuries. The airplane was operated by the pilot as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot reported that the instrument flight rules flight departed from St. Pete-Clearwater International Airport (PIE), Clearwater, Florida, at 1153 and proceeded en route to his home airport of Newnan Coweta County Airport (CCO), Newnan, Georgia. After about 2 hours and 15 minutes, 20 miles south of the destination, the pilot completed an en route descent from 8,000 ft mean sea level (msl) to 5,000 ft msl. Upon reaching 5,000 ft msl, the engine power was set to 2300 rpm; however, it abruptly decreased to 1500 rpm. The pilot reported that the engine did not sputter, but rather it just “rolled back.” He then moved the mixture to rich, ensured the fuel selectors were selected to the main tanks, and turned on the electric fuel pump; however, power did not increase. He then declared an emergency with air traffic control, and they advised him of the Roosevelt Memorial Airport (5A9), Warm Springs, Georgia behind his flight path. The pilot completed a left 180° turn and saw the runway at 5A9 about 6-7 miles ahead, and as he maneuvered toward the runway, the engine lost all power. The pilot realized that he did not have the glide performance to reach the runway and turned toward a small logging road. The airplane impacted terrain and trees during the approach to the small road, which was about 1.5 miles north of the runway. According to a Federal Aviation Administration (FAA) inspector who examined the airplane at the accident site and supervised the recovery of the airplane, the airplane sustained substantial damage to the wings and fuselage. When the airplane’s electrical power was turned on, the left and right main fuel tank gauges displayed a reading of about 1/4 full, and the left tip tank gauge measured just below 1/4 full. When turned on, the electric fuel pump could be heard running. Both fuel selectors were found selected to the main positions. The inspector observed that the main wing fuel tanks were found with no trace of fuel, no breaches of the fuel bladders were observed, and when the wings were removed for recovery, no fuel exited either main fuel tanks. The left tip tank remained connected to the wing, was not breached, and contained about 3 gallons of fuel. The right tip tank separated from the wing, was partially breached, and no fuel was present in the tank. Further examination of the engine at the recovery facility found that the engine displayed crankshaft and camshaft continuity and thumb compression on all cylinders. Both magnetos produced spark and the spark plugs exhibited normal combustion signatures. No anomalies were observed with the engine-driven fuel pump, and it contained no residual fuel. During low pressure air tests of the fuel lines, with the fuel selector positioned to the main wing tanks, no fuel was observed to exit the lines, and no blockages were present. There was no evidence of oil or fuel leakage on the airframe. According to the pilot, throughout the accident flight he switched from using the left and right main tanks and did not use the tip tanks at any point. When he initiated the descent preceding the loss of engine power, he recalled moving both left and right fuel selectors to the main tank on positions. The pilot reported using the electric fuel pump during the loss of engine power; however, carburetor heat was not used during the accident flight. The pilot recalled that the fuel level on both main tanks were near his finger length from full when visually checked during the preflight, but the main tanks were not topped-off. He reported that he utilized the airplane’s onboard fuel calculator to monitor the fuel flow; however, it was not his practice to use the device as a calculator to determine or track the total fuel onboard. He recalled after the accident that 59 gallons of fuel was onboard at takeoff, and that the fuel flow throughout the accident flight was 13 gallons per hour en route. According to basic fuel calculation estimates, the accident flight would have burned about 31 gallons. According to the airplane’s owner handbook and the tip tanks supplemental type certificate (STC), the airplane was equipped with two main fuel tanks per each wing that totaled 60 gallons (30 per main tank) and two tip tanks totaling 30 gallons (15 per tip tank). Photographs of the two fuel selector switches revealed that the engine could be operated from one or both main tanks, and either tip tank. The STC flight manual supplement warned that the fuel selector should not be selected to any tank that is empty, and that the switch should either be placed to a tank with fuel remaining or turned off. The tip tank fuel was only to be used during level flight. Review of the FAA Special Airworthiness Information Bulletin (SAIB) CE-09-35 Carburetor Icing Probability Chart found that the airplane was at risk of serious icing at glide power while descending from 8,000 ft msl to 5,000 ft msl. -
Analysis
The pilot reported that after descending from 8,000 ft above mean sea level (msl) to 5,000 ft msl following a 2 hour cross-country flight, the engine power decreased from 2,300 rpm to 1,500 rpm. The pilot attempted to troubleshoot the partial loss of power by applying full rich mixture, ensuring that both fuel selectors were selected to the main wing tanks, and he turned on the electric fuel pump; however, full power was not restored. The pilot advised air traffic control of the emergency and he was informed of a nearby airport that required a 180° turn. While maneuvering to the airport, the engine lost all power, the descent rate increased, and the airplane impacted terrain and trees as the pilot attempted to land on a small road. The wings and fuselage sustained substantial damage. Examination of the airplane at the accident site discovered that no fuel was present in either main wing tanks, nor was there any evidence that fuel had leaked from either main tanks. The left tip tank contained about 3 gallons of fuel, and the right tip tank was found empty, as it had been breached during the collision with trees. Examination of the engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Furthermore, the main fuel tank fuel lines and engine driven fuel pump displayed no evidence of fuel present when examined. There was also no evidence of in-flight fuel siphoning leakage discovered on the fuselage or wings. The pilot reported that about 59 gallons of fuel was onboard for takeoff. It was estimated that for the 2 hour and 15 minute flight that had elapsed the airplane likely consumed about 31 gallons of fuel. He reported that during the preflight inspection he checked the fuel quantity visually, and he recalled that the main tanks were about his finger length from full. The pilot reported that he did not top-off the fuel tanks before departing, and that throughout the flight he switched between the left and right main fuel tanks, feeding the engine from one main tank at a time. He did not use the tip tanks during the flight. During the descent, he switched both main tanks to the on position. It is likely that the pilot’s initial partial loss of power was due to one of the main tanks containing no fuel, which introduced air into the fuel lines. The flight manual supplemental cautioned pilots from selecting a tank that contains no fuel. A few minutes later, the remaining wing tank likely was exhausted of fuel, which resulted in the total loss of power. The investigation could not determine the discrepancy between how much fuel the pilot reported that he departed with versus what was likely consumed, and ultimately discovered on board at the accident site. The pilot had added fuel multiple times in the days preceding the accident between flights; however, the pilot did not use the fuel calculator onboard the aircraft and the fuel gauges postaccident indicated that both main tanks were about 1/4 full, when in fact they were both empty. These factors contributed to why the pilot likely departed with less fuel than he realized. The pilot could have used the tip tank fuel while en route; however, the tip tanks were only to be used during level flight; thus, after the partial loss of power, the tip tanks were likely not a reliable source of fuel for the engine given the maneuvering that would have been required to reach the alternate airport. Had the pilot departed with sufficient fuel and topped-off the tanks before departure, or managed the fuel appropriately en route, the fuel starvation would have been prevented.
Probable cause
The loss of engine power due to fuel starvation as the result of the pilot’s inadequate preflight inspection of the fuel supply before flight and the mismanagement of fuel during flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N14FC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-924
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-08T16:03:00Z guid: 105375 uri: 105375 title: WPR22LA238 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105391/pdf description:
Unique identifier
105391
NTSB case number
WPR22LA238
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-26T20:45:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2022-07-05T20:05:10.302Z
Event type
Accident
Location
Challis, Idaho
Airport
LOWER LOON CREEK (C53)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Due to a 2,040-ft increase in elevation between the departure airport (4,200 ft msl) and the accident site (6,240 ft msl), the airplane’s climb rate, assuming it was within the center of gravity envelope and the pilot was operating within the airplane owner’s handbook instructions, would have decreased from about 477 feet per minute (fpm) to about 360 fpm. - At the time of departure, the calculated density altitude for the airport was about 6,500 ft and a pressure altitude of 3,930 ft. - On June 26, 2022, about 1945 mountain daylight time, a Piper PA-20-135, N1231C, was substantially damaged when it was involved in an accident near Challis, Idaho. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. On day of the accident flight, a witness observed the accident airplane land at the Lower Loon Creek airport (C53), Challis, Idaho. She spoke briefly with the pilot and passenger, who indicated that they were camping at the Johnson Creek Airport (3U2) but were going to spend the day at Lower Loon. Later that evening, she observed the accident airplane taxi, take off, and then fly into the box canyon. Shortly thereafter, she observed a dust cloud. A friend of the pilot reported that he and the accident pilot were camping at 3U2. Earlier in the day, they had flown to C53 and, due to the density altitude, they waited to depart C53 for the return flight to 3U2, until later that evening. He further added that, at the time of departure, the density altitude was indicating about 6,200 ft msl. He observed the accident airplane depart to the north, climb, and then turn back toward the runway about 1930. He last observed the accident airplane on a southbound heading. Shortly after departing from C53, he observed smoke, which he believed to be a small ground fire. After landing and refueling at McCall Municipal Airport (MYL), McCall, Idaho, he continued his flight to 3U2 where he expected to meet with the accident pilot and passenger. They had not arrived, and he reported N1231C as missing. - The calculated density altitude for the accident time and location was about 8,980 ft msl and a pressure altitude of 5,974 ft msl. - First responders located the airplane wreckage by air, about 1 ½ miles north of C53. The airplane impacted steep, rising mountainous terrain at an elevation of about 6,240 ft msl on an approximate southerly heading. The main wreckage came to rest upright about 30 ft below the initial impact point and was mostly consumed by fire. All major structural components of the airplane were observed at the accident site. Figure 1: Overview of the accident site location. Postaccident examination of the recovered airframe and engine did not reveal evidence of any mechanical anomalies that would have precluded normal operation. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. -
Analysis
A witness at the departure airport watched the accident airplane take off and fly into a box canyon. Shortly thereafter, the witness saw a dust cloud in the same area. A friend of the accident pilot reported that they were camping in the area and had flown to the departure airport earlier in the day. The friend reported that they waited until later in the day to fly back to their camping area due to density altitude considerations. He watched the accident airplane depart to the north and then turn back toward the airport. He then departed in his airplane and flew to the camp site destination, where he expected to meet up with the accident pilot and passenger. He reported them missing when they did not arrive at the camp site. Postaccident examination of the airplane revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. The accident site was in a box canyon about 1 1/2 miles north of the airport at an elevation of 6,240 ft above mean sea level (msl). The change in elevation from the departure airport to the accident location was about 2,040 ft. As the airplane climbed, the calculated climb performance from the departure airport to the accident site location would have likely degraded from about 477 ft per minute (fpm) to about 360 fpm. The accident is consistent with the pilot turning toward rising terrain with limited climb performance that resulted in the pilot’s failure to maintain obstacle clearance and a subsequent impact with terrain.
Probable cause
The pilot's turn towards rising terrain with limited climb performance and his subsequent failure to maintain clearance from terrain that resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA20
Amateur built
false
Engines
1 Reciprocating
Registration number
N1231C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
20-967
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-05T20:05:10Z guid: 105391 uri: 105391 title: RRD22MR010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105369/pdf description:
Unique identifier
105369
NTSB case number
RRD22MR010
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-27T04:00:00Z
Publication date
2023-09-18T04:00:00Z
Report type
Final
Event type
Accident
Location
Mendon, Missouri
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between Amtrak train 4 and the MS Contracting LLC dump truck was the truck driver proceeding for unknown reasons into the highway-railroad grade crossing without stopping despite the presence of a stop sign and approaching train. Contributing to the collision was the grade crossing’s design, which reduced drivers’ ability to see approaching trains and made stopping as required by Missouri law difficult for heavy trucks.
Has safety recommendations
false

Vehicle 1

Railroad name
Amtrak
Equipment type
Passenger train-pulling
Train name
Amtrak train 4
Train number
Southwest Chief
Train type
FRA regulated passenger
Total cars
8
Total locomotive units
2
Findings

Vehicle 2

Railroad name
MS Contracting
Train name
Kenworth Dump Truck
Train type
Unregulated fixed guideways
Findings
creator: NTSB last-modified: 2023-09-18T04:00:00Z guid: 105369 uri: 105369 title: DCA22FM026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105382/pdf description:
Unique identifier
105382
NTSB case number
DCA22FM026
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-06-27T16:15:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-06-15T04:00:00Z
Event type
Accident
Location
Freeport, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire aboard the towing vessel Mary Dupre was undetected cracks in the starboard muffler that allowed exhaust gases from an operating engine to escape and ignite wooden structures affixed to the common bulkhead of an accommodation space. Contributing to the extent of the fire damage was the substantial use of combustible materials in the joinery, outfitting, and furnishings in the accommodation spaces.
Has safety recommendations
false

Vehicle 1

Callsign
WDH2629
Vessel name
Mary Dupre
Vessel type
Towing/Barge
Port of registry
Houma, LA
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-06-15T04:00:00Z guid: 105382 uri: 105382 title: ERA22LA296 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105404/pdf description:
Unique identifier
105404
NTSB case number
ERA22LA296
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-28T11:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2022-07-14T22:21:02.533Z
Event type
Accident
Location
Knoxville, Tennessee
Airport
KNOXVILLE DOWNTOWN ISLAND (DKX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After performing maneuvers in the local area, the pilot receiving instruction and the flight instructor returned to the departure airport and performed two practice landings. During the third landing, the flight instructor heard a “bang” noise and the airplane veered left away from the runway centerline. The airplane came to rest in the grass next to the runway and the airplane’s fuselage and rudder were substantially damaged. A Federal Aviation Administration inspector examined the airplane after the accident. The airplane’s left main landing gear had collapsed and the inspector found that the left main landing gear through bolt was fractured. The inspector further reported that the airplane’s most recent annual inspection had been completed more than 22 months before the accident. Additionally, the airframe manufacturer’s maintenance manual required that the through bolt be removed and inspected at every 100 hour/annual inspection and replaced as necessary, in addition to a mandatory replacement every 500 hours. The airplane’s maintenance records did not show when the last though bolt change had occurred. Based on this information, it is likely that the landing gear collapsed due to a failure of the left main landing gear through bolt, and that the through bolt had likely not been maintained in accordance with the airframe manufacturer’s requirements.
Probable cause
The inadequate maintenance of the left main landing gear through bolt, which resulted in a left main landing gear collapse and subsequent runway excursion during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN CHAMPION AIRCRAFT
Model
8KCAB
Amateur built
false
Engines
1 Reciprocating
Registration number
N721SD
Operator
SUPER D AVIATION TRAINING CO LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
722-93
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-14T22:21:02Z guid: 105404 uri: 105404 title: ERA22LA366 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105686/pdf description:
Unique identifier
105686
NTSB case number
ERA22LA366
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-06-29T12:45:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-09-16T18:21:51.302Z
Event type
Accident
Location
Wilmington, North Carolina
Airport
PILOTS RIDGE (03NC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On June 29, 2022, at about 1145 eastern daylight time, a Piper PA-32RT-300, N4321M, was substantially damaged when it was involved in an accident near Wilmington, North Carolina. The private pilot sustained minor injuries and the passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and a neighbor were taking the airplane for a local pleasure flight. The pilot performed a preflight inspection of the airplane in accordance with the airframe manufacturer’s checklist. He performed a “normal” taxi and engine run up before beginning his takeoff. He reported that shortly after beginning the initial climb, within about 3 to 5 seconds, “the engine hesitated and stopped developing normal takeoff power.” The pilot aborted the takeoff and landed back on the runway he had departed from with about 500 ft of its length remaining (the runway’s total length was 3,000 ft). The runway was wet and the pilot attempted to stop before exiting the runway, but was unsuccessful. The airplane continued through grass and came to rest in a retention pond. A postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane was in about 5 ft of water, in a nose-low attitude, and the airplane’s right wing had been substantially damaged. The inspector observed that there was fuel inside the left wing fuel tank with the appearance and smell of 100LL aviation fuel. The pilot reported there were about 60 gallons of fuel aboard before the takeoff. The airplane’s engine was examined after recovery from the pond. Water drained from the engine crankcase when the oil sump suction screen was removed. The crankshaft could not be rotated by hand. When the interiors of the cylinders were examined with a lighted borescope, water and corrosion debris were observed and the cylinder walls exhibited heavy corrosion. The Nos. 1, 3, and 5 cylinders were removed to gain access to the interior of the crankcase. Continuity of the crankshaft to the rear accessory drive gears and to the valvetrain was confirmed by visual observation. Additionally, no damage to the crankshaft, camshaft, or camshaft followers was observed. The fuel injector servo remained attached to the engine and the throttle and mixture control cables remained attached to the servo through their respective control arms. Liquid with an odor consistent with aviation gasoline drained from the fuel servo when it was tilted, from the fuel hoses connecting the engine-driven fuel pump to the fuel servo, and from the fuel servo to the fuel flow divider. The servo fuel regulator section was partially disassembled, and no damage was noted to the rubber diaphragms or other internal components. The fuel servo fuel inlet screen was absent of debris. The fuel flow divider remained attached to the engine, the fuel injector lines were secure, a few drops of water were drained, and no damage was noted to any of the internal components. The fuel injector nozzles were secure and unobstructed. The engine-driven fuel pump remained attached to the engine, a liquid with an odor consistent with aviation gasoline drained from the pump when it was removed and tilted. The pump produced air at the outlet port when operated by hand and no damage was noted to any of the internal components. The dual magneto was removed from the engine and when its input shaft was rotated using an electric drill, spark was produced from all of the left magneto ignition towers but none of the right towers. The magneto was partially disassembled, and water and corrosion products were observed on the internal components, including the contact points. The spark plugs’ electrodes exhibited dark gray coloration and exhibited a normal wear condition. Water and corrosion were observed in the spark plug electrode wells. No damage to the ignition harness was noted. The vacuum pump remained attached to the engine and no damage was noted. It was removed and produced air at the outlet port when rotated by hand. The oil suction screen exhibited wet, white corrosion products but no metallic debris. The oil filter media was absent of debris. The propeller remained attached to the crankshaft flange. The propeller spinner tip was impact damaged. One propeller blade was undamaged, one was bent aft about 5° at about mid-span, and the remaining blade was bent aft about 15° at about mid-span. The propeller governor remained attached to the engine and no damage was noted. The propeller governor cable remained attached to the governor control arm. The governor drive was rotated by hand and produced oil at the outlet port. The governor oil screen was absent of debris. No evidence of any preimpact mechanical malfunctions or failures of the engine were identified during the examination. A review of maintenance records showed that the airplane’s last annual inspection was completed on May 19, 2022. During the inspection the engine, airframe, and propeller were found to be in an airworthy condition. -
Analysis
The pilot was departing for a local flight, and following an uneventful preflight inspection, runup, and taxi, he began the takeoff. About 3 to 5 seconds into the initial climb the engine sustained a partial loss of power and the pilot elected to land straight ahead on the remaining runway. The runway was wet, and the airplane exited the departure end of the runway, coming to rest in a small retention pond. The pilot received minor injuries, the passenger was not injured, and the airplane’s right wing was substantially damaged. A postaccident examination of the engine found no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation and the reason for the partial loss of engine power could not be determined.
Probable cause
A partial loss of engine power during initial climb for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32RT
Amateur built
false
Engines
1 Reciprocating
Registration number
N4321M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-7985078
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-16T18:21:51Z guid: 105686 uri: 105686 title: CEN22LA297 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105408/pdf description:
Unique identifier
105408
NTSB case number
CEN22LA297
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-01T13:25:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2022-07-02T01:40:11.934Z
Event type
Accident
Location
Air Force Academy, Colorado
Airport
USAF ACADEMY AFLD (AFF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 1, 2022, about 1225 mountain daylight time, a Cub Crafters CC18-180 airplane, N469AK, sustained substantial damage when it was involved in an accident at the U.S. Air Force Academy, Colorado. The pilot sustained minor injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 glider tow flight. The airplane was owned, operated, and maintained by Akima Logistics Services LLC, a federal government contractor. The airplane was part of a fleet used to tow gliders for the U.S. Air Force Academy cadet glider flight training program. Civilian pilots are employed to operate the airplanes. On the day of the accident, the pilot reported for duty to assume the afternoon shift around 1145 and received the daily safety brief from the lead tow pilot. The accident occurred following the pilot’s second glider tow of the day. The pilot classified the approach to runway 16R as normal and stated that he was preparing for a wheel landing. The pilot reported that he encountered “meteorological conditions I hadn’t seen/felt before,” and the airplane began to “drift quickly left” “more forcibly than normal turning tendencies.” The pilot decided to initiate a go-around. As the airplane accelerated during the go-around, it started “turning/yawing” even though the pilot was trying to accelerate straight and level. The pilot surmised this was from the same meteorological effect that initially pushed the airplane left, and he classified it as a “wind vane effect.” The pilot noticed that the airplane seemed to yaw to the right without the wing drop characteristics of an aerodynamic stall. The airplane began descending, touched down, and came to rest inverted in a grass field. The glider tow rope remained attached to the airplane. The pilot egressed from the airplane via the cockpit door without further incident. The airplane sustained substantial damage to both wings and the empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. First responders provided medical treatment to the pilot at the accident site. The first responders reported that they smelled alcohol on the pilot’s breath in the ambulance. The pilot admitted to first responders that he had consumed alcohol earlier that morning. The pilot’s evaluation upon arrival at the local hospital included a clinical serum ethanol test that was collected at 1324 and showed a serum ethanol level of 0.079 g/dL. The physician’s note documented that first responders reported that the pilot smelled like alcohol and had been drinking 8 hours before the flight. The physician documented that the pilot admitted to drinking alcohol the night before the accident date but could not state the amount that he had consumed or when he had stopped drinking, although the pilot felt that it had been more than 8 hours before flying. The physician documented alcohol intoxication among the pilot’s visit diagnoses. The FAA Forensic Sciences Laboratory performed toxicological testing of leftover specimens from the pilot’s postaccident hospital care that found ethanol at 0.057 g/dL in the pilot’s blood. The pilot’s employer subjected him to a non-Department of Transportation (DOT) breath alcohol test following the accident. According to records of this test, the test was performed at 1702, and was negative. The pilot’s employer also subjected him to a non-DOT urine drug test following the accident. According to records of this test, it was collected at 1707. A medical review officer verified the urine drug test results, reporting the test as negative for tested-for substances. -
Analysis
The glider tow pilot had completed one flight and was returning to the airport following the second tow of the day. The pilot reported that, during the approach, he encountered a meteorological effect and the airplane drifted to the left and the pilot decided to initiate a go-around. As the airplane was accelerating during the go-around, it started “turning/yawing” even though the pilot was trying to accelerate straight and level. The pilot surmised this was from the same meteorological effect that initially pushed the airplane left. The pilot noticed that the airplane seemed to yaw to the right, the airplane began descending, touched down, and came to rest inverted in a grass field, resulting in substantial damage to both wings and the empennage. The pilot admitted to first responders that he had consumed alcohol earlier that morning. The pilot was evaluated at a hospital, where he was diagnosed with alcohol intoxication based on a serum ethanol test result of 0.079 g/dL collected about one hour after the accident. It is likely that the pilot was experiencing impairing effects of ethanol at the time of the accident. It is unknown whether ethanol’s impairing effects were worsened by altitude effects (the field elevation of the airport was about 6,500 ft above mean sea level); however, it is likely that ethanol effects increased the pilot’s risk of making serious errors and diminished his ability to effectively maintain airplane control. Thus, pilot impairment from effects of alcohol consumption likely contributed to the accident.
Probable cause
The pilot’s failure to maintain airplane control during the go-around, which resulted in impact with terrain. Contributing to the accident was the pilot’s impairment from the effects of alcohol consumption.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUB CRAFTERS INC
Model
CC18-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N469AK
Operator
AKIMA LOGISTICS SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Glider tow
Commercial sightseeing flight
false
Serial number
CC18-0088
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-02T01:40:11Z guid: 105408 uri: 105408 title: CEN22LA311 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105444/pdf description:
Unique identifier
105444
NTSB case number
CEN22LA311
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-01T13:30:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-07-13T22:52:21.553Z
Event type
Accident
Location
Mead, Oklahoma
Airport
N/A (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 1, 2022, about 1230 central daylight time, a Rotorsport UK Ltd MTOSport 2017 gyroplane, N44AL, was substantially damaged when it was involved in an accident near Mead, Oklahoma. The pilot was not injured. The gyroplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported initially departing about 0800. He landed “off field to visit a friend” and subsequently departed again about 1100. During that flight, he experienced a partial loss of engine power while in cruise flight. The gyroplane impacted a power line and trees during the forced landing. The fuselage and empennage sustained substantial damaged during the impact. The gyrocopter was recovered from the site 2 days after the accident. The pilot/owner stated that the engine assembly appeared intact and undamaged, and engine control continuity was confirmed. All fuel lines were secure with no chafing damage. About 1 cup of water was recovered from the fuel tank/lines. The fuel tank cap was securely installed, and the seal appeared intact. After installation of a new propeller, an engine test run was conducted by the pilot/owner. It started with some difficulty; however, once it was running, the operation smoothed out and it ran without any obvious anomalies. The aircraft fuel pump operated normally when tested. The pilot noted that the gyroplane was refueled with automotive fuel before the initial flight of the day, and directly from a gas station. He did not use any type of intermediate container such as fuel cans to transfer fuel to the gyroplane and was diligent in obtaining preflight fuel samples. He was uncertain how any water could have been introduced into the fuel system. -
Analysis
The pilot reported a partial loss of engine power during cruise flight. The gyroplane impacted a power line and trees during the subsequent forced landing. The fuselage and empennage sustained substantial damaged during the impact. About 1 cup of water was recovered from the fuel tank/lines. A subsequent engine test run performed by the pilot/owner did not reveal any anomalies with respect to normal operation. The pilot stated that he was diligent in obtaining preflight fuel samples and was uncertain how any water could have been introduced into the fuel system. After an approximate 2-hour flight since refueling, the likelihood of a fuel contamination event was remote. However, based on the subsequent engine run with no anomalies noted, the reason for the partial loss of engine power could not be determined.
Probable cause
A partial loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
Rotorsport UK Ltd
Model
MTOSport 2017
Amateur built
false
Engines
1 Reciprocating
Registration number
N44AL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
RSUK-M01835
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-13T22:52:21Z guid: 105444 uri: 105444 title: CEN22LA303 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105417/pdf description:
Unique identifier
105417
NTSB case number
CEN22LA303
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-02T09:29:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-07-07T19:41:41.203Z
Event type
Accident
Location
Oklahoma City, Oklahoma
Airport
SUNDANCE (HSD)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On July 2, 2022, about 0829 central daylight time, a Piper PA-28-140 airplane, N270SA, sustained substantial damage when it was involved in an accident near Oklahoma City, Oklahoma. The pilot sustained serious injuries and the passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after takeoff from runway 18 at the Sundance Airport (HSD), Oklahoma City, Oklahoma, the airplane did not perform as it normally would. He stated that, as the airplane climbed above the height of the nearby houses, the airspeed and altitude began to decrease. Unable to climb, he allowed the airplane to drift west to avoid “putting anything in danger.” As he began a right turn, he lowered the nose to remain under transmission lines, but the airplane seemed to immediately “fall out of the sky.” The airplane subsequently impacted the ground and slid to a stop, which resulted in substantial damage to both wings and the fuselage. Several witnesses described seeing the airplane low to the ground, not climbing, and in a right turn before it impacted the ground. A review of weight and balance documentation revealed that the airplane had a basic empty weight of 1,263.04 lbs. The pilot stated that he weighed 180 lbs and the passenger weighed about 300 lbs. He stated that the airplane was filled to the tabs with fuel, which equated to about 36 gallons. With no reported cargo, the airplane’s weight totaled 1,959.04 and the center of gravity (CG) was 86.24 inches aft of datum. The maximum gross weight of the airplane was 2,150 lbs and the forward CG limit was 84 inches and the aft CG limit was 95.9 inches. When the weight and balance envelope is viewed in a graphical format in the Type Certificate Data Sheet, it becomes evident that the forward CG limit changes with weight. When the airplane was 1,650 lbs or less, the CG forward limit was 84 inches and the aft limit was 95.9 inches. At 1,975 lbs, the forward limit was 85.9 inches and the aft limit was 95.9 inches. (See Figure). Weight and Balance Envelope from the Type Certificate Data Sheet for Serial Number 28-21576 A postaccident examination of the airframe and engine did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The computed density altitude based upon the field elevation of 1,192 ft, an altimeter setting of 29.97 and a temperature of 26° C was 2,729 ft. -
Analysis
The pilot reported that after takeoff, as the airplane climbed above the height of the nearby houses, the airspeed and altitude began to decrease. Unable to climb, he allowed the airplane to drift to the right to avoid “putting anything in danger.” As he began a right turn, he lowered the nose to remain under transmission lines, but the airplane seemed to immediately “fall out of the sky.” The airplane subsequently impacted the ground and slid to a stop, which resulted in substantial damage to both wings and the fuselage. A postaccident examination of the airframe and engine did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. A calculation of the weight and balance revealed that the airplane was within both weight and center of gravity limitations.
Probable cause
The pilot’s failure to maintain adequate airspeed for unknown reasons during the initial climb, which resulted in an inadvertent aerodynamic stall and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N270SA
Operator
SUNDANCE AIRPORT FBO LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-21576
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-07T19:41:41Z guid: 105417 uri: 105417 title: CEN22FA298 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105410/pdf description:
Unique identifier
105410
NTSB case number
CEN22FA298
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-02T12:35:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-07-12T23:53:45.907Z
Event type
Accident
Location
St. Jacob, Illinois
Airport
ST LOUIS METRO-EAST/SHAFER FLD (IL48)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
The Piper Comanche PA-24-250 Owner’s Manual, Design Features, 1. Specifications, stated that the cruising range with 60 gallon fuel tanks, at sea level, and 75% power is 4.3 hours. Aircraft logbooks provided by the pilot’s son included a separate page that was not part of the “Aircraft Log”. The separate page did not cite the aircraft’s registration number and had only three printed entries that were not consistent in completion and format as those entries in the “Aircraft Log” and “Engine Log.” These entries did not meet requirements cited in 14 CFR Part 43.11, “Content, form, and disposition of records for inspections conducted under parts 91 and 125 and 135.411(a)(1) and 135.419 of this chapter.” The first entry on the separate page stated that an annual inspection was completed and it was signed by an airframe and powerplant mechanic with inspection authorization. The first entry had a date entry of April 12, 2022, and had blank entries for aircraft total time and tachometer time. The second entry on the separate page was for a 100-hour inspection of the engine with the pilot’s printed name and airframe and powerplant certification number; there was no signature. The second entry’s aircraft total time, tachometer, time since major overhaul, and date were blank. The third entry on the separate page was for an oil change with the pilot’s printed name and airframe and powerplant certification number; there was no signature. The third entry’s aircraft total time, tachometer, time since major overhaul, and date were blank. - On July 2, 2022, at 1135 central daylight time, a Piper PA-24-250, N5235P, was involved in an accident near St. Jacob, Illinois. The airplane was destroyed. The pilot rated passenger received serious injuries and the pilot was fatally injured. The airplane was operated under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The private pilot/airplane owner and his son departed in the accident airplane from St Louis Metro-East Airport/Shafer Field (IL48), St Jacob, Illinois, to pick up the airline-transport-pilot-rated passenger at Eagle Creek Airpark (EYE), Indianapolis, Indiana. The pilot was to familiarize the pilot-rated passenger with the airplane so that he could later provide flight instruction to the pilot’s son. Before departure from IL48, the airplane was “topped off” with fuel by the pilot’s son, and no fuel was obtained at EYE. Before departure from EYE, an “abrupt” airplane preflight was performed and the airplane fuel system was not sumped, and the fuel level within the fuel tanks was not [visually] checked. Upon return to IL48, the pilot’s son stated that he exited the airplane and at that time the right fuel tank gauge indicated just under a ¼ tank, and the left fuel tank gauge indicated just under ½ tank; he estimated there was about 12 gallons of fuel remaining. The pilot’s son stated that after he exited the airplane, his father and the pilot-rated passenger switched seats so that the pilot-rated passenger was in the left seat and the his father was in the right seat. They then performed five normal takeoffs and full-stop landings. He heard the engine sputter on the last takeoff, the landing gear retracted, and the airplane began to climb. The airplane then rolled to the right, nosed down, and impacted the terrain. The pilot-rated passenger stated that they were “just above the treetops” when the engine lost power during climbout from the sixth takeoff. He noted that the pilot took control of the airplane and began “actions that you would undertake following engine power loss.” Although he recalls the pilot turning the airplane to the right “pretty aggressively,” he did not recall any indications of a stall, such as a stall warning horn, before the airplane quickly descended in a nose-low attitude into the ground. A witness stated that he saw the airplane make several full-stop takeoff and landings before the accident takeoff, during which the “engine started to sputter right after it lost power, in and out couple of times.” The airplane’s right wing then dropped down, and the airplane started to rotate clockwise as viewed from above. He saw the airplane descend behind a hill with a soybean field, at which time he lost sight of the airplane. - The 60-year-old male pilot held a second class medical certificate with the limitation that he must wear corrective lenses and possess glasses for near/intermediate vision. At his most recent Federal Aviation Administration (FAA) medical certification examination on January 19, 2022, he reported taking no medications. He had a history of hay fever and asthma. According to the autopsy report, the cause of death of the private pilot was craniocerebral, thoracic, and abdominal blunt trauma, and the manner of death was accident. The private pilot was found to have an enlarged heart (600 grams) with a left ventricular wall of 1.6 centimeters and 50% atherosclerosis in his left anterior descending and right coronary arteries. Toxicology testing detected the generally non-impairing asthma medication albuterol in the private pilot’s cavity blood and urine. The 39-year-old male pilot-rated passenger held a first class medical certificate without limitation. At the time of his most recent FAA medical certification examination on May 27, 2022, he reported no medical concerns, and no significant conditions were identified on physical examination. No specimens were obtained from the pilot-rated passenger for toxicology testing. - The pilot/owner held a mechanic’s certificate with airframe and powerplant ratings in addition to his pilot certificate and ratings. The pilot’s logbook showed entries for the completion of flight reviews in 2017, 2019, and an undated entry for the completion of a flight review. A National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident form was not received from the airline-transport-pilot-rated passenger. - The airplane impacted terrain and came to rest in an upright attitude in a field southeast of the departure end runway 13. The airplane wings, fuselage, and empennage exhibited vertical crush/deformation and low-speed impact features. The airplane was destroyed by impact forces. Postaccident examination of the airplane’s fuel system revealed that both wing fuel lines were attached and secured to their respective fuel tanks and to the fuel selector assembly. The fuel lines were unbroken and did not exhibit fuel leakage. There was no usable fuel in either the left- or right-wing fuel tanks. Air was heard flowing from the wing’s respective fuel filler ports and into their respective fuel tanks when air was blown into the left- and right-wing fuel tank underwing vent tubes. Fuel system diagrams show that the airplane’s main fuel tank lines connect to the fuel selector assembly, which provide left, right, and off positions. Fuel cannot flow from a fuel tank when the selector is selected to the opposite tank. The fuel selector handle was found positioned to the right fuel tank. The fuel selector handle was rotated by hand and no detents were felt. The fuel selector handle was positioned to the right and then the left fuel tank, and air was blown into the fuel selector output line. The resultant airflow could be heard from each wing’s respective filler port. Air could not be blown through the fuel selector when the fuel selector handle was in the off position. The fuel flow transducer, which was part of the cockpit fuel flow indicator, was tested and met the manufacturer’s test specifications. Removal of left- and right-wing fuel tank fuel senders revealed that the metal float arm of the left fuel tank sender had an acute angular bend near its midpoint and near its float. The right fuel tank sender float arm had an approximate 45o angular bend near its midpoint. The shapes of both fuel sender arms were not in accordance with the airplane manufacturer’s design specifications. Both sender float arms were able to free fall without binding in both directions of travel and their respective floats did not display weighting from fluid within the floats. Resistance measurements of both senders at the bottom stop, mid-travel, and top stop, showed values of: Left fuel tank: bottom stop - 3 ohms, mid-travel – mid-travel - fluctuated 13-35 ohms, top stop - 32 ohms Right fuel tank: bottom stop 3 ohms, mid-travel - 20 ohms, top stop - 35 ohms The Piper Comanche Service Manual for PA-24-250 (May 1, 2010), Section 8-10, Fuel Quantity Indicating System, specifies the fuel sender resistance when the fuel sender arm was at the bottom stop as: 0.0 to 0.5 ohms. There is no mid-travel resistance specification in the service manual. The fuel sender resistance when the sender arm is at the top stop is specified as 29.6 to 31.3 ohms. The manual states that if incorrect resistance or fluctuation is found, the sender should be replaced. Examination of the wing tank fuel tank bladders revealed that the left-and right-wing tank fuel bladders were collapsed and those areas of collapse were equipped with bayonet attachment clips. The left-wing fuel tank bladder was collapsed at the inboard and forward middle sections from the wing filler port. Three inboard and one forward middle bladder mounting clips were not connected to the top of wing. The left-wing tank fuel bladder was part number (P/N): 524, serial number (S/N) CR544, which replaced original equipment manufacturer (OEM) P/N 454-324, manufactured 6/1998. The right-wing fuel tank fuel bladder was collapsed at the inboard section of the wing filler port. Three inboard bladder mounting clips were not connected to the top of wing. The right-wing fuel tank bladder was P/N: 525, S/N: CR564, which replaced OEM P/N: 454-325, manufactured: 11/1999. The electric-driven fuel pump was drained of about 1 ounce of liquid, consistent in smell and color with 100 low lead (100LL) fuel, through the inlet and outlet lines. A 12V source of DC power was then applied to the pump, and the pump motor was heard operating. The captured liquid that was drained was tested with water sensing paste and there was no change in paste color that would have indicated the presence of water. The fuel pump screens did not contain debris. The engine-driven fuel pump was disassembled and the diaphragm was intact and pliable. There was residual liquid consistent in smell with 100LL and was less than the pump’s internal capacity within the assembly that spilled out during disassembly. The carburetor sustained impact damage and, upon removing the carburetor bowl, there were about 2 ounces of liquid consistent in smell and color with that of engine oil and 100LL fuel. Examination of the engine and engine accessories revealed no mechanical anomalies that would have precluded normal engine operation. Examination of the airframe revealed no other mechanical anomalies, aside from those noted within the fuel system, that that would have precluded normal airplane operation. -
Analysis
The airplane was topped off with fuel on the day of the accident. The airplane was flown to an intermediate airport then back to the original departure airport. After returning to the departure airport, the pilot and a pilot-rated passenger took off to practice full-stop takeoffs and landings. They performed five uneventful takeoffs and landings; during the last takeoff climb, the airplane sustained a loss of engine power. Witnesses reported that the airplane’s right wing dropped and the airplane rotated clockwise, as viewed from above, before it impacted the ground. Postaccident examination of the airplane revealed no useable fuel in the wing’s fuel bladder tanks. Both fuel bladders were collapsed and the attachment hardware for the bladder was not properly attached to the wing. Examination of the fuel system revealed that the fuel sending units had bends on their float arms inconsistent with their design and did not meet airplane maintenance manual specifications for resistance values. Additionally, the fuel selector valve did not contain detents for the position of each fuel tank selection. Examination of the engine, engine accessories, and airframe revealed no other mechanical anomalies that would have precluded normal engine operation. The last maintenance entries that were provided, including the annual inspection, were not part of the airframe and engine logbook(s), and did not show date of maintenance, time-in-service, and signature. Investigators were unable to determine who performed the most recent maintenance of the airplane. The collapsed fuel bladder would have reduced the fuel capacity when the airplane was last serviced with fuel. The fuel sending units likely provided incorrect fuel tank indications on the fuel gauges in the cabin. The pilot likely would have performed fuel calculations based upon the designed fuel tank capacity. Both the diminished fuel bladder capacity due to the collapsed bladders and the improper fuel level indications likely led to the loss of engine power due to fuel exhaustion. The pilot had cardiomegaly with left ventricular wall thickening and moderate atherosclerosis in two coronary arteries. He also had asthma and the bronchodilator albuterol was detected in his blood in urine. While these medical conditions can result in a sudden impairing or incapacitating event, there was no evidence that this occurred. The pilot had opportunity to discontinue the flight if he felt ill, he was actively flying the airplane, and there was a pilot-rated passenger aboard who could assist. Thus, the pilot’s medical conditions were not a factor in this accident.
Probable cause
The inadequate maintenance of the airplane fuel system that resulted in fuel exhaustion and a loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N5235P
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
24-265
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-12T23:53:45Z guid: 105410 uri: 105410 title: CEN22LA308 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105432/pdf description:
Unique identifier
105432
NTSB case number
CEN22LA308
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-03T08:35:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2022-07-08T02:37:38.07Z
Event type
Accident
Location
Aurora, Colorado
Airport
COLORADO AIR AND SPACE PORT (CFO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 3, 2022, about 0735 mountain daylight time, an experimental, Vans RV-6 airplane, N184CB, sustained substantial damage when it was involved in an accident near Aurora, Colorado. The pilot was not injured; the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane had a total of 35 gallons of fuel onboard for the cross-country flight. The pilot reported that, shortly after takeoff from runway 26, as he began a left turn, the engine lost total power. The pilot contacted the control tower about the loss of engine power, and he was cleared to land on runway 8. After assessing the altitude and airspeed, the pilot determined that the airplane would not be able to land on runway 8 and he decided to perform a forced landing straight ahead to a flat cornfield. The airplane came to rest upright in the field and the occupants egressed without further incident. The airplane sustained substantial damage to the engine mount and the lower fuselage. A postaccident examination of the airplane revealed a piece of black plastic material lodged in the carburetor throttle body downstream of the air intake filter. The foreign object debris (FOD) was like the material used with common trash bags. The pilot reported that he did not know where the FOD may have originated. The pilot reported that the last time the area, consisting of the air filter, the air filter bowl, and the carburetor, was accessed was in April, 2021, when the pilot, working as a repairman, performed inspection work. At the time of the accident, the airplane had accumulated about 62 flight hours since that inspection. In the RV-6 series airplanes, the carburetor heat valve provides heated air forward of the air filter; thus, the carburetor heat air flow does not bypass the air filter. -
Analysis
The pilot of the experimental airplane reported that the engine lost total power shortly after takeoff. The pilot decided to perform a forced landing straight ahead to a flat cornfield which resulted in substantial damage to the engine mount and lower fuselage. Postaccident examination of the airplane revealed a piece of black plastic material lodged in the carburetor throttle body. The foreign object debris (FOD) was similar to the material used with common trash bags. The pilot reported that he did not know where the FOD may have originated. It is likely that the FOD blocked the engine’s air intake, which resulted in a total loss of engine power. The airplane’s carburetor heat valve provided heated air forward of the air filter; thus, the carburetor heat air flow did not bypass the air filter. While is it possible that the FOD may have been left in the carburetor heat system during previous maintenance work about 60 flight hours before the accident, the source of the FOD and when it was introduced could not be determined based on the available evidence. It is likely that the FOD, which was lodged in the carburetor throttle body, blocked air intake for the engine, which resulted in a total loss of engine power.
Probable cause
A total loss of engine power due to foreign object debris blockage of engine air intake. The source of the debris could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
true
Engines
1 Reciprocating
Registration number
N184CB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25454
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-08T02:37:38Z guid: 105432 uri: 105432 title: ERA22LA310 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105470/pdf description:
Unique identifier
105470
NTSB case number
ERA22LA310
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-03T10:30:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-15T17:28:23.822Z
Event type
Accident
Location
Findlay, Ohio
Airport
NONE (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 3, 2022, about 0930 eastern daylight time, a Cub Crafters CC11 160 airplane, N55JV, was substantially damaged when it was involved in an accident near Findlay, Ohio. The commercial pilot was not injured. The airplane was operated by the pilot as a flight test conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot reported that the airplane was involved in an accident in 2020 (in which he was not the pilot). He purchased the airplane and made extensive repairs to return it to an airworthy condition. This accident flight was the first test flight since the previous accident. The pilot taxied from his property to an adjacent off-airport soybean farm field and performed a run-up without issue. He then operated the electric horizontal stabilizer trim via the rocker switch on the control stick, to the “nose up position” as indicated on the primary flight display (PFD). He then moved the trim back in a nose down direction towards the neutral takeoff position.   When the trim indicator reached the takeoff position, he removed his thumb from the trim switch and initiated the takeoff roll. The airplane accelerated normally, and he moved the control stick aft to rotate; however, he felt a “very heavy” nose down pressure on the control stick. He immediately aborted the takeoff and, in his effort to slow the airplane, it nosed over. The left wing and empennage sustained substantial damage. A Federal Aviation Administration (FAA) inspector examined the airplane after it was moved from the accident site. The horizontal stabilizer trim position found at the flight control surface and as indicated on the PFD was consistent with a full nose down setting. The pilot reported that shortly after the accident he observed this trim setting as well. Examination and tests of the trim rocker switch found that it would move the horizontal stabilizer; however, when the switch was released, it would not return to the neutral position as designed. In order to stop the trim movement, the switch needed to be moved to the center position, or else it would continue until the maximum nose up/down limit was reached. The airplane’s operating manual described that pitch trim was accomplished via an electric servo which moved the leading edge of the horizontal stabilizer up and down, changing the angle of incidence. The servo was actuated with a rocker switch located on the control stick. Review of maintenance records found that the accident pilot was the mechanic who completed the major repair and alteration and the most recent conditional inspection. The repairs were completed and signed off on June 27, 2022. According to the FAA inspector who interviewed the mechanic/pilot, he was unable to provide evidence or indication that the trim switch had been inspected for proper operation during the most recent repairs or preflight prior to the flight test. The airplane was involved in an accident on September 18, 2020 (National Transportation Safety Board investigation identification number CEN20CA404). The trim system was not reported as a factor in the accident. -
Analysis
The pilot, who was also a mechanic, purchased the airplane after it had been involved in an accident. The pilot completed major repairs and a conditional inspection on the airplane and planned to complete the first test flight from a soybean farm field near his residence. He taxied the airplane to the field and completed a normal run-up. He then operated the electric horizontal stabilizer trim, via the rocker switch on the control stick, to the takeoff position (full nose up) as indicated on the primary flight display (PFD). When the trim indicator reached the takeoff position, he removed his thumb from the trim switch and initiated the takeoff roll. The airplane accelerated normally, and he moved the control stick aft to rotate however, a heavy nose down pressure was felt. He immediately aborted the takeoff and, in his effort to slow the airplane, it nosed over. The left wing and empennage sustained substantial damage. Examination of the horizontal stabilizer trim position found that it was set to a full nose down position, as observed at the control surface and on the PFD trim indication. Examination of the trim rocker switch found that it would operate the trim actuator; however, when the switch was released, it would not return to the neutral position as designed. In order to stop the trim movement from continuing to run until it reached its maximum nose up/down limit, the switch was required to be moved to the center position, which would stop the trim movement. It is likely that the stabilizer trim continued to operate towards the nose down position during the takeoff roll, after the pilot had released his thumb from the switch, which resulted in the pilot feeling a heavy nose down force during the takeoff. There was no evidence that the pilot/mechanic evaluated the rocker switch’s proper operation during the major repairs and recent conditional inspection. Had he inspected the switch for proper movement, it is likely that he would have detected the faulty condition of the switch, and the accident likely would have been prevented.
Probable cause
The pilot/mechanic’s inadequate inspection of the faulty horizontal stabilizer trim switch, which resulted in an uncommanded trim movement during the takeoff roll, which resulted in an aborted takeoff, and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUBCRAFTERS INC
Model
CC11-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N55JV
Operator
C & J AIR INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
CC11-00392
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-15T17:28:23Z guid: 105470 uri: 105470 title: CEN22LA307 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105431/pdf description:
Unique identifier
105431
NTSB case number
CEN22LA307
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-04T08:35:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-01T20:35:13.975Z
Event type
Accident
Location
Frankston, Texas
Airport
Aero Estates Airport (T25)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that during a takeoff from a wet grass airstrip, he glanced down at a point down the runway that had a reduction in elevation. When he looked back up, his perception of the tree height at the end of the runway increased. He stated that he aborted the takeoff even though the airplane attained rotation speed. The airplane slid about 1,200 ft down and off the runway end and impacted trees and terrain. The airplane sustained substantial damage to the left wing and fuselage. The pilot stated there was no mechanical malfunction/failure of the airplane that would have precluded normal operations.
Probable cause
The pilot’s delayed aborted takeoff that resulted in a runway overrun and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32RT-300T
Amateur built
false
Engines
1 Reciprocating
Registration number
N25RC
Operator
Pilot
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32R-7887078
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-01T20:35:13Z guid: 105431 uri: 105431 title: ERA22LA365 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105685/pdf description:
Unique identifier
105685
NTSB case number
ERA22LA365
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-04T16:50:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-09-06T17:44:55.096Z
Event type
Accident
Location
Windsor, Virginia
Airport
Garner Airport (3VA8)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that after departing for local area soaring, he found himself in “dying lift”. He attempted to recover altitude but was unsuccessful. He said that the glider encountered additional “sink” and did not have sufficient altitude to reach the airport. During the forced landing on rough terrain the left wing sustained substantial damage. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the glider that would have precluded normal operation.
Probable cause
The glider’s encounter with atmospheric conditions, where lift was not sufficient to maintain flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 1-26D
Amateur built
false
Registration number
N249AF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
421
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-06T17:44:55Z guid: 105685 uri: 105685 title: ERA22LA298 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105424/pdf description:
Unique identifier
105424
NTSB case number
ERA22LA298
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-04T20:01:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-07T21:27:03.829Z
Event type
Accident
Location
Akron, Ohio
Airport
AKRON FULTON INTL (AKR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On July 4, 2022, about 1901 eastern daylight time, a Cessna 172M, N12115, was substantially damaged when it was involved in an accident near Akron, Ohio. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and passenger were returning from Connecticut and had stopped at Skyhaven Airport (76N), Tunkhannock, Pennsylvania, to fuel the airplane on the way back to Weltzien Skypark Airport (15G), Wadsworth, Ohio, which was the pilot’s home airport. Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that the airplane was first detected at 1627 shortly after departing 76N. The airplane climbed to an altitude of about 4,500 ft mean sea level (msl) and continued a westerly course for about 2 hours 15 minutes. The pilot reported that, as he began a descent toward 15G and looked at the fuel gauges, he noted that he had never recalled seeing them so low. He decided to divert to the Akron Fulton Airport (AKR), Akron, Ohio, to purchase fuel, and turned toward the southwest. Shortly after, the engine stopped producing power. The passenger questioned the pilot when “all of a sudden, everything got quiet,” and he responded, “We're out of fuel.” He executed a forced landing to a parking lot; however, on final approach, the landing gear impacted trees and the airplane pitched down. Track data showed that after the southwesterly turn, the airplane descended and impacted a parking lot .9 nautical mile short of runway 25 at AKR. Examination of the accident site by a Federal Aviation Administration (FAA) inspector revealed that the airplane impacted the parking lot nose-first, substantially damaging the fuselage and right wing. The FAA inspector noted no fuel odor at the accident site. Fuel receipts obtained after the accident supported the pilot’s statement that he purchased fuel at each stop along his route of flight. The 76N airport manager watched the pilot fuel the airplane and believed that he “topped off both tanks.” In a follow-up interview with the pilot, he stated that he occasionally leaned the mixture, but not always, and that on the accident flight he was “fighting a headwind . . . and was running [the engine] more rich than normal.” He reported that he typically set the power to 2,350-2,400 rpm. Postaccident examination of the airplane revealed no fuel in the fuel lines or carburetor bowl and a trace amount of fuel in the fuel filter. Examination of the fuel selector revealed no preimpact anomalies. The left and right fuel tanks were removed and examined, and no leaks were noted in the left fuel tank. The right fuel tank was impact damaged and breached. The left fuel tank fuel screen was free of obstruction. The airplane had an endurance of about 3.9 hours with 38 gallons of useable fuel. Referencing the Owner’s Manual Cruise & Performance Range Chart, at maximum gross weight with standard conditions, zero wind and lean mixture, the fuel consumption would be 8.1 gallons per hour (gph) at 75% power and 5,000 ft msl. According to ADS-B data, the first flight was 2.2 hours. Adding 1.75 gallons for takeoff, the fuel consumption would have been 19.57 gallons. Per the airport owner’s statement, the pilot performed a go-around maneuver on his first landing attempt at 76N. Adding an additional gallon for the go-around, the total fuel consumed would have been 20.57 gallons. The fuel receipt from 76N indicated 11.23 gallons were purchased, bringing the total fuel available for the accident flight to 28.66 gallons. According to ADS-B data, the flight was 2.6 hours, with a total fuel consumption of 22.92 gallons including 1.86 gallons for takeoff. Using the above-described standard conditions, at the time of the accident, the airplane would have had 5.74 gallons of fuel remaining. The Owner’s Manual states that: “Allowances for fuel reserve, headwinds, take-off and climb, and variations in mixture leaning technique should be made and are in addition to those shown on the chart.” The Operator’s Manual for the Lycoming O-320 series engine indicated a fuel consumption of 8.8 gph at 2,350 rpm, 65% economy cruise. At this fuel consumption rate, the first flight would have consumed 22.11 gallons (climb fuel 1.75 gallons, 2.2 hours at 8.8 gph, plus one gallon for the go around), leaving 15.89 gallons fuel available. Adding the 11.23 gallons purchased at 76N, the airplane would have had 27.12 gallons available for accident flight. The accident flight consumed 24.74 gallons (climb fuel 1.86 gallons, 2.6 hours at 8.8 gph). This would have resulted in 2.38 gallons remaining at the time of the accident. These calculations do not include leaning procedures, or fuel used during start, taxi, and run-up. -
Analysis
The pilot fueled the airplane before takeoff on the last leg of the cross-country flight. As he began the descent toward his home airport, the pilot noted that the fuel gauges were indicating lower than he had ever observed them to be. Shortly after he turned to a nearby airport to purchase additional fuel, the engine stopped producing power. During the forced landing, the airplane’s landing gear impacted trees, and the airplane descended nose-first to the ground, substantially damaging the fuselage and right wing. Examination of the wreckage revealed no evidence of fuel in the fuel tanks, fuel lines, or carburetor. No preimpact anomalies or malfunctions that would have precluded normal operation were observed. Fuel calculations for the takeoff and cruise portions of the accident flight revealed that between about 2 and 6 gallons of fuel could have remained at the time of the accident; however, these calculations did not account for improper fuel mixture leaning or fuel used during start, taxi, and run-up. Given that the pilot did not lean the mixture during the cross-country flight, it is likely the airplane’s fuel supply had been completely exhausted, resulting in the total loss of engine power. Had appropriate preflight fuel planning and inflight fuel monitoring been performed by the pilot, the fuel exhaustion likely would have been prevented.
Probable cause
The pilots’ improper preflight fuel planning and in-flight fuel management, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N12115
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17261818
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-07T21:27:03Z guid: 105424 uri: 105424 title: ERA22LA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105428/pdf description:
Unique identifier
105428
NTSB case number
ERA22LA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-05T14:00:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-07-31T18:24:23.549Z
Event type
Accident
Location
Plymouth, Connecticut
Airport
WATERBURY (N41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot described the takeoff from the 2,000 ft-long turf runway surrounded by tall trees. He stated the airplane was making “takeoff power” and that all instruments were “in the green.” At the departure end of the runway the airplane encountered “windshear or a downdraft” and that the leaves in the treetops were being “pushed down.” The 6,000-hour pilot said he had never encountered windshear or a downdraft like it before. He said he adjusted the pitch attitude to best angle of climb, but that the airplane settled into the trees and descended to the ground while substantially damaging the wings, fuselage, and the empennage. The Federal Aviation Administration inspector who responded to the accident site discussed the forecast and PIREPS for low-level windshear with the pilot. The pilot said he had reviewed the weather, but as it was “nothing he hadn’t flown in before,” he elected to depart. The pilot reported that there were no pre-accident mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s encounter with known and forecast adverse weather which resulted in a collision with trees during the initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N2423A
Operator
HUTTER CHARLES G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18504225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-31T18:24:23Z guid: 105428 uri: 105428 title: ANC22LA054 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105498/pdf description:
Unique identifier
105498
NTSB case number
ANC22LA054
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-05T17:25:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2022-09-21T23:46:39.67Z
Event type
Accident
Location
McGrath, Alaska
Airport
McGrath Airport (PAMC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, after landing, the nose landing gear began a “severe shimmy” and subsequently fractured. The propeller contacted the runway, and the engine mounts sustained substantial damage. The airplane was not made available for examination following the accident, and the source of the shimmy could not be determined based on the available information.
Probable cause
A nose landing gear collapse during landing for reasons that could not be determined based on the available information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182D
Amateur built
false
Engines
1 Reciprocating
Registration number
N8754X
Operator
Thomas C Coyle
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18253154
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-21T23:46:39Z guid: 105498 uri: 105498 title: WPR22LA246 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105453/pdf description:
Unique identifier
105453
NTSB case number
WPR22LA246
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-06T19:45:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-07-13T04:09:34.529Z
Event type
Accident
Location
Silver Springs, Nevada
Airport
SILVER SPRINGS (SPZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 6, 2022, about 1845 Pacific daylight time, a Cessna 172B, N7609X, was substantially damaged when it was involved in an accident near Silver Springs, Nevada. The flight instructor sustained a minor injury and the pilot receiving instruction was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that, after conducting a preflight inspection, they departed the Silver Springs Airport (SPZ), with a planned destination of Fallon Municipal Airport (FLX), Fallon, Nevada. During a power reduction on the instrument approach at FLX, the engine experienced a slight backfiring. On the return flight to SPZ, the engine rpm began to fluctuate, followed by additional backfiring. The engine continued to produce partial power and the pilot completed the emergency loss of engine power checklist. Unable to maintain altitude, the flight instructor elected to land the airplane on open desert terrain near a highway. During the landing roll, the nosewheel collapsed and the propeller impacted terrain. Postaccident examination of the airplane revealed that the fuselage undercarriage was substantially damaged. The engine and various instruments and components were removed from the airplane prior to its recovery by unknown person(s) without authorization, precluding additional examination. -
Analysis
The instructional flight was returning to the airport when the engine rpm began to fluctuate, followed by backfiring. The pilot completed the emergency loss of engine power checklist. Unable to maintain altitude, the flight instructor assumed control of the airplane and performed an off-airport landing on open desert terrain. During the landing roll, the nosewheel collapsed, resulting in substantial damage to the fuselage’s undercarriage. The engine and various instruments and components were removed from the airplane before the airplane was recovered, which prevented examination of the engine and related systems to determine the cause of the loss of engine power.
Probable cause
A loss of engine power for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172B
Amateur built
false
Engines
1 Reciprocating
Registration number
N7609X
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17248109
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-13T04:09:34Z guid: 105453 uri: 105453 title: DCA22LA179 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105738/pdf description:
Unique identifier
105738
NTSB case number
DCA22LA179
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-07T18:30:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-08-15T22:56:44.919Z
Event type
Incident
Location
New York, New York
Weather conditions
Unknown
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight crew of Delta Air Lines Flight 211reported that they experienced roll control difficulties after being informed of a water leak emanating from the two mid cabin lavatories while enroute from the Václav Havel Prague Airport (PRG), Prague, Czechia to the John F Kennedy International Airport (JFK), New York, New York. The event flight was a Line Check flight flown by two complete crews, each consisting of a captain and a first officer (FO). The flight crew who was flying at the time of the event indicated that a flight attendant called and informed them of water leaking from the two mid cabin lavatories. The flight crew who was not flying at the time confirmed that one lavatory was leaking water from under the lower right side of the toilet onto the floor; the water supply was subsequently shut off and the lavatory was locked to prevent further use. The other lavatory was leaking water from on top of the filter canister under the sink; the water supply to the sink was subsequently shut off and the lavatory was left open for toilet use only. The crew cleaned up as much excess water from the floor as possible. The FO who was the pilot flying during the event stated that shortly after the water leak was reported, an AUTOPILOT caution message was displayed on the engine indicating and crew alerting system (EICAS) screen, along with an audible annunciation. The FO disengaged and reengaged the autopilot several times, however the caution messages, and audible indication persisted, and the aircraft made no lateral course corrections. The FO stated that he then disengaged the autopilot and attempted to make the course corrections manually; however, he was unable to move his control wheel to the left more than a couple of degrees of deflection and was thus unable to input the needed corrections. He then transferred control of the airplane to the captain, who confirmed the FO’s findings of minimal control to the left about the longitudinal axis of the airplane. The FO stated that a “Jammed or Restricted Flight Controls” procedure was performed, and, in coordination with dispatch and maintenance control, it was determined that frozen water was a suspected cause due to the multiple water leaks. The flight crew declared an emergency and was given clearance to descend to 9,000 ft where the temperature was above freezing. As the airplane descended through 12,000 ft, a minor “jolt” was felt by the flight crew. After this, the control wheel operated normally, and the flight continued to and landed safely at JFK. There were no injuries to the 233 passengers and crew onboard the airplane. A review of flight data by Boeing revealed evidence of a temporary restriction in the lateral control system, starting shortly before the initial disconnect of the center autopilot. The evidence of a restriction was apparent in both automatic and manual flight and continued until shortly after the descent began from flight level (FL) 360. During the period of restricted movement, the captain’s control wheel showed a restriction at approximately 7 degrees of deflection to the left. Boeing indicated that the 767 lateral flight control system is designed to allow for the override of a restriction in either the captain’s or FO’s flight controls by applying a breakout force to the control wheel on the opposite side. Boeing’s review of the flight data did not find evidence that the airplane lost the ability for an override to take place. The FO’s control wheel position, and control wheel forces for both wheels, is not recorded on the flight data recorder (FDR). The FDR data and statements by the flight crew on the incident flight were inconclusive about the total force input into the flight control system during the event. According to Delta Air Lines, during corrective action after the subject event, the forward and aft lavatory drain mast heater circuit breakers (CBs), located in the electronic equipment bay, were found open. Although there were no current or previous maintenance write-ups on these heaters, Delta removed and replaced them as a precaution. Subsequent testing found the heater elements for the forward drain mast functioned normally. Delta Air Lines reported that before the subject event, this airplane was out of service for maintenance which required pulling the forward and aft lavatory drain mast heater CB’s. It is possible that these CBs were inadvertently left open when the airplane was returned to service on June 23, 2022. Due to the open drain mast heater CBs, it is likely that ice formed in the forward drain mast, allowing drain water from all equipment routed to the forward drain mast to back up in the lines until it leaked outside of the drain system plumbing. The water likely traveled into and drained through the canted pressure bulkhead in the vicinity of aileron control system components located within the main landing gear wheel well. The water likely froze on one or more of the components which led to the pilots’ limited control of the ailerons. Boeing could not identify a location in the roll flight control system where ice formation could restrict both the left and right ailerons if the control wheel breakout was activated.
Probable cause
The failure of maintenance personnel to close the drain mast heater circuit breakers which resulted in the formation of ice in the forward drain mast, an improper flow of wastewater into the main landing gear wheel well, and the formation of ice on one or more aileron system components.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
767-332
Amateur built
false
Engines
2 Turbo jet
Registration number
N181DN
Operator
DELTA AIR LINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
25986
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-08-15T22:56:44Z guid: 105738 uri: 105738 title: DCA22FM027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105436/pdf description:
Unique identifier
105436
NTSB case number
DCA22FM027
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-07-08T04:00:00Z
Publication date
2023-07-11T04:00:00Z
Report type
Final
Last updated
2023-06-16T04:00:00Z
Event type
Accident
Location
Gloucester, Massachusetts
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the flooding and sinking of fishing vessel Grace Marie was uncontrolled flooding of the engine room from an undetermined source, likely a failure of the doubler-plated hull below the engine room.
Has safety recommendations
false

Vehicle 1

Callsign
WCX7766
Vessel name
F/V Grace Marie
Vessel type
Fishing
IMO number
7908366
Maritime Mobile Service Identity
367300850
Port of registry
Gloucester, MA
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-06-16T04:00:00Z guid: 105436 uri: 105436 title: ERA22LA301 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105438/pdf description:
Unique identifier
105438
NTSB case number
ERA22LA301
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-08T14:05:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-07-12T17:11:00.151Z
Event type
Accident
Location
Cleveland, Georgia
Airport
Mountain Airpark (0GE5)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On July 8, 2022, at 1305 eastern daylight time, an experimental amateur-built Kolb Firestar II airplane, N6136Y, was substantially damaged when it was involved in an accident near Cleveland, Georgia. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot/owner held a sport pilot certificate and the airplane was based at the Mountain Airpark (OGE5), Cleveland, Georgia. A review of airpark surveillance video showed the airplane taking off on the grass runway and, as it began its initial climb, the pitch angle increased, and the airplane entered a steep left bank turn. The airplane turned left about 180° and descended behind trees. The airplane collided with a hangar then terrain before it came to rest in the driveway of a residence. The engine sounded normal from the beginning of the takeoff roll until impact. There was no post-impact fire. The airplane was constructed of mostly tube and fabric, and it sustained extensive damage from impact. The cockpit area was crushed. Both wings remained attached to the fuselage but were pushed aft with extensive leading-edge damage. The tail section exhibited minor damage. A Federal Aviation Administration (FAA) inspector responded to the accident site and reported that flight control continuity for the left wing and tail section were established; however, the right aileron was fractured. A section of the right aileron push/pull tube separated from the airplane and was located in the grass near the wreckage. The section of fractured aileron tube was retained and further examined by the National Transportation Safety Board Investigator-in-Charge. Visual examination of the fractured ends of the tube were consistent with overload. The engine sustained impact damage. Compression was achieved on each cylinder when the engine crankshaft was rotated. The fuel, ignition, cooling, and lubrication systems were also examined and no anomalies were observed. The two-bladed propeller remained secured to the engine and both blades exhibited leading edge damage. One of the blades was twisted in its hub due to impact. A postaccident examination of the airframe, engine, and propeller revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The 79-year-old pilot did not have an FAA medical certificate. He was flying a Light Sport Aircraft, and as such, was medically eligible to fly as a light sport pilot with a valid driver’s license. A review of his pilot logbook revealed the last entry was made on April 8, 2022. At that time, he had logged a total of 245.5 flight hours, of which 17.2 hours were in the accident airplane. Before the date of the last log entry, the last time the pilot flew the accident airplane was in February 2022. According to the autopsy report from the Division of Forensic Sciences, Georgia Bureau of Investigation, Decatur, Georgia, the pilot’s cause of death was multiple blunt force injuries, and the manner of death was an accident. Toxicology testing by the FAA Forensic Sciences Laboratory screened negative for drugs of abuse in the pilot’s hospital admission serum sample. Ketamine was detected in the pilot’s cavity blood and urine; its metabolite norketamine was also detected in his cavity blood and urine. Cetirizine, amitriptyline, and its metabolite nortriptyline were detected in the pilot’s urine, but not in his cavity blood. The high blood pressure medications diltiazem and propranolol, the gastric reflux medication famotidine, and the topical anesthetic pramoxine were detected in the pilot’s cavity blood and urine; these four medications are generally considered non-impairing. Hospital records document the administration of ketamine, diltiazem, propranolol, and famotidine. Thus, these drugs were postaccident findings. The hospital records did not show that the potentially impairing medications amitriptyline or cetirizine were administered at the hospital. The pilot’s wife denied any medication use by the pilot. Amitriptyline is an antidepressant that is also used for chronic nerve pain; it is available by prescription. Amitriptyline has a long half-life—30 to 50 hours. Since this medication was not found in either the pilot’s serum or cavity blood and only trace amounts of amitriptyline and its metabolite nortriptyline were in his urine, the source of the amitriptyline was most likely from blood transfusions received postaccident. -
Analysis
The pilot was attempting a soft-field takeoff in his light-sport airplane. A review of surveillance video revealed that, as the airplane began its initial climb, the pitch angle increased, and the airplane entered a steep left bank turn. The airplane turned left about 180° and descended behind trees. The airplane collided with a hangar and terrain before it came to rest in the driveway of a residence. The engine sounded normal from the beginning of the takeoff roll until impact. Postaccident examination of the airframe, engine, and propeller revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of postaccident medical records, including the autopsy data and toxicology reports, revealed no obvious medical issues that would have contributed to the accident. As such, the reason for the pilot’s failure to maintain control of the airplane on takeoff was not determined.
Probable cause
The pilot’s failure to maintain control of the airplane on takeoff for unknown reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KOLB
Model
FIRESTAR
Amateur built
true
Engines
1 Reciprocating
Registration number
N6136Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-12T17:11:00Z guid: 105438 uri: 105438 title: WPR22LA243 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105445/pdf description:
Unique identifier
105445
NTSB case number
WPR22LA243
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-10T15:25:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-07-11T19:02:05.702Z
Event type
Accident
Location
Oxnard, California
Airport
OXNARD (OXR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, the day before the accident, he filled the airplane to capacity with fuel and then flew 50 miles to his home base. On the day of the accident, he visually examined the fuel tanks through the filler caps but did not use a dipstick. The right tank was full, and he determined that the left fuel tank contained about 15 gallons. He selected the right tank for takeoff and initial cruise, however the selector valve handle felt stiffer than usual. About halfway into the flight as he was about to switch tanks, he noticed that the right fuel tank gauge was still indicating full, but the left tank was empty. He confirmed the right tank was selected, but a short time later the engine lost all power. He performed trouble shooting steps and moved the fuel selector valve back and forth, but it now felt loose. A forced landing was initiated at a nearby airport, however, the airplane landed short of the runway, struck a fence, and the right wing sustained substantial damage. Post-accident examination revealed that the right fuel tank had been breached on impact and contained no fuel, and although the left fuel tank was intact, it was empty. There was no fuel in the line from the fuel selector valve to the carburetor, and the carburetor bowl was empty. Both fuel caps were in place at their respective filler necks, all fuel lines fittings were tight, and there was no evidence on the airframe or wings of staining or streaks to indicate an inflight fuel leak. The fuel selector valve handle was pointing to the right tank and could be moved between positions but felt tight and had a rasping action. Once in the respective tank positions, the handle was loose, and no definitive detent was felt. Further examination revealed that the handle was slipping on the selector shaft, which remained stationary at the left tank position. Mooney specifications called for the handle to be keyed in position with a roll pin fitted to the shaft and secured with a set screw. Examination revealed that the roll pin had previously broken, and the handle was instead held in place with an oversized stainless-steel screw in place of the set screw. The screw appeared to have come loose, such that without the roll pin it was not positively attached to the shaft. Under this condition, movement of the handle did not result in movement of the fuel sector valve, and it was stuck in the left position throughout the accident and previous flights. A photo of the instrument panel that the pilot stated he took about 40 minutes before the loss of engine power indicated that the airplane was flying at an altitude of 6,500 ft. The left tank contained between 8 and 10 gallons of fuel. This should still have been sufficient for continued flight beyond the accident location. However, the accuracy of the gauges could not be determined, and the airplane was not equipped with a secondary fuel quantity reference device such as a totalizer. Additionally, because the pilot did not dip the tank before takeoff, the true quantity of preflight fuel could not be determined.
Probable cause
Fuel starvation due to an inappropriately maintained and modified fuel selector valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20C
Amateur built
false
Engines
1 Reciprocating
Registration number
N6416U
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2163
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-11T19:02:05Z guid: 105445 uri: 105445 title: CEN22LA313 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105449/pdf description:
Unique identifier
105449
NTSB case number
CEN22LA313
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-10T19:10:00Z
Publication date
2023-09-14T04:00:00Z
Report type
Final
Last updated
2022-07-13T19:09:26.027Z
Event type
Accident
Location
Rapid City, South Dakota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 10, 2022, about 1810 mountain daylight time, a Piper PA-24-260 airplane, N478WT, sustained substantial damage when it was involved in an accident near Rapid City, South Dakota. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he departed for an estimated 30-minute flight. When the airplane was about 6,000 ft above mean sea level, the engine lost all power. The pilot declared an emergency with air traffic control and stated that he needed to return to the airport. He subsequently switched fuel tanks and attempted multiple engine restarts, but power could not be restored. Unable to reach the runway, he performed a forced landing to a field, during which the airplane bounced, the right main landing gear collapsed, and the airplane slid until it came to rest upright, which resulted in substantial damage to the elevator. The pilot stated that, following the accident, he turned off the fuel selector to prevent a fire. The pilot stated that the airplane had undergone an annual inspection about 2 days before the accident flight. Following the inspection, the pilot flew the airplane in the traffic pattern and then added 30 gallons of fuel to each main fuel tank for a total of 68 gallons of fuel on board the airplane. He said that it was his habit to start the flight with the left main fuel tank selected. When the engine lost power, he switched to the right main fuel tank for the restart attempts. He said that he did not use the auxiliary fuel tanks. During a postaccident examination by the Federal Aviation Administration, fuel was drained from the left and right main fuel tanks as well as the right auxiliary fuel tank. When the left auxiliary fuel tank was checked, no fuel was present. No contaminants were found in any of the fuel samples. A detailed engine examination could not be accomplished because the insurance company sold the wreckage before it was released by the National Transportation Safety Board. -
Analysis
The pilot reported that, shortly after departure, about 6,000 ft above mean sea level, the engine lost all power. He declared an emergency with air traffic control and stated that he needed to return to the airport. He subsequently switched fuel tanks and attempted multiple engine restarts, but power could not be restored. Unable to reach the runway, he performed a forced landing to a field, during which the airplane bounced, the right main landing gear collapsed, and the airplane slid until it came to rest upright, which resulted in substantial damage to the elevator. Following the accident, fuel was drained from the left and right main fuel tanks as well as the right auxiliary fuel tank. When the left auxiliary fuel tank was checked, no fuel was present. No contaminants were found in any of the fuel samples. The pilot stated that he departed with an estimated 68 gallons of fuel on board, after adding about 60 gallons in the main fuel tanks. The wreckage was sold before it could be examined by the National Transportation Safety Board; therefore, the reason for the loss of engine power could not be determined.
Probable cause
A total loss of engine power for reasons that could not be determined because the airplane was unavailable for examination.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N478WT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-4634
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-13T19:09:26Z guid: 105449 uri: 105449 title: ERA22LA326 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105535/pdf description:
Unique identifier
105535
NTSB case number
ERA22LA326
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-10T20:30:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-05T16:09:54.323Z
Event type
Accident
Location
Waynesville, Ohio
Airport
Caesar Creek Soaring Club Gliderport (2OH9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot, who held a private pilot certificate with an airplane single-engine land rating, was transitioning to flying gliders and had about 27 hours of glider flying experience at the time of the accident. On the afternoon of the accident flight he had completed two instructional flights before being signed off for his first solo flight. After departing on the solo flight, the pilot released the glider from the tow airplane at the planned altitude of 2,000 ft above ground level (agl). The pilot knew he was about 2 miles from the departure airport, but he was having difficulty locating the turf runway due to the glare of the setting sun. After descending to about 1,100 ft agl, and still not being able to locate the runway, he selected a corn field for an off-airport landing. The glider’s fuselage and right wing were substantially damaged during the subsequent landing. The pilot reported that there were no preaccident mechanical malfunctions or failures of the glider that would have precluded normal operation.
Probable cause
The pilot’s loss of situational awareness (geographic position), which resulted in his inability to locate the intended landing runway and his decision to perform an off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 2-33A
Amateur built
false
Registration number
N3616Q
Operator
SOARING SOCIETY OF DAYTON INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
567
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-05T16:09:54Z guid: 105535 uri: 105535 title: CEN22LA312 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105448/pdf description:
Unique identifier
105448
NTSB case number
CEN22LA312
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-11T07:30:00Z
Publication date
2024-02-21T05:00:00Z
Report type
Final
Last updated
2022-07-11T23:34:15.212Z
Event type
Accident
Location
Decatur, Illinois
Airport
Decatur Airport (DEC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 11, 2022, about 0630 central daylight time, an Air Tractor AT-502B, N5850R, was substantially damaged when it was involved in an accident at Decatur Airport (DEC), Decatur, Illinois. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 flight. During initial climb out from DEC, the pilot heard a “pop” and observed white smoke trailing the airplane. The pilot noticed a loss of power and lowered the nose to gain airspeed, and then made a forced landing into a bean field, during which the airplane struck an airport perimeter fence that substantially damaged both wings. Postaccident examination of the engine revealed that all CT rotor blades were fractured at varying spanwise locations. The PT rotor blades immediately downstream of the CT exhibited impact damage and were fractured at varying spanwise locations. Circumferential rub was observed on multiple components, most notably the PT vane ring, consistent with engine rotation at impact. The CT rotor blades were removed for materials analysis. A microstructure analysis of sampled blades identified alloy solutioning consistent with exposure to temperatures in excess of engine operating limits. A scanning electron microscope analysis of the CT rotor blades revealed micro-voids along the material grain boundaries, indicative of creep. Pratt & Whitney Canada service bulletin PT6A-72-1767 (revision 5) includes the following information regarding CT blade creep: There can be blade creep at the CT area when the engine is operated at higher temperatures and power than the Pilot Operating Handbook (POH) recommended power settings. To prevent creep-related events, introduce a new CT Disk Balancing Assembly which incorporates redesigned turbine blades made from a different material and increased gap at the blade inter and under platform. The new CT blade design features single-crystal material, which is comprised of a continuous crystal lattice that eliminates grain boundaries to improve creep resistance. The new CT blade was not intended to prevent blade creep if the engine is operated outside of the engine limitations. The service bulletin was not mandated by Transport Canada or the Federal Aviation Administration, so compliance was at the discretion of the owner/operator. -
Analysis
During departure climbout for spray operations, the pilot heard a “pop” and observed white smoke trailing the airplane. The pilot made a forced landing, during which the airplane struck an airport perimeter fence that resulted in substantial damaged to both wings. Examination revealed that all compressor turbine (CT) rotor blades were fractured at varying spanwise locations. The power turbine (PT) rotor blades downstream of the CT blades exhibited impact damage and were fractured at varying spanwise locations. Metallurgical analysis of the CT blades revealed micro-voids were present along the material grain boundaries and rafting of the gamma prime which were indicative of creep. Metallurgical analysis of the CT blades revealed solutioning of the gamma prime which is consistent with exposure to temperature in excess of the engine operating limits. It was not determined if the exposure to elevated temperatures occurred before or during the event.
Probable cause
Fracture of the compressor turbine (CT) blades due to creep.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-502B
Amateur built
false
Engines
1 Turbo prop
Registration number
N5850R
Operator
ADAMS AERIAL SOLUTIONS LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
502B-0685
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-11T23:34:15Z guid: 105448 uri: 105448 title: ANC22FA053 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105476/pdf description:
Unique identifier
105476
NTSB case number
ANC22FA053
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-11T18:30:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-07-16T20:15:10.484Z
Event type
Accident
Location
Valdez, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On July 11, 2022, about 1730 Alaska daylight time, a Champion 7EC airplane, N4340C, was destroyed when it was involved in an accident about 20 miles northeast of Valdez, Alaska. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed from Valdez Pioneer Field Airport (VDZ), Valdez, and was returning to a private airstrip in Sutton, Alaska. When the pilot did not arrive in Sutton, family and friends reported the airplane overdue. The Federal Aviation Administration (FAA) issued an alert notice at 2246, and search personnel from the Civil Air Patrol, Alaska State Troopers, Alaska Air National Guard, and the U.S. Coast Guard, along with several volunteers, searched for the overdue airplane. Due to poor weather conditions along the anticipated flight route and the lack of an emergency locator transmitter (ELT) signal, the wreckage was not located until July 14th in an area known as Thompson Pass, at an elevation of about 2,560 ft mean sea level. Multiple witnesses along the route of flight reported seeing the airplane flying just above the trees in very poor weather conditions. - Toxicology testing indicated that the pilot had used cannabis some time before the accident; however, neither the primary psychoactive compound, THC, nor its short-lived psychoactive metabolite, 11-hydroxy-delta-9-THC, were detected in his blood or urine. The non-psychoactive metabolite, THC-COOH, was detected in blood and urine at very low levels. - An AIRMET Sierra advisory was issued at 1206, valid for the accident site at the accident time, that forecast mountain obscuration conditions due to clouds and precipitation. The Area Forecast valid for the accident site at the accident time was issued at 1204 and forecast few clouds at 600 ft above ground level (agl), with broken clouds at 3,000 agl. After 1600, the Terminal Aerodrome Forecast (TAF) for VDZ expected variable wind at 3 knots, 3 miles visibility, light rain, mist, few clouds at 800 ft agl, a broken ceiling at 1,500 ft agl, overcast clouds at 8,000 ft agl, and cloud tops at 18,000 ft with occasional light rain. The accident pilot did not request nor receive weather information from FAA Flight Services or ForeFlight. A search of archived ForeFlight information indicated that the accident pilot did have a ForeFlight account, which recorded several route string combinations retrieved before the accident flight. It is unknown what, if any, additional weather information the accident pilot viewed before or during the accident flight.An FAA weather camera near the accident site showed near-zero visibility and a cloud layer near the surface (see Figure 1), when compared to the clear day image from the same camera. (see Figure 2.) Figure 1. Weather camera at Thompson Pass, AK Figure 2. Clear day visual of Thompson Pass camera - The student pilot had a solo cross-country endorsement dated March 21, 2022, with limitations of 2,500-ft cloud ceiling, 10 knots of wind, and 5 statute miles visibility; the endorsement expired on June 29, 2022. The pilot’s flight instructor stated that he did not provide any flight planning training for a flight to Valdez and the pilot did not have a cross-country solo endorsement for a flight to Valdez. The instructor had not provided any instruction in flight by reference to instruments to the accident pilot because the pilot’s airplane was not equipped for instrument flight. - The airplane impacted an area of tundra and rock-covered terrain in a near-vertical attitude. Flight control continuity was established from the cockpit to all flight control surfaces. The right aileron cable was separated near the upper pulley in the cockpit, consistent with tension overload. The fuselage had numerous broken frame tubes consistent with impact damage. Fuselage was detached from the wings at the wing attachment points and the firewall. The fuselage came to rest inverted with the tail 90 degrees to the right of the direction of travel. Both wings displayed leading edge impact damage. Both ends of the propeller were curled back toward the spinner with rotational scratches/scoring along the cambered side of the blade. There was evidence of fuel blight and a strong smell of fuel at the accident site. The exhaust, induction, and fuel systems were crushed from impact. Both magnetos remained attached to the engine with no damage. -
Analysis
The student pilot was conducting a solo cross-country flight when he did not arrive at his destination as expected. The wreckage was located three days later at an elevation of about 2,560 ft mean sea level in an area of tundra and rock-covered terrain. Examination indicated that the airplane impacted terrain in a near-vertical attitude. There were no preimpact mechanical malfunctions or anomalies of the airplane that would have precluded normal operation, and the propeller displayed evidence that the engine was producing power at the time of impact. Multiple witnesses along the route of flight reported seeing the airplane flying just above the trees in very poor weather conditions. Weather camera images taken near the accident site around the time of the accident showed near-zero visibility and clouds near the surface. Although these conditions had been forecast, there was no record of the pilot obtaining weather information from an access-controlled source before he departed on the flight. Review of the pilot’s flight training history and endorsements revealed that he did not possess a valid solo cross-country endorsement for the accident flight. The pilot’s flight instructor had not provided any instruction in flight by reference to instruments because the pilot’s airplane was not equipped for instrument flight. Although toxicology testing of the pilot indicated that he had used cannabis at some point before the accident, given that no psychoactive compounds were identified in blood and that urine and blood concentrations of the inactive metabolite, THC-COOH, do not necessarily reflect recent use, it is unlikely that the pilot’s use of cannabis contributed to the accident. Based on the wreckage signature and weather at the time of the accident, the pilot likely lost control of the airplane while maneuvering after encountering near-zero visibility in the dense cloud cover.
Probable cause
The pilot’s decision to continue visual flight rules flight into instrument meteorological conditions which resulted in loss of control and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHAMPION
Model
7EC
Amateur built
false
Engines
1 Reciprocating
Registration number
N4340C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7EC-356
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-16T20:15:10Z guid: 105476 uri: 105476 title: CEN22LA315 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105464/pdf description:
Unique identifier
105464
NTSB case number
CEN22LA315
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-12T11:00:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-14T19:03:37.157Z
Event type
Accident
Location
Eufaula, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 12, 2022, about 1000 central daylight time, a Zenith 650B airplane, N452VC, sustained substantial damage when it was involved in an accident near Eufaula, Oklahoma. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilots, who were both owners and builders of the airplane, while maneuvering during a local flight to adjust the airplane’s autopilot, the engine began to run rough. The engine power continued to decrease until they could not maintain altitude. Unable to make a nearby airport, the pilot flying elected to perform an off-airport emergency landing. During the landing, the airplane impacted uneven terrain, which resulted in substantial damage to the right wing. Postaccident examination of the Corvair conversion engine revealed the No. 5 cylinder exhaust valve rocker arm attach stud/bolt had failed (see Figure). No. 5 cylinder valve components (Photograph provided by the Federal Aviation Administration) About 5 flight hours before the accident, the owners had replaced the No. 5 cylinder exhaust valve, which included the removal and reinstallation of the rocker arm hardware. The push rod contained an oil passage hole on one end that allowed for lubrication of the rocker arm, and the other end did not contain an oil passage. According to the owner, during the installation he incorrectly installed the push rod in a backward position. -
Analysis
According to the pilots, who were both owners and builders of the airplane, while maneuvering during a local flight, the engine began to run rough. The engine power continued to decrease until they could not maintain altitude. Unable to reach a nearby airport, the pilot flying elected to perform an off-airport emergency landing. During the landing, the airplane impacted uneven terrain, which resulted in substantial damage to the right wing. Postaccident examination of the engine revealed the No. 5 cylinder exhaust valve rocker arm attach stud/bolt had failed. About 5 flight hours before the accident, the owners had replaced the No. 5 cylinder exhaust valve, which included the removal and reinstallation of the rocker arm hardware. The push rod contained an oil passage hole on one end that allowed for lubrication of the rocker arm, and the other end did not contain an oil passage. According to the owner, during the installation he incorrectly installed the push rod in a backward position. The incorrect installation did not allow lubrication to reach the rocker arm, causing it to fail.
Probable cause
The loss of engine power due to a push rod that was incorrectly installed by the airplane owner.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
ZODIAC 650B
Amateur built
true
Engines
1 Reciprocating
Registration number
N452VC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
65-8452
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-14T19:03:37Z guid: 105464 uri: 105464 title: ERA22LA308 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105466/pdf description:
Unique identifier
105466
NTSB case number
ERA22LA308
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-13T12:57:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-08-02T21:51:36.477Z
Event type
Accident
Location
Pittstown, New Jersey
Airport
SKY MANOR (N40)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 13, 2022, about 1157 eastern daylight time, a Cessna 150F, N8761G, was substantially damaged when it was involved in an accident near Alexandria, New Jersey. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   According to the pilot, during the initial takeoff roll “something didn’t feel right,” and she noticed she was still not airborne further down the runway than normal. She aborted the takeoff, taxied to a run-up area, and completed a second engine run-up; there were no abnormalities, and the engine rpm was within normal range. She taxied back to runway 7 and departed. During takeoff the airplane was not climbing as expected. The pilot was able to clear the trees but not a set of transmission powerlines ahead, so she performed a forced landing before reaching the powerlines. During the landing roll the airplane impacted uneven terrain and came to rest upright, resulting in substantial damage to the left wing and fuselage.   Postaccident examination of the engine revealed the No. 4 cylinder exhaust valve was stuck closed and could not be opened. There was no heat or impact damage noted. Thumb compression was obtained on cylinder Nos. 1, 2, and 3; no compression was obtained on No. 4. No additional evidence indicated any preexisting mechanical malfunction or failure that would have precluded normal operation. The airplane’s maintenance logs indicate that the engine passed a cylinder compression check at the last annual inspection, about 10 months before the accident. -
Analysis
The pilot reported that during takeoff roll the airplane was not performing as normal. The pilot aborted the takeoff, completed an additional engine run-up and no anomalies were noted. The pilot performed a second takeoff, and the airplane did not gain sufficient altitude to clear powerlines along the flight path. The pilot initiated a forced landing to a field and the airplane sustained substantial damage when it contacted the rough terrain. Postaccident examination of the engine revealed the No. 4 cylinder exhaust valve was stuck closed. No additional evidence indicated any preexisting mechanical malfunction or failure that would have precluded normal operation. Thus, the stuck valve likely caused the partial loss of engine power.
Probable cause
The partial loss of engine power due to a stuck exhaust valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N8761G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15062861
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-02T21:51:36Z guid: 105466 uri: 105466 title: DCA22FM029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105481/pdf description:
Unique identifier
105481
NTSB case number
DCA22FM029
Transportation mode
Marine
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-15T04:00:00Z
Publication date
2023-06-20T04:00:00Z
Report type
Final
Last updated
2023-06-07T04:00:00Z
Event type
Accident
Location
Gig Harbor, Washington
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire aboard the recreational yacht Pegasus was spontaneous combustion due to the self-heating of used oil-soaked rags that had been improperly disposed of on the aft deck of the vessel.
Has safety recommendations
false

Vehicle 1

Callsign
WN5243RR
Vessel name
Pegasus
Vessel type
Yacht
Port of registry
Roche Harbor, Washington
Flag state
USA
Findings
creator: NTSB last-modified: 2023-06-07T04:00:00Z guid: 105481 uri: 105481 title: RRD22FR011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105482/pdf description:
Unique identifier
105482
NTSB case number
RRD22FR011
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-15T12:01:00Z
Publication date
2023-09-12T04:00:00Z
Report type
Final
Last updated
2023-09-12T04:00:00Z
Event type
Accident
Location
Oakland, California
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the Union Pacific Railroad roadway maintenance machine and Amtrak train 531 was the roadway maintenance machine operator moving for unknown reasons onto unprotected track and into the path of an approaching train.
Has safety recommendations
false

Vehicle 1

Railroad name
Amtrak
Equipment type
Passenger train-pulling
Train name
Amtrak 531
Train number
CDTX 2009
Train type
FRA regulated passenger
Total cars
4
Total locomotive units
1
Findings

Vehicle 2

Railroad name
Union Pacific
Equipment type
Special maintenance-of-way equipment
Train name
Pettibone - Speed Swing 445E
Train number
U.P. #SS007
Train type
Unregulated fixed guideways
Findings
creator: NTSB last-modified: 2023-09-12T04:00:00Z guid: 105482 uri: 105482 title: ERA22LA317 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105495/pdf description:
Unique identifier
105495
NTSB case number
ERA22LA317
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-15T13:45:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-07-18T15:31:35.087Z
Event type
Accident
Location
Monticello, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 15, 2022, at 1245 eastern daylight time, a Cessna T210F, N6195R, was destroyed when it was involved in an accident near Monticello, New York. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he conducted an uneventful flight earlier during the day from Maine to Sussex County Airport (FWN), Sussex, New Jersey, to fly a potential buyer in the airplane, which he was selling. After the short flight, the pilot dropped off the potential buyer at FWN and planned to fly to Sullivan County International Airport (MSV), Monticello, New York, for fuel before returning home to Maine. Upon beginning a descent into MSV, the engine began losing power and “making noises.” The pilot verified the fuel quantity and mixture setting, and estimated that 10 gallons of fuel remained in each tank. He switched fuel tanks, but the power loss continued. He subsequently began looking for a place to land the airplane.  The pilot then heard what sounded like an “explosion” from the engine. The oil service door blew open and began spewing oil and smoke from the service door opening, covering the windscreen. Smoke then began entering the cabin. The pilot reported extending the wing flaps and landing gear, but did not have time to verify extension. He identified a field as an emergency landing location. As the airplane approached the field, about 200 ft above the ground, the pilot saw high voltage power lines crossing the field and he repositioned the airplane for a landing on a road. After landing, the airplane caught on fire, and the pilot egressed before the cockpit was consumed. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed that the landing gear did not extend, and that the engine had a large section of the crankcase missing from the forward left side. The No. 6 connecting rod was laying on top of the engine and the crankshaft and camshaft were fractured. Further examination revealed that the engine was thermally damaged. The spark plug wires were burnt. The oil filter was thermally damaged. When it was cut open, metal shavings were noted in the filter element. The fuel pump was thermally damaged; however, the shear shaft was unremarkable. The oil pump was impact damaged and could not be rotated. The turbocharger was thermally damaged but rotated freely. Both magnetos were thermally damaged and would not produce spark on any leads. The oil pan was melted away and missing. The crankshaft and camshaft were fractured at the No. 5 cylinder. The propeller, oil cooler, front section of the camshaft and crankshaft were fractured off the engine. The spark plugs exhibited normal wear. The cylinder skirts on cylinder Nos. 5 and 6 were damaged by the corresponding connecting rod failures and the cylinders could not be removed. The connecting rod for cylinder No. 5 was missing. The No. 6 connecting rod was thermally damaged and discolored. The fuel flow divider was thermally damaged, and the diaphragm was melted. The propeller was thermally damaged, and one blade tip was melted away. Review of the airplane’s maintenance logbooks revealed that 105 and 106 flight hours before the accident (about 5 months), engine through-bolt nuts were removed and resealed due to oil leaks. -
Analysis
The pilot was descending toward the destination airport when the engine began losing power and “making noises.” The pilot switched fuel tanks, but the power loss continued. He subsequently began looking for a place to land the airplane. The pilot then heard what sounded like an “explosion” from the engine. The oil service door blew open and began spewing oil and smoke from the service door opening, covering the windscreen. Smoke then began entering the cabin. The pilot landed on a road with the landing gear retracted, and the airplane slid to a stop. The airplane caught on fire, and the pilot egressed before the cockpit was consumed. Postaccident examination of the engine revealed that the Nos. 5 and 6 connecting rods were fractured. The No. 5 connecting rod was missing and the No. 6 connecting rod exhibited thermal discoloration consistent with a loss of lubrication. The crankshaft and camshaft were fractured at the No. 5 cylinder. Review of the engine logbook revealed that about 100 flight hours (5 months) before the accident flight, engine through-bolt nuts were removed and resealed for oil leaks. Given this information, it is likely that maintenance personnel did not properly torque the crankcase through-bolts, which allowed the No. 5 main bearing to shift, resulting in loss of lubrication to that area and subsequent engine failure.
Probable cause
Maintenance personnel’s improper torque of the engine through-bolts during maintenance, which resulted in a bearing shift, oil starvation, and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210F
Amateur built
false
Engines
1 Reciprocating
Registration number
N6195R
Operator
SIMMONS MARK K TRUSTEE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
T210-0095
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-18T15:31:35Z guid: 105495 uri: 105495 title: ERA22FA314 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105484/pdf description:
Unique identifier
105484
NTSB case number
ERA22FA314
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-15T19:15:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-19T21:40:52.182Z
Event type
Accident
Location
Shelby, Michigan
Airport
Oceana County (C04)
Weather conditions
Instrument Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On July 15, 2022, about 1815 eastern daylight time, a Cessna 210C, N3659Y, was destroyed when it was involved in an accident near Shelby, Michigan. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The flight departed from runway 9 at Oceana County Airport (C04), Shelby, Michigan, with a destination of Warsaw Municipal Airport (ASW), Warsaw, Indiana. Two witnesses, who were both commercial pilots, were at the airport and observed the airplane depart. One witness reported that the ceiling at the time of takeoff was no higher than 100 ft, and the other witness reported that the airplane entered instrument meteorological conditions as it crossed a road about 1,300 ft past the departure end of the runway. Both witnesses reported that the visibility was poor and it was raining at the time.     Another witness, who owned the land were the airplane impacted the ground, was inside his home at the time. He heard a “big roar outside.” He got up to look, thinking it was a tractor-trailer going by his house. He then heard a “big bang,” looked outside his picture window, and saw smoke or dust. He realized that an airplane had crashed adjacent to his house in the woods and the big roar was the engine running and it was “revving up.” The entire sequence lasted about 30 seconds. No recorded radar or automatic dependent surveillance-broadcast (ADS-B) data was recorded for the accident flight. - According to Medical Examiner’s autopsy report from the Western Michigan University School of Medicine, Kalamazoo, Michigan, the cause of death of the pilot was multiple severe injuries and the manner of death was accident. Testing for ethanol and drugs was negative. - At the time of the accident, a low-pressure system was located in Iowa associated with a cold front and stationary front that stretched from Nebraska through southern Iowa and Illinois and eastward through Kentucky. Also, a mid-level trough was located above the accident site. Troughs and fronts can act as lifting mechanisms to help produce clouds and precipitation if sufficient moisture is present. In addition to the Fremont, Michigan Municipal Airport (FFX) weather detailed in this report, C04 weather was provided to investigators by the airport manager. No ceiling information was available for C04; however, at 1815:03, the Automated Weather Observing System recorded wind from 130° at 5 knots, visibility 2 miles, temperature 17° C, relative humidity 98%, and an altimeter setting of 30.09 inches of mercury. National Weather Service forecast information for the area surrounding the accident site included instrument meteorological conditions that were expected to persist beyond 2300. A search of the Leidos and ForeFlight systems revealed that the accident pilot did not request weather information from these providers before the flight. - The pilot’s widow was asked if her husband showed any sense of urgency in commencing the flight in instrument weather conditions. She stated that their son was driving in a demolition derby race in Warsaw and her husband had missed his previous races and did not want to miss this race. - The wreckage was located in a wooded area about 1.5 nautical miles southeast of C04. There was no fire. The wreckage was highly fragmented. The measured descent angle through the broken tree limbs was about 50°. All structural components of the airplane were accounted for within the wreckage path. Smooth, angular cuts, consistent with propeller blade contact, were found on several tree branches scattered throughout the wreckage path. The right wing struck a large-diameter tree and was impact-separated from the fuselage. The right wing was located about 30 ft west of the fuselage. The right flap and a portion of the outboard right aileron were separated from the crushed wing structure. The nose of the aircraft impacted soft, sandy soil and the propeller was embedded about 4 ft deep into the ground. The left wing was also impact-separated and was located about 40 ft east of the fuselage. The left wing was fractured into multiple pieces. The majority of the left flap and the left aileron remained attached to a section of the aft spar. The empennage sustained significant compression damage and remained attached to the crushed fuselage. The left and right horizontal stabilizer and both elevators remained attached. The vertical stabilizer and rudder sustained tree impact damage at approximately mid-span. An approximate 3-ft section of the top of the rudder, with the balance weight attached, was found adjacent to the empennage. Control cable continuity within the flight control system was not established due to the general fragmentation of the wreckage and multiple impact-related cable separations. The hydraulic flap actuators indicated the flaps were in the fully retracted positions. The fuel tanks were fragmented, and pieces of rubber bladder were observed throughout the accident site; no residual fuel was observed. The instrument panel was fractured into multiple pieces. The directional gyro, attitude indictor, and turn coordinator were found near the impact crater. The gyro instruments were disassembled by investigators. All three gyros exhibited minor scoring, indicative of rotation at the time of impact. The airspeed indicator was separated and recovered from the impact crater. The needle was bent aft and captured in place near 230 knots indicated airspeed. Engine compression and valve train continuity could not be established due to impact damage. The magnetos were found loose on top of the engine. Both magnetos sustained impact damage and spark was not produced. The top spark plugs were removed and exhibited normal color and wear when compared to a Champion inspection chart. The engine accessories, including the engine-driven hydraulic pump, fuel pump, vacuum pump, and alternator, were impact-separated from the engine. The fuel pump drive coupling and vacuum pump coupling were found intact. The fuel control inlet screen and fuel manifold screen were clean and free of obstructions. Fuel was observed inside the manifold during disassembly. The oil filter paper element was clean. The propeller assembly was found in the impact crater. One propeller blade was separated from the hub. It was twisted, bent aft, and exhibited polishing and chordwise scratches on the cambered side. The second propeller blade remained attached to the hub. It was bent aft approximately 90 degrees at mid-span. Chordwise scratches were observed on the face of the second blade near the propeller hub, consistent with rotation at the time of bending and impact with the engine cowling. -
Analysis
The accident occurred shortly after the non-instrument rated pilot and passenger departed the airport on a visual flight rules flight in instrument meteorological conditions. Two pilots at the airport reported that the weather was poor at the time of the takeoff, with low ceilings and rain prevailing. After the departure, a local resident who lived about 1.5 miles south of the airport heard the airplane over his property for about 30 seconds, and the engine was “revving up” before the airplane crashed in the woods near his house. The airplane impacted trees and terrain at a steep, nose-low descent angle. The fragmentation of the wreckage and damage to the terrain at the accident site were indicative of a high-speed impact. Examination of the wreckage did not reveal evidence of a preexisting mechanical failure or anomaly that would have precluded normal operation of the airframe or engine. There was no evidence that the pilot obtained a weather briefing prior to the flight. The family of the pilot reported that the purpose of the flight was to attend an event in another state, that he had missed a similar previous event, and that did not want to miss this one. The pilot most likely entered instrument meteorological conditions immediately after takeoff, experienced spatial disorientation, and lost control of the airplane. The pressure that the pilot placed upon himself to attend the event was likely a factor in the accident.
Probable cause
The non-instrument rated pilot’s decision to commence the flight in instrument meteorological conditions, which resulted in spatial disorientation and a subsequent loss of airplane control. Contributing to the accident was the pilot’s self-induced pressure to initiate the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210C
Amateur built
false
Engines
1 Reciprocating
Registration number
N3659Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21058159
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-19T21:40:52Z guid: 105484 uri: 105484 title: RRD22LR012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105486/pdf description:
Unique identifier
105486
NTSB case number
RRD22LR012
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T02:50:00Z
Publication date
2023-06-20T04:00:00Z
Report type
Final
Last updated
2023-06-06T04:00:00Z
Event type
Accident
Location
Chicago, Illinois
Injuries
null fatal, null serious, null minor
Probable cause
The NTSB determines the probable cause of the July 16, 2022, customer service attendant fatality was electrocution due to contact with the third rail because of a trip and fall, while the employee attempted to cross the right-of-way for unknown reasons.
Has safety recommendations
false

Vehicle 1

Railroad name
Chicago Transit Authority
Equipment type
Commuter train-pulling
Train name
Chicago Transit Autority
Train number
435
Train type
FTA regulated transit
Total cars
8
Findings
creator: NTSB last-modified: 2023-06-06T04:00:00Z guid: 105486 uri: 105486 title: ERA22LA323 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105528/pdf description:
Unique identifier
105528
NTSB case number
ERA22LA323
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T07:35:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-07-21T17:24:11.475Z
Event type
Accident
Location
Baker, Florida
Airport
Skypark Estate Owners Association Airport (18FD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 16, 2022, about 0635 central daylight time, an experimental amateur-built Thatcher CX4, N347CX, was substantially damaged when it was involved in an accident near Baker, Florida. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he had just completed an overhaul of the automotive conversion engine installed in the airplane. Earlier in the month, the pilot conducted several engine ground runs. During most of the engine ground runs, the engine would not run smoothly when at the idle throttle setting; however, on the last ground run, the engine ran smoothly at idle power while using the left, right, and both ignition sources. On the day of the accident, the pilot planned to break in the engine during a flight over the airport. The engine started normally, although it “hit a rough spot at one point on taxi and low RPM.” He determined that the engine was not fully “warmed up” and continued. After takeoff, while the airplane was climbing to traffic pattern altitude, the pilot felt something dripping onto his leg, thought it was fuel, and decided to perform a precautionary landing rather than continue the climb to pattern altitude. When he pulled the throttle back to idle to initiate a descent, the engine stopped producing power. Unable to restore power to the engine, he navigated toward the airport; however, the airplane was unable to reach the runway. The pilot selected a field just short of the airport for a forced landing and during the landing the left wing contacted a tree, which resulted in the right wing and the nose impacting the ground. Examination of the wreckage by a Federal Aviation Administration inspector revealed that the main wreckage came to rest in a nose-down attitude at the edge of a road. Both wings and the fuselage sustained substantial damage. The pilot later determined that it was likely condensation and not fuel that was dripping on his leg after departure. Although the pilot did not run the engine due to propeller damage, his postaccident examination of the engine revealed no anomaly which would have precluded normal operation. Furthermore, he reported that the loss of engine power could have been due to the “idle setting” or carburetor icing. At the time of the accident, the temperature and dew point at a weather reporting facility 9 nautical miles southeast of the accident site were both 73.4° F, with a relative humidity of 100%. These atmospheric conditions were conducive to carburetor icing at glide power. -
Analysis
The pilot reported that he had just completed an overhaul of the automotive conversion engine that was installed in the experimental amateur-built airplane. Before the day of the accident, the pilot conducted several engine ground runs. During most of the ground runs, the engine would not run smoothly when at the idle throttle setting; however, on the last ground run, the engine ran smoothly at idle. On the day of the accident, the pilot planned to break in the engine during a flight over the airport. After takeoff, while the airplane was climbing to traffic pattern altitude, the pilot felt something dripping onto his leg and decided to perform a precautionary landing. When he pulled the throttle back to idle to initiate a descent, the engine stopped producing power. Unable to restore power to the engine, he elected to execute a forced landing, during which the left wing impacted a tree. Although the pilot did not run the engine after the accident, his postaccident examination of the engine revealed no anomaly that would have precluded normal operation. The atmospheric conditions at the time of the accident were conducive to carburetor icing at glide power; however, the airplane’s engine was at a climb power setting before the pilot reduced the throttle to idle to initiate the descent. Therefore, it is not likely that the loss of engine power was the result of carburetor ice. Since the pilot had just completed an overhaul of the engine and the engine would not run smoothly at idle during several engine ground runs, it is likely that the engine idle setting was misadjusted, which resulted in the engine losing power when the throttle was reduced to idle.
Probable cause
The improper engine idle setting, which resulted in a total loss of engine power when the pilot reduced the throttle to idle to initiate a descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ALLAN G PIXLEY
Model
THATCHER CX4
Amateur built
true
Engines
1 Reciprocating
Registration number
N347CX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-21T17:24:11Z guid: 105528 uri: 105528 title: ERA22LA433 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106071/pdf description:
Unique identifier
106071
NTSB case number
ERA22LA433
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T09:10:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-10-06T14:35:15.411Z
Event type
Accident
Location
Okeechobee, Florida
Airport
Okeechobee Couty AIrport (OBE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot landed on a runway that was scheduled to be closed about 9 minutes after he arrived. A NOTAM had been issued about the closure. The pilot was aware of the NOTAM and confirmed the runway was still open by communicating over the airport’s common traffic advisory frequency before he landed. The pilot said that when he was on short final approach to the runway, the airplane struck the top cross-arms of an unlit airport runway closure marker. The pilot was subsequently able to land safely. The pilot said he was unable to see the marker as he approached the runway due to the nose-high flight attitude of his airplane on approach. The impact with the marker resulted in substantial damage to the airplane’s wing spar. A representative of the engineering company contracted by the airport acknowledged to the Federal Aviation Administration that their employees had moved the marker in front of the runway’s threshold prior to it being closed because they thought they had permission to do so by the airport; however, the person or entity who had granted that permission was never determined.
Probable cause
The premature placement of an airport runway closure marker short of the runway, which resulted in the airplane’s collision with the marker during the landing approach. Contributing was the pilot’s inability to see the marker due the nose-high attitude of the airplane during the approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EASTER WILLIAM C
Model
M-1
Amateur built
false
Registration number
N150MM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-1-1115
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-06T14:35:15Z guid: 106071 uri: 106071 title: ERA22FA315 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105485/pdf description:
Unique identifier
105485
NTSB case number
ERA22FA315
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T10:35:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-20T19:10:30.628Z
Event type
Accident
Location
Middle Township, New Jersey
Airport
Paramount Air Airport (JY04)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
FAA publication FS-I-8700-1 (Rev. 1), “Information For Banner Towing Operations” stated: …Stalls during the banner pickup procedure constitute one of the more frequent causes of banner towing operational accidents. A stall occurs when an airfoil reaches a critical angle of attack (AOA) and is a function of wing loading, independent of airspeed. In fact, an excessively abrupt rotation of an airplane during a pickup, or a snap or steep turn after a missed pickup, may be sufficient to precipitate an accelerated stall… - On July 16, 2022, about 0935 eastern daylight time, a Piper PA-12, N3703M, was substantially damaged when it was involved in an accident near Middle Township, New Jersey. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 banner-tow flight. According to the operator, who witnessed the accident, the pilot was hired about 2 months before the accident. The airplane was fueled to capacity before to the flight. On the accident flight, the pilot departed runway 32 and flew a left traffic pattern to pick up the banner at the approach end of runway 14, which was normal procedure. The airplane descended toward the banner, but missed the haul line during the pickup attempt. The airplane then climbed nose-high and stalled, spinning right and impacting the runway. Engine noise was consistent throughout the accident sequence. Another witness stated that he was seated in an airplane, with the engine running, waiting to take off next and pick up a banner. He observed the accident airplane come down between the poles, miss the banner, and the accident pilot made a really “hard snap,” climbing almost vertically. It looked to the witness as though the accident pilot "kicked rudder" at the top of his climb to see if he had picked up the banner. The witness added that he believed this caused the right wing to come out from the slipstream, resulting in an aerodynamic stall. - The wreckage came to rest nose-down, oriented about a 320° magnetic heading, and no debris path was observed. The wreckage remained intact. Both wings exhibited leading edge damage and buckling, with the left wing exhibiting more damage than the right. The ailerons remained attached to their respective wing. The empennage remained intact and was canted right. Flight control continuity was confirmed from all flight control surfaces to the cockpit. Measurement of the horizontal stabilizer trim jackscrew corresponded to a nose-down trim position; 14 threads were observed, with 17 threads being full nose-down and 1 thread being full nose-up. The cockpit area was crushed, but the pilot’s 4-point harness remained latched and was cut by rescue personnel. The engine remained attached to the airframe and the propeller remained attached to the engine. One propeller blade remained undamaged, while the other exhibited s-bending and leading-edge gouging. The top spark plugs were removed from the engine. Their electrodes were intact and gray in color, except for the No. 4 spark plug, which was oil soaked. The rocker covers were removed and oil was observed throughout the engine. Both magnetos were removed from the engine and sparked at all leads when rotated by hand. When the propeller was rotated by hand, crankshaft, camshaft, and valvetrain continuity were confirmed to the rear accessory section of the engine and thumb compression was attained on all cylinders. The carburetor butterfly valve was in the open position. The carburetor floats and needle remained intact and the fuel screen was absent of debris. -
Analysis
The banner tow pilot had worked for the operator for about 2 months, and the accident flight was the first flight of the day. The pilot departed from the runway and flew a left traffic pattern to pick up the banner at the approach end of the opposite runway, which was normal procedure. Witnesses stated that the airplane descended between the poles, missed the banner, and the pilot initiated an aggressive, almost vertical climb. One witness stated that it appeared as though the accident pilot "kicked rudder" at the top of the climb to see if he had picked up the banner. The airplane entered an aerodynamic stall/spin and descended to ground contact. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions of the airplane that would have precluded normal operation. Based on the available information, it is likely that the pilot exceeded the airplane’s critical angle of attack during the banner pickup attempt, which resulted in an aerodynamic stall/spin and loss of control at an altitude too low to recover.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during a missed banner pickup, which resulted in an aerodynamic stall/spin and loss of control at an altitude too low to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA12
Amateur built
false
Engines
1 Reciprocating
Registration number
N3703M
Operator
Paramount Air Service Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Banner tow
Commercial sightseeing flight
false
Serial number
12-2648
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-20T19:10:30Z guid: 105485 uri: 105485 title: WPR22FA254 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105487/pdf description:
Unique identifier
105487
NTSB case number
WPR22FA254
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T12:53:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-07-20T19:12:32.652Z
Event type
Accident
Location
Topeka, Kansas
Airport
BUENA TERRA (33KS)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On July 16, 2022, about 1153 central daylight time, an experimental amateur-built RV-7, N283S, was substantially damaged when it was involved in an accident near Topeka, Kansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness reported that he had spoken to the pilot earlier in the day, who said he was going to fly to another airport for fuel. The witness stated it was normal to see the pilot perform maneuvers when he departed, such as a wing over, then over fly the runway before departing the area. The witness observed the airplane depart and enter a near-vertical climb. The airplane’s nose dropped with a turn to the right and entered a nose-low, near-vertical descent until the airplane impacted terrain near the departure end of the runway. Other witnesses reported that the airplane attained an altitude of about 150-200 ft above ground level before the nose dropped. A local resident reported that he did not observe the accident flight; however, he routinely observed the accident airplane perform various aerobatic maneuvers, such as inverted flight over the airport, spins, and barrel rolls. It was common to see the accident airplane take off, climb in a near-vertical attitude, then turn toward the ground and overfly the airport. - The Shawnee County Coroner's Office, Topeka, Kansas, performed an autopsy of the pilot. The pilot's cause of death was multiple blunt impact injuries. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected ethanol in the pilot’s cavity blood at 0.069 gm/dL, vitreous fluid at 0.077gm/dL, gastric contents at 0.390 gm/dL, liver tissue at 0.026 grams per hectogram (gm/hg) 2, kidney tissue at 0.067 gm/hg, and muscle tissue at 0.083 gm/hg; results were inconclusive for ethanol in brain tissue. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Title 14 CFR Section 91.17 (a) states, in part, that no person may act or attempt to act as a crewmember of a civil aircraft (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) while having an alcohol concentration of 0.040 gm/dL or greater in a blood or breath specimen. - Examination of the accident site revealed that the airplane came to rest upright after it impacted an open grass field about 375 ft southwest of the departure end of runway 19. The wreckage came to rest on a heading of about 340° magnetic. No visible ground scars were observed in the area near the wreckage. All major structural components of the airplane were located at the accident location. Figure 1: View of the accident site diagram. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. Postaccident examination of the recovered airframe and engine did not reveal evidence of any mechanical anomalies that would have precluded normal operation. -
Analysis
On the day of the accident, witnesses saw the airplane depart from the runway and enter a near-vertical climb before the airplane’s nose dropped and began a right turn. The airplane remained in a nose-low, near-vertical descent until it impacted a grass field off the end of the runway. Several witnesses had previously watched the pilot take off and perform various aerobatic maneuvers similar to the accident flight. Toxicological tests detected a level of ethanol known to cause some level of impairment. The test results were also consistent with the pilot having consumed alcohol near the time of the flight. Therefore, it is likely that the pilot’s impairment contributed to the loss of control as the pilot performed an aerobatic maneuver on takeoff.
Probable cause
The pilot’s failure to maintain aircraft control while performing an aerobatic maneuver on takeoff, which resulted in exceedance of the airplane’s critical angle of attack, a subsequent aerodynamic stall, and impact with terrain. Contributing to the accident was the pilot’s impairment from alcohol consumption before the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STUCKY STEVEN D
Model
RV-7
Amateur built
true
Engines
1 Reciprocating
Registration number
N283S
Operator
WAKE TURBULENCE CORP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
73041
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-20T19:12:32Z guid: 105487 uri: 105487 title: ERA22LA367 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105719/pdf description:
Unique identifier
105719
NTSB case number
ERA22LA367
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T15:00:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-15T18:36:25.204Z
Event type
Accident
Location
Butler, Georgia
Airport
BUTLER MUNI (6A1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
Just before touching down to land, the pilot could not remember if he extended the landing gear. He said he then grabbed the gear handle (which was in the down position) and retracted the gear. The glider landed gear up and bounced, which resulted in substantial damage to the fuselage, tail boom, and tail section.
Probable cause
The pilot’s retraction the landing gear just prior to touchdown on the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
VICKERS-SLINGSBY
Model
T65A
Amateur built
false
Engines
1 None
Registration number
N157HH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1894
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-15T18:36:25Z guid: 105719 uri: 105719 title: CEN22LA341 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105576/pdf description:
Unique identifier
105576
NTSB case number
CEN22LA341
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-16T17:20:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2022-07-26T18:00:37.426Z
Event type
Accident
Location
Riverdale, Nebraska
Airport
ONION CREST AIRPARK (43NE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 16, 2022, about 1620 central daylight time, a Cessna 421B airplane, N21GF, sustained substantial damage when it was involved in an accident near Riverdale, Nebraska. The two pilots and two passengers were uninjured and one passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight.   The private pilot seated in the left seat reported that, before the flight, the airplane had about 50 gallons of fuel on board, and he elected to add an additional 60 gallons for a total of 110 gallons. The airplane departed Goodland, Kansas (GLD), about 1520 for the estimated one-hour flight to Riverdale Airport (43NE), Riverdale, Nebraska. The pilot stated that he initially planned a straight-in landing to runway 35; however, he elected to enter the downwind leg for runway 17. While on the base leg with the landing gear and flaps extended, he noted that he was too far west for landing and increased engine power and retracted the landing gear to initiate a go-around. When the throttle was applied, the left engine lost power and the airplane descended into a corn field. The airplane sustained substantial damage to both wings when the leading edges were crushed aft. The crushing damage exceeded 10% of the total wing span.   The second pilot reported that, on short final for runway 17, both engines sputtered “like fuel exhaustion.” He estimated the total fuel consumption to be about 40 to 45 gallons per hour. He stated that he thought the airplane had about 80 gallons of fuel on board at the time of the accident.   A postaccident examination revealed that the fuel selector for the left engine was in the “LEFT MAIN” position and the selector for the right engine was in the “RIGHT MAIN” position. The left main fuel tank (located on the wingtip) separated from the airplane during the impact and was absent of fuel. The right main tank contained about 1 gallon of fuel, the right auxiliary tank contained about 5 gallons of fuel, and the left auxiliary tank and left nacelle tank were absent of fuel. Although the fuel quantity indicating system wiring was disconnected during recovery operations, the right wing fuel quantity system, main and auxiliary tank systems, were still intact postaccident. The left wing main tank fuel quantity indicating system could not be tested due to impact damage. The wiring for the right wing fuel quantity system was reconnected to the airplane via the use of “jumper wires” and electrical power was restored to the airplane for testing. Once fully connected, the right wing fuel quantity indicating system functioned as designed. When a known quantity of fuel was poured into the main tank, the fuel quantity gauge indicator responded to the fuel level change and indicated roughly the amount of fuel poured into the tank in pounds of fuel. Using the right wing tank system, the wiring from the right wing fuel quantity sending system was connected to the left side of the indicator system. As with the previous test, when a known quantity of fuel was poured into the wing, the left gauge responded correctly to the amount of fuel poured into the wing tanks. Postaccident examination of the engines revealed no mechanical malfunctions or anomalies that would have precluded normal operation. -
Analysis
The pilot reported that he departed on the estimated 1-hour flight with about 110 gallons of fuel onboard. Upon reaching the destination airport, he elected to perform a go-around. During the go-around the left engine lost total power. The airplane descended into a corn field, resulting in substantial damage to both wings.   The second pilot on board reported that, while on final approach for landing, both engines sputtered at about the same time, “like fuel exhaustion.” He estimated the airplane’s total fuel consumption to be about 40 to 45 gallons per hour. He stated that he thought the airplane had about 80 gallons of fuel on board at the time of the accident. A postaccident examination revealed that the fuel selector for the left engine was in the “LEFT MAIN” position and the selector for the right engine was in the “RIGHT MAIN” position. The left main fuel tank (located on the wingtip) separated from the airplane during the impact and was absent of fuel. The right main tank contained about 1 gallon of fuel, the right auxiliary tank contained about 5 gallons of fuel, and the left auxiliary tank and left nacelle tank were absent of fuel. After reconnecting the wiring, fuel quantity indicators were functionally checked with no anomalies noted. During a postaccident engine examination, no mechanical malfunctions or anomalies were found that would have precluded normal operation. The total amount of fuel onboard the airplane before the flight could not be determined; however, given the lack of fuel found in the tanks after the accident and no indications of engine anomalies, it is likely that the loss of engine power was the result of fuel exhaustion.
Probable cause
A total loss of engine power as a result of fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
421B
Amateur built
false
Engines
2 Reciprocating
Registration number
N21GF
Operator
HAWKFITZ LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Unknown
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
421B-0209
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-26T18:00:37Z guid: 105576 uri: 105576 title: ERA22LA324 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105529/pdf description:
Unique identifier
105529
NTSB case number
ERA22LA324
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-17T15:25:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-07-29T18:44:25.311Z
Event type
Accident
Location
Lawrenceville, Georgia
Airport
GWINNETT COUNTY - BRISCOE FLD (LZU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that he performed a straight-in approach for landing at the conclusion of his first solo cross-country flight. At the time, a 6-knot, left crosswind was reported at the field. Prior to touchdown, the airplane was “on the correct glide path” with the flaps fully deployed. While in the landing flare and just prior to touchdown, the nose of the airplane “shifted left” and the airplane touched down headed off the left side of the runway. The pilot said he briefly corrected, but eventually the airplane performed a runway excursion to its left coming to rest upright in the grass. Postaccident examination of the airplane revealed substantial damage to the nose landing gear mount structure. The pilot reported there were no pre-accident mechanical failures or malfunctions of the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control while landing with a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N62405
Operator
FLIGHT SCHOOL OF GWINNETT INC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17275263
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-29T18:44:25Z guid: 105529 uri: 105529 title: CEN22LA321 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105508/pdf description:
Unique identifier
105508
NTSB case number
CEN22LA321
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-17T21:00:00Z
Publication date
2024-02-21T05:00:00Z
Report type
Final
Last updated
2022-07-19T01:34:04.524Z
Event type
Accident
Location
Bennington, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane’s maintenance records (including the most recent weight and balance record), and recent fuel records were not available for review. The amount of fuel onboard the airplane when it departed could not be determined. According to the airframe manufacturer, the Just Highlander is a short takeoff and landing (STOL) airplane. The airframe manufacturer also classifies the airplane as a bush airplane. The airplane was equipped with tundra tires that facilitate off-airport landings and takeoffs. The airplane was equipped with vortex generators on both wings and the empennage. A stall warning system was not observed on the leading edge of the wings, nor was one required by regulation. - On July 17, 2022, about 2000 central daylight time, an experimental Just Highlander, N7514N, sustained substantial damage when it was involved in an accident near Bennington, Oklahoma. The pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the family members of the two occupants, the purpose of the local area flight was to conduct low-level flight operations over and on the Red River. The Red River, mainly located in rural areas, flows from the west to the east and separates Oklahoma and Texas. The airplane departed from Jones Field Airport (F00), Bonham, Texas, around 1927. The pilot was seated in the left seat and the passenger, who was a student pilot, was seated in the right seat. The passenger texted a family member at 1928 that the airplane was airborne. The expected return time back to F00 was undetermined. After not hearing from either occupant, concerned family members initiated a search and found the wreckage around 0200 on July 18, 2022. The airplane came to rest on a remote island in the Red River, nose-down with the empennage in a near-vertical position. The airplane sustained substantial damage to the fuselage and both wings. According to a family member, the accident likely occurred between 1930 and 2030, as the two occupants would not likely fly in night conditions. There were no known witnesses to the accident. A search did not reveal any flight track data for the accident flight. - Pilot Toxicology testing performed by the Office of the Chief Medical Examiner was negative for ethanol and tested-for drugs in the pilot’s femoral blood. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected the potentially sedating antihistamine medication cetirizine in the pilot’s heart blood at 12 nanograms per milliliter (ng/mL) and urine at 278 ng/mL. The allergy medication fexofenadine, its metabolite azacyclonol, and the high blood pressure medication losartan were detected in his heart blood and urine; these substances are generally considered non-impairing. Passenger Toxicology testing performed by the Office of the Chief Medical Examiner was negative for ethanol and tested-for drugs in the passenger’s femoral blood. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected ethanol in the passenger’s heart blood at 0.019 grams per deciliter (g/dL) and liver tissue at 0.010 grams per hectogram (g/hg), but not in his brain tissue. Ethanol is the intoxicating alcohol in beer, wine, and liquor, but alcohol consumption is not the only possible source of ethanol in postmortem specimens; ethanol can be produced by microbes in the body after death. N-propanol, another alcohol which can be produced by microbes after death, was detected in the passenger’s heart blood. - A review of astronomical data showed that, on the day of the accident, sunset was at 2035. The estimated density altitude for the closest meteorological reporting station was 3,245 ft mean sea level. - The wreckage was recovered from the accident site on August 6, 2022. During the recovery operation, no fuel was recovered from the airplane. Flight control continuity was established from the cockpit controls to the corresponding control surface. The flap position at the time of impact was not determined. The leading edge of both wings exhibited aft accordion crush damage and the engine was pushed aft into the cabin of the airplane. The right fuel tank was found breached with no fuel present. The left fuel tank remained intact, and a small amount of an unknown white liquid was found inside the tank. The auxiliary fuel tank in the cabin was intact and a small amount of clear blue liquid was found inside the tank. The fuel tank selector was not observed in the wreckage. Airframe to engine control continuity was established. Rotational continuity was established throughout the engine and valvetrain when the crankshaft was rotated. No fuel samples were recovered from the engine. The hub for the three-blade, composite propeller was found intact and was connected to the crankshaft flange. Blade 1 was found separated near the hub and the remains were not observed. Blade 2 was found intact with no chordwise scratching observed. Blade 3 was found separated about midspan with no chordwise scratching observed. There were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. -
Analysis
The pilot and student pilot-rated passenger departed to conduct low-level flight operations over and on a river in a remote area. After not hearing from either occupant, family members initiated a search and found the wreckage several hours later. The airplane came to rest on a remote island in the river, nose-down with the empennage in a near-vertical position. The leading edge of both wings exhibited aft accordion crush damage and the engine was pushed aft into the cabin of the airplane. Postaccident examination of the wreckage found that the damage to the propeller was consistent with no or low power at the time of the accident. The right fuel tank was breached with no fuel present. The left fuel tank was intact, and a small amount of a white liquid was found inside the tank. The auxiliary fuel tank in the cabin was intact and a small amount of clear blue liquid was found inside the tank. No fuel samples were obtained from the engine and no fuel was recovered during the removal of the airplane from the accident site. The amount of fuel onboard the airplane at the time of departure could not be determined. An examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operations. It could not be determined if there was a loss of engine power or not. The position of the wreckage when it was located and the uniform crush damage to both wings is consistent with the airplane encountering an aerodynamic stall before it impacted the ground. It is likely that the pilot exceeded the airplane’s critical angle of attack at an altitude too low to recover which resulted in a loss of control and impact with terrain. Toxicology testing detected the potentially sedating antihistamine, cetirizine, in the pilot’s system, but based on the drug’s low level in the pilot’s heart blood, it is unlikely to have caused significant psychomotor effects. Ethanol was detected at low levels in some specimens and not detected in others from the passenger; a postmortem ethanol source was likely, and ethanol likely did not contribute to the crash.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack which resulted in an aerodynamic stall and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JUST
Model
HIGHLANDER
Amateur built
true
Engines
1 Reciprocating
Registration number
N7514N
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JAESC0102
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-19T01:34:04Z guid: 105508 uri: 105508 title: ERA22LA322 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105519/pdf description:
Unique identifier
105519
NTSB case number
ERA22LA322
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-18T09:04:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-19T23:16:02.739Z
Event type
Accident
Location
Palatka, Florida
Airport
PALATKA MUNI - LT KAY LARKIN FLD (28J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 18, 2022, at 0804 eastern daylight time, an experimental amateur-built RV-10 airplane, N910BW, was substantially damaged when it was involved in an accident near Palatka, Florida. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that shortly after takeoff, the engine sputtered then lost total power. He was unable to return to the airport and made a forced landing to heavily wooded terrain, resulting in substantial damage to the fuselage, both wings, and the tail section. Postaccident examination of the engine revealed that the cannon plug type circular connector that connected the electronic ignition wiring harness to the firewall was not locked, and the connector was partially engaged. The connector provided the connection between the wiring harness and the two electronic control units located on the cockpit side of the firewall. According to a representative of the manufacturer of the ignition system, if the firewall connector was not secure “…this would result in a single point failure of the entire ignition system.” A review of the airplane’s maintenance records revealed that the electronic ignition system was installed in October 2020. There were no subsequent entries that discussed maintenance of the ignition system since that date. -
Analysis
Shortly after takeoff, the experimental amateur-built airplane’s engine lost total power and the pilot made an off-airport forced landing, resulting in substantial damage to the fuselage, both wings, and the tail section. Postaccident examination of the engine revealed that a cannon plug-type circular connector that connected the engine’s electronic ignition system’s wire harness to the two electronic control units was not properly connected. The manufacturer of the ignition system stated that disengagement of the connector, which carried all electrical signals required to run the ignition system, “…would result in a single point failure of the entire ignition system.” Maintenance records showed that the ignition system had been installed about 21 months before the accident, with no other work to that system detailed between that time and the accident. Based on this information, it is likely that the connector had not been fully secured when the system was installed, and that over time, the partial connection had loosened, ultimately resulting in the loss of engine power.
Probable cause
Total loss of engine power due to the improper installation of an electronic ignition system connector plug.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV10
Amateur built
true
Engines
1 Reciprocating
Registration number
N910BW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
40929
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-19T23:16:02Z guid: 105519 uri: 105519 title: ERA22FA320 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105504/pdf description:
Unique identifier
105504
NTSB case number
ERA22FA320
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-18T11:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-07-24T17:44:49.034Z
Event type
Accident
Location
Basehor, Kansas
Airport
HOELTING (SN22)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On July 18, 2022, about 1000 central daylight time, an experimental amateur-built AA Nieuport 28, N6170, was destroyed when it was involved in an accident near Basehor, Kansas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a witness, he met the pilot about 0900 on the day of the accident and helped him perform the preflight inspection and pull the airplane from its hangar. The witness stated that there were no issues with the preflight inspection and that the 12gallon fuel tank was full. The witness also stated that the pilot planned to climb straight out to an altitude of about 500 ft above ground level (agl) and then turn left and stay close to the runway while he checked the airplane. The pilot started the engine and let it warm up for about 10 minutes. The pilot then gave the witness a thumbs up and applied full throttle for the takeoff. During the takeoff roll, the airplane veered to the left, and the witness thought that the airplane was going to hit a large round hay bale next to the runway. The airplane lifted off the ground and cleared the hay bale by 6 ft. The pilot flew back toward the runway centerline but was going “very slow.” After clearing the treetops, the airplane started to make a slow left turn at an altitude of about 200 ft agl. The witness then observed the tail drop down and the left wing roll, and the airplane subsequently spun to the ground. A postcrash fire ensued. According to the witness, the pilot built the biplane from a kit in 2016 and equipped it with a Volkswagen engine. Between 2016 and the accident date, the pilot had operated the airplane about 30 hours. During that time, the airplane had several problems with the engine and oil leaks. In 2020, the pilot made a hard landing that fractured the main landing gear. During the next 2 years, the pilot repaired the landing gear, which would have included removing and reassembling the wing struts, and installed a Lycoming O-320 engine on the airframe. The work was completed in April 2022. The pilot performed several slow-speed taxies during the weeks that followed and, on the day of the accident, the pilot intended to fly the airplane for the first time since 2020. The current airplane’s maintenance logbooks and the pilot’s logbook were not located. The accident site was located in a field about 1,600 ft east of the runway. The airplane impacted the ground in a nose-down attitude. The wooden propeller blades were splintered into numerous pieces at the impact point. The main landing gear separated and the airplane slid about 60 ft before it came to rest upright on a 15° magnetic heading. The center portion of the wings and fuselage were almost completely consumed by fire. The engine was fractured at its mounts and was located under the left wing. The fabric was burnt except for a small piece on the tips of the upper and lower right wing. Flight control continuity was established from the control surfaces to the control stick, which was thermally destroyed. Examination of the engine revealed no preimpact mechanical anomalies that would have precluded normal operation. Examination of the airframe revealed the left outer interplane strut was not correctly attached to the left lower wing compression strut. The bolt and nut were present through the outer interplane strut, but the interplane strut had not been attached to the lower wing compression strut through the bolt mounting hole. -
Analysis
On the day of the accident, the pilot intended to fly the airplane for the first time since it had been repaired following a previous hard landing. The pilot, who was the builder of the experimental biplane, was taking off on a personal flight when the airplane veered to the left, lifted off the runway, and flew back toward the runway centerline. A witness noted that the airplane was going “very slow.” When the airplane reached an altitude of about 200 ft above ground level, the airplane started to make a slow left turn. The witness then observed the tail of the airplane drop down and the left wing roll, and the airplane subsequently spun to the ground. A postcrash fire ensued. About 2 years before the accident, the airplane was involved in a hard landing, which damaged the landing gear. The pilot subsequently repaired the landing gear, which would have included removal and reassembly of the wing struts. Postaccident examination of the airplane found that the left outer interplane strut was not correctly attached to the lower left wing compression strut. The bolt and nut were present through the outer interplane strut but had not been secured to the lower wing compression strut. The disconnected strut would have resulted in an out-of-rig condition and change the flight characteristics of the upper and lower left wings, potentially inducing drag while in flight. In this case, the upper and lower left wings would have each displayed different flight characteristics because the lower wing angle was pushed down and the upper wing was pushed up during the wire-tensioning process. The faster the airplane flew in the out-of-rig condition, the more pronounced the changed flight characteristics of the upper and lower left wings would have become. During the accident sequence, the pilot likely tried to slow the airplane to improve the changed flight characteristics, but the airplane’s critical angle of attack was exceeded and resulted in the airplane’s subsequent stall and spin to the ground.
Probable cause
The pilot’s incorrect installation of the left-wing strut, which resulted in a loss of airplane control during takeoff and a subsequent aerodynamic stall and spin from which the pilot could not recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KNIGHT
Model
AA Nieuport 28
Amateur built
true
Engines
1 Reciprocating
Registration number
N6170
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-24T17:44:49Z guid: 105504 uri: 105504 title: CEN22LA323 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105514/pdf description:
Unique identifier
105514
NTSB case number
CEN22LA323
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-18T19:49:00Z
Publication date
2023-10-25T04:00:00Z
Report type
Final
Last updated
2022-07-20T16:17:53.286Z
Event type
Accident
Location
Verona, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 18, 2022, about 1849 central daylight time, a Bell 206B3 helicopter, N6BU, sustained substantial damage when it was involved in an accident near Verona, Illinois. The pilot was uninjured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight.   The pilot reported that this was not the first flight of the day and, before departure, he had about 30 gallons of fuel and 80 gallons of spray product. After takeoff from a load truck, he received a low rotor alarm and the helicopter began to sink. He performed an autorotation and the helicopter bounced upon landing. The tailboom was severed by the main rotor blades which resulted in substantial damage. During a postaccident examination, the engine N1 system turned freely and was continuous from the compressor to the starter generator. The engine N2 system turned and was connected to the powertrain. No foreign object damage was noted on the first stage compressor blades or compressor inlet, and the inlet particle separator system was intact and was not blocked. The fourth stage turbine wheel was normal in appearance when viewed from the exhaust collector. Linkages from the collective to the Power Turbine Governor (PTG) and from the throttle twist grip to the Fuel Control Unit (FCU) were secure. The FCU throttle input lever was rigged appropriately and contacted the minimum and maximum stops when the throttle was rotated to the cut off and fly positions respectively. The PTG rotated through about 20° (from 60 to 80 on the indicator) when the collective was moved from full down to full up. Helicopter electrical power was switched on, and no engine chip lights were noted. The fuel quantity gage indicated 30 gallons. The fuel boost pumps were individually tested, and fuel flowed freely from both.   The engine was removed from the airframe and subsequently placed on a test stand. The engine started, idled, and accelerated as designed during the testing with no flame outs or uncommanded power fluctuations noted. No anomalies were observed during the exam or testing that would have precluded normal operation. -
Analysis
Before departure, the helicopter was loaded with about 30 gallons of fuel and 80 gallons of spray product. After takeoff from a load truck, the pilot received a low rotor alarm and the helicopter began to sink. He performed an autorotation and the helicopter bounced upon landing. The tailboom was severed by the main rotor blades which resulted in substantial damage. During a postaccident examination and engine test run, no anomalies were noted that would have precluded normal operation. The reason for the loss of rotor rpm could not be determined based on the available evidence.
Probable cause
A loss of rotor rpm for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N6BU
Operator
TOP GUN PRECISION AG LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
4034
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-20T16:17:53Z guid: 105514 uri: 105514 title: CEN22LA330 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105542/pdf description:
Unique identifier
105542
NTSB case number
CEN22LA330
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-20T19:45:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-07-21T23:12:43.917Z
Event type
Accident
Location
Wardsville, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 20, 2022, about 1845 central daylight time, a Beech N35 airplane, N1228Z, was substantially damaged when it was involved in an accident near Wardsville, Missouri. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot reported that the departure, climb, and cruise portions of the flight were without incident. During the approach into the intended destination airport, he observed the oil pressure drop to zero and, shortly afterward, the engine started running rough. The pilot subsequently heard a “bang” from the engine and observed smoke from under the engine cowling. The engine lost power completely and he executed a forced landing to a field. The airframe sustained damage to the forward fuselage. An engine examination revealed that the Nos. 1 and 4 cylinder connecting rods, connecting rod caps, and bolts had failed at the crankshaft journal. In addition, the No. 5 connecting rod was discolored at the crankshaft consistent with overheating due to oil starvation. The upper portion of the crankcase above the No. 4 cylinder exhibited a 3 inch by 3 inch hole. Connecting rod cap and retaining bolt fragments were recovered from the crankcase and oil sump, along with about one quart of oil. At the time of the examination, the aftermarket oil filter adapter was loose and could be rotated about 40° using only finger-tip pressure. One safety wire was installed directly from the adapter spool to the oil pump housing and without any significant tension. There was no safety wire installed between the adapter sleeve and the engine. According to the airplane’s maintenance records, the engine was overhauled in March 2021 and installed on August 7, 2021, at an airframe time of 7,329 hours. A representative of the overhaul facility reported the oil filter adapter was furnished installed with the overhauled engine. The maintenance records noted that, on February 19, 2022, at 7,379 hours airframe time, the oil filter adapter was removed and reinstalled using new copper gaskets due to an oil leak. The mechanic confirmed that a torque wrench was used when reinstalling the adapter. On June 21, 2022, at 7,405 hours airframe time, the engine oil was replaced by the pilot/owner. According to the pilot/owner, the oil filter was not replaced at that time. In addition, he stated the alignment marks between the adapter and the engine were still matched up. At the time of the accident, the airframe time was 7,420 hours. On February 21, 2020, the oil filter adapter manufacturer issued updated installation instructions (DN ST002 Rev 1) that implemented the use of copper gaskets, replacing the original fiber gaskets. The instructions required the use of a torque wrench to 65-ft lbs and installation of safety wire from the adapter spool to the engine, and from the adapter sleeve to the engine. On June 17, 2021, the oil filter adapter manufacturer revised a previously issued mandatory service bulletin (SB-001 Rev B) regarding the oil filter adapter installation. The bulletin specified removal of any fiber gaskets still in service and the use of copper gaskets due to reports of oil leaks. The adapter installation was to be inspected for security and proper safety wire installation at each oil change, each 100-hour/annual inspection, and any time the adapter was removed or installed. The bulletin reiterated that safety wire be installed from the adapter spool to the engine, and from the adapter sleeve to the engine. FAA Airworthiness Directive (AD) 2022-04-04 became effective on March 29, 2022. The AD mandated replacement of the fiber gaskets with copper gaskets and the reinstallation of the adapter, as noted in the corresponding service bulletin, within 50 flight hours or at the next oil change, whichever occurred first. The oil filter adapter was equipped with copper gaskets at the time of the accident. On June 16, 2022, the adapter manufacturer revised the service bulletin (SB-001 Rev C) to specify an improved gasket to be used in place of the lower copper gasket. It also specified an inspection of the adapter installation within 10 flight hours or at the next annual/100-hour inspection, whichever occurred first. Service bulletins are not regulatory in nature and compliance is not required for aircraft operated under 14 CFR Part 91. Airworthiness directives are regulatory in nature and compliance is required as specified in the directive. -
Analysis
The pilot reported the flight was uneventful until he was approaching the destination airport. During the approach, he observed the oil pressure drop to zero and, shortly afterward, the engine started running rough. The pilot subsequently heard a “bang” from the engine and observed smoke from under the engine cowling. The engine lost power completely and he executed a forced landing to a field. The airframe sustained substantial damage to the forward fuselage. Postaccident examination revealed that the engine failed because of oil starvation. At the time of the examination, the aftermarket oil filter adapter was loose and not safety wired in accordance with the manufacturer’s instructions and the Federal Aviation Administration (FAA) airworthiness directive.
Probable cause
Engine failure due to oil starvation resulting from an oil leak at the improperly installed aftermarket oil filter adapter.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
N35
Amateur built
false
Engines
1 Reciprocating
Registration number
N1228Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
D-6688
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-21T23:12:43Z guid: 105542 uri: 105542 title: ERA22LA329 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105547/pdf description:
Unique identifier
105547
NTSB case number
ERA22LA329
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-21T13:00:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-08-08T16:41:59.559Z
Event type
Accident
Location
Plant City, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On July 21, 2022, about 1200 eastern daylight time, an Aeronca 7AC, N84423, was substantially damaged when it was involved in an accident near Plant City, Florida. The pilot and a passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was repositioning the airplane back to his home airport following the completion of its annual inspection. About 5 to 10 minutes after takeoff, the engine lost all power. The pilot performed a forced landing to a field; however, the airplane impacted a bump and bounced twice. The airplane continued through a fence and impacted a pipe in a drainage pond; the right main landing gear collapsed and the airplane came to rest upright at the edge of the pond. Initial examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial damage to the forward fuselage and right wing strut. The wreckage was subsequently examined by a mechanic and an FAA inspector following its recovery to a storage facility. When the propeller was rotated by hand, camshaft, crankshaft, and valvetrain continuity were confirmed to the rear accessory section and thumb compression was attained on all cylinders. Both magnetos produced spark at all leads when rotated by hand. The carburetor was absent of fuel and about 75 ml of fuel remained in the gascolator. The FAA inspector initially did not observe any fuel in the fuel tank. He then examined the tank via borescope, verified that it was not breached, and observed a small, immeasurable amount of fuel in one corner of the tank, but the tank was otherwise empty. -
Analysis
About 5 to 10 minutes after takeoff, the engine lost total power. The pilot performed a forced landing to a field, during which the airplane collided with a fence and drainage pipe, resulting in substantial damage. Examination of the engine and ignition system did not reveal any preimpact mechanical malfunctions. Examination of the fuel system revealed that the carburetor was absent of fuel and only a trace amount of fuel remained in the gascolator. A subsequent borescope examination of the fuel tank revealed that it was intact and that a small, immeasurable amount of fuel was in one corner of the tank, but the tank was otherwise empty. Based on the lack of mechanical anomalies and the absence of fuel in the intact fuel tank, it is likely that the loss of engine power was the result of fuel exhaustion.
Probable cause
A total loss of engine power due to fuel starvation as a result of the pilot’s inadequate preflight fuel planning.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N84423
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-3121
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-08T16:41:59Z guid: 105547 uri: 105547 title: ERA22LA330 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105548/pdf description:
Unique identifier
105548
NTSB case number
ERA22LA330
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-21T16:00:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-09-07T14:58:51.887Z
Event type
Accident
Location
Kenton, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 21, 2022, about 1500 eastern daylight time, a Bell 206B, N39MK, was substantially damaged when it was involved in an accident near Kenton, Ohio. The commercial pilot was not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 137 agricultural flight. According to the pilot, before the flight the helicopter was filled with minimal fuel because of a heavy load of pesticide. He said he received about 8 to 10 gallons of Jet-A fuel and flew over to the crop field. He flew about 4 minutes over to the field and started the aerial application. During his first pass he noticed the engine rpm starting to drop. He did not have enough altitude to initiate an autorotation and the helicopter descended and collided with the ground. The pilot did not know how much his total fuel quantity was before the flight but said he “used a 5-gallon mark as our zero mark to ensure we have enough fuel.” Postaccident examination of the helicopter by a Federal Aviation Administration inspector revealed that the fuselage and the skids were buckled. An examination of the fueling system revealed no anomalies with the fuel lines or fuel tank. The fuel tank cell was found empty of fuel and not breached. An examination of the engine did not reveal any anomalies that would have precluded normal operation. A review of fuel flow chart excerpts for the 206B revealed that the general fuel consumption rate was about 25 gallons per hour. At this rate, the flight time with 8 to 10 gallons of fuel would be about 20-25 minutes. -
Analysis
The pilot was uncertain how much fuel was onboard the agricultural application helicopter before 8 to 10 gallons were added prior to departing on the accident flight. The helicopter had been filled with minimal fuel because of a heavy load of pesticide. After a flight to the field of about 4 minutes, he started the aerial application. During his first pass the engine rpm started to drop; he did not have enough altitude to initiate an autorotation and the helicopter descended before colliding with the ground. A postaccident examination of the fueling system revealed no fuel remained within the intact fuel tank. Additionally, examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures. Based on this information, the engine likely lost power due to fuel exhaustion.
Probable cause
The pilot’s inadequate fuel management, which resulted in fuel exhaustion and a loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N39MK
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
2984
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-07T14:58:51Z guid: 105548 uri: 105548 title: CEN22LA334 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105561/pdf description:
Unique identifier
105561
NTSB case number
CEN22LA334
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-22T17:47:00Z
Publication date
2024-02-07T05:00:00Z
Report type
Final
Last updated
2022-07-25T20:34:43.261Z
Event type
Accident
Location
Beaver Dam, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 22, 2022, about 1647 central daylight time, a Van’s Aircraft RV-10 airplane, N4400K, sustained substantial damage when it was involved in an accident near Beaver Dam, Wisconsin. The pilot and one passenger sustained no injuries and one passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot reported that after take off from the Dodge County Airport (UNU), Juneau, Wisconsin, he heard a “very loud pop” from the experimental engine. Smoke entered the cockpit, but then the smoke cleared. The amount of smoke in the cockpit did not inhibit the pilot from performing visual functions. The pilot decided to perform an off-airport landing to a field. During the landing, the pilot was able to add power to the engine to avoid impacting power lines. After landing, the right wing impacted a soccer goal post. The airplane continued with the rollout and impacted a streetlight and a portable toilet. The airplane came to rest upright, and all three occupants were able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the right wing. After the accident, the pilot reported that the engine was operating after he heard the “very loud pop;” however, he did not confirm this with the cockpit gauges or try to maintain level flight. A postaccident examination of the engine found that the lower spark plug wire boot for the No. 6 cylinder was not connected to the spark plug. The rubber boot had signatures consistent with the boot being burned on the outside of the 90° bend on the boot, and at the end of the boot, where the boot likely contacted the exhaust pipe it was resting on. The boot was burned enough so the electrode was able to contact the exhaust pipe. There were no other areas in the engine that showed signs of burning. Airframe to engine control continuity was established. Except for the burned spark plug wire boot, there were no preimpact mechanical malfunctions or failures that would have precluded normal operation of the engine. A review of the maintenance records showed that on March 22, 2022, a condition inspection was performed on the airplane. For the engine, a compression check was satisfactorily performed by a mechanic. For both the airframe and the engine, the entries stated that the condition inspection was performed in accordance with 14 CFR Part 43 Maintenance, Preventive Maintenance, Rebuilding, and Alteration, and the “manufacturer’s maintenance and inspection procedures.” According to information provided by the pilot, the engine had accumulated 79.7 hours since the inspection work. -
Analysis
The pilot of the airplane stated that after departure he heard a “very loud pop” from the engine and then saw smoke enter the cockpit. After the smoke cleared, he decided to perform an off-airport landing even though the engine continued to operate. He stated that he did not check the engine gauges to evaluate any anomalies. The pilot reported that the engine was operating after he heard the “loud pop” noise. During the approach to the field, the pilot added engine power to avoid hitting power lines. The airplane impacted a soccer goal, a streetlight, and a portable toilet, which resulted in substantial damage to the fuselage and right wing. Postaccident examination of the engine found the spark plug wire boot for the No. 6 cylinder was not connected to the spark plug and was found resting on the exhaust pipe. The rubber boot likely sustained thermal damage when it contacted the exhaust pipe; there were no other mechanical anomalies that would have precluded normal operation. A review of the maintenance records showed that 79.7 hours had accumulated on the engine since the last inspection, which was a condition inspection. It possible that the spark plug wire boot was not secured during the last maintenance work performed. Based on the available records, investigators were not able to determine why the spark plug wire boot was unsecured.
Probable cause
The improperly secured spark plug boot that resulted in smoke in the cockpit and a subsequent off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Van's Aircraft
Model
RV-10
Amateur built
true
Engines
1 Reciprocating
Registration number
N4400K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
42074
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-25T20:34:43Z guid: 105561 uri: 105561 title: WPR22LA271 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105586/pdf description:
Unique identifier
105586
NTSB case number
WPR22LA271
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-22T20:11:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-08-07T19:53:10.686Z
Event type
Accident
Location
San Jose, California
Airport
REID-HILLVIEW OF SANTA CLARA COUNTY (RHV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 22, 2022, about 1911 Pacific daylight time, a Piper PA-32-301 airplane, N300BH, was substantially damaged when it was involved in an accident near San Jose, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 business flight. According to the pilot, the airplane had received an annual inspection after having been out of service for more than 2 months while it awaited a part. The pilot stated that he was notified by the maintenance facility about 1730 on the day of the accident that the airplane was ready. He noted that he had planned to fly the airplane in the airport traffic pattern at Reid-Hillview Airport of Santa Clara County (RHV), San Jose, California before flying the Norman Y Mineta San Jose International Airport (SJC), San Jose, California, located about 5 nm east of the departure airport. According to the pilot’s recount, he spent about 25 minutes talking with the mechanic who showed him some of the work that was completed. The mechanic who spoke with the accident pilot stated that the pilot arrived in the late afternoon and talked with him for about 5 minutes; however, none of the conversation subject matter involved the airplane or the fuel level. The mechanic stated that he heard the airplane start about five minutes after they finished their conversation. The pilot reported that after his conversation with the mechanic he performed a preflight inspection of the airplane. During this time, he noted that the fuel level was 15 gallons in each wing by observing the sight gauges and observed that the fuel had an odor and appearance consistent with 100 low lead aviation grade gasoline when he sumped the fuel system. He also reported that he confirmed that the fuel level from the sight gauges was consistent with fuel quantity indicators in the cockpit. The pilot did not attempt to refuel the airplane. After his preflight inspection the pilot boarded the airplane and spent an additional 5 minutes in the cockpit reviewing his checklists before he taxied to the run-up area for runway 31R. After an uneventful engine run-up, he received clearance from the tower, and then taxied onto the active runway. The airplane departed normally and the pilot transitioned into a climb; as the airplane reached about 500 ft mean sea level it sustained a partial loss of power. The pilot looked for a possible landing site but was unsuccessful, as he was over a densely populated area. The pilot began a left turn to return to RHV, but during the turn the engine lost all power. According to the pilot, he verified the mixture was full rich, the fuel pump was on, and he switched the fuel tank selector to the opposite fuel tank. The pilot did not recall which tank he departed on. The propeller was windmilling during this time and the engine did not restart. After a descent, the airplane impacted the ground and struck a fence before it came to rest about 0.3 nm northwest of the departure end of runway 31R. Photographs provided by law enforcement showed that the airplane came to rest upright. The left wing exhibited a steep upward bend about midspan and the right wing outboard leading edge was crushed. The forward fuselage was damaged and the engine was displaced from its normally mounted position. According to a mechanic who worked on the airplane during its recent annual inspection, the airplane had 15 gallons of fuel in each wing before they started the inspection. During the inspection he verified the fuel quantity through both the cockpit fuel gauge and the fuel gauges at each wing. At the time they received the airplane the mechanic noted that the color of the fuel was blue, consistent with 100 low lead aviation grade gasoline. He did not remove or add any fuel. During the inspection, they replaced the wing sight gauges and noted 15 gallons in each wing, which was consistent with the cockpit fuel quantity indicators. After the inspection was completed, they performed a ground engine test run for 45-60 minutes at full throttle and full manifold pressure with the fuel selector on the left fuel tank. They momentarily selected the right fuel tank and then immediately switched back to the left fuel tank and noted that the fuel flow remained stable during the transitions. According to another mechanic who arrived on scene about 20 minutes after the accident, the right wing contained approximately 15 gallons of fuel at the accident site and the left wing was breached and void of fuel. An on scene photograph captured by the Federal Aviation Administration showed the fuel selector in the right tank position. Postaccident examination of the airplane and engine did not reveal any preimpact mechanical anomalies that would have precluded normal operation. Control continuity was traced from each flight control surface to the cockpit through separations made by recovery personnel. Examination of the fuel system also did not reveal any preimpact mechanical anomalies that would have affected fuel flow. A visual inspection of the left wing sight gauge did not reveal any preimpact anomalies and functional testing revealed that the unit defaulted to 0 gallons and movement of the fuel arm produced a movement of the needle. Mechanical continuity was established throughout the engine when the propeller was rotated by hand. Thumb compression was achieved at all six cylinders and the valves displayed normal lift as the crankshaft was rotated. Examination of the cylinders’ combustion chamber interior components using a lighted borescope revealed normal piston face and valve signatures, and no indications of foreign ingestion or detonation. The three-bladed constant speed propeller remained attached at the crankshaft flange. All three blades remained attached to the hub. Two blades were bent aft about midspan and the third blade was bent aft near the blade tip. Fuel testing revealed that the composition of the fuel was consistent with 100 low lead aviation grade gasoline. A water reaction analysis of water-soluble components that would allow free water to be incorporated with the fuel indicated 0 mL of volume change. Fuel Consumption According to the pilot’s operating handbook (POH), the airplane had a total capacity of 107 gallons of fuel evenly split between two wing fuel tanks. The unusable fuel quantity was 5 gallons: 2.5 gallons per side. The power setting table from the performance section of the POH showed that the fuel consumption would have ranged from 11.9 gph at 55% power, 13.8 gph at 65%, or 16.0 gph at 75% power depending on the selected power setting. The POH did not indicate how these fuel consumption values would change with altitude. The mechanic reported that they ran the airplane at full throttle and full manifold pressure for the entire engine test. Factoring a left tank usable fuel quantity of 13.5 gallons, fuel performance computations showed that the engine would have depleted the left tank of its fuel supply in approximately 50 minutes. Fuel Availability According to the airport manager, RHV ceased sales of 100 low lead aviation grade gasoline on January 1, 2022, which prompted numerous aircraft to outsource their fuel requirements to fuel depots at nearby airports, such as SJC. Pilot in command and Preflight Action According to 14 CFR §91.103 Preflight Action, “Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight. This information must include - (a) For a flight under IFR or a flight not in the vicinity of an airport, weather reports and forecasts, fuel requirements, alternatives available if the planned flight cannot be completed, and any known traffic delays of which the pilot in command has been advised by ATC” As described in 14 CFR §91.3 Responsibility and authority of the pilot in command, “(a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft.” -
Analysis
The pilot had planned to fly the airplane on a short flight back to the owner’s hangar following an annual inspection. According to the pilot, the engine lost all power during climbout from the departure airport. The airplane impacted the ground, struck a fence and came to rest upright. Postaccident examination of the airplane revealed no preimpact mechanical anomalies of the airplane or engine that would have precluded normal operation. The airplane contained 15 gallons of fuel in each wing fuel tank before the annual inspection began. The maintenance facility ran the engine at maximum power with the fuel selector positioned on the left fuel tank for at least 45 minutes during the annual inspection. Fuel consumption calculations indicate this would have nearly depleted the left fuel tank of fuel. No additional fuel was added by the mechanics or the pilot before the accident flight nor was there any discussion between the pilot and mechanic regarding the amount of fuel remaining in the airplane. It is likely that the pilot departed without a thorough preflight inspection or he would have observed the low fuel quantity and switched to the right fuel tank before departure. The pilot stated that he switched tanks once during the accident flight after the power loss. As the fuel selector was found in the right tank position at the accident site, it is likely that he departed on the left fuel tank. This evidence suggests that the pilot’s improper fuel management resulted in fuel starvation and a total loss of engine power. Further, the departure airport did not sell the type of fuel required to power the accident airplane. However, it is unlikely that this would have influenced the pilot’s decision as he believed he had sufficient fuel to complete the flight.
Probable cause
The pilot’s inadequate preflight inspection and fuel management, which resulted in fuel starvation, a total loss of engine power, and an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-301
Amateur built
false
Engines
1 Reciprocating
Registration number
N300BH
Operator
GREEN VALLEY CORPORATION I
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
32-8006011
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-07T19:53:10Z guid: 105586 uri: 105586 title: DCA22FM030 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105572/pdf description:
Unique identifier
105572
NTSB case number
DCA22FM030
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-07-23T04:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-05-22T04:00:00Z
Event type
Accident
Location
Port Fourchon, Louisiana
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the bulk carrier Bunun Queen and the offshore supply vessel Thunder was the Bunun Queen officer’s distraction due to performing non-navigational tasks and the Thunder officer’s distraction due to cell phone use, which kept both officers from keeping a proper lookout. Contributing to the casualty was the Thunder’s officer on watch not following his company’s watchkeeping policies.
Has safety recommendations
false

Vehicle 1

Callsign
WDH7787
Vessel name
OSV Thunder
Vessel type
Offshore
IMO number
9684847
Maritime Mobile Service Identity
366088000
Port of registry
New Orleans
Classification society
ABS
Flag state
USA
Findings

Vehicle 2

Callsign
5LDJ6
Vessel name
MV Bunun Queen
Vessel type
Cargo, Dry Bulk
IMO number
9912438
Port of registry
Monrovia
Classification society
NK
Flag state
LI
Findings
creator: Coast Guard last-modified: 2023-05-22T04:00:00Z guid: 105572 uri: 105572 title: HWY22FH011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105569/pdf description:
Unique identifier
105569
NTSB case number
HWY22FH011
Transportation mode
Highway
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-23T04:39:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2024-03-04T05:00:00Z
Event type
Occurrence
Location
Hamden, Connecticut
Injuries
0 fatal, 0 serious, 2 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the Hamden, Connecticut, fire on a battery electric transit bus was moisture in the high voltage lithium-ion battery system, which led to battery damage resulting in the fire. Contributing to the injuries to facility personnel was the lack of a safety plan by CTtransit for mitigating risks associated with high voltage lithium-ion battery fires during emergency response.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2021 New Flyer battery electric bus (BEB)
Traffic unit type
Single Vehicle
Units
Findings
creator: NTSB last-modified: 2024-03-04T05:00:00Z guid: 105569 uri: 105569 title: WPR22FA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105555/pdf description:
Unique identifier
105555
NTSB case number
WPR22FA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-23T14:31:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-08-17T06:03:23.907Z
Event type
Accident
Location
Fallbrook, California
Airport
FALLBROOK COMMUNITY AIRPARK (L18)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 1 minor
Factual narrative
The T-28B trainer was a two-place, single-engine, low-wing monoplane. The airplane was powered by a nine-cylinder R-1820-86 Wright engine developing 1,425 horsepower and driving a Hamilton Standard three-blade constant-speed propeller. Dual flight controls were installed in the tandem cockpit, and a speed brake was installed on the bottom fuselage aft of the main landing gear wheel wells. The tricycle landing gear was fully retractable. The pilot owned the airplane for over 10 years. During that time, he never had any work done on the carburetor and never had issues with it. He estimated that at the time of the accident, the engine had just under 400 hours since major overhaul. A review of the maintenance records revealed that they were incomplete, and it is unknown the full extent of maintenance the airplane and engine had undergone. The last conditional inspection was recorded as occurring on September 5, 2021, at an airframe total time of 14,772.3 hours and a Hobbs time of 362.3 hours. The rebuilt electric fuel pump was purchased in September 2015. The carburetor was last overhauled in February 2010, over 12 years before the accident. The engine-driven fuel pump was last overhauled in February 2010 and the paperwork indicated the reason for removal as “engine failure,” and normal wear was noted. There was no other indication of an engine failure. The last engine overhaul was recorded as being completed in April 2010. Fuel System The fuel system consisted of four bladder-type fuel cells, an aluminum alloy sump tank containing an electric boost pump, a fuel shutoff valve, a fuel strainer, an engine-driven fuel pump, check valves, and necessary fuel feed and vent lines. The system was controlled by the fuel shutoff valve handle in either cockpit. The system is designed where fuel flows by gravity from all internal cells into the sump tank (located in the inboard right wing). A fuel shutoff control handle, located on the left console of each cockpit, has two positions: “ON” and “OFF”. Each position operates the fuel shutoff valve and the electric boost pump simultaneously. An electric fuel-boost-pump test switch was located on the electrical switch panel in the bottom forward right cockpit. The test switch was wired in series with the electric fuel pump switch on the fuel shutoff control handle. When held in the “TEST” position, the system was designed for power to the electric pump to be interrupted, allowing the pilot to confirm that the engine-driven fuel pump pressure is adequate. The electric pump forced fuel under a pressure of 19 to 24 psi through the shutoff valve, strainer, and engine-driven fuel pump. When the engine started, the engine-driven fuel pump maintained the fuel to the carburetor at an operating pressure of 23 to 25 psi. If the electric pump fails below 10,000 feet pressure altitude, fuel drawn by the engine-driven pump is designed to bypass through the electric pump and sustain approximately normal fuel flow to the carburetor (with a slight drop in fuel pressure indication that may be noted). If the engine-driven fuel pump failed, fuel was forced by the electric pump to the carburetor to maintain normal engine operation. The airplane’s take-off checklist stated that at 1,800 rpm “Place FUEL BOOST PUMP switch to TEST, check fuel pressure 21 to 25 psi.” - On July 23, 2022, at 1331 Pacific daylight time, a North American T-28B, N787AS, was substantially damaged when it was involved in an accident near Fallbrook, California. The pilot was seriously injured and the pilot-rated passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   A law enforcement officer interviewed the pilot immediately after the accident. The pilot stated that he and the passenger have been good friends for over 50 years, and both have extensive aviation experience. Earlier in the day, he and the passenger both departed from Chino, California, in separate airplanes. The pilot was flying the T-28 and the passenger was flying the pilot’s Cessna 150 with the purpose of dropping it off in Fallbrook. The plan was for them to both leave Fallbrook in the T-28, stop for lunch in Temecula, California, and then return to Chino.    The airplanes departed from Chino and the T-28 landed in Fallbrook about four minutes ahead of the Cessna. After dropping off the Cessna, the pilot performed a pre-flight inspection. The pilot then positioned himself in the front seat and the passenger was in the rear seat. The pilot stated that after takeoff, with the airplane about 200 feet above ground level (agl), the engine sustained a total loss of power. He checked the mixture, power, and fuel, and lowered the nose in an effort to avoid a stall. The airplane collided with a plant nursery. The pilot estimated that about 30 seconds had elapsed from the engine failure to the time of impact. After impact, several people helped him exit the airplane by prying the canopy open. The pilot stated that he forgot to open the canopy before impact.      The pilot additionally stated that he is a mechanic and performs the maintenance on the airplane. He recalled the last time he performed any maintenance on the airplane was about six months before the accident.     Investigators reviewed video recordings, audio recordings, and flight track data covering the area of the accident during the time surrounding the accident using automatic dependent surveillance-broadcast (ADS-B) data. A review of the data revealed that the T-28 landed in Fallbrook about 1255. At 1326:01 the airplane taxied to runway 18 and began the takeoff roll at 1331:20. The airplane began the departure roll and was midfield about 12 seconds later at a ground speed of 88 kts. At 1331:44, the airplane was about 300 ft south of the runway identifier markings and the airspeed was 97 knots. The last position recorded was at 1331:49 and located about 160 ft north of the first identified impact point; the airspeed at that point was 94 knots and the airplane was on a heading of about 180° (see Figure 1 below). Figure 1: ADS-B Plot with Inset of Video Images of the Takeoff A sound spectrum analysis from a witness’s recorded cell phone video revealed the engine was idling smoothly about 1,530 rpm. Thereafter, it was running rough for about 10 seconds as it increased its speed to about 2,420 rpm and the airplane was moving along the runway. The engine was then running smoothly for the next 12 seconds as it passed by the camera. The engine then suddenly decreased in rpm, similar to when it was at idle, and the airplane impacted several seconds later. - Recorders Data obtained from the Advanced AF-5500 revealed that the device began recording at 1331:26. Airspeed was increasing, and the heading of the airplane was recorded consistent with that of the accident event. Manifold pressure and fuel flow were increasing. At 1331:31, manifold pressure and fuel flow appeared to stabilize, and the airplane’s heading was continually recorded consistent with the accident runway. In the next few seconds, the pitch began to increase, as well as vertical speed. At1331:39, manifold pressure and fuel flow began decreasing, followed shortly thereafter by vertical speed. Airspeed plateaued and began a slight decreasing trend. As the data reached the end of the recording, the pitch decreased but was only below 0 degrees for one sample. The recording ended at 13:31:46. - The accident site was located in a nursery about 1,815 feet from the departure end of runway 36. The debris field was located on upsloping terrain with numerous plants in plastic crates and an asphalt pile toward the end. The main wreckage, consisting of the engine and almost all the fuselage, came to rest upright and the right-wing had impacted a greenhouse structure. The wreckage was found distributed over a 415 ft distance on a median magnetic bearing of about 175° (see Figure 2 below). Figure 2: Map of Accident Site An on-scene examination revealed no external evidence of catastrophic failure. The forward spark plugs were removed; no mechanical damage was noted and the electrodes and posts exhibited a light ash gray coloration, consistent with normal operation (the No. 6 plug was oil-soaked). Upon rotation of the propeller, “thumb" compression was observed in proper order on all nine cylinders. The complete valvetrain was observed to operate in proper order and appeared to be free of any pre-mishap mechanical malfunction. Normal lift action was observed at each rocker assembly. Both magnetos were found securely clamped at their respective mounting pad and the timing was found within the manufacturer specifications. Both oil screens were removed and found free of debris. The carburetor sustained impact damage and continuity of the mixture and throttle could not be established. There were over 50 gallons of fuel found in each inboard wing tank. The fuel selector was in the on position. There was a fluid consistent in odor and appearance with fuel found in the carburetor’s fuel strainer reservoir; the screen was clean of debris and no water was detected. The header tank contained trace amounts of fuel and the electronic fuel boost pump was intact. Investigators' efforts to obtain continuity of the electronic fuel pump revealed that there was a short with the electronic connector box on the pump. The box contained a copper jumper between two posts (presumably high and low setting). Disassembly of the electronic fuel pump revealed that metal shavings were lodged in the armature creating a short in the system. The blades on the impeller showed wear consistent with instability of the shaft during rotation. The upper commutator was cracked and showed wear on the upper portion. The brushes appeared normal. Figure 3: Inside Components of Electric Fuel Pump Further disassembly revealed that the pump-end bearing was worn on the outside with the labyrinth seal, washer, and shims deformed. The bearing cage was absent. Further examination of the metal pieces in the armature revealed that they were shaped with rounded lips consistent with being pieces of the bearing cage. Figure 4: Pump-End Bearing and Fragments Inside the Pump Continuity was established from the boost pump test switch in the cockpit to the pump. Using a multi-meter, investigators confirmed wire continuity from the boost pump to the 20-amp circuit breaker. The breaker could be moved in and out. Attempts to trip the breaker were unsuccessful. The circuit breaker was taken for testing and found to operate as expected and it could not be determined why the breaker was unable to trip when installed. Carburetor Examination The carburetor, a Stromberg PD-12-K18 (s/n 792490), was an injection carburetor that was a double-barrel, downdraft unit equipped with a fuel head enrichment valve, a constant head idle spring, an automatic mixture control unit, a mechanically operated accelerator pump, and an electric primer valve. The mixture control had settings for "IDLE CUTOFF," "NORMAL," and "RICH," offering control over performance. The power enrichment valve in the fuel control unit is operated by a diaphragm exposed to un-metered fuel pressure on one side and metered fuel pressure on the other. When the pressure differential applied across the enrichment valve diaphragm creates a force greater than the enrichment valve spring force, the valve opens. The opening point of the valve can be adjusted to a predetermined point by increasing or decreasing the tension on the enrichment valve spring. The carburetor remained attached to the engine and had sustained impact damage; continuity of the mixture and throttle could not be established. At the accident site, fuel was found in the carburetor. Later, corrosion was found in the screen housing and on the spring. A flow test of the carburetor revealed that numerous parameters were out of limits. At low power settings the carburetor ran rich (more fuel flow than required for normal operation) and at high power settings the carburetor ran lean (less fuel flow than required for normal operation). This would be consistent with the engine running lean (not providing enough fuel) at takeoff power. Disassembly revealed that the enrichment valve’s diaphragm was stiff/rigid, consistent with it not being submerged in fuel for long durations. The carburetor manufacturer recommended that it should be overhauled at least every ten years and be pressurized regularly (if in a hot and dry climate, it should be done monthly). The internal diaphragms become brittle and can fail if not wetted with fuel regularly. -
Analysis
The pilot flew the airplane earlier in the day and made a stop at the accident airport. He performed a pre-flight inspection and positioned himself in the front seat, with the pilot-rated passenger in the rear seat. After takeoff, with the airplane about 200 feet above ground level (agl), the engine sustained a loss of power. The airplane collided with a plant nursery. The fuel system was designed where fuel flowed by gravity from all internal cells into the sump tank where an electric fuel boost pump was located. The airplane was also equipped with an engine-driven fuel pump. When the pilot turned the fuel “ON”, the electric fuel pump would simultaneously be turned on. An electric fuel-boost-pump test switch was in the cockpit and, as part of the start-up checklist, the switch had to be activated to momentarily interrupt power to the electric pump, allowing the pilot to confirm that the engine-driven fuel pump pressure is adequate (and that the electric fuel pump is operational). There was a 20-amp circuit breaker in series with the switch and the pump. If the electric pump fails below 10,000 feet pressure altitude, fuel drawn by the engine-driven pump is designed to bypass through the electric pump and sustain approximately normal fuel flow to the carburetor (with a slight drop in fuel pressure indication that may be noted). Disassembly of the electric fuel pump revealed that metal shavings were lodged in the armature creating a short in the system. The blades on the impeller showed wear consistent with instability of the shaft during rotation. The upper commutator was cracked and showed wear on the upper portion. The pump-end bearing was worn on the outside with the labyrinth seal, washer, and shims deformed. The bearing cage was determined to be the metal pieces shorting out the armature. Continuity was established from the electric pump test switch in the cockpit to the electric pump and to the circuit breaker. Attempts to trip the breaker were unsuccessful and further testing of the unit revealed it was functional. It could not be determined why the breaker did not trip when the electric pump shorted, but if the pilot had used the test switch, he likely would have been able to see the pump had failed. A flow test of the carburetor revealed that numerous parameters were out of limits. At low power settings, the carburetor ran rich (more fuel flow than required for normal operation), and at high power settings the carburetor ran lean (less fuel flow than required for normal operation). Disassembly revealed that the enrichment valve’s diaphragm was stiff/rigid, consistent with it not being submerged in fuel for long durations. The carburetor manufacturer recommended that it should be overhauled at least every ten years and be pressurized regularly (if in a hot and dry climate, it should be done monthly). The internal diaphragms become brittle and can fail if they are not wetted with fuel regularly. The carburetor was overhauled over 12 years before the accident, equating to about 400 hours of flight time; during that time the pilot stated he had not completed any maintenance on it. At takeoff power, the carburetor was not able to provide enough fuel to the engine because the enrichment diaphragm was brittle from inactivity. Additionally, because the electric fuel pump was inoperative, the fuel flow pressure was diminished providing less fuel to the carburetor.
Probable cause
A loss of power due to an unmaintained carburetor diaphragm and inoperative electric fuel pump that resulted in fuel starvation to the engine.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
T-28B
Amateur built
false
Engines
1 Reciprocating
Registration number
N787AS
Operator
MACH ONE AIR CHARTERS INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
137787
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-17T06:03:23Z guid: 105555 uri: 105555 title: ERA22LA333 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105557/pdf description:
Unique identifier
105557
NTSB case number
ERA22LA333
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-23T15:00:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-08-03T02:59:51.832Z
Event type
Accident
Location
Batesburg, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 23, 2022, about 1400 eastern daylight time, a Stinson 108-3, N6020M, was substantially damaged when it was involved in an accident near Batesburg, South Carolina. The private pilot and a passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that during cruise flight, while flying about 2,300 ft above mean sea level, the engine “went dead.” He made a forced landing to a field, and after touchdown the airplane collided with trees that bordered the field. Postaccident examination of the engine following recovery of the airplane revealed no valvetrain continuity with rotation of the crankshaft. Partial disassembly of the engine revealed that the crankshaft gear was fractured. Examination of the crankshaft gear by the National Transportation Safety Board Materials Laboratory revealed it failed due to fatigue that initiated from multiple origins at a corner of a keyway cut in the gear. There was no plating at the fatigue initiation site. A review of the maintenance records revealed a nearly 15-year gap in entries, and then the engine was overhauled by an airframe and powerplant mechanic on June 18, 2014, and installed on the airframe on June 1, 2016. Further review of the maintenance records associated with the engine overhaul revealed the crankshaft gear was magnafluxed and approved for return to service on April 25, 2012. Since installation, the engine remained installed in the airframe and underwent routine inspections and maintenance, accruing about 247 hours since major overhaul at the time of the accident. -
Analysis
Shortly after takeoff the engine sustained a total loss of engine power caused by fatigue failure of the crankshaft gear, necessitating the pilot to perform an off-airport forced landing that resulted in substantial damage. The fatigue fracture initiated from multiple origins at a corner of a keyway cut in the gear. The crankshaft gear underwent magnaflux inspection and was approved for return to service associated with an engine overhaul nearly 8 years and 247 hours earlier. While there was no evidence of plating at the fatigue initiation site, it could not be determined from the available evidence whether the fatigue existed in the part at the last inspection or how fast the fatigue crack was growing.
Probable cause
The fatigue failure of the crankshaft gear, resulting in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108
Amateur built
false
Engines
1 Reciprocating
Registration number
N6020M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
108-4020
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-03T02:59:51Z guid: 105557 uri: 105557 title: DCA22FM031 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105595/pdf description:
Unique identifier
105595
NTSB case number
DCA22FM031
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-07-23T15:30:00Z
Publication date
2023-12-12T05:00:00Z
Report type
Final
Last updated
2023-11-30T05:00:00Z
Event type
Accident
Location
Houston, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the failure of the hoisting wire on the cargo ship Thorco Basilisk’s crane was undetected corrosion and wear in strand wires.
Has safety recommendations
false

Vehicle 1

Callsign
HBLG
Vessel name
Thorco Basilisk
Vessel type
Cargo, General
IMO number
9539377
Maritime Mobile Service Identity
269021000
Port of registry
Basel, Switzerland
Classification society
DNV-GL
Flag state
SZ
Findings
creator: Coast Guard last-modified: 2023-11-30T05:00:00Z guid: 105595 uri: 105595 title: ERA22LA332 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105556/pdf description:
Unique identifier
105556
NTSB case number
ERA22LA332
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-23T19:54:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-23T18:36:38.696Z
Event type
Accident
Location
Meritt Island, Florida
Airport
Merritt ISland (COI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot had accrued 954 total hours of flight experience but had only flown about 3.2 hours during four flights in the experimental amateur-built amphibious accident airplane. The pilot departed from a grass area next to a runway at the airport where he kept the airplane. After an uneventful local flight he returned to the airport to land. He performed go-arounds during the first two landing approaches due to being either too high or too fast. During the third landing attempt, the pilot thought the approach looked “OK” but then he noticed that he was too low, and too slow, so he increased engine power and applied slight up elevator. The pilot explained that the engine was on top of the wing (mounted in a pusher configuration) and normally when power was added the airplane would initially pitch down but would level off and then climb. The pilot described that this time though when he was too slow (about 45 knots), he added an extra amount of power, which pushed the nose down and made the airplane descend. He then “got scared,” “gave too much up elevator,” and believed that the airplane entered an aerodynamic stall. The airplane then struck the ground and a fence at an airspeed of about 55 knots. The pilot was seriously injured and postaccident examination of the airplane revealed that the fuselage was substantially damaged. The pilot reported that during the accident flight, the flight controls and engine all operated normally.
Probable cause
The pilot’s failure to maintain control of the airplane during final approach to land, which resulted in an exceedance of the airplane’s critical angle of attack, aerodynamic stall, and collision with a fence and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WHITTEN ROBINSON
Model
AVENTURA II
Amateur built
true
Engines
1 Reciprocating
Registration number
N709CW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA2A0143
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-23T18:36:38Z guid: 105556 uri: 105556 title: CEN22LA336 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105563/pdf description:
Unique identifier
105563
NTSB case number
CEN22LA336
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-24T15:50:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-07-26T18:23:53.489Z
Event type
Accident
Location
Ray, Michigan
Airport
RAY COMMUNITY (57D)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Factual narrative
On July 24, 2022, about 1450 eastern daylight time, a Beech A36 airplane was substantially damaged when it was involved in an accident near Ray, Michigan. The pilot and two passengers were seriously injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that during the takeoff roll, when the airplane reached 70 KIAS, he rotated the airplane for takeoff. He pitched the nose of the airplane for the takeoff climb and upon reaching 77 KIAS he retracted the landing gear. The airplane then started to drift to the right, the right wing dipped, and the nose began a slight pitch down. When the pilot checked airspeed, it indicated 64 KIAS and the airplane felt “sloshy.” The pilot reported the airplane was descending toward the trees at the end of the runway and the stall warning horn sounded. The airplane collided with the trees and descended to impact with the terrain before a fire erupted. The pilot and passengers were able to exit the airplane before it was engulfed by the flames. The pilot reported the engine rpm’s never seemed to diminish and there were no abrupt changes in power during the takeoff. A witness saw the airplane as it departed runway 28 (2,495 ft long). According to the witness, the airplane rotated about 3/4 of the length down the runway. The landing gear was seen to retract, and the airplane appeared to struggle to climb. The wings wobbled and the airplane yawed to the right. The airplane did not climb and then collided with the trees. All three occupants were hospitalized. A review of information on file with the Federal Aviation Administration (FAA) showed the accident airplane was modified via supplemental type certificate to be turbo normalized. Examination of the engine and turbocharger did not detect any preimpact anomalies which would have precluded normal operation of the engine. The pilot reported that before the flight he fully fueled the airplane. He estimated the weight and balance calculations to be 3,829 lbs and 83.84 inches. The estimated takeoff distance to clear a 50 ft obstacle was about 2,200 ft. Performance charts provided by Textron Aviation showed that at a takeoff weight of 3,650 lbs, the rotation speed is 73 knots for no obstacle and 84 knots for a 50 ft obstacle. Calculated takeoff distance for a 50 ft obstacle was 2,200 ft. However, according to the Tornado Alley Airplane Flight Manual Supplement, when modified the airplane was approved to operate at a maximum gross weight of 4,000 lbs. When operating at increased weights, pilots should expect an increased takeoff distance of up to 30%, a decreased rate-of-climb of up to 13%, an increased stall speed of up to 7%, and increased takeoff speeds of 2 knots. For the accident flight, the takeoff distance was calculated to be 2,860 ft and rotation speed would be 75 knots (no obstacle) or 86 knots for a 50 ft obstacle. In the FAA publication, The Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B), dated 2016, Chapter 11, Aircraft Performance, states that if “the pilot attempts to climb out of ground effect without first attaining normal climb pitch attitude and airspeed, the airplane may inadvertently enter the region of reversed command at a dangerously low altitude. Even with full power, the airplane may be incapable of climbing or even maintaining altitude. The pilot’s only recourse in this situation is to lower the pitch attitude in order to increase airspeed, which inevitably results in a loss of altitude. -
Analysis
The pilot reported that during the takeoff roll, when the airplane reached 70 knots indicated airspeed (KIAS), he rotated the airplane for takeoff. He pitched the nose of the airplane for the takeoff climb and at 77 KIAS he retracted the landing gear. The airplane drifted to the right, the right wing dipped, and the nose began to pitch down. When the pilot checked airspeed, it indicated 64 KIAS and the airplane felt “sloshy.” The pilot reported the airplane was descending toward the trees at the end of the runway as the stall warning horn sounded. The airplane then collided with the trees and descended to impact with the terrain before a fire erupted. The pilot and passengers were able to exit the airplane before it was engulfed by the flames. The pilot reported the engine rpm’s did not diminish and there were no abrupt changes in power during the takeoff. A witness saw the airplane as it departed runway 28 (2,495 ft long). According to the witness, the airplane rotated about 3/4 of the length down the runway. The witness then saw the landing gear retract and the airplane appeared to struggle to climb. The wings wobbled and the airplane yawed to the right. An examination of the airframe, engine, and turbocharger did not detect any preimpact anomalies. The airplane was modified via supplemental type certificate with a turbocharger that allowed for operation of the airplane at weights above the original airplane’s type certificate design. Using the original manufacturer’s performance chart, takeoff distances and airspeeds are increased, and for the accident flight, the pilot rotated the airplane between 5 to 16 knots early depending on his expectation of a 50 ft obstacle. This early rotation likely rendered the airplane incapable of climbing.
Probable cause
The pilot’s early rotation on takeoff, which resulted in insufficient airspeed and an inability to gain sufficient altitude to clear the trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N60ED
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-2241
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-26T18:23:53Z guid: 105563 uri: 105563 title: ERA22LA335 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105578/pdf description:
Unique identifier
105578
NTSB case number
ERA22LA335
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-25T10:42:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-07-27T02:33:38.015Z
Event type
Accident
Location
Calhoun, Georgia
Airport
TOM B DAVID FLD (CZL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot explained that during the 20-minute flight, the weight-shift airplane was “in good working order with no known problems.” He completed his final approach, and at 2-3 feet above the runway surface, the left wing “stalled.” The airplane rotated to its left, the left main landing gear touched the surface, which rotated the airplane further left, and just after the nose landing gear touched down, the airplane departed the runway to its left about “55 degrees” off the runway heading. The pilot “applied full power” to clear the drainage swale to the airplane’s front but was unsuccessful. The airplane passed through the swale and rolled onto its left side which resulted in a serious injury to the pilot’s ankle and substantial damage to the wing structure. The pilot repeated that there were no pre-accident mechanical anomalies with his airplane that precluded normal operation.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the landing flare, which resulted in a loss of directional control, a runway excursion, and substantial damage to the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
EVOLUTION AIRCRAFT INC
Model
REVOLT
Amateur built
false
Engines
1 Reciprocating
Registration number
N199KS
Operator
SUTZ KENNETH J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001012
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-27T02:33:38Z guid: 105578 uri: 105578 title: ERA22LA334 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105574/pdf description:
Unique identifier
105574
NTSB case number
ERA22LA334
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-26T05:55:00Z
Publication date
2024-02-07T05:00:00Z
Report type
Final
Last updated
2022-07-31T15:57:45.306Z
Event type
Accident
Location
Hamilton, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Factual narrative
On July 26, 2022, at 0455 eastern daylight time, a Eurocopter AS365N3, N520CF, was substantially damaged when it was involved in an accident near Hamilton, Ohio. The pilot and two crew members sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 air medical flight. According to the pilot, he was dispatched to a car accident in Hamilton, Ohio. He checked the weather, approved the flight, and departed for the accident scene around 0428 in dark night visual meteorological conditions. About 9 miles out from the scene, he contacted on-scene fire department personnel, stated that he was a few minutes out, and asked for site information. The fire department personnel reported that there were high voltage power lines on the south side of the landing zone. As the pilot continued to the scene, he knew the winds were calm and, therefore, he orbited the scene from the south to the north. The pilot made an approach from the south and was looking out for the powerlines but could not locate the wires. The pilot stated that he did not think the wires would be in and around the landing zone. He stated that he was wearing night vision goggles and could see the tower but not the wires. Furthermore, he did not know which way the wires were running off the tower. The pilot used the landing light and moved it up and down to try and find the wires but could not locate them. He thought the wires were further out from the landing zone and not below the helicopter. As the helicopter descended, the main rotor blades contacted the wires and the helicopter fell about 30 to 50 ft. All three crew members egressed after the pilot shut down the engines. Postaccident examination of the helicopter by a Federal Aviation Administration inspector revealed that the helicopter struck the high voltage wires, severing one wire, and then landed hard. Portions of each main rotor blade were separated near their mid-span, and the main rotor gearbox and mounts were fractured. The left engine was hanging off the engine motor mounts. The helicopter came to rest on its left side with. The stabilizer was bent and substantially damaged, and the landing gear were impact damaged. -
Analysis
The pilot was conducting an air medical flight in the helicopter during early morning hours in dark night visual meteorological conditions. About 9 miles out from the intended landing zone, he contacted on-scene fire department personnel and asked for site information. The fire department personnel reported that there were high voltage power lines on the south side of the landing zone. The pilot made an approach and was looking out for the powerlines but could not locate the wires. He was wearing night vision goggles and could see the tower but not the wires. He also could not determine which way the wires were running off the tower. The pilot used the landing light and moved it up and down to try and find the wires but could not locate them. He thought the wires were farther out from the landing zone and not below the helicopter. However, as the helicopter descended for landing, the main rotor blades contacted the wires and the helicopter fell about 30 to 50 ft. All three crew members egressed after the pilot shut down the engines. The helicopter sustained substantial damage to the main rotor blades, main rotor gearbox, and motor mounts; additionally, the left engine was hanging off the side of the helicopter.
Probable cause
The pilot’s decision to continue the landing without having visually identified wires that were known to be in the vicinity of the landing zone, which resulted in a collision with the wires while attempting an off-airport landing in dark night visual meteorological conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
AS365
Amateur built
false
Engines
2 Turbo shaft
Registration number
N520CF
Operator
Air Methods Corp
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Other work use
Flight service type
Passenger
Flight terminal type
Domestic
Medical flight type
Medical emergency
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
6537
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-07-31T15:57:45Z guid: 105574 uri: 105574 title: CEN22LA349 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105633/pdf description:
Unique identifier
105633
NTSB case number
CEN22LA349
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-26T14:30:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-08-09T17:41:08.761Z
Event type
Accident
Location
Knox, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 26, 2022, about 1330 central daylight time, a Schweizer Aircraft Corporation G-164B airplane, N629EH, sustained substantial damage when it was involved in an accident near Knox, Indiana. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the pilot, the accident flight was the 5th aerial application flight of that day. Shortly after takeoff, about 15 ft agl, the airplane would not continue to climb. The pilot stated that he advanced the throttle, but the engine did not seem to respond. The airplane was in a nose-high attitude when the right wing impacted a corn field about 300 ft from the end of the grass airstrip. The airplane came to rest in the corn field and sustained substantial damage to the fuselage and wings (see Figure 1). Figure 1. Accident airplane as it came to rest in a field (Source: Federal Aviation Administration (FAA)) The pilot reported he had exclusively been operating the airplane for about 5 years without experiencing an issue. According to the pilot and airplane records, a 100-hour inspection was completed on July 18, 2022, and an overhauled propeller governor was installed for an unknown reason during that inspection. The airplane had accumulated about 40 hours total time since the 100-hour inspection. A review of the aircraft records revealed that on May 16, 2013, the Pratt & Whitney PT6A-34 engine was installed on the airplane in accordance with supplemental type certificate (STC) SA1377GL. The airplane flight manual supplement for the engine STC, to include revised performance charts, was not located with the pilot’s operating handbook. On July 8, 2018, the airplane completed a flight check in accordance with the Civil Aeronautic Manual that increased the special purpose loading to 4,200 pounds. According to the FAA, based on the pilot’s reported load weight for the accident flight, the airplane was being operated within the weight limitations of the airplane. Aircraft recovery personnel reported that when they removed the airframe to engine fuel line, “a lot” of fuel drained from the fuel line. Initial postaccident examination revealed earthen debris within the compressor and power turbine sections. The engine air lines and accessories, to include the fuel control unit, fuel pump, start control unit, propeller and overspeed governors, were removed for further examination and testing. All observed fuel and oil filter screens were clear of contaminants. The three propeller blades were bent aft and found loose in the propeller hub. The blades displayed leading edge damage and chordwise scratching. Visual examination of the engine revealed external damage consistent with the impact, and the engine was covered with earthen debris. The compressor and accessory gearbox rotated freely through the starter pad gearshaft splines. The propeller shaft would not rotate; the reduction gearbox was dirty, and the exhaust duct showed torsional buckling at the top and bottom. The compressor turbine shroud displayed localized scoring wear, consistent with compressor turbine blade impacts. The 1st stage compressor rotor airfoils contained debris and the bearings rotated freely. The power turbine vane airfoils contained whitish deposits and debris. The power turbine disc and blades exhibited circumferential scoring wear from contact with the power turbine baffle. The blade tips and shroud exhibited rubbing wear. There were no indications of any preimpact mechanical anomalies with the engine that would have precluded normal operation. Due to damage, the fuel pump and fuel control unit (FCU) were unable to be functionally tested and were disassembled. Disassembly of the fuel pump revealed unknown black deposits or contamination on the inside diameter of the FCU front side carbon seal, and the mating surface of the drive gear face showed light circular scratches. Disassembly of the FCU revealed a material consistent with the appearance of RTV silicone sealant on the nylon coupling between the fuel pump and FCU. The coupling was removed with unusual resistance, and the driveshaft rotated with resistance. The engine maintenance manual does not allow for that type of material to be used to fit the coupling on the driveshaft. Black granular deposits were present in the P3 and Py ports. The FCU governor bellows was tested and no leaks were detected. Chemical examination of the black deposits revealed the presence of environmental contaminants and engine oil. The start flow control unit was partially tested due the improper transfer valve which prevented further testing. The transfer valve was removed and disassembled, which revealed a seized plunger. The plunger showed score marks and contamination on the sleeve bore. Orange colored debris was noted in the minimum pressurizing valve and contamination was observed in the housing bypass cavity. Chemical analysis of the contaminants revealed the presence of iron oxide, silicon dioxide, and other environmental elements. The propeller and overspeed governors were examined and functionally tested with no anomalies noted. There were no indications of any preimpact mechanical anomalies with the accessories that would have precluded normal operation. -
Analysis
The aerial application flight, which was operated within the load limitations of the airplane, was the pilot’s 5th flight of that day. The pilot stated that shortly after takeoff, about 15 ft above ground level (agl), the airplane would not continue to climb. The pilot advanced the throttle, but the engine did not seem to respond. The airplane was in a nose-high attitude when the right wing impacted a corn field near the end of the grass airstrip. The airplane came to rest in the corn field and sustained substantial damage to the fuselage and wings. Postaccident examination of the engine and accessories revealed no mechanical malfunctions or failures that would have precluded normal operation. Earthen debris within the engine, internal rotational scoring, and the exhaust duct torsional buckling were consistent with engine operation at the time of impact. Some contaminants were noted within the engine accessories; however, these contaminants were consistent with environmental exposure during the impact sequence and the presence of rust due to the length of time between the accident and subsequent examinations. The reason for the reported partial loss of engine power could not be determined.
Probable cause
A partial loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SCHWEIZER AIRCRAFT CORP
Model
G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N629EH
Operator
THUNDER VALLEY AG AVIATION
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
827B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-09T17:41:08Z guid: 105633 uri: 105633 title: ERA22FA338 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105589/pdf description:
Unique identifier
105589
NTSB case number
ERA22FA338
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-26T18:01:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-08-12T19:40:54.06Z
Event type
Accident
Location
Portland, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On August 8, 2022, the Professional Aerial Applicator’s Support System (PAASS) published a safety bulletin on avoiding mid-air collisions. The bulletin reminded pilots of the PAASS slogan, “Ferry above five (hundred) and stay alive.” The bulletin also stated that ferrying above 500 ft agl greatly increases the chances of avoiding a collision with another agricultural aircraft making an application. According to the SATLOC G4 data, the pilot of the AT-802A applied chemical to three other fields before the accident. The application patterns were examined to determine maximum altitude gained during the reverse-direction turns. The data revealed that the AT-802A routinely exceeded 500 ft GPS altitude, and consistently reached maximum altitudes between 600 and 700 ft agl. According to the AgPilotX data, the pilot of the AT-802 applied chemical to a field before the accident. The application patterns were examined to determine maximum altitude gained during the reverse-direction turns. The data revealed that the AT-802 routinely exceeded 500 ft GPS altitude, and consistently reached maximum altitudes between 700 and 850 ft agl. - An examination of the AT-802’s planform revealed that, with the low-wing design, downward and forward visibility was most restricted at the AT-802 pilot’s 9:00 (o’clock) to 9:30 and 2:30 to 3:00 positions. Upward visibility for the AT-802A was restricted by the cockpit window and door frames and the cockpit roof. - On July 26, 2022, about 1701 central daylight time, an Air Tractor AT-802A airplane, N749LA, and an Air Tractor AT-802 airplane, N214RL, were involved in an accident near Portland, Arkansas. The AT-802A was destroyed and the AT-802 was substantially damaged. The pilot of the AT-802A was fatally injured and the pilot of the AT-802 was seriously injured. Both aircraft were operated as Title 14 Code of Federal Regulations Part 137 aerial application flights.   According to a witness who was familiar with both airplanes and pilots, the AT-802 was transiting the area at low altitude in a southeasterly direction. The area consisted mainly of mature soybean and cotton fields. Concurrently, the AT-802A pilot was applying chemical to a soybean field in a southerly direction. The pilot of the AT-802A pitched up at the end of his application run and collided with the AT-802 as it was flying overhead. The AT-802A continued to the northeast for about ¼ mile and crashed in a soybean field. The AT-802 began to spin vertically downward and impacted a cotton field underneath the point of collision. First responders extricated the pilot of the AT-802 and extinguished a postaccident fire in the engine compartment. He was airlifted to a hospital for treatment of his injuries. The pilot of the AT-802 was interviewed by the National Transportation Safety Board (NTSB) investigator-in-charge after the accident and the pilot reported that he had finished spraying soybeans on a friend’s farm and was ferrying the airplane back to his home airstrip. He was on a southeasterly heading and his hopper was empty. Suddenly, he heard and felt an impact. He recalled seeing the red striping on the other airplane and knew that it was the AT-802A. His airplane immediately started to spin and it spun 3-4 times before hitting the ground. The descent was straight down with no lateral movement. He believed that the forward windscreen blew out during the collision because the breeze was coming through the open cockpit and it was very quiet. He did not recall hearing the engine running after the collision with the AT-802A. The pilot of the AT-802 thought that he was about 500-600 ft above ground level (agl) when the collision occurred. He was familiar with the phrase, “Ferry at 5, stay alive.” He was not communicating on his radio at the time and was unaware that the pilot of the AT-802A, who he had been friends with for years, was working in the area. He also reported the larger, turbine-powered airplanes normally top out at 600-700 ft when making a reverse-direction turn, especially on cool days. He stated that there are a lot of blind spots on the AT-802 due to its large, low-mounted wing.   The AT-802A was equipped with a SATLOC G4 aerial guidance system and the AT-802 was equipped with an AgPilotX GPS system. The nonvolatile memory units were sent to the NTSB Vehicle Recorders Laboratory for download and analysis of the data. The data revealed that the AT-802A departed from runway 1 at Lake Village Municipal Airport (M32), Lake Village, Arkansas, about 1655. The AT-802A made a left, climbing turn to a southwesterly heading. About 1700:35, at 289 ft (all altitudes for both airplanes are in GPS altitude), the AT-802A made a left turn to a southerly heading and descended to below 100 ft, presumably to apply chemical. Concurrently, the AT-802 was positioned to the west of the AT-802A on a southeasterly heading. The altitude of the AT-802 varied between 407 and 465 ft during the 1 minute before the collision. Based on the relative positions of both airplanes, as the AT-802A was on its southwesterly heading, the AT-802 would have been located at the pilot’s approximate 1 o’clock position. Simultaneously, about 45 seconds before the collision, as the AT-802 was flying on the southeasterly heading, the AT-802A would have been positioned at the pilot’s approximate 10 o’clock position. Just before the collision (1701:07), the AT-802 indicated 477 ft altitude and about 139 knots ground speed, while the AT-802A indicated 341 ft altitude and 110 knots ground speed. The data indicated that the AT-802A was in a climbing, left turn at the time of impact, while the AT-802 was flying relatively straight and level (see figure 1). Figure 1: Track of the AT-802 (214RL, Cyan) and the AT-802A (N749LA, Yellow). Approximate location of collision is where the lines converged. - According to autopsy an report from the State Crime Laboratory, Little Rock, Arkansas, the cause of death of the pilot of the AT-802A was multiple blunt force injuries and the manner of death was accident. - The sun position data at 1700 for Portland, Arkansas included an azimuth of 269.51° with an altitude of 34.67° above the horizon. The sky was clear at the time of the accident. - Both airplanes crashed into fields of actively growing crops. The wreckage of the AT-802 came to rest upright in a cotton field consistent with a near-vertical descent path to the ground. The wreckage of the AT-802A was highly fragmented and the main wreckage came to rest in a soybean field. The main wreckages were about 0.25 nautical mile apart, with the AT-802 located southwest of the AT-802A. AT-802 Wreckage Examination An examination of the AT-802 wreckage revealed impact signatures to the leading edge of the left wing and forward wind screen, consistent with contact with the AT-802A. The wind screen and its frame separated in flight and were found about 50 ft southeast of the main wreckage. A large section of the left wing’s outboard leading edge was separated and missing. Red paint transfer marks matching the paint scheme of the AT-802A were found on the remaining left wing structure. The engine remained attached to the engine mount and the mount was attached to the firewall. The forward area of the engine and the surrounding cowling showed evidence of postaccident fire. An external examination of the engine revealed no evidence of an in-flight case breach or oil leak. The five-bladed propeller was separated from the engine consistent with ground impact forces; it was located immediately forward of the engine. The blades exhibited “s” bending, twisting, and chordwise scratching. The on-scene examination of the AT-802 did not reveal evidence of a preexisting malfunction or failure that would have prevented normal operation of the airplane. AT-802A Wreckage Examination The wreckage of the AT-802A was highly fragmented and spread over a path about 300 ft in length and about 75 ft wide. There was no fire observed in the AT-802A wreckage. Due to the general fragmentation of the wreckage and the similar paint schemes of both aircraft, no transfer marks were found suggesting in-flight contact with the AT-802. Both aircraft were painted yellow; however, the AT-802A had red and black paint stripes, while the AT-802 had blue and black paint stripes. The fuselage came to rest on its right side on a northeasterly heading. The fuselage separated from the wing box and came to rest adjacent to the wing. The left and right wings remained attached at the through spar as a single unit. The engine and engine mount separated from the fuselage and were found about 15 ft northeast of the cockpit area. The forward section of the engine case was fractured and loose in the debris field. An external examination of the engine revealed no evidence of an in-flight case breach or oil leak. The five-bladed propeller was separated from the engine consistent with ground impact forces at the second stage reduction gear; it was found adjacent to the right-wing leading edge. The blades exhibited “s” bending, twisting, and chordwise scratching. One of the blades was separated and was buried in the soil near the point of initial ground impact. The on-scene examination of the AT-802A did not reveal evidence of a preexisting malfunction or failure that would have prevented normal operation of the airplane. -
Analysis
The pilot of an Air Tractor AT-802A was applying chemical on the first pass over a cotton field in a southerly direction. Simultaneously, an AT-802 was ferrying in a southeasterly direction, between 400 and 500 ft above the ground. As the AT-802A pilot completed his pass and climbed to reverse the direction of turn, his airplane collided with the ferrying AT-802 passing overhead. The AT-802A continued in a left turn and crashed into a soybean field, killing the pilot. The AT-802 began to spin and descended vertically to the ground; its pilot was seriously injured. The surviving pilot of the AT-802 later reported that he was unaware that the other pilot was operating in the area. The two pilots were not communicating by radio. Although there may have been some sun glare that could have affected the AT-802A pilot’s visibility, the investigation revealed that both pilots were in positions to see the other airplane in ample time to avoid a collision. An examination of both wreckages did not reveal evidence of a preexisting malfunction or failure that would have prevented normal operation of the either airplane. Although the Professional Aerial Applicator’s Support System (PAASS) slogan, “Ferry above five (hundred) and stay alive” was known to the AT-802 pilot and was commonly known in the aerial application industry, this investigation revealed that both pilots consistently climbed above 500 ft agl during their reverse-direction turns while applying chemical. If the pilot of the AT-802 had flown his airplane at or above 1,000 ft agl, the collision would likely have been avoided.
Probable cause
The failure of both pilots to see and avoid the other airplane during aerial application and ferry operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Air Tractor Inc.
Model
AT-802A
Amateur built
false
Engines
1 Turbo prop
Registration number
N749LA
Operator
WESTWIND AIR LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
802A-0932
Damage level
Destroyed
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
Air Tractor Inc.
Model
AT-802
Amateur built
false
Engines
1 Turbo prop
Registration number
N214RL
Operator
LASSCO LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
802-0896
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-12T19:40:54Z guid: 105589 uri: 105589 title: ANC22LA064 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105645/pdf description:
Unique identifier
105645
NTSB case number
ANC22LA064
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T10:10:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-08-03T00:53:09.382Z
Event type
Accident
Location
Soldotna, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 27, 2022, about 0910 Alaska daylight time, a 5 Rivers LLC SQ2 airplane, N58SQ, was substantially damaged when it was involved in an accident near Soldotna, Alaska. The private pilot sustained serious injuries, and the passenger was uninjured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, while in cruise flight at about 4,000 ft msl, he advanced the throttle to initiate a climb, but the engine began to lose power. In an effort to regain power, he further advanced the throttle and propeller levers and switched the fuel selector to the left tank to no avail. He subsequently made a forced landing in a small gully, which resulted in substantial damage to the wings and fuselage. A postaccident examination revealed no preaccident mechanical malfunctions or anomalies with the airplane that would have precluded normal operation. A Global Data Assimilation System (GDAS) model sounding was created for the accident time and location, with the modeled surface elevation about 2,415 ft msl. When the GDAS sounding data was interpolated for an elevation of 4,000 ft msl, the data indicated the temperature was about 4.9°C (40.8°F) and the dewpoint was about 1.6°C (34.9°F), with a relative humidity of about 79 percent. Based on the carburetor icing probability chart, these conditions would result in “serious icing – cruise power.” When the pilot was asked if he applied carburetor heat after the loss of power, he stated that he did not, as there was no visible moisture in the area, and he thought carburetor ice would be unlikely. Figure 1. Carburetor icing probability chart (Courtesy of FAA). The conditions present at the time of the power loss are indicated with a red circle. A Lycoming Service Instruction states in part: "Flight Operation – During normal flight, leave the carburetor air heat control in the full cold position. On damp, cloudy, foggy or hazy days, regardless of the outside air temperature, be alert for loss of power. This will be evidenced by an unaccountable loss in manifold pressure or RPM or both, depending on whether a constant speed or fixed pitch propeller is installed on the aircraft. If this happens, apply full carburetor air heat, and open the throttle to limiting manifold pressure and RPM.” -
Analysis
The pilot reported that, while in cruise flight at about 4,000 ft mean sea level (msl), he advanced the throttle to initiate a climb, but the engine began to lose power. In an effort to regain power, he further advanced the throttle and propeller levers and switched the fuel selector to the left tank to no avail. He subsequently made a forced landing in a small gully, which resulted in substantial damage to the wings and fuselage. When the pilot was asked if he applied carburetor heat after the loss of power, he stated that he did not, as there was no visible moisture in the area, and he thought carburetor ice would be unlikely. A postaccident examination revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to a carburetor icing probability chart, the ambient conditions present at the time of the accident were conducive to the development of serious icing at cruise power. It is likely that the loss of engine power was the result of the formation of carburetor icing, and had the pilot applied carburetor heat, engine power would likely have been restored.
Probable cause
A total loss of engine power due to carburetor icing, which resulted from the pilot's failure to use carburetor heat while operating in conditions conducive to the formation of carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
5 RIVERS LLC
Model
SQ-2
Amateur built
true
Engines
1 Reciprocating
Registration number
N58SQ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2009
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-03T00:53:09Z guid: 105645 uri: 105645 title: ERA22LA340 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105598/pdf description:
Unique identifier
105598
NTSB case number
ERA22LA340
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T14:45:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-08-18T00:07:03.306Z
Event type
Accident
Location
Hollywood, Florida
Airport
North Perry (HWO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On July 27, 2022, about 1345 eastern daylight time, a Robinson R22 helicopter, N42WC, was substantially damaged when it was involved in an accident near Hollywood, Florida. The flight instructor was not injured, and the student pilot received minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the instructor, after completing an engine run-up, he “picked up” the helicopter and was air-taxiing to the practice area to conduct some hover work. Before reaching the practice area, a “popping” and “banging” sound was heard from behind the helicopter, followed by an uncommanded right yaw. The instructor attempted to regain control, but the helicopter collided with the ground and rolled over onto its right side. The instructor and student pilot exited the helicopter. Examination of the helicopter by a Federal Aviation Administration inspector revealed that the tail rotor assembly was separated; both tail rotor blades remained attached and the output shaft was also attached. Both tail rotor blades were bent and were impact damaged. The tail rotor gearbox was fractured, with half of the casing missing. The main rotor blades were bent down and curled, with multiple kinks and creasing from leading edge to trailing edge. Multiple impact signatures were noted on the ground within the rotor diameter of the helicopter. Examination of the tail rotor gear box and tail rotor blades revealed corrosion within both blades. The exam revealed that erosion of the leading edge provided a path for moisture to ingress into the bond joint and deteriorate the adhesive. The owner and the mechanic stated that the helicopter’s maintenance records were previously damaged by water and had to be reconstructed digitally. The records provided appeared to show that most life-limited parts had been overflown by 374.1 hours. The pilot stated that he had noted damage on the helicopter’s tail rotor blades during a preflight inspection about two weeks before the accident and that the operator had replaced the blades. Review of the available maintenance records for the helicopter revealed that the serial numbers of the tail rotor blades installed did not match that noted in the maintenance records. The available records also did not document any replacement of the tail rotor blades. -
Analysis
The instructor reported hearing a popping and banging sound while hover-taxiing during an instructional flight followed by an uncommanded right yaw. The instructor attempted to regain control, but the helicopter collided with the ground and rolled over onto its right side. Postaccident examination of the helicopter revealed that the tail rotor gearbox had fractured and that the tail rotor assembly had separated from the helicopter. Additional examination of the tail rotor blades, which had remained attached to the tail rotor drive shaft and gearbox, revealed corrosion and interior delamination of the blades. There was also erosion present on the blade leading edges, which likely provided a path for moisture to ingress, thereby resulting in the observed corrosion as well the failure of the bonding adhesive within the blade. It is likely that this condition resulted in an imbalance of the blades that imparted a vibratory loading onto the tail rotor gearbox that ultimately resulted in its failure during the accident flight. Review of partial maintenance records provided by the operator revealed that the tail rotor blades installed on the accident helicopter were not the blades that were noted in the maintenance logbooks, and the service history of the installed blades could not be determined.
Probable cause
Inadequate maintenance of the helicopter’s tail rotor blades, which resulted in a failure of the tail rotor drive system, and an inflight loss of yaw control from which the flight instructor was unable to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R22 MARINER
Amateur built
false
Engines
1 Reciprocating
Registration number
N42WC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1531M
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-18T00:07:03Z guid: 105598 uri: 105598 title: ERA22LA360 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105672/pdf description:
Unique identifier
105672
NTSB case number
ERA22LA360
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T15:31:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-05T22:43:31.493Z
Event type
Accident
Location
Barnstable, Massachusetts
Airport
Cape Cod Airfield (2B1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Prior to landing, the pilot obtained a weather report, which included wind from 190° at 10 knots. The first attempt to land on runway 23 “felt high” and the pilot elected to perform a go-around maneuver. He landed “long” during the subsequent landing and was unable to slow the airplane before it overran the end of the runway. He stated that he was unable to perform a go-around maneuver due to trees at the departure end of the runway. The airplane came to rest against trees, resulting in substantial damage to the left wing and fuselage. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. The wind reported at an airport about 6 nm east around the time of the accident was 170° at 7 knots gusting to 16 knots.
Probable cause
The pilot’s failure to attain a proper touchdown point, which resulted in a runway overrun in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N7437G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17259137
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-05T22:43:31Z guid: 105672 uri: 105672 title: CEN22LA440 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106192/pdf description:
Unique identifier
106192
NTSB case number
CEN22LA440
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T16:00:00Z
Publication date
2024-03-07T05:00:00Z
Report type
Final
Last updated
2022-10-27T18:41:25.438Z
Event type
Accident
Location
Merrill, Wisconsin
Airport
Merrill Municipal Airport (RRL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was conducting a zero-flap takeoff when shortly after liftoff the airplane entered an unintentional right roll that neither the student pilot nor his flight instructor could correct with full left aileron and left rudder input. The airplane continued to roll right until the right wingtip struck the ground. The nose landing gear and left main landing gear separated from the airplane during the hard landing. The airplane sustained substantial damage to a fuselage longeron, the left side of the stabilator, and the right aileron. Postaccident examination of the airplane revealed no evidence of any preaccident mechanical failures or malfunctions that would have precluded normal operation. Flight control cable continuity was confirmed for the ailerons, rudder, and stabilator. The aileron system exhibited binding due to impact-related damage to the right aileron. The airport’s weather station reported a calm wind condition about 5 minutes before the accident. However, the airport manager reported that the surface wind at the time of the accident was from the southwest at 16.5 knots, gusting 19 knots. A postaccident weather model for the airport included a west surface wind (277°) at 9 knots. Based on the wind model data, the airplane likely departed runway 7 with an 8 knot left quartering tailwind. The unintentional right roll was likely due to the student pilot not maintaining adequate roll control after liftoff.
Probable cause
The student pilot's failure to maintain adequate roll control during takeoff with a quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C23
Amateur built
false
Engines
1 Reciprocating
Registration number
N2240L
Operator
De Plane LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
M-1888
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-27T18:41:25Z guid: 106192 uri: 106192 title: ERA22LA341 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105600/pdf description:
Unique identifier
105600
NTSB case number
ERA22LA341
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T16:15:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-09-12T15:04:01.248Z
Event type
Accident
Location
Bloomsburg, Pennsylvania
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During an aerial application flight while spraying a corn field, the helicopter’s tail section struck a powerline. The pilot did not see the powerline, which crossed over the middle of the cornfield perpendicular to the spray pass he was performing, but he knew what he had struck as soon as the helicopter came into contact with it. He had already begun to pull up out of the field when the helicopter struck the powerline and was still moving forward at approximately 50 mph. As the helicopter slowed and he reached about 200’ agl, the helicopter began a yaw to the right that developed into an uncontrollable spin in the same direction. As the helicopter began spinning faster and faster, the pilot rolled off throttle to minimize the torque induced rotations. During the touchdown, the helicopter impacted in an approximately level attitude, and then rolled over on its right side, and was substantially damaged. The pilot noted that there were no preimpact mechanical malfunctions or failures of the helicopter that would have precluded normal operation and that the accident could have been avoided if more “field recon” procedures were done to be certain that powerlines are avoided.
Probable cause
The pilot's inadequate preflight planning and visual lookout, which resulted in impact with a powerline.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
GARLICK
Model
OH-58A+
Amateur built
false
Engines
1 Turbo shaft
Registration number
N132HD
Operator
TRIPLE F FLYING INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
41930
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-12T15:04:01Z guid: 105600 uri: 105600 title: ERA22LA358 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105670/pdf description:
Unique identifier
105670
NTSB case number
ERA22LA358
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-27T18:25:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-08-08T19:17:11.446Z
Event type
Accident
Location
Dillingham, Alaska
Airport
Dilingham (DLG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 27, 2022, about 1725 Alaska daylight time, a Cessna 207A, N6908M, was substantially damaged when it was involved in an accident near Dillingham, Alaska. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 scheduled flight. The pilot reported that, during approach to landing he became aware that the left rudder pedal was not responsive. The pilot declared an emergency and landed uneventfully. Examination of the airplane by a Federal Aviation Administration inspector revealed that one of the rudder cables had fractured, and rust was visible at the fracture location. Because the failure of the rudder cable adversely affected the performance and flight characteristics of the airplane and required replacement of the cable, the damage to the airplane was substantial. Follow-up examination revealed that the rudder cable was fractured about 94 inches from the turnbuckle terminal end and 152 inches from the center of the attachment holes in the clevis at the other end. The bearings at the centers of the pulleys moved freely in both submitted pulleys; however, examination revealed abrasion of the outer rim of the left pulley and orange deposits consistent with rust in the groove for the left pulley in addition to rubbing around much of the circumference of the groove contact surface. Although no rubbing damage was observed on the right pulley, the cable contact pattern was offset from the groove centerline. The fractured ends of the cable were mostly worn to a tapered end with no discernable fracture features, consistent with ductile overstress fracture. Review of the maintenance logs revealed that the last inspection of the flight controls was completed on November 23, 2021, about 8 months before the accident, at an airplane total time of 40,516.8 hours. An entry on January 5, 2022, and airplane total time 40,536.6 hours, notated that “the left hand rudder stuck pulley at the aft baggage bulkhead” as well as “corrosion of the L/H rudder cable at aft baggage bulkhead.” The mechanic’s response to the entry stated, “upon further inspection, determined cable not corroded. . . No defects.” The airplane had accrued 40,885 total hours at the time of the accident. -
Analysis
The pilot reported that, during approach to landing, he became aware that the left rudder pedal was not responsive. He declared an emergency and landed uneventfully. Examination revealed that the left rudder cable fractured due to corrosion and severe cable wear at the left pulley location. Nearly all wires on the cable were worn to a chisel-like point, leaving a small number of wires in the core strand to fracture in ductile overstress during final separation. The cable corrosion and wear were likely accelerated due to sliding contact with the left pulley. Issues with the rudder control system installation were evident on both pulleys. Rubbing damage on the face of the left pulley indicated that the pulley was contacting adjacent structure at the outer diameter. This contact likely interfered with pulley rotation, leading to the accelerated corrosion and wear of the control cable from sliding contact within the pulley groove. Although no rubbing damage was observed on the right pulley, the cable contact pattern was offset from the groove centerline, indicating an alignment problem in the rudder control system at the right pulley. Review of the maintenance logs revealed that the last inspection of the flight controls was completed about 8 months before the accident, and an entry about 3 months later noted a stuck pulley and corrosion of the left rudder cable. The maintenance response to the entry stated, “upon further inspection, determined cable not corroded. . . No defects.” Given the findings of the postaccident examination, it is likely that the accident would have been prevented had maintenance personnel taken more proactive action at that time.
Probable cause
Maintenance personnel’s failure to detect and correct improper rudder control system alignment, the resulting interference with the pulley’s rotation, and the accelerated corrosion and wear of the control cable, which ultimately led to its failure in flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
207
Amateur built
false
Engines
1 Reciprocating
Registration number
N6908M
Operator
GRANT AVIATION INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
20700672
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-08T19:17:11Z guid: 105670 uri: 105670 title: DCA22FM032 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105611/pdf description:
Unique identifier
105611
NTSB case number
DCA22FM032
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-07-28T09:13:00Z
Publication date
2023-10-12T04:00:00Z
Report type
Final
Last updated
2023-09-27T04:00:00Z
Event type
Accident
Location
Seattle, Washington
Injuries
0 fatal, 0 serious, 1 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the contact of the passenger vessel Cathlamet with the dolphin at the Fauntleroy Ferry Terminal was the master’s incapacitation, likely due to a microsleep, while the vessel was docking, and the quartermaster not actively monitoring the approach to the ferry terminal and intervening before the contact.
Has safety recommendations
false

Vehicle 1

Vessel name
Cathlamet
Vessel type
Passenger
Port of registry
Seattle , WA
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-09-27T04:00:00Z guid: 105611 uri: 105611 title: CEN22LA344 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105619/pdf description:
Unique identifier
105619
NTSB case number
CEN22LA344
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-28T15:38:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-08-01T20:55:18.486Z
Event type
Accident
Location
Dallas, Texas
Airport
Dallas Executive Airport (RBD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 28, 2022, at 1438 central daylight time, a Piper PA-32RT-300T, N3027J, was substantially damaged when it was involved in an accident near Dallas, Texas. The pilot sustained serious injuries. The airplane was operated under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The pilot reported to air traffic control (ATC) that the airplane had a rough running engine and declared an emergency. ATC then provided flight radar vectors to Dallas Executive Airport (RBD), Dallas, Texas. The pilot advised ATC that he would be unable to reach RBD, and he was going to land in trees. The airplane landed about 0.5 miles southwest of RBD and was substantially damaged when it impacted trees and terrain. Postaccident examination of the airplane revealed that the engine was equipped with a dual magneto, in which the left and right magnetos were housed in a single casing. The magneto case had a yellow tag affixed to it with the following information: Continental Motors, Inc., type: D6LN-3000, part number: 10-682560-13 serial number: G199915GR. The magneto case also had a blue tag affixed to it with identifying information of a 14 CFR Part 145 repair station. Postaccident examination of the magneto revealed all four of the magneto case screws were loose before the case was opened. Grounding of the magneto halves and its capacitors occurred through the magneto case. Upon opening the case, the cam follower for the right side of the magneto assembly was melted, which would not provide clearance for the contact point. The left side of the magneto assembly did not exhibit melting or electrical arcing, and its contact point clearance was 0.008 in. According to the magneto manufacturer’s maintenance information, the contact point clearance is specified as 0.016 +/-0.002 in. The magneto capacitors that were installed at the time of the accident were tested and found to be within the magneto manufacturer’s specifications. The magneto case was reassembled in preparation for an initial bench test of the magneto. During the test, there was no ignition on the right side and very intermittent, almost nonexistent, ignition from the left side. The test leads were then swapped so that the left side was operating off the right capacitor and the right side was operating off the left capacitor; no ignition was produced. Examination of the magneto afterward revealed that the left-side cam follower began to melt. In preparation of a second bench test, the magneto’s left-side contact point clearance was then re-gapped to 0.018 and good test capacitors were used with test leads bypassing the installed capacitors. During the test, the ignition from the left side of the magneto functioned normally. In preparation for a third bench test, the test capacitors that were used for the second bench test were disconnected and the leads from the original capacitors from the time of the accident were reconnected. During the test, intermittent ignition was produced again. When a separate ground lead was connected directly to the left-side capacitor to bypass the magneto case, the ignition from the left side of the magneto functioned normally. The right-side capacitor was then tested in the same manner, and the ignition from the right side functioned normally. When the direct ground wire was removed, ignition was almost nonexistent, and arcing was observed melting the cam follower. The left capacitor was then removed from the magneto case and corrosion was noted on the inner and outer portions of the case, which provided a ground to the capacitor. Teledyne Continental Service Bulletin (SB) 651 provides capacitor information and installation for D-2000 and D-3000 series magnetos, which states the following warning: “High resistance or discontinuity between the capacitor and the remainder of the magneto will result in destruction of the contact assembly, loss of ignition, and loss of engine power.” The SB further states: “When a magneto is removed from an engine for replacement, its capacitors are sometimes left on the engine with the separated harness. If the reason for the original magneto's removal originated in the capacitor circuit, but the capacitors are not changed, the same symptoms can be expected to recur with the replacement magneto.” “If either the ground return path or the flag terminal lead path presents high resistance, arcing will occur at the points. Arcing causes the points to overheat, which also overheats the spring to which one of the points is attached. The nylon cam follower then melts where it bears against the hot spring.” The airplane tachometer indication at the time of the accident was 2,876.6 hours. A review of maintenance records showed that the last annual inspections of the airframe and engine were dated July 2, 2021, with a tachometer time of 2,876.3 hours. An invoice to the pilot from a maintenance facility, dated May 22, 2021, with a tachometer time of 2,876.2 hours, showed that the magneto was removed and replaced for a 500-hour inspection. There were no corresponding entries, as required by regulation, in the engine logbook for the magneto removal and installation. An Airworthiness Approval Tag, Federal Aviation Administration Form 8130-3, for the magneto’s 500-hour inspection by the repair station identified by the blue tag affixed to the magneto case, stated that the installer must comply with SB651. -
Analysis
The pilot declared an emergency to air traffic control after the airplane’s engine began to run rough while en route to the destination airport. He received radar vectors to an alternate airport but was unable to reach that airport. During the subsequent off-airport landing, the airplane impacted trees and sustained substantial damage to the wings and fuselage. Postaccident examination of the airplane revealed the magneto case’s cover screws were loose and there was corrosion present on the magneto housing. The corrosion would have resulted in the magneto’s capacitors not properly grounding to the magneto case due to the corrosion, which also resulted in electrical arcing near the points and melting that was found on the cam follower. Without a proper attachment of the magneto case due to the loose cover screws, there would have been a slight case separation that would result in a simultaneous failure of both magneto sides due to a lack of ground. A review of airframe logbooks showed that there was no logbook entry, as required by regulation, stating that the magneto was removed and replaced after a 500-hour inspection of the magneto was performed by a repair station. An invoice from a maintenance facility to the pilot stated that the magneto was removed and replaced for a 500-hour inspection. The repair station’s Airworthiness Approval Tag for the magneto stated that the installer of the magneto must comply with the magneto manufacturer’s Service Bulletin SB651, which was not performed based on the corrosion and electrical arching found during the postaccident examination.
Probable cause
Maintenance personnel’s inadequate maintenance of the magneto, which resulted in a loss of engine ignition, a loss of engine power, and a subsequent forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32RT-300T
Amateur built
false
Engines
1 Reciprocating
Registration number
N3027J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32R-7987075
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-01T20:55:18Z guid: 105619 uri: 105619 title: CEN22LA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105648/pdf description:
Unique identifier
105648
NTSB case number
CEN22LA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-29T07:52:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-08-03T20:26:03.529Z
Event type
Accident
Location
River Falls, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On July 29, 2022, about 0652 central daylight time, a Sonex Aircraft Sonex airplane, N1557S, sustained substantial damage when it was involved in an accident near River Falls, Wisconsin. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 test flight. The pilot reported the purpose of the flight was to check the position of the trim tabs, as the right wing was “heavy,” and he would have to hold “a little left” rudder to maintain the airplane in straight-and-level flight. The pilot completed the preflight inspection with no issues noted and the airplane had about 10.3 gallons of UL94 avgas onboard for the local flight. The airplane departed from the South St. Paul Municipal Airport (SGS), South St. Paul, Minnesota. While enroute for several miles, the pilot completed the trim tab position checks and after between 30 and 45 minutes decided to return to SGS. Shortly after turning back toward the airport, at about 2,700 ft msl, the engine sustained a total loss of power. The pilot reported that the engine did not emit any noises, nor did he notice a drop in the engine’s rpm. The pilot tried restarting the engine three times. Although the engine would “turn over,” it would not start. The pilot elected to perform a forced landing to a corn field. During the landing, the right wing impacted a traffic sign and the airplane came to rest upright in a grass ditch. The airplane sustained substantial damage to the right wing and the fuselage. On-site examination of the airplane found that the sole fuel tank, located forward of the instrument panel, was intact with the fuel cap installed properly. No fuel was observed inside of the fuel tank. The fuel tank drain plug was removed, and no fuel came out. There were no signs of a fuel leak on the airframe or from the engine, nor were there any signs of a fuel leak or spillage on the ground such as with vegetation blighting at the accident site. There were no odors of fuel at the accident site. Postaccident examination of the airplane confirmed flight control continuity. Airframe to engine control continuity was established. Rotational continuity was established throughout the engine and valvetrain when the crankshaft was rotated. The fuel line to the carburetor was removed and no fuel was observed. No fuel was observed from the fuel supply line to the strainer. The drain from the fuel strainer was found separated. The bowl from the strainer was removed and no fuel was found. There were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. Fuel System The Sonex Builders & Pilots Foundation has published the Sonex Aircraft New Pilot Training Guidelines and Transition Training Syllabus. This document discusses the fuel system and states: The stock fuel tank in the Sonex is a rotationally molded, polyethylene fuel cell located under the glareshield in the forward fuselage. Fuel tank capacities vary depending on model, with the legacy Sonex models holding 16 gallons, the B-Models holding 20 gallons, and the Onex holding 15 gallons. The system is designed to operate on a gravity feed setup, and as such a fuel pump is generally not installed or needed. Fuel level monitoring can be accomplished by an electronic, capacitance style fuel probe threaded into the bottom of the fuel tank, or by incorporating a clear visual sight tube into an upper and lower port into the fuel tank. A shutoff ball-valve is standard, located under the instrument panel at the outlet of the fuel tank. It is common practice to close this valve when the aircraft is not in use. -
Analysis
The pilot completed the preflight inspection with no issues noted; the airplane had about 10.3 gallons of fuel onboard for the local flight test. The airplane departed and, after flying for between 30 and 45 minutes, the pilot decided to return to the airport. Shortly thereafter, the engine sustained a total loss of power. The pilot reported that the engine did not emit any noises, nor did he notice a drop in the engine’s rpm. The pilot tried restarting the engine three times. Although the engine would “turn over,” it would not start. The pilot elected to perform a forced landing to a corn field. During the landing, the right wing impacted a traffic sign and the airplane came to rest upright in a grass ditch. The airplane sustained substantial damage to the right wing and the fuselage. The on-site examination of the airplane found no fuel inside of the fuel tank; the fuel tank was not compromised. There were no signs of a fuel leak on the airframe or from the engine, nor were there any signs of a fuel leak or spillage on the ground at the accident site. During a postaccident examination, the fuel line to the carburetor was removed and no fuel was observed. No fuel was observed from the fuel supply line to the strainer. The bowl from the strainer was removed and no fuel was found. There were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. Based on the available evidence, it is likely that the engine lost power due to fuel exhaustion.
Probable cause
The pilot’s improper fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SONEX AIRCRAFT
Model
SONEX
Amateur built
true
Engines
1 Reciprocating
Registration number
N1557S
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
1557
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-03T20:26:03Z guid: 105648 uri: 105648 title: ERA22FA343 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105621/pdf description:
Unique identifier
105621
NTSB case number
ERA22FA343
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-29T15:02:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-08-03T16:13:00.488Z
Event type
Accident
Location
Andalusia, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 1 minor
Factual narrative
An Appareo Vision 1000 cockpit video recorder was retained and forwarded to the National Transportation Safety Board Vehicle Recorders Laboratory for data download. The video recorder’s SD card was in the locked position and no data from the accident flight had been stored on it. Additionally, no data was retrieved from the internal memory of the unit. - On July 29, 2022, about 1402 central daylight time, a Eurocopter AS 350 B2, N124LN, was substantially damaged when it was involved in an accident near Andalusia, Alabama. The commercial pilot and one crewmember were seriously injured, and a second crewmember sustained minor injuries. The helicopter was operated as a Title 14 Code of Federal Regulations Part 135 air medical flight. The approximately 15-minute flight departed a base in Evergreen, Alabama, and cruised at 2,000 ft mean sea level, destined for Andalusia Health Hospital to pick up a patient for transfer to a different hospital. During a postaccident interview, the pilot stated that he remembered reporting 7 miles from South Alabama Regional Airport (79J), Andalusia, Alabama. Although 79J was not the destination, the pilot made the report on the common traffic advisory frequency for traffic avoidance as an airplane had just departed 79J. The pilot recalled feeling sweaty and clammy toward the end of the flight. He remembered someone telling him to “pull up” three times and then remembered receiving on-site medical care after the accident. The pilot did not recall the accident sequence. The flight paramedic stated in a postaccident interview that the helicopter was approaching the hospital helipad and descending; however, it seemed low as the helipad was still about 1 mile away. The paramedic recalled that the flight nurse, who was seated behind the pilot, tapped the pilot on the shoulder and said that they were too low. The pilot replied “yeah, yeah, yeah,” and initially leveled off, but then the nose began to pitch down into another descent. At that point the flight nurse made a mayday call, shook the pilot’s seat and told him to “pullup, pullup, pullup.” The helicopter subsequently nosed up, made a left turn, and impacted a field on its right side. The flight nurse was critically injured and could not provide a statement. Witnesses in the field near the accident site stated that the helicopter flew overhead about 300 ft above ground level, then nosed up 90° or more before turning left and impacting trees, powerlines, and the ground. - The pilot’s Federal Aviation Administration (FAA) medical certification file, postaccident emergency treatment records, and selected personal medical records were reviewed. Results were reviewed from toxicological testing performed by the FAA Forensic Sciences laboratory of specimens collected during the pilot’s initial postaccident hospital care. The pilot’s most recent FAA second-class medical certificate was issued on April 22, 2022. At that time, he reported no medication use or active medical conditions. Seven days later, the pilot made an initial visit to a primary care physician on April 29, 2022. During that visit, he reported a history of OSA, which he was getting relief from an oral appliance he had been using to treat the OSA since 2015. The pilot did not report his OSA to the FAA. The pilot was admitted to the hospital after the accident and underwent evaluation for injury and syncope (loss of consciousness). No definitive cause of the pilot’s syncope was identified. The FAA toxicological testing results revealed that ethanol was detected in blood at 0.024 g/dL and in urine at 0.08 g/dL. Benzoylecgonine, an inactive metabolite of cocaine, was detected at 165 ng/mL in urine but was not detected in blood. Cocaethylene, a substance that forms in a person’s body when cocaine is metabolized in the presence of ethanol, was detected in urine but not in blood. According to hospital records, the pilot’s initial hospital blood collection was at 1539 on the date of the accident, and his initial hospital urine collection was at 1729. Ethanol is the intoxicating alcohol in beer, wine, and liquor. It can adversely affect judgment, coordination, perception, cognition, and vigilance. Even in a small amount, ethanol can impair pilot performance, and the number and seriousness of pilot errors tends to increase with blood ethanol level. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibitions on piloting a civil aircraft within 8 hours of drinking ethanol or while having a blood ethanol level of 0.04 g/dL or greater. Once ethanol has been absorbed into the bloodstream, it is typically eliminated at a rate of about 0.01 to 0.035 g/dL per hour, depending on individual metabolism. Cocaine (metabolites of which were detected in this case) is a stimulant drug that is commonly used illicitly by recreational users who may seek euphoric effects, feelings of increased alertness, strength, and decisiveness, and appetite suppressant effects. Cocaine is a Schedule II controlled substance under federal law, with a high potential for abuse and dependence, and is a prohibited drug under FAA drug and alcohol regulations for on-demand operators. Cocaine has a myriad of potentially impairing psychological and physiological effects and increases the risk of cardiovascular problems. The major inactive cocaine metabolite benzoylecgonine may be detected in urine for days after last cocaine use. Symptoms from crashing or withdrawing after stopping cocaine use may last for days to weeks. Review of law enforcement records revealed that the pilot had a conviction for driving under the influence (DUI) in 2012 and an arrest for DUI in May 2022. The pilot did not report his DUI history to his employer or to the FAA before the accident. During the day before the accident, the pilot called out sick from work, reporting a stomach illness (for more information, see Medical Factual Report in the public docket for this accident). - The wreckage came to rest on its right side, oriented about 165° magnetic. An approximately 100-ft debris path was oriented on a westerly heading. The beginning of the path consisted of fallen tree branches and powerlines, followed by the aft tail boom and the main wreckage at the end of the path. The three main rotor blades remained attached to their respective hinges; however, all 3 star arms were fractured at an approximately 45° angle and the main rotor blades were resting on the ground in a stacked position. The aft tail section separated in two sections, forward of the horizontal stabilizer and forward of the tail rotor gearbox. The tail rotor system remained attached to the vertical stabilizer. The tail rotor blades remained attached with one exhibiting tip damage and the other partially separated at the root. The tail rotor drive shaft separated at the flex coupling and at the forward steel short shaft. The right horizontal stabilizer exhibited leading edge damage, consistent with a wire strike. The helicopter was equipped with an air medical interior, which had a right pilot seat and a litter in lieu of a left pilot seat. Two rear seats were for the flight paramedic and flight nurse. Flight control continuity was traced from the cyclic and collective, through crushed and separated push-pull tubes (the left lateral cyclic control push-pull tube and bellcrank under the transmission deck were fractured and separated, consistent with impact forces), to the main rotor system. Anti-torque system continuity was traced from the pedals, through crushed push-pull tubes, to the flexball cable, to the aft tail rotor servo. Three of the four transmission suspension bars were found broken. The engine remained installed in the helicopter with the front and rear mounts still intact. The gas generator and free turbine could be rotated by hand. The axial compressor exhibited impact marks consistent with foreign object ingestion. The intake bellmouth separated at the three connection points to the compressor casing. Continuity was confirmed through the gas generator to the accessory gearbox and from the free turbine to the end of the transmission shaft. The flector group between the transmission shaft and main transmission input separated. -
Analysis
The medical helicopter was flying a 15-minute flight from its base to a hospital to pick up a patient for transfer to another hospital. The cruise portion of the flight was uneventful. As the helicopter began its descent to the hospital helipad, the pilot lost consciousness, as witnessed by the flight paramedic. The helicopter then departed controlled flight and impacted a field about 1 mile from the hospital helipad. During a posaccident examination of the helicopter, no evidence of any preimpact mechanical malfunctions or failures of the helicopter were identified, nor did the pilot report any. After the accident, the pilot was admitted to a hospital and underwent evaluation for injury and syncope (loss of consciousness), but no definitive cause of the syncope was identified. Toxicological testing detected ethanol at 0.024 g/dL in a blood specimen collected from the pilot more than 1.5 hours after the crash and detected ethanol in his urine. Testing also detected the cocaine metabolites benzoylecgonine and cocaethylene in the pilot’s urine but not in his blood. Based on the pilot’s blood ethanol level and an estimated ethanol elimination rate of 0.01 to 0.035 g/dL per hour, the pilot’s blood ethanol level at the time of the accident was likely between 0.04 g/dL to 0.08 g/dL. Ethanol at this level would not sufficiently explain the pilot’s loss of consciousness but would be expected to have adverse effects on his performance capacity. Thus, it is likely that the pilot was impaired by effects of ethanol at the time of the accident. The benzoylecgonine detected in the pilot’s urine indicated that he had used cocaine. The cocaethylene in his urine indicated that both cocaine and ethanol had been in his system at the same time, with more than a small amount of cocaine likely used. The time elapsed between the pilot’s last cocaine use and his blood specimen collection was sufficient for cocaine to be metabolized and for its metabolites to fall below detectable levels in his blood. However, the precise time of his last cocaine use could not be determined, and the possibility of residual adverse effects from his cocaine use could not be excluded. The pilot also had a history of obstructed sleep apnea (OSA) and had called out sick the day before the accident, reporting a stomach illness. At the time of the accident, the pilot likely was experiencing some impairing effects from alcohol use and may also have been experiencing impairing effects related to his use of cocaine. However, the event that precipitated the loss of helicopter control was the pilot’s acute incapacitation by a syncopal episode, the precise medical cause of which is unknown. Whether the pilot’s substance use, reported illness, or OSA (or a combination thereof) contributed to his syncopal episode cannot be determined.
Probable cause
The pilot’s acute incapacitation by a syncopal episode, which resulted in the helicopter departing controlled flight and colliding with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
AS350
Amateur built
false
Engines
1 Turbo shaft
Registration number
N124LN
Operator
AIR METHODS CORP
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Other work use
Flight service type
Passenger
Flight terminal type
Domestic
Medical flight type
Discretionary
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
4130
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-03T16:13:00Z guid: 105621 uri: 105621 title: ERA22LA348 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105636/pdf description:
Unique identifier
105636
NTSB case number
ERA22LA348
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-29T15:04:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-08-03T18:49:17.432Z
Event type
Accident
Location
Raeford, North Carolina
Airport
Raeford West Airport (NR20)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On-Board Recorder Information and Ballistics Study According to ballistic calculations, the SIC left the airplane between 14:31:53 and 14:32:01. A portable wireless receiver on the accident airplane that contained global positioning system (GPS) location data and attitude and heading reference system (AHRS) data was recovered and examined. During the 8-second time frame that the SIC left the airplane, a roll transient and spike in vertical load factor occurred that was an outlier compared to the earlier seven minutes and following three minutes of flight. This event could have been before, during, or after the SIC departed the airplane, and it could not be determined if this roll transient was commanded or a result of external forces on the airplane. - The CASA C-212 was a turboprop short take-off and landing (STOL) medium-sized cargo plane equipped with two aft doors: the upper cargo door and the ramp door. The cargo door opened upwards and inwards, and the ramp door opened downward and outward. Both were hydraulically-operated from the cockpit via the cargo door handle located directly behind the SIC’s station. Per the Aircraft Flight Manual, the cargo and ramp door are closed for all takeoffs and landings. To allow the skydivers to exit the airplane, the SIC would typically ensure that the ramp surface was level with the cabin floor. In this position, the level cabin floor and ramp surface measured 25 feet, 10 inches from the cockpit bulkhead to end of ramp door. A company pilot stated that, when fully lowered, the downward angle of the ramp door was “very steep” and slippery. The distance from the cockpit bulkhead to where the cabin floor would have dropped off steeply with the ramp fully lowered was about 21.5 feet, about 4 feet closer than the SIC would have been accustomed to seeing the jumpers exit the airplane. A company pilot stated that the SIC had likely never been in the back of the airplane with the ramp lowered. - On July 29, 2022, about 1404 eastern daylight time, a CASA 212-200 airplane, N497CA, was substantially damaged during a hard landing near Raeford, North Carolina. The pilot-in-command (PIC) was not injured, and the second-in-command (SIC) sustained fatal injuries during the subsequent diversion to Raleigh-Durham International Airport (RDU), Durham, North Carolina. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 skydiving flight. Federal Aviation Administration (FAA) radar data revealed that the accident flight departed at 1341 and climbed above 13,000 ft mean sea level (msl). According to the PIC, the SIC was flying the airplane and, after unloading the skydivers, he descended to pick up another group of skydivers. The PIC stated that the approach was stabilized until the airplane descended below the tree line and “dropped.” Both pilots called for a go-around maneuver, which the SIC initiated; however, before the SIC could arrest the airplane’s sink rate and initiate a climb, the right main landing gear (RMLG) impacted the runway surface. The PIC took control of the airplane about 400 ft above ground level and flew a low approach over the runway so that airfield personnel could verify the damage. The personnel subsequently called the PIC to let him know that they recovered the fractured RMLG on the runway. The flight crew contacted air traffic control (ATC) at 1411 and declared an emergency, reported the loss of the right wheel, and requested to divert to RDU. While enroute to RDU, the crew reviewed emergency procedures and planned the landing. During this time, the SIC was primarily responsible for communicating with controllers and reviewing checklist procedures while the PIC flew the airplane. The PIC stated that the SIC was engaged and offered input on runway assignment based on his knowledge of RDU, which the PIC accepted. Review of ATC information revealed that communications between the SIC and controllers were routine. In his final transmission at 1429, the SIC acknowledged a course heading. The PIC reported that, about this time, which was about 20 minutes into the diversion to RDU, the SIC became visibly upset and repeatedly apologized then said, “I think I am going to be sick.” The PIC described that the SIC opened his side cockpit window, turned his head toward it, and “may have gotten sick.” The PIC took over radio communications, and the SIC lowered the ramp in the back of the airplane, indicating that felt like he was going to be sick and needed air. The PIC reported that he, “did not find this overly alarming as this (was) a common practice in a hot environment and given our situation.” Subsequently, the PIC stated that the SIC looked at him and stated, “I am sorry,” then disconnected his seat belt, dropped his headset, and ran out the back of the airplane toward the fully open ramp in a headfirst dive. In a radio transmission to ATC about 1 1/2 minutes after the SIC’s radio acknowledgement of the course heading, the PIC notified ATC that the copilot had just “jumped out the back of the plane without a parachute.” The PIC proceeded on course to RDU, where he performed a low approach and then an emergency landing. Upon landing, the airplane departed the right side of the runway and came to rest in the grass. Examination of the accident site by an FAA inspector revealed substantial damage to the RMLG, landing gear fittings, and the airframe structure. - The North Carolina Office of the Chief Medical Examiner performed the autopsy of the SIC. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident. Toxicological testing of the SIC’s urine performed by the North Carolina Office of the Chief Medical Examiner was negative for tested-for substances. Toxicological testing by the FAA Forensic Sciences Laboratory detected ethanol at 0.396 g/dL in the SIC’s liver tissue and at 0.011 g/dL in his urine and did not detect ethanol in his brain tissue. Acetone was detected at a low level in his brain tissue and was not detected in his liver tissue or urine. Mitragynine was detected in his liver tissue and urine. Ethanol can be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury. Acetone is an organic compound that is used industrially and occurs naturally, including as a byproduct of fat metabolism by living cells. Acetone at the low level detected in the SIC’s brain tissue does not have specific significance and would not be expected to have impairing effects. Mitragynine is a predominant active substance in the drug kratom. Kratom comes from the leaves of a tropical tree species native to Southeast Asia. In the United States, kratom products are widely available for online and retail purchase. Users typically consume kratom by chewing the leaves, brewing the leaves into a tea, or consuming extracts, powder, or pills derived from the leaves. Americans who self-medicate with kratom commonly do so with the intention of relieving pain, anxiety, depression, or opioid withdrawal symptoms. Various other medicinal effects might be sought by users, including treating cough, diabetes, diarrhea, insomnia, or alcohol withdrawal. The United States Food and Drug Administration has not approved kratom for any use, and warns consumers not to use the drug, citing safety concerns that need further research, including risk of abuse and addiction. The United States Drug Enforcement Administration has identified kratom as a “Drug of Concern,” but has not listed it as a federally-controlled substance. Kratom use is considered disqualifying for pilots under internal FAA policy. Notably, some of the symptoms of kratom use and/or withdrawal may overlap with symptoms of conditions that kratom users may seek to treat. For example, anxiety control is a common motivation for kratom use, and anxiety itself may predispose people to heightened physiological responses to stress, which sometimes manifest with nausea, dizziness, or feeling hot or smothered. - The PIC reported that there was moderate turbulence during the flight. Weather reports along the route of flight to RDU included moderate downdraft convective energy in the area. Additionally, the Severe Weather Gust Potential and Microburst Gust Potential were 50 knots and 57 knots, respectively, along the route of flight. Recorded data downloaded from the flight included vertical load factors supportive of turbulence enroute to RDU. - Pilot-in-Command In an interview with police, the PIC stated he and the SIC met for the first time during this assignment and flew together on the day of the accident as well as the day before. The PIC also served as the Chief Pilot for the operator and had interviewed the SIC when he applied for the pilot position. Interviews with several company pilots indicated that the PIC was well-liked, knowledgeable, patient, and respected. One company pilot stated that the PIC would never “get into a situation where he corrects an SIC in a manner that makes the situation worse, especially not on an operation.” Another company pilot stated that the PIC was “very approachable. He’s a guy you never want to disappoint. He’s like your dad, and you’d feel bad if you disappointed him. He’s trying to get you to the best and you want to show him your best. He’s not banging on the dash.” Second-in-Command The SIC’s family was under the impression that the accident flight was a checkride; however, the operator stated that this was not correct. The SIC’s father stated that his son “could be tough on himself” and that he could see him “being physically sick because of (the loss of the landing gear on the flight with the Chief Pilot).” He also reported that his son had performed a gear-up landing in his previous position as a flight instructor. The operator referenced “internal reports” that indicated that the SIC placed significant professional importance upon a successful flight with the Chief Pilot (the PIC). Interviews with colleagues and family of the SIC indicated that he was well-liked, happy, smart, and very pleased to be working for the operator. One of the pilots who flew with the SIC stated that: (The SIC) strove to be near perfect in everything. If we were coming back and we were a few degrees off on the heading, he would chide himself. His approaches were absolutely perfect. I was impressed with his abilities. . . The one thing I noticed is that he wanted to be perfect all the time. He didn’t allow himself any slack. One time he was so flustered after he dropped the fuel card. He was so upset with himself. “I dropped the card, I can’t believe I dropped the card.” His face was red, and he was sweating. I told him to take 20 minutes to walk to the fuel farm and find it. He RAN to the farm and found it. He was hard on himself, really hard. He knew what the customers needed for a precise product, and he really strove for that and wanted to do a good job. -
Analysis
After dropping a load of skydivers, the pilots were returning to the airport to pick up another group of skydivers, with the second-in-command (SIC) as the pilot flying. The pilot-in-command (PIC) indicated that the approach was stabilized until the airplane descended below the tree line and encountered what he described as windshear. The SIC initiated a go-around; however, before he could arrest the airplane’s sink rate and establish a climb, the right main landing gear impacted the runway surface and separated from the airplane. The crew declared an emergency, reported the loss of the right wheel, and requested to divert to a larger airport. During this diversion, the crew planned the landing, and the SIC communicated with air traffic control (ATC) while the PIC flew the airplane. The PIC reported that, about 20 minutes into the diversion, after conducting approach and emergency briefings, the SIC became visibly upset following the hard landing. The PIC described that, about this time, the SIC opened his side cockpit window and lowered the ramp in the back of the airplane, indicating that he felt like he was going to be sick and needed air. The PIC stated that the SIC looked at him and said he was sorry, got up from his seat, removed his headset, and ran out of the airplane via the aft ramp door. The PIC subsequently notified the controller that the copilot had just jumped out of the back of the airplane without a parachute. The PIC subsequently performed a successful emergency landing. Although the PIC and operator reported that the SIC’s departure from the airplane was an intentional act, there was insufficient information to support that assertion. No family or company personnel shared concerns about the SIC’s state of mind or behavior until the events that resulted in his departure from the aircraft; however, a company pilot shared an event during which the SIC had seemed to have a disproportionate, intense emotional and physical reaction upon becoming worried that he had lost a fuel payment card. The operator and family also indicated that the SIC felt that the accident flight with the PIC, who was also the chief pilot for the operator, was very important. This would have added to the SIC’s stress and emotional response after the hard landing, during which he was the pilot flying. In the 20 minutes of flight while serving as the monitoring pilot, the SIC was actively engaged in communicating with ATC, reviewing emergency procedures, and providing recommendations to the PIC on the landing runway at the diversion airport. In his initial statement to authorities, the PIC stated that, before departing the airplane, the SIC became visibly upset and apologetic, and reported feeling sick. His actions to increase ventilation in the cabin, which included opening the window and lowering the ramp, as well as his hurried departure from his seat, are consistent with an attempt to address increasing nausea symptoms and a desire to not throw up in the cockpit. However, the SIC made an unsafe decision to run to the rear of the cabin with the ramp in a fully lowered position, as he likely had not previously been in the cabin in flight with the ramp down. It is possible in his haste he lost his footing when encountering the area of the ramp and inadvertently fell from the airplane. Weather sounding and radar data supported the potential for windshear and turbulence activity, and the PIC reported that there had been moderate turbulence during the flight. The postaccident toxicological finding of mitragynine in the SIC’s liver tissue and urine indicated that he had used a kratom product, which had the potential to cause impairment. Notably, anxiety control was a common motivation for kratom use, and anxiety itself may predispose people to heightened physiological responses to stress, which sometimes manifest with nausea, dizziness, or feeling hot or smothered. Although it is possible that effects of kratom may have contributed to nausea or to some dizziness or perceptual impairment that may have increased his risk of falling, there is insufficient evidence to determine whether effects of the SIC’s kratom use contributed to the accident.
Probable cause
The airplane’s encounter with windshear during landing, which resulted in a hard landing and separation of the right main landing gear, and the pilot’s subsequent decision to leave his seat in flight, which resulted in his fall from the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CASA
Model
C212
Amateur built
false
Engines
2 Turbo prop
Registration number
N497CA
Operator
Rampart Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Skydiving
Commercial sightseeing flight
false
Serial number
291
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-03T18:49:17Z guid: 105636 uri: 105636 title: WPR22LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105630/pdf description:
Unique identifier
105630
NTSB case number
WPR22LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-30T09:00:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-08-17T01:35:26.609Z
Event type
Accident
Location
Livermore, California
Airport
LIVERMORE MUNI (LVK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 30, 2022, about 0800 Pacific daylight time, a Cessna 177RG, N2591V, sustained substantial damage when it was involved in an accident near Livermore, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. The pilot departed Salinas Airport (SNS), Salinas, California, en route to Livermore Municipal Airport (LVK) after an uneventful prefight check and engine runup. About 30 minutes after takeoff, he noticed that the engine monitor was indicating an increase in EGTs for all cylinders. The engine then briefly “stuttered,” and he decided to divert to an airport en route for a precautionary landing. He then adjusted the fuel mixture control, and the temperatures returned to normal, so he decided to continue to the original destination. About 10 minutes later, he initiated the landing descent to LVK by reducing engine power and moving the fuel mixture to full rich. During the landing approach, the EGTs again began to rise, and the engine lost all power. The airplane sustained substantial damage to the left wing and stabilator after landing short of the runway and striking a set of instrument landing system lights. Postaccident examination did not reveal any anomalies with the engine or airframe, and the engine could be operated at varying speeds during a ground run. Review of the data recorded by the airplane’s engine monitor indicated that the EGT rise was about 200° F, and during the periods of EGT rise, there was no discernible change in fuel flow. (The fuel flow transducer was installed at the inlet of the fuel injection servo, rather than the outlet to the flow divider.) The airplane was equipped with a Bendix RSA-5AD1 fuel injection servo. The servo and flow divider were tested and examined at Precision Airmotive’s facility. The testing revealed that both units met the performance specifications required following a field overhaul. However, disassembly of the fuel injection servo revealed significant internal corrosion and corrosion deposits throughout. The diaphragm cavities displayed “water lines” and corrosion on the metered and unmetered fuel sides, consistent with water contamination (figures 1 and 2). Corrosion deposits were present in the servo valve seat cavity and in the mixture control assembly (figures 3 and 4). Figure 1 - Water line and corrosion on metered side Figure 2 - Water line and corrosion on unmetered side Figure 3 - Corrosion deposits on the lower side of the mixture control spring Figure 4 - Corrosion on the surfaces of the idle and mixture valve housing bore Precision Airmotive Service Bulletin PRS-97, revision 2, issued in August 2013, stated that the time between overhaul (TBO) for all fuel injection system components is either the same as the TBO specified by the engine manufacturer for the engine or 12 years since placed in service or last overhauled, whichever occurs first. The bulletin also stated that an overhaul is mandatory if the fuel system is contaminated with water. Maintenance records indicated that the last rebuild of the fuel injection servo was performed in August 1999, 23 years before the accident while the engine was undergoing an overhaul. Another engine overhaul was performed in August 2012, and the corresponding logbook entry stated that no accessories were overhauled at that time. The maintenance logbooks did not indicate the fuel system had been exposed to water; however, examination of the airplane indicated that the gascolator had recently been replaced. There was no maintenance entry to reflect this work, and the mechanic who performed the most recent annual inspection stated that he did not replace the gascolator at that time. There were no significant periods of inactivity noted in the logbook, although the owner stated that the airplane sat idle for 6 months before he purchased it in June 2020. He stated that the airplane was kept in a hangar for much of its recent life. -
Analysis
About 30 minutes after takeoff on a cross-country flight, the pilot noticed an increase in engine exhaust gas temperatures (EGTs) for all cylinders. The engine then briefly “stuttered,” and he decided to divert to an airport en route for a precautionary landing. The EGTs then returned to normal, and he decided to continue to the original destination. However, during the landing approach, the EGTs again began to rise; the engine lost all power; and the airplane landed short of the runway and struck approach lights, which resulted in substantial damage to the left wing and stabilator. Data recorded by the airplane’s engine monitor showed the EGT increases that were reported by the pilot. Disassembly of the fuel injection servo revealed significant internal corrosion and corrosion deposits along with evidence of water ingestion. The corrosion deposits likely resulted in a partial blockage (restriction) of fuel to the cylinders, which manifested itself as a lean fuel mixture. This lean mixture was consistent with the observed increase in EGTs. During the final approach, the blockage likely became severe enough to result in the total loss of power. The fuel injection servo manufacturer recommends by service bulletin that the unit should be overhauled either every 12 years or at the time of engine overhaul. The unit had last been overhauled 23 years before the accident, and it was not overhauled at the last engine overhaul 10 years before the accident. Additionally, the service bulletin stated that the unit should be overhauled in the event of water contamination. The unit had clearly ingested water at some point during its life, although it could not be determined when this occurred.
Probable cause
The total loss of engine power due to an inadequately maintained fuel injection servo.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177RG
Amateur built
false
Engines
1 Reciprocating
Registration number
N2591V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
177RG0627
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-17T01:35:26Z guid: 105630 uri: 105630 title: CEN22LA362 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105677/pdf description:
Unique identifier
105677
NTSB case number
CEN22LA362
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-30T10:11:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-08-18T06:03:25.82Z
Event type
Accident
Location
Longmont, Colorado
Airport
Vance Brand Airport (LMO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 30, 2022, at 0911 mountain daylight time, a Cessna 172N, N6587E, sustained substantial damage when it was in involved in an accident near Broomfield, Colorado. The flight instructor and student pilot were uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that during the fifth touch-and-go landing, the student pilot’s landing approach was unstable. While the airplane was 20 ft above the runway, the airplane’s right main landing gear wheel was about 5 ft from the runway edge. The instructor told the student pilot to go around. The student pilot applied full engine power, but there was no “major increase of thrust from the engine.” The flight instructor then took the controls from the student. He said the airplane climbed very slowly out of ground effect and the flaps were at 40°. He retracted flaps, one notch at a time, and knew that upon incrementally retracting flaps, the airplane would sink to the ground. The instructor stated that he retracted flaps to 20° to reduce drag, but the airplane sank and was not accelerating with full engine power. The airplane then impacted the grass/ditch area on the left side of runway 29. The airplane sustained substantial damage to the left and right wings. The flight instructor stated he believed that the engine was not producing full power. Postaccident examination of the airframe revealed no mechanical anomalies that would have precluded normal operation. Postaccident engine testing revealed that the engine met the engine manufacturer’s test specifications. -
Analysis
The flight instructor stated that the approach during the student’s fifth landing became unstable. The airplane was near the runway edge when the instructor told the student pilot to initiate a go-around. The instructor said that full engine power was applied, but there was no major increase in thrust. The flight instructor then took the controls from the student but was unable to regain control of the airplane. The airplane then impacted the ground alongside the runway and sustained substantial damage to the wings. Postaccident examination of the airframe and testing of the engine revealed no mechanical anomalies that would have resulted in the engine not producing full power.
Probable cause
The flight instructor’s failure to properly supervise the student pilot, which resulted in a continued unstablized approach for landing, and the instructor’s delayed recovery that resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N6587E
Operator
Rocky Mountain Flight School
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17272040
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-18T06:03:25Z guid: 105677 uri: 105677 title: ERA22LA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105655/pdf description:
Unique identifier
105655
NTSB case number
ERA22LA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-30T11:40:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-05T16:13:56.786Z
Event type
Accident
Location
Columbus, Ohio
Airport
JOHN GLENN COLUMBUS INTL (CMH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, while landing, the airplane bounced twice and during the landing roll the airplane veered to the right. The pilot applied left rudder, but the airplane continued to turn right and came to a stop. Once the pilot egressed the airplane, he noticed that the left main landing gear had collapsed. Postaccident examination of the airplane revealed that it had sustained substantial damage to the fuselage and left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a bounced landing and a collapse of the left main landing gear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N9162K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
108-2162
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-05T16:13:56Z guid: 105655 uri: 105655 title: CEN22FA347 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105624/pdf description:
Unique identifier
105624
NTSB case number
CEN22FA347
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-30T14:00:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-07-31T01:29:54.985Z
Event type
Accident
Location
Ute, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On July 30, 2022, about 1300 central daylight time, an Air Tractor AT-502A airplane, N501MW, was destroyed when was involved in an accident near Ute, Iowa. The pilot was fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 137 as an aerial application flight. The airplane was applying chemicals to a field. The airplane struck a wire on the western edge of the field and subsequently impacted terrain. A postcrash fire ensued. There are no known witnesses to the accident. No ADS-B data was located for the accident flight. - Toxicology was conducted on samples from the pilot. Testing was negative for carbon monoxide and ethanol. Loratadine and desloratadine were detected which are a nonprescription sedating antihistamine used to treat allergies. - The airplane wreckage came to rest on a paved road, upright, facing a magnetic heading of 130°. The field that the pilot was spraying was to the east of the accident site and was bordered on three sides by power lines. Damaged power lines were located on the western edge of the field. Portions of the left wing were scattered around the powerlines and to the north of the wreckage. The airplane engine was driven near vertical into the edge of a paved road about 7 yards west of the damaged powerlines. A post-impact fire consumed a majority of the left wing, fuselage, and empennage. Figure 1 Accident Site (Photo from Monona County Sheriff's Office) Examination of the airplane did not reveal any preimpact anomalies which would have precluded normal operation. -
Analysis
While conducting an aerial application flight, the airplane’s left wing contacted a power line on the western edge of the field. The airplane subsequently impacted the ground nose-low and a postimpact fire ensued. Examination of the wreckage did not reveal any anomalies which would have precluded normal operation of the airplane.
Probable cause
The pilot’s inflight collision with a power line during aerial application.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR
Model
AT502
Amateur built
false
Engines
1 Turbo prop
Registration number
N501MW
Operator
Midwest Custom Ag Aviation
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
502A-3232
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-07-31T01:29:54Z guid: 105624 uri: 105624 title: CEN22LA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105650/pdf description:
Unique identifier
105650
NTSB case number
CEN22LA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-07-30T15:50:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-08-11T19:58:37.177Z
Event type
Accident
Location
Marshall, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On July 30, 2022, about 1450 central daylight time, a Cessna 150E airplane, N6212Y, was substantially damaged when it was involved in an accident near Marshall, Texas. The student pilot was not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a solo instructional flight. The student pilot reported that while en route to his home airport, the engine rpm momentarily decreased. When the engine rpm decreased a second time, he reported to air traffic control that he had engine issues. The student pilot pulled carburetor heat and engine power was restored, but shortly thereafter, the engine lost total power. Unable to make it to the destination airport, the student pilot performed a forced landing to a field. During the landing rollout the airplane collided with trees and a fence line, resulting in substantial damage to the left wing and fuselage. Examination of the airframe by a responding Federal Aviation Administration inspector found both the left and right fuel tanks were empty when checked with a dipstick and no fuel came out when either tank was sumped. About 7 ounces of fuel was sumped from the fuel strainer. The student pilot reported that after the airplane was moved to a hangar, he was able to drain an additional empty water bottle of fuel from the bottom of the engine. He also reported that he started the engine and that it ran for about 10 minutes before it quit. Fuel range and endurance calculations were performed using ADS-B data and the student pilot’s statements. He had fully fueled the airplane the morning of the accident and departed to another airport to meet with an instructor. The student and instructor performed several takeoffs and landings and airwork. The instructor then flew the airplane solo for several takeoffs and landings. The student pilot was signed off for a solo flight and the accident occurred on the student pilot’s return leg to his home airport. The total flight time since fueling the airplane was calculated to be about 4 hours. The student reported using full rich for the mixture during flight and estimated the airplane consumed about 6 gallons per hour. The total fuel capacity of the airplane was 26 gallons, of which 22.5 gallons were listed as being usable. -
Analysis
While en route to his home airport, the student pilot reported that the engine rpm momentarily decreased. When the engine rpm decreased a second time, he reported to air traffic control that he had engine issues. The student pilot applied carburetor heat, and engine power was restored, but shortly thereafter the engine lost total power. Unable to reach the destination airport, the student pilot performed a forced landing to a field. During the landing, the airplane collided with trees and a fence line, resulting in substantial damage to the left wing and fuselage. Postaccident examination of the airframe revealed both the left and right fuel tanks were empty when checked with a dipstick and no fuel came out when either tank was sumped. About 7 ounces of fuel was sumped from the fuel strainer and an additional empty water bottle of fuel was drained from the bottom of the engine after the airplane was recovered. After the accident the engine started and ran for about 10 minutes before it quit. Fuel range and endurance calculations were performed using automatic dependent surveillance-broadcast (ADS-B) data and the student pilot’s statements. The student pilot had fully fueled the airplane on the morning of the accident and departed to another airport to meet with a flight instructor for several flights. The total flight time was calculated to be about 4 hours. The student reported using a full rich mixture setting during the flight and estimated the airplane consumed about 6 gallons per hour. The total fuel capacity of the airplane was 26 gallons of which 22.5 gallons were listed as being usable. The circumstances of the accident are consistent with fuel exhaustion. The fact that the engine started and ran on residual fuel in the fuel system is evidence that there were no mechanical failures or malfunctions that would have prevented normal operation of the engine during the flight.
Probable cause
The student pilot’s inadequate fuel planning and improper in-flight decision-making which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N6212Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15061390
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-11T19:58:37Z guid: 105650 uri: 105650 title: ERA22LA349 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105641/pdf description:
Unique identifier
105641
NTSB case number
ERA22LA349
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-01T12:30:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2022-08-11T22:03:54.78Z
Event type
Accident
Location
Wauchula, Florida
Airport
WAUCHULA MUNI (CHN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 1, 2022, about 1130 eastern daylight time, a Beech 35, N119ED, was substantially damaged when it was involved in an accident near Wauchula, Florida. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he purchased the airplane as a “barn find,” and that it had not been flown or serviced in 12 years. The accident flight was the first flight after completing the annual inspection. The pilot reported that, while en route, the radios began blinking and the airplane subsequently experienced a total loss of electrical power. He used the emergency handle to lower the landing gear and diverted to the closest airport. He prepared for a faster than normal landing because he was unable to lower the wing flaps. The airplane touched down and immediately veered to the left. He attempted to correct with right brake to no avail. The airplane exited the side of the runway and impacted a utility box, and the left main landing gear collapsed. According to the pilot, the tires were new, and the wheel bearings had been removed, cleaned, and repacked. The pilot further reported that, “due to the age of the plane and the lack of service for so many years, all of the wheel components could have used replacement.” A Federal Aviation safety inspector from the Orlando Flight Standards District Office reported that his postaccident examination of the airplane revealed that the left wing and fuselage sustained substantial damage. There were ground scars from the three tire tracks in the airplane’s direction of travel from the runway to the utility box. The landing gear was down and locked. The main landing gear brakes moved freely, and no bald spots were observed on the tires. He noted that the left main landing gear wheel rotated, but it was “hard to spin.” There was no evidence of any other preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot had purchased the airplane as a “barn find” and reported that it had not been flown or serviced in 12 years. The accident flight was the first flight following completion of an annual inspection. While en route, the airplane sustained a total loss of electrical power, and the pilot diverted to a nearby airport. The pilot was able to lower the landing gear using the emergency landing gear extension system, and he prepared for a faster than normal landing because he was unable to lower the electrically actuated wing flaps. After touchdown, the airplane veered left, and the pilot was unable to correct. The airplane exited the runway and impacted a utility box, which collapsed the landing gear, resulting in substantial damage. Postaccident examination of the airframe revealed that the left main wheel rotated, but it was “hard to spin.” There was no evidence of any other preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control after landing. A contributing factor was a degraded left main landing gear wheel assembly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35
Amateur built
false
Engines
1 Reciprocating
Registration number
N119ED
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-1497
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-11T22:03:54Z guid: 105641 uri: 105641 title: DCA22FM033 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105654/pdf description:
Unique identifier
105654
NTSB case number
DCA22FM033
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-08-02T20:55:00Z
Publication date
2024-02-15T05:00:00Z
Report type
Final
Last updated
2024-02-06T05:00:00Z
Event type
Accident
Location
Nunez Point, Alaska
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the capsizing and sinking of fishing vessel Hotspur was flooding from an unknown source into the lazarette or the port void space, causing the vessel to lose stability, capsize, and sink.
Has safety recommendations
false

Vehicle 1

Callsign
WDB7756
Vessel name
F/V HOTSPUR
Vessel type
Fishing
Maritime Mobile Service Identity
366947560
Port of registry
Juneau, Alaska
Flag state
USA
Findings
creator: Coast Guard last-modified: 2024-02-06T05:00:00Z guid: 105654 uri: 105654 title: ERA22LA352 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105658/pdf description:
Unique identifier
105658
NTSB case number
ERA22LA352
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-03T13:25:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-09-16T19:18:45.931Z
Event type
Accident
Location
Nixon, Pennsylvania
Airport
PITTSBURGH/BUTLER RGNL (BTP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported, that while departing from the runway the right cockpit door opened. The pilot was unable to close the door and he decided to return to the airport to close the door on the ground. While on final approach and near the runway, the pilot thought he heard the stall warning horn, so he immediately flared the airplane to land. The airplane bounced twice on the runway, so the pilot attempted to abort the landing by advancing the throttle. The airplane veered to the left, exited the runway, and the pilot reduced the throttle in an attempt to maintain directional control. The airplane then struck the runway’s precision approach path indicator before coming to rest in a ditch. The airplane’s firewall was substantially damaged. Following the accident, the pilot stated, “In hindsight I don't think the sound I heard was the stall warning horn, but rather the sound squealing through the partially open door which confused me into thinking the aircraft had stalled.” Given this information, it is likely that the pilot was distracted by the open right door during the landing, which contributed to his loss of control during the landing attempt. A Federal Aviation Administration inspector examined the airplane after the accident reported that she did not observe evidence of any preaccident mechanical malfunction or failure of the airplane that would have precluded normal operation, and specifically that there were no mechanical issues with the airplane’s right door latch. Given this information, it is also likely that the pilot had failed to ensure that the door was properly secured prior to departing on the accident flight.
Probable cause
The pilot’s failure to maintain directional control while landing, resulting in a runway excursion. Contributing to the outcome was the pilot’s failure to ensure that the airplane’s right side door was properly secured prior to departing on the accident flight, and his subsequent distraction due to the door during the landing attempt.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N459BT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-16T19:18:45Z guid: 105658 uri: 105658 title: ERA22LA357 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105669/pdf description:
Unique identifier
105669
NTSB case number
ERA22LA357
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-03T13:50:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-11T18:33:13.879Z
Event type
Accident
Location
Leghighton, Pennsylvania
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot explained that the accident occurred at the completion of a local flight that departed from a private residence. While landing from a hover to a “slight slope,” the pilot said he lowered the collective “too rapidly,” the helicopter “landed roughly” and that he raised the collective control to recover the landing. “At that point, I entered a dynamic rollover to the left in which I was unable to recover.” The helicopter came to rest on its side with substantial damage to the cabin and the tailboom. The pilot reported there were no mechanical deficiencies with the helicopter that precluded normal operation.
Probable cause
The pilot’s improper recovery from a bounced landing on a slope, which resulted in dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N45CA
Operator
EDH SERVICES LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2242
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-11T18:33:13Z guid: 105669 uri: 105669 title: ERA22LA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105664/pdf description:
Unique identifier
105664
NTSB case number
ERA22LA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-03T16:18:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-09-28T23:14:09.14Z
Event type
Accident
Location
Cranberry Township, Pennsylvania
Airport
Eakin Airport (11PN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot/owner reported that the pilot rated passenger, who had not previously flown in nearly 25 years, was attempting to land the tailwheel-equipped airplane. Upon touchdown, the airplane began to drift to the left. The pilot/owner attempted to correct but was unable. The airplane subsequently impacted trees resulting in substantial damage to the right wing and aft fuselage structure. The pilot/owner further described that “there was a gust of wind that got the better of him” in reference to the pilot rated passenger. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilots’ failure to maintain directional control of the airplane while landing in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7BCM
Amateur built
false
Engines
1 Reciprocating
Registration number
N9325H
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
47-807
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-28T23:14:09Z guid: 105664 uri: 105664 title: ERA22FA354 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105660/pdf description:
Unique identifier
105660
NTSB case number
ERA22FA354
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-03T18:25:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2022-08-07T22:51:08.969Z
Event type
Accident
Location
Cynthiana, Kentucky
Airport
CYNTHIANA-HARRISON COUNTY (0I8)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On August 3, 2022, about 1725 eastern daylight time, a Piper J3C-65, N88550, was substantially damaged when it was involved in an accident at Cynthiana-Harrison County Airport (0I8), Cynthiana, Kentucky. The passenger sustained fatal injuries and the private pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. About 1710, the pilot and passenger, who were seated in the aft and front seat respectively, departed the airport for a brief flight. About 10 minutes after departure, witnesses reported seeing a thunderstorm coming in from the south. The storm consisted of a “wall of rain” that they could see several miles out. There was also a “rapid wind shift accompanied by an increase in wind speed,” and the air temperature was dropping quickly. A witness reported that the airplane returned to the airport and flew an unusually low airport traffic pattern. The airplane approached the airport at a low altitude, just over the trees from the north, and then made a left turn to join the left downwind leg of the airport traffic pattern for runway 29. The engine went to full throttle but sounded like it was having trouble getting there and sounded “warbly.” The airplane then made a low approach, skipping the base leg, turning directly over the runway numbers. Then the airplane entered a descending left spin before impacting the ground adjacent to the runway. The witness further stated the winds were picking up and it was gusty with a crosswind. Almost immediately after impact, heavy rain and wind began at the airport. The automated weather observing system (AWOS) at Georgetown-Scott County Regional Airport (27K), Georgetown, Kentucky, located 11 miles southwest of the accident location at an elevation of about 950 ft, reported that at 1715 the wind was from 230° at 7 knots, the visibility was 10 statute miles or greater, with scattered clouds at 4,700 ft above ground level (agl), scattered clouds at 5,500 ft agl, a temperature of 32° Celsius (C), dew point temperature of 23°C, and an altimeter setting of 29.98 inches of mercury. At 1735, the 27K AWOS reported wind from 160° at 19 knots with gusts to 25 knots, visibility of 10 statute miles or greater, scattered clouds at 4,500 ft agl, ceiling broken at 5,500 ft agl, broken clouds at 7,000 ft agl, temperature of 28°C and dew point temperature of 20°C, and an altimeter setting of 30.00 inches of mercury. Weather radar imagery from near Jackson, Kentucky, located about 65 miles southeast of the accident location, indicated an area of convective activity approaching the airport (Figure 1). The radar data depicted an isolated convective cell approaching the accident location from the south-southwest during the accident period. As the cell approached the accident site, reflectivity values decreased, and the Federal Aviation Administration’s Corridor Integrated Weather System analysis of the cell identified a large amount of decay. About this time the weather radar also depicted a new area of +50dBZ growing immediately to the west of the previously isolated cell. Figure 1 Sequential weather radar showing convective activity moving towards accident site from the southwest. Nos 1 through 4 are time stamped at 1711, 1718, 1725 and 1735 respectively. The wreckage came to rest in the grass about 20 ft north of runway 29 at an elevation of 719 ft. The wreckage path was compact, oriented on a magnetic heading of 151°, and all major components of the engine and airframe were accounted for at the scene. Examination of the airplane revealed that the fuselage was buckled, and the left wing was severely crushed and broken aft. The magnetos switch was on BOTH and the fuel selector was in the ON position. The empennage was bucked and bent to the left. The entire engine assembly was bent upwards and canted to the right with the left side of the engine covered in dirt. Both wood propeller blades were splintered although they remained attached to the center hub and crankshaft flange; one blade was shattered down to the spinner with the opposing blade shattered outboard of the erosion strip. There were several dozen propeller fragments in a 40 ft radius of the main wreckage and there were 3-inch-deep rotational scalp marks in the grass and dirt at the primary impact site. There were red navigation light lens fragments on the runway edge followed by a primary impact crater that contained propeller fragments and small pieces of wreckage. The cockpit’s occupiable space was severely compromised in the forward seat area and no shoulder harnesses were observed. The fuel tank remained intact and contained about 5 gallons of aviation fuel. Flight control continuity was confirmed on all control surfaces through their respective control cables and into the cockpit. The engine crankshaft was rotated 720° with no binding noted. Valvetrain continuity was confirmed, there was thumb compression and suction in each of the cylinders, and both magnetos created spark at each of the posts. There were no preimpact mechanical anomalies discovered with the airframe or the engine that would have precluded normal performance or engine operation. -
Analysis
The pilot and his passenger departed the airport for a personal flight but shortly after takeoff, the pilot elected to return to the airport. Witnesses stated that a thunderstorm was coming in from the south. Meteorological data showed an approaching area of convection with tops at 45,000 ft. The pilot attempted to return to the airport and did not fly a standard airport traffic pattern; instead, he approached from the north, unusually low over the tree line, crossing midfield, then made a sharp left turn to join the downwind traffic, before turning left again to land. As the airplane crossed over the runway perpendicular to the runway numbers, it suddenly entered a left descending spiral and impacted terrain adjacent to the runway. The postaccident examination of the engine and airframe, combined with the examination of the impact site, revealed no anomalous findings that would have precluded normal airplane or engine performance. It is likely that shortly after the pilot took off, he witnessed the approaching convective activity and attempted to rush back to the airport to land before the storm arrived, as evident from his nonstandard approach to landing. About the time of the accident, witnesses described a rapid wind shift accompanied by an increase in wind speed and a rapidly decreasing temperature. Witness observations were consistent with experiencing convective outflow from the nearby convective activity and are validated by the weather radar and data that suggest the convective cell was decaying and nearby convection was forming; weather conditions were changing rapidly, and the winds were likely shifting. As the pilot performed the low and nonstandard approach, he likely turned steeply to the left after crossing over the runway numbers; exacerbated by a left quartering crosswind during his turn, he exceeded the airplane’s critical angle of attack and entered a subsequent aerodynamic stall and loss of control.
Probable cause
The pilot’s failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall while maneuvering to land with approaching convective activity.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N88550
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
16175
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-07T22:51:08Z guid: 105660 uri: 105660 title: ERA22LA356 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105667/pdf description:
Unique identifier
105667
NTSB case number
ERA22LA356
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-04T14:09:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-08T18:47:42.82Z
Event type
Accident
Location
Holly Ridge, North Carolina
Airport
Holly Ridge/Topsail (N21)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot was on final approach when he collided with a set of unmarked powerlines that ran perpendicular to the runway. The airplane flipped over and impacted the ground resulting in substantial damage to the tail section. The pilot said he reviewed the airport facility directory prior to the flight and was aware that the runway had a displaced threshold and a set of powerlines located between the end of the runway and a section of pine trees, which were equal in height to the powerlines. He said that as he cleared the pine trees on final approach, he saw the powerlines and struck them “five feet too low.” The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance of powerlines on final approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182C
Amateur built
false
Engines
1 Reciprocating
Registration number
N8865T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
52765
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-08T18:47:42Z guid: 105667 uri: 105667 title: ERA22LA370 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105728/pdf description:
Unique identifier
105728
NTSB case number
ERA22LA370
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-04T16:57:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-23T22:55:18.479Z
Event type
Accident
Location
Shirley, New York
Airport
Brookhaven (HWV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor of the glider reported that the takeoff for the instruction flight was along a grass area adjacent to a paved runway. The takeoff began with the right wing down to practice a standard unassisted takeoff. As the takeoff roll began, the right wing rose, and the glider entered ground effect. Several seconds later, the flight instructor heard a “boom” as the glider bounced up. He then released the tow rope and landed straight down the grass runway uneventfully. The flight instructor exited the glider and noted damage to the right wing as a result of a collision with an electrical junction box for the runway’s precision approach path indicator. He added that there were no preimpact mechanical malfunctions with the glider. Postaccident examination of the glider by a Federal Aviation Administration inspector confirmed substantial damage to the glider’s right aileron.
Probable cause
The flight instructor’s failure to ensure clearance from an electrical junction box during takeoff, which resulted in a collision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 2-33A
Amateur built
false
Registration number
N2055T
Operator
LONG ISLAND SOARING ASSOCIATION INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
495
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-23T22:55:18Z guid: 105728 uri: 105728 title: CEN22LA367 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105688/pdf description:
Unique identifier
105688
NTSB case number
CEN22LA367
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-05T12:10:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-08-11T20:13:04.694Z
Event type
Accident
Location
Benton, Kansas
Airport
LLOYD STEARMAN FLD (1K1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 5, 2022, about 1110 central daylight time, a Cessna 182Q airplane, N97683, was substantially damaged when it was involved in an accident near Benton, Kansas. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that shortly after takeoff, at 400 to 500 ft above ground level, the airplane’s engine stopped producing power. The pilot performed a forced landing to a plowed field. During the landing, the airplane nosed over and came to rest inverted. Substantial damage was sustained to the left wing, empennage, rudder, and vertical stabilizer. An examination of the engine was conducted under the auspices of the Federal Aviation Administration. The engine rotated freely, and the valves in all 6 cylinders operated properly, as did both magnetos. The engine fuel bowl and filter, as well as the carburetor’s finger fuel screen, contained no foreign material. All cylinders except No. 6 had good compression. The No. 6 cylinder walls were scored, and between the 2nd compression ring and the oil control ring some non-ferrous material was present. Throttle, propeller, and mixture controls functioned properly. An adequate amount of fuel was found in the fuel tanks and no fuel contamination was found. Meteorological conditions were not conducive to the production of serious carburetor icing under the conditions which the airplane was operating. No anomalies were detected which would have contributed to a loss of engine power. -
Analysis
The pilot stated that after takeoff, at an altitude of 400 to 500 ft above ground level, the engine stopped producing power. The pilot performed a forced landing to a plowed field. During the landing, the airplane nosed over and came to rest inverted. The left wing, empennage, rudder, and vertical stabilizer sustained substantial damage. Postaccident examination of the airplane and engine did not reveal any anomalies that would have contributed to a loss of engine power. A sufficient amount of fuel was found in the fuel tanks. Meteorological conditions were not conducive to the production of serious carburetor icing. The reason for the loss of engine power could not be determined.
Probable cause
The loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N97683
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18267167
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-11T20:13:04Z guid: 105688 uri: 105688 title: DCA22LA175 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105684/pdf description:
Unique identifier
105684
NTSB case number
DCA22LA175
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-05T21:32:00Z
Publication date
2023-04-25T04:00:00Z
Report type
Final
Last updated
2022-08-08T21:41:35.527Z
Event type
Accident
Location
Chicago, Illinois
Airport
CHICAGO O'HARE INTL (ORD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Qatar Airways flight 8141 struck a light pole with its right wingtip while taxing to parking at Chicago O’Hare International Airport (KORD), Chicago, Illinois. The 2 pilots on board were uninjured, and the airplane was substantially damaged. The non-scheduled international cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 129 from Hartsfield-Jackson International Airport (KATL), Atlanta, Georgia, to KORD. After landing runway 10C at KORD, the tower controller instructed the accident airplane to taxi off the runway via taxiway F followed by a left turn onto taxiway P, and to contact ground on 121.75. The ground controller verified the flight was cargo and instructed the aircraft to continue to taxiway CC and hold short of runway 10L. Shortly after the hold, they were cleared to cross runway 10L, instructed to hold short of taxiway K, and told to contact ground on 121.9. According to air traffic control (ATC) audio, the ground controller instructed the accident airplane to turn left on taxiway K and taxi via taxiway BB to taxiway BB2 to taxiway Z. While taxiing down taxiway BB2, the right wingtip contacted a light pole in the central deicing area adjacent to the taxiway. Figure 1. Airport diagram zoomed into the area of aircraft collision with light pole - with taxi route (green line) and accident location (yellow star) superimposed onto the airport map. The Qatar Airways crew had access to information on the taxi limitations on taxiway BB2. The FAA chart supplement valid for the time of the accident stated in the airport remarks on the 2nd page that taxiway BB2 was closed “to wingspan more than 118 ft.” Additionally, an airport notice to air mission (NOTAM), valid at the time of the accident, designated that taxiway AA between taxiway K and taxiway U as a non-movement area between June 5 and October 15, 2022. The crew reported reviewing NOTAMs prior to leaving their departure airport and the captain was referencing the airport diagram on his electronic flight bag during the taxi since this was his second time at the airport and the first time for the first officer. Taxiway BB2 was on the southern border of the central deicing facility for the airport. The area on taxiway BB2 where the accident occurred (between taxiway Z and taxiway AA) was considered a non-movement area as part of the central deicing facility and was not to be used to route taxiing aircraft. Facility SOPs noted that “all non-movement areas will be depicted on the ASDE-X as a restricted trait area (YELLOW BOX)” At the time of the accident, the ASDE-X depicted a yellow restricted trait area for the central deicing pad, however the restricted area on the display did not extend to taxiway BB2, despite the taxiway’s classification as a non-movement area. Figure 2: Screen capture zoomed into the area of impact at the time of event from the FAA legal recording playback of the ASDE-X display processor. The accident aircraft is shown as an orange airplane symbol, and the restricted trait area is shown within the hashed yellow box. (Source: FAA)
Probable cause
The ground controller’s inappropriate routing of the B777 through a non-movement area, resulting in the airplane’s right wingtip contacting a light pole. Contributing to the accident was the lack of an appropriate display of taxiway BB2 as a restricted movement area on the ASDE-X and the flight crew’s acceptance of ATC instruction that was contrary to NOTAM information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
777
Amateur built
false
Engines
2 Turbo fan
Registration number
A7-BFH
Operator
Qatar Airways Group Q.J.S.C
Flight conducted under
Part 129: Foreign
Flight service type
Cargo
Flight terminal type
International
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
42298
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-08T21:41:35Z guid: 105684 uri: 105684 title: CEN22LA377 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105705/pdf description:
Unique identifier
105705
NTSB case number
CEN22LA377
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-05T23:15:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2022-08-26T23:40:03.251Z
Event type
Accident
Location
Vernon Hills, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 5, 2022, about 2215 central daylight time, a Piper PA-28-140 airplane, N6460R, was substantially damaged when it was involved in an accident near Vernon Hills, Illinois. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he departed from Campbell Airport (C81), Grayslake, Illinois, earlier in the day and flew to Reese Airport (7I2), Muncie, Indiana. He was returning to C81 when the accident occurred. The route took the airplane along the southeast shore of Lake Michigan and the pilot reported that shortly after crossing the lake’s shore the airplane’s engine began losing power. He reported that he performed emergency procedures that included applying carburetor heat, switching the selected fuel tank from the left to the right, activating the electric fuel pump, and attempting to restart the engine. He noted that he made about 3 such attempts without success in restarting the engine. The airplane’s altitude was about 2,000 ft mean sea level when the engine lost power because it was operating below the outer layers of the O’Hare Airport Class B airspace. The pilot attempted to turn the airplane and glide to the Waukegan National Airport (UGN), Waukegan, Illinois, but realized that there was insufficient altitude. He executed a forced landing to a road. During the landing rollout, the airplane sustained substantial damage to its right wing when it impacted a road sign. Automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane departed C81 at 1724 and arrived at 7I2 at 2023, a flight of 1 hour 59 minutes. ADS-B data further indicated that the return flight from 7I2 began at 2039, and the last recorded position was at 2215, a flight duration of 1 hour 36 minutes. The total flight duration for the round trip was 3 hours 35 minutes. Postaccident examination of the airplane confirmed substantial damage to the right wing. The left fuel tank fuel gauge read empty and the right fuel tank fuel gauge read between 5 and 6 gallons. All remaining fuel was drained from both wing fuel tanks. The left fuel tank contained about 1 quart of fuel and the right fuel tank contained about 10 gallons of fuel and 1-1/2 ounces of water. Examination of the engine revealed that the flexible tube from the heat shroud to the carburetor heat box was partially collapsed. The damage to the tube did not appear to be impact related. Investigators were not able to establish when the damage occurred. Several of the engine spark plug ignition leads were loose. The engine rotated freely, and compression was felt on all cylinders. The fuel that was drained was placed back into the tanks and an engine run was performed. The ignition leads and collapsed induction tube were reinstalled as-found following the accident for the engine run. The engine started normally and ran smoothly. The engine rpm was increased, and a magneto check performed at 2,000 rpm with normal rpm drop. When the carburetor heat check was performed, the engine rpm reduced by 700 rpm, but returned to normal rpm when the carburetor heat was turned off. The induction tube could not be seen from the cockpit during the engine run. No other anomalies were detected during the engine test run that would have precluded normal operations. Investigators then disconnected the induction hose and ran the engine a second time. During the second engine run the carburetor heat system performed as expected during the carburetor heat check. A review of the airplane maintenance records showed that an annual inspection was completed on April 11, 2022. There was no mention of the collapsed induction tube in the entries for the annual inspection, or any previous entries provided. The recorded temperature and dew point, 25° C and 22°C respectively, were in the range of susceptibility for serious carburetor icing at glide power settings. -
Analysis
The pilot was on the return leg of a cross-country flight when the airplane’s engine lost power. He reported that he performed emergency procedures that included applying carburetor heat, switching the selected fuel tank from the left fuel tank to the right fuel tank, activating the electric fuel pump, and attempting to restart the engine. He noted that he made about 3 such attempts without success in restarting the engine. He landed on a road and the airplane’s right wing was substantially damaged when it impacted a road sign during rollout. Flight track data indicated that the airplane had been airborne on the round-trip flight for about 3 hours and 35 minutes. Postaccident examination revealed that the airplane’s left fuel tank was nearly empty, and the right tank contained about 10 gallons of fuel and 1-1/2 ounces of water. Examination of the engine revealed that the flexible tube from the heat shroud to the carburetor heat box was partially collapsed. The damage to the tube did not appear to be impact related and investigators were not able to establish when the collapse occurred. During the engine run the collapsed induction tube was reinstalled as-found following the accident. The engine started normally and ran smoothly; however, when the carburetor heat check was performed, the engine rpm reduced by 700 rpm, but returned to full rpm when the carburetor heat was turned off. No other anomalies were detected during the engine test run that would have precluded normal operations. During the second engine run the collapsed flexible tube was removed and the carburetor heat system performed as expected during the carburetor heat check. Based on the available information, the loss of engine power was likely due to fuel starvation. The collapsed induction hose only affected engine operation when carburetor heat was applied, so it would not have resulted in the initial power loss. However, the collapsed induction tube could have hampered the pilot’s attempts to restart the engine following the loss of power.
Probable cause
The pilot’s improper in-flight fuel management, which led to a loss of engine power due to fuel starvation. Contributing to the accident was the collapsed carburetor heat induction tube that restricted airflow to the engine preventing engine restart.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N6460R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-21646
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-26T23:40:03Z guid: 105705 uri: 105705 title: ERA22LA364 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105682/pdf description:
Unique identifier
105682
NTSB case number
ERA22LA364
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-06T14:25:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-09-16T18:01:55.614Z
Event type
Accident
Location
Erwinna, Pennsylvania
Airport
VANSANT (9N1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The private pilot of a predominately black and orange colored, tailwheel-equipped airplane (black airplane) reported that he was taxiing in the grass next to the turf runway 25 for departure. The taxi route required him to cross another converging turf runway 23. During the taxi, he did not make any radio calls on the airport common traffic advisory frequency (CTAF) announcing that he was taxiing or crossing runway 23. The commercial pilot of a predominately red and white colored, tailwheel-equipped airplane (red airplane) that was based at the airport stated that he was departing runway 23, which was primarily used for glider operations but also was routinely used by powered airplanes when available based on runway conditions. He scanned ahead on runway 23 and after observing there was no conflicting traffic and not hearing any announcements from other aircraft, he broadcast his intent to depart from runway 23 on the CTAF. That transmission was heard by the pilot of the black airplane but at the time it did not register to him that the red airplane was departing from a converging runway, adding that he looked along runway 25 and expected to see the red airplane departing but he did not. The pilot of the red airplane reported that just after lifting off, the right wing of his airplane and the right wing of the black airplane collided; he never saw the other airplane. Following the collision, the red airplane impacted the ground and rolled onto its right side. The pilot of the black airplane, who was taxiing slowly, reported he heard a loud engine followed immediately by the sight of something hitting his right wings. Both airplanes sustained substantial damage to their wings during the collision. The pilots of both airplanes reported no preimpact mechanical malfunctions or failures with their airplanes that would have precluded normal operation. According to the airport manager, the runway utilized by the pilot of the red airplane was specified in the airport facility directory to be for gliders only, though that was not strictly enforced.
Probable cause
The inability of both pilots to see and avoid the collision. Contributing to the accident was the pilot of the red airplane’s decision to utilize the converging runway for takeoff, contrary to the guidance published in the airport facility directory. Also contributing was the failure of the pilot of the black airplane to adequately utilize his radio to announce his taxi on the common traffic advisory frequency and his failure to recognize that an airplane was departing from a converging runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AEROTEK
Model
PITTS SPECIAL S-1S
Amateur built
false
Engines
1 Reciprocating
Registration number
N49310
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
KA-103
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
WACO
Model
UPF-7
Amateur built
false
Engines
1 Reciprocating
Registration number
N32141
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
5773
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-16T18:01:55Z guid: 105682 uri: 105682 title: DCA22FM036 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105720/pdf description:
Unique identifier
105720
NTSB case number
DCA22FM036
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-08-07T08:00:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2023-08-17T04:00:00Z
Event type
Accident
Location
Karluk, Alaska
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the grounding of the fishing vessel Challenger was the captain’s decision to navigate close to shore in an area known to him to have an uncharted rock. Contributing to the capsizing of the vessel was the lack of a watertight collision bulkhead and subdivision or compartmentalization below the main deck, which allowed for progressive flooding.
Has safety recommendations
false

Vehicle 1

Vessel name
F/V Challenger
Vessel type
Fishing
Port of registry
Homer, AK
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-08-17T04:00:00Z guid: 105720 uri: 105720 title: ERA22LA363 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105680/pdf description:
Unique identifier
105680
NTSB case number
ERA22LA363
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-07T10:35:00Z
Publication date
2023-08-30T04:00:00Z
Report type
Final
Last updated
2022-09-12T19:49:06.936Z
Event type
Accident
Location
Ellenville, New York
Airport
JOSEPH Y RESNICK (N89)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On August 7, 2022, about 0935 eastern daylight time, a Cessna 150H, N50439, was substantially damaged when it was involved in an accident near Ellenville, New York. The commercial pilot sustained minor injuries, and a pilot-rated passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   According to the commercial pilot, who was also a flight instructor, the purpose of the flight was to fly the airplane from Joseph Y. Resnick Airport (N89), Ellenville, New York, to Shelbyville Municipal Airport (GEZ), Shelbyville, Indiana, following the purchase of the airplane by the pilot-rated passenger. The commercial pilot was in the right seat and the pilot-rated passenger was in the left seat. The pilot-rated passenger had a private pilot certificate; however, he did not possess a Federal Aviation Administration medical certificate.   The pilot-rated passenger performed the takeoff with 10° of flaps for “extra lift to get us away from the ground.” The airplane lifted off with about 1,000 ft of the 3,839 ft-long runway remaining and climbed “fine” until it reached about 100 ft above ground level. At that point, the airplane would no longer continue to climb. With mountains approaching, the commercial pilot took control of the airplane and looked for a place to land. The stall warning horn sounded, and the nose was lowered to maintain flying airspeed. As the airplane approached two sets of power lines, he pitched up to clear the first set of wires, and once clear, he cut power to the engine and raised the flaps. The airplane dropped about 30 ft and crashed onto the roadway. The airplane came to a stop and the pilots exited the airplane.   The wreckage came to rest on a wooded embankment at the side of a roadway. The airplane sustained structural damage to both wings, the fuselage, and the empennage. The wreckage was recovered to a salvage facility where an examination of the airframe and engine was performed. The engine remained attached to the airframe. The wings were removed during recovery of the wreckage. The fuselage was secured to a forklift to attempt an engine run. Due to impact damage, the induction air, carburetor heat boxes, and left-side exhaust pipe were removed. An external fuel tank was plumbed into the left-wing root fuel line and a battery charger was connected to the airplane’s battery. The grounding leads from the magnetos were removed and the engine was started. It ran smoothly, without hesitation, from idle to about 2,300 rpm. Bending damage to the propeller blade tips prevented operating the engine at a higher rpm. The engine was then shut down. While still warm, the propeller was rotated by hand; compression and suction were attained on all four cylinders. During the examination, fuel flowed normally through the fuel system. The cockpit fuel selector handle shut off fuel to the engine when commanded. Flight planning information was provided by the pilots during the investigation. They reported that the airplane’s weight at takeoff was 1,595 lbs and the maximum allowable takeoff weight was 1,600 lbs. They computed the pressure altitude to be 1,934 ft. Textron reported that the takeoff roll under the reported conditions would be about 490 ft and the expected climb rate would be about 640 ft per minute; however, no climb performance data is available for the 10° flap setting. The Cessna 150H Owner’s Manual addresses takeoffs with 10° flaps. The manual states that, “Normal and obstacle clearance takeoffs are performed with flaps up. The use of 10° will shorten the ground run approximately 10%, but this advantage is lost in the climb to a 50-foot obstacle. Therefore the use of 10° flap is reserved for minimum ground runs or for take-off from soft or rough fields with no obstacles ahead.” -
Analysis
The private pilot-rated passenger, who was accompanied by a commercial pilot, was performing the takeoff at near-maximum gross weight after purchasing the airplane. The pilot-rated passenger took off with 10° of flaps for “extra lift to get us away from the ground.” Both pilots reported that there was high terrain near the airport. The airplane lifted off with about 1,000 ft of runway remaining, climbed to about 100 ft above the runway, and then would no longer climb. The commercial pilot took control of the airplane and looked for a place to land. The stall warning horn sounded, so he lowered the nose to maintain flying airspeed. He maneuvered around some power lines, raised the flaps, and the airplane crashed onto a roadway. It came to rest on an embankment adjacent to the road and was substantially damaged. Postaccident examination of the wreckage, including a test run of the engine, revealed no evidence of a preexisting mechanical malfunction or anomaly. The owner’s manual for the airplane stated that normal and obstacle clearance takeoffs should be performed with flaps up. Use of 10° flaps will shorten the takeoff roll; however, that advantage is lost in the climb to a 50-ft obstacle. The manual further notes that use of 10° flaps should only be used for takeoffs with minimum ground runs or soft/rough fields with no obstacles ahead.
Probable cause
Both pilots’ decision to perform the takeoff near maximum gross weight with 10° of flaps, contrary to the owner’s manual procedure, which resulted in the airplane’s degraded climb performance approaching high terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150H
Amateur built
false
Engines
1 Reciprocating
Registration number
N50439
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15069304
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-12T19:49:06Z guid: 105680 uri: 105680 title: DCA22FM035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105702/pdf description:
Unique identifier
105702
NTSB case number
DCA22FM035
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-08-07T17:25:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-09-07T04:00:00Z
Event type
Accident
Location
Ingleside, Texas
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the grounding of the CC Portland was the mate attempting a bow-to-bow maneuver while the tugboat and LNG Fukurokuju were transiting at a speed that was excessive for the advanced harbor-assist maneuver. Contributing to the casualty was the CC Portland mate’s lack of experience in tractor tug bow assist operations.
Has safety recommendations
false

Vehicle 1

Callsign
WDK3262
Vessel name
CC Portland
Vessel type
Towing/Barge
IMO number
9824112
Maritime Mobile Service Identity
368043490
Port of registry
Galliano, LA
Classification society
ABS
Flag state
USA
Findings

Vehicle 2

Callsign
C6BU3
Vessel name
LNG Fukurokuju
Vessel type
Cargo, Liquid Bulk
IMO number
9666986
Maritime Mobile Service Identity
311000365
Port of registry
Nassau
Classification society
NK
Flag state
BF
Findings
creator: Coast Guard last-modified: 2023-09-07T04:00:00Z guid: 105702 uri: 105702 title: DCA22PM034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105692/pdf description:
Unique identifier
105692
NTSB case number
DCA22PM034
Transportation mode
Marine
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-08T04:00:00Z
Publication date
2023-08-01T04:00:00Z
Report type
Final
Last updated
2023-07-03T04:00:00Z
Event type
Accident
Location
Vega Baja, Puerto Rico
Injuries
1 fatal, 1 serious, 1 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the US Coast Guard cutter Winslow Griesser and the center-console boat Desakata was the failure by both vessels’ crews to maintain a proper lookout. Contributing to the casualty was the Winslow Griesser commanding officer and officer of the deck not taking sufficient measures to increase situational awareness while transiting at a high speed.
Has safety recommendations
true

Vehicle 1

Callsign
NDOD
Vessel name
Winslow Griesser
Vessel type
Patrol/Small Craft
IMO number
4686175
Maritime Mobile Service Identity
338926416
Flag state
USA
Findings

Vehicle 2

Vessel name
Desakata
Vessel type
Fishing
Port of registry
San Juan
Flag state
USA
Findings
creator: NTSB last-modified: 2023-07-03T04:00:00Z guid: 105692 uri: 105692 title: CEN22LA378 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105706/pdf description:
Unique identifier
105706
NTSB case number
CEN22LA378
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-09T11:57:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2022-08-10T23:12:36.784Z
Event type
Accident
Location
Clinton, Arkansas
Airport
CLINTON MUNI (CCA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 9, 2022, about 1057 central daylight time, a Cessna 210B airplane, N9637X, sustained substantial damage when it was involved in an accident near Clinton, Arkansas. The pilot was uninjured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The pilot reported that the landing gear retracted normally during takeoff; however, when he attempted to extend the landing gear in preparation for the landing, the nosewheel extended and locked into place but the main landing gear did not fully extend. The pilot completed the checklist items for “landing gear emergency operation,” but the landing gear still did not fully extend and lock into place. Unable to extend the main landing gear, the pilot elected to accomplish the landing with the nosewheel extended and the main landing gear in the trail position. The pilot shut down the engine when the landing was assured to protect the engine. After the touchdown and during deceleration, the airplane rolled slightly to the left and the left elevator and horizontal stabilizer contacted the runway, which resulted in substantial damage to both structures.   Postaccident examination revealed a fracture of the hydraulic actuator which allowed the hydraulic fluid to escape the system. After removal, the hydraulic actuator was sent to the National Transportation Safety Board Materials Laboratory for a detailed fracture analysis. The barrel of the housing was sectioned to separate the cracked area from the rest of the assembly. The examination of the fracture surfaces revealed features consistent with fatigue cracking having initiated along the retaining ring groove of the actuator, propagating outward in a circumferential direction. Once the fatigue crack grew to its terminal size, the remainder of the cross-section fractured from mixed overstress and fatigue. This cracking led to part of the housing barrel fracturing in overstress, allowing the release of the internal pressurized hydraulic fluid. Maintenance records for the airplane show that overhauled main landing gear actuators were installed on June 10, 2021, about 14 months and 179 hours of airframe total time before the accident occurred. -
Analysis
The pilot reported that the landing gear retracted normally on takeoff; however, when he attempted to extend the landing gear in preparation for landing, the nosewheel extended and locked into place but the main landing gear did not fully extend. The pilot completed the checklist items for “landing gear emergency operation,” but the landing gear still did not fully extend and lock into place. Unable to extend the main landing gear, the pilot elected to accomplish the landing with the nosewheel extended and the main gear out of the wheel well, but not in the down-and-locked position. The pilot shut down the engine when the landing was assured to protect the engine. After the touchdown and during deceleration, the airplane rolled slightly to the left and the left elevator and horizontal stabilizer contacted the runway, which resulted in substantial damage. Postaccident examination of the hydraulic actuator revealed a fatigue crack that initiated along the retaining ring groove of the actuator. The crack propagated in a circumferential direction outward and once the fatigue crack grew to its terminal size, the remainder of the cross-section fractured from mixed overstress and fatigue. This led to part of the housing barrel fracturing in overstress, allowing the release of the internal pressurized hydraulic fluid.
Probable cause
A fatigue crack in the hydraulic actuator, which resulted in the loss of hydraulic fluid and the pilot’s inability to fully extend the landing gear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210B
Amateur built
false
Engines
1 Reciprocating
Registration number
N9637X
Operator
ACP ENTERPRISES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21057937
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-10T23:12:36Z guid: 105706 uri: 105706 title: CEN22FA375 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105703/pdf description:
Unique identifier
105703
NTSB case number
CEN22FA375
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-09T12:06:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-08-10T00:49:06.916Z
Event type
Accident
Location
Maxwell, California
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The FAA has published Advisory Circular 90-109A Transition to Unfamiliar Aircraft. This document discusses the classification of the Sonex Aircraft Waiex airplane. The Sonex Aircraft Waiex airplane is classified as having light control forces and/or rapid airplane response, along with nontraditional and/or unfamiliar airplane system operations. This document discusses light control forces and rapid airplane response and states in part: The hazard of light forces and rapid response is that without some level of training, the pilot may over-control the airplane. This can manifest itself during any phase of flight. The risks can vary from frustration to damage during takeoff and landing, to loss of control up to and including overstressing the airframe and structural failure. This document discusses nontraditional and/or unfamiliar airplane system operations and states in part: Builders of experimental airplanes are able to customize every aspect of their airplane to their own personal preferences. This extends to the installation of systems not found on standard airplanes in the training and rental fleet, such as the fuel valve location discussed in the example above. Builders also sometimes place familiar instruments and controls in unfamiliar locations on the panel or in the cockpit area. This is true even in seemingly identical examples of a particular design. The ability to completely customize the airplane is one reason builders choose to build their own, rather than purchase a standard airplane. The hazard in operating these airplanes is the potential for misuse or system mismanagement. The risks of this misuse or mismanagement can include an inadvertently induced abnormal or emergency situation. - A review of Federal Aviation Administration (FAA) registration records showed that the pilot and another individual had purchased the airplane from the airplane builder in September 2021. A review of the airplane maintenance records showed that a new CAMit 33SLRE reciprocating engine was installed in the airplane in June 2016. - On August 9, 2022, about 1106 Pacific daylight time, a Sonex Aircraft Waiex airplane, N51YX, was destroyed when it was involved in an accident near Maxwell, California. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the family members of the pilot, the purpose of the flight was personal and the exact route of the flight was unknown. A review of automatic dependent surveillance – broadcast (ADS-B) data showed that the experimental airplane departed runway 13 at the Colusa County Airport (O08), Colusa, California. The airplane traveled to the north of Colusa and then traveled to the west. The airplane crossed Highway I-5, then traveled to the north of Maxwell, California, where the ADS-B data terminated in a remote area populated with fields used for agricultural work. The airplane came to rest nose down, in a flat dirt field. The wreckage, which was destroyed, sustained fire damage. The airplane was equipped with a Dynon FlightDEK-D180 unit. The unit recorded about 22 minutes of data that began when the engine was started. A review of the data showed that shortly before the data ended, the airplane went from a straight and level attitude to a nose down attitude. A review of the various experimental engine parameters recorded did not show any signatures consistent with a loss of engine power. - According to the pilot’s autopsy report, his cause of death was high-velocity acceleration-deceleration polytrauma and his manner of death was accident. The extent of injuries severely limited evaluation for natural disease, preventing structural evaluation of the brain, heart, and lungs. Examinable trachea and bronchi showed no evidence of smoke inhalation. Toxicological testing of postmortem specimens from the pilot identified ethanol at 0.16 g/hg in one liver tissue specimen, 0.078 g/hg in another liver tissue specimen, 0.038 g/hg in lung tissue, 0.064 g/hg in kidney tissue, and 0.033 g/hg in heart tissue. N-propanol was detected in lung tissue, kidney tissue, and heart tissue. Ondansetron was detected in liver tissue. No urine, vitreous fluid, or suitable blood was available for testing. The pilot previously had esophageal cancer that had been successfully treated with surgery in 2013. - The estimated density altitude for the closest meteorological reporting station was 1,561 ft above mean sea level. - According to the family members of the pilot, the pilot had been flying airplanes for over 30 years, with various breaks in between. The pilot never reported any concerns with the airplane to family members. He recently reported to family members, that he felt “really comfortable” operating the airplane. The pilot purchased the airplane with a partner about 1 year before the accident. According to his logbook, he had flown the airplane 26.2 hours, of which 20.0 hours were with a flight instructor. - A postaccident examination revealed that flight control continuity was established from the cockpit to the empennage, and from the wings to the cockpit. For the cockpit, the flight controls were destroyed from fire damage. The flight control hardware appeared to be intact. In the cockpit, the control rods were destroyed from the fire damage. The breached fuel tank, along with the fuel lines, were also destroyed by the fire. The engine, which sustained impact damage, was examined. The crankshaft flange was able to be rotated by hand to confirm internal engine continuity with no issues noted. Rocker arm movement was confirmed on all cylinders for both the intake and exhaust. All pistons moved within the cylinders and each of the accessory gears moved when the propeller remnant was rotated by hand. The sump remains were removed and all internal components were found to be connected and moved when the engine was rotated. The wood propeller was destroyed from the impact sequence. The examination discovered no preimpact mechanical malfunctions or failures with the airframe or the engine. Additionally, no fire damage specifically related to an in-flight fire was found in the wreckage. -
Analysis
The pilot departed in the experimental airplane for a personal flight. A review of the onboard recorded data showed that shortly before the data terminated, the airplane went from a straight and level attitude to a nose-down attitude. A review of the recorded engine parameters did not show any signatures consistent with a loss of engine power. The airplane came to rest nose down, in a flat dirt field. The wreckage, which was destroyed, sustained fire damage. Postaccident examination did not reveal any preimpact mechanical malfunctions or failures with the airframe and the engine. No fire damage specifically related to an in-flight fire was found in the wreckage. The pilot purchased the airplane with a partner about 1 year before the accident. According to his logbook, he had flown the airplane 26.2 hours, of which 20.0 hours were with a flight instructor. Toxicological tests revealed ethanol was detected in lung, liver, kidney, and heart tissue samples along with N-propanol detected in lung tissue, kidney tissue, and heart tissue. Based on the pattern of toxicology results, some or all the ethanol detected in the pilot’s postmortem specimens likely was from sources other than ethanol consumption. Given the unclear accident circumstances, there was insufficient evidence to determine whether low-level ethanol effects may have contributed to the accident. The pilot’s autopsy was severely limited by the extent of the injuries sustained and therefore reduced the potential for determining if the pilot suffered from impairment or incapacitation due to medical reasons during the flight. Based on the available evidence, it is likely the airplane departed from controlled flight for unknown reasons, entered a nose-down attitude that was not recovered from, and the airplane impacted terrain. The reason for the loss of control in flight was undetermined.
Probable cause
A loss of control in flight for undetermined reasons that resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SONEX AIRCRAFT
Model
WAIEX
Amateur built
true
Engines
1 Reciprocating
Registration number
N51YX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
W0051
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-08-10T00:49:06Z guid: 105703 uri: 105703 title: CEN22LA389 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105769/pdf description:
Unique identifier
105769
NTSB case number
CEN22LA389
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-10T10:30:00Z
Publication date
2024-03-07T05:00:00Z
Report type
Final
Last updated
2022-08-22T18:10:33.929Z
Event type
Accident
Location
Appleton, Minnesota
Airport
Appleton Municipal Airport (AQP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that he listened to the airport’s automated weather station broadcast before taxi and, at that time, the surface wind was from 080° at 8 knots. However, while he taxied to runway 13 the airport’s windsock direction was consistent with a surface wind from the north-to-northeast. Before takeoff, he relistened to the airport’s automated weather station broadcast, which still reported the surface wind was from 080° at 8 knots. Believing the automated weather station report was accurate, the pilot continued with a takeoff on runway 13. The pilot stated the takeoff was conducted with 10° of flaps extended but recalled that the takeoff roll was longer than normal. He kept the control stick full aft and to the left (into the wind) during the initial takeoff roll. After the airplane accelerated to 60 mph, he pushed the control stick forward to raise the tail, but the airplane suddenly veered left and off the left side of the runway into a drainage ditch. The pilot was unable to regain directional control with a full right rudder input. During the runway excursion, the right main landing gear separated which resulted in substantial damage to both wings when they impacted the ground. The pilot reported that there were no mechanical failures or anomalies with the airplane that would have prevented normal operation. The pilot believes a left quartering tailwind may have contributed to his loss of directional control during takeoff. He also opined that the surface wind direction reported by the airport’s automated weather station was incorrect, which led him to believe using runway 13 was appropriate for the reported wind direction. A review of the airport’s automated weather station data revealed the reported surface wind direction was 080°-090° in the minutes before and after the accident. A postaccident weather model for the airport included an east-northeast surface wind (061°) at 4.5 knots. Based on the pilot’s windsock observation, the unintentional left veer during the takeoff roll was likely due to the pilot not maintaining directional control with a left quartering tailwind.
Probable cause
The pilot’s failure to maintain directional control during the takeoff roll with a quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR
Model
AT502
Amateur built
false
Engines
1 Turbo prop
Registration number
N73194
Operator
Schwenk Aircraft Inc.
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
502-0014
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-22T18:10:33Z guid: 105769 uri: 105769 title: CEN22LA385 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105735/pdf description:
Unique identifier
105735
NTSB case number
CEN22LA385
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-10T11:30:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2022-08-15T23:22:25.7Z
Event type
Accident
Location
Sparta, Michigan
Airport
Paul C Miller - Sparta (8D4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 10, 2022, about 1030 eastern daylight time, a Piper PA-28-140 airplane, N55338, was substantially damaged when it was involved in an accident near Sparta, Michigan. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that after liftoff, the airplane did not seem to be accelerating. She pushed the nose down to accelerate in ground effect; however, the airplane was approaching the end of the runway and, in her judgement, may not have had sufficient altitude to clear a line of trees. The pilot decided to reject the takeoff. After touching down, she “immediately” applied full brakes but was unable to stop before the airplane departed the runway pavement. It continued into the grass and impacted the airport perimeter fence. The airframe sustained damage to the right wing during the impact. A postaccident engine examination did not reveal any anomalies consistent with an inability to produce rated power. In addition, the pilot stated that there was no mechanical failure or malfunction associated with the airplane. She noted that factors adversely affecting airplane takeoff performance were density altitude, airplane gross weight, an upsloping runway, and the additional altitude required to clear the tree line. The preflight weight and balance calculation provided by the pilot indicated a gross takeoff weight of 2,072 lbs and a center-of-gravity location of 90.405 inches. This was within the allowable loading envelope for the airplane. At the time of the accident, the calculated density altitude was about 1,674 ft. Airplane performance data indicated the expected takeoff performance was about 900 ft ground roll, 2,000 ft required to clear a 50-foot obstacle, and an initial climb rate of 550 feet per minute. -
Analysis
The pilot reported that after liftoff, the airplane did not seem to be accelerating. She pushed the nose down to accelerate in ground effect; however, the airplane was approaching the end of the runway and, in her judgement, may not have had sufficient altitude to clear a line of trees. The pilot decided to reject the takeoff. After touching down, she “immediately” applied full brakes but was unable to stop before the airplane departed the end of the runway. It continued into the grass and impacted the airport perimeter fence. A postaccident engine examination did not reveal any anomalies consistent with an inability to produce rated power. The airplane was loaded within the specified gross weight and center-of-gravity limits and the runway length was sufficient based on published performance data. The pilot noted that factors adversely affecting airplane takeoff performance were the elevated density altitude, the near-maximum airplane gross weight, the upsloping runway, and the additional altitude required to clear the tree line. She added that a short field takeoff procedure may have provided additional climb performance and clearance from the tree line. Although the published airplane performance indicated the takeoff could have been completed safely, the pilot prudently decided to reject the takeoff when the obstacle clearance was in doubt. The decision was made without sufficient runway available to land and resulted in the runway excursion and impact with the airport perimeter fence.
Probable cause
The pilot’s delayed decision to reject the takeoff, resulting in a runway excursion and impact with a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N55338
Operator
West Michigan Flight Academy
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-7325370
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-15T23:22:25Z guid: 105735 uri: 105735 title: ERA22LA377 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105773/pdf description:
Unique identifier
105773
NTSB case number
ERA22LA377
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-10T19:23:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-23T04:19:28.001Z
Event type
Accident
Location
Lehighton, Pennsylvania
Airport
JAKE ARNER MEML (22N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he stated he was landing in the evening and the sun was low on the horizon. While he was on the downwind leg of the traffic pattern, he heard another pilot state that they were departing from the runway. As the pilot turned onto the final leg of the traffic pattern, the sun was in his eyes, and he could not see very well. After the airplane touched down on the runway, he noticed the departing airplane right in front of him and he veered hard to the right to avoid a collision. The airplane departed the right side of the runway and contacted runway lights resulting in substantial damage to the leading edge of the right wing. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have resulted normal operation.
Probable cause
The pilot failure to ensure the runway was clear before landing, resulting in a runway excursion and collision with runway lights.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7695W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-1618
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-23T04:19:28Z guid: 105773 uri: 105773 title: ERA22LA369 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105726/pdf description:
Unique identifier
105726
NTSB case number
ERA22LA369
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-11T23:58:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-08-16T21:39:33.795Z
Event type
Accident
Location
Jamestown, New York
Airport
Goose Creek Airport (NY89)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On August 11, 2022, about 2258 eastern daylight time, a Cessna 172N, N4751F, was substantially damaged when it was involved in an accident near Jamestown, New York. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, the flight was scheduled as a night cross-country flight from Lake County Executive Airport (LNN), Willoughby, Ohio, to Chautauqua County/Jamestown Airport (JHW), Jamestown, New York. The airplane was fully fueled before departure, and the instructor noted no issues during the flight to JHW. During the climb to cruise altitude after the touch-and-go procedure at JHW, the engine began to “sputter.” The pilot receiving instruction pitched the airplane for the best glide speed and circled back toward JHW while attempting to restore engine power. He applied carburetor heat, but the engine did not regain power and seemed to be “at idle, just sputtering” with the propeller windmilling. Air traffic control advised the pilots of a private airstrip below the airplane’s location, and the flight instructor took control of the airplane to “spiral” down to the airstrip. The pilots were unable to locate the airstrip; as a result, the instructor “maintained best glide [speed] and went forward into the trees.” The airplane came to rest nose down at the base of a tree in the yard of a private residence. The fuselage, empennage, and both wings sustained substantial damage. Postaccident examination of the engine revealed that the single-drive dual magneto, which remained attached to the engine, would not produce a spark when the engine crankshaft was rotated. Internal examination of the magneto revealed that, when the magneto input drive was rotated, its drive cam lobe pushed the felt padding on both sides but that neither set of contact points opened. A screwdriver was applied to the hold-down screws for the contact points, and they appeared to be torqued. The maintenance logbooks showed no engine overhaul information or time-in-service information for the magneto. The operator thought that the engine had been overhauled before purchasing the airplane in 2016; however, they had no record of the overhaul. The airplane’s pre-purchase inspection entry on May 19, 2016, showed a tachometer time of 2,110.6 hours. At the time of the accident, the tachometer time was 4,020.3 hours. The logbooks contained no entries indicating that 500-hour inspections had been completed on the magneto. The most recent magneto repair occurred on June 26, 2019, at a tachometer time of 2,893.8 hours. The maintenance entry read, “Removed magneto unit for timing issues; installed magneto and adjusted timing per engine manual.” The Continental Ignition Systems Service Support Manual stated the following: Inspect all magnetos according to the “500 Hour Inspection” in Section 6-2.3, at the first 500 hours in service and every 500 hours thereafter. If the magneto has more than 500 hours, inspection as outlined above must take place within the next 100 hours, or at the next scheduled inspection period, whichever occurs first, and at 500-hour intervals thereafter. Make an appropriate logbook entry signifying compliance with this paragraph and referencing the magneto serial numbers involved after completing the inspections. Ignition systems are subject to the same environmental conditions and wear as the engine. Therefore, overhaul the magnetos and replace the ignition harnesses at the same time as the engine. Engine overspeed, sudden stoppage or other unusual circumstances may require engine overhaul prior to engine manufacturer's recommendations. In such circumstances overhaul the magneto, regardless of “in service time”, with particular attention focused on rotating parts, bearings and electrical components. Inspect magnetos and harnesses for airworthiness at the expiration of four years, without regard to the accumulated operating hours since new or last overhaul. At 2256, the weather reported at JHW, which was about 7 miles northeast of the accident site, included a temperature of 60.8° F and a dew point of 53.6° F. The calculated relative humidity at this temperature and dewpoint was about 77.16%. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were conducive to “serious icing at glide and cruise power.” -
Analysis
During a night cross-country instructional flight, the pilot receiving instruction performed a touch-and-go maneuver. Shortly afterward, during the climb to cruise flight on the return leg, the engine began to lose power. The flight instructor briefly attempted to troubleshoot the engine (including applying carburetor heat); however, he was unable to restore engine power, which remained at idle with the propeller windmilling. Because the airplane would be unable to reach an airport, the flight instructor established the airplane’s best glide speed. The airplane subsequently impacted trees. Postaccident examination of the engine revealed that the single-drive dual magneto, which remained attached to the engine, would not produce a spark when the engine’s crankshaft was rotated. Internal examination revealed that, when the magneto’s input drive was rotated, neither set of contact points opened. The magneto manufacturer’s service support manual stated that the magneto should be inspected every 500 hours with particular attention focused on rotating parts, bearings, and electrical components. The maintenance logbooks showed no record of 500-hour magneto inspections having been completed during the almost 2,000 hours that the airplane was operated since the operator had purchased it. The weather conditions about the time of the accident were conducive to carburetor icing at cruise and glide engine power settings, and while the instructor applied carburetor heat with no engine power improvement after the engine had begun to faulter, it is possible that the engine might not have been developing sufficient heat by that point to deice an accumulation of ice in the carburetor. Thus, it could not be determined whether the anomalous operation of the magneto’s points that was observed during the postaccident examination, the possible formation of carburetor ice, or a combination of both these factors ultimately resulted in the partial loss of engine power during the accident flight.
Probable cause
A partial loss of engine power for reasons that could not be definitively determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N4751F
Operator
VECTOR AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17273078
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-16T21:39:33Z guid: 105726 uri: 105726 title: WPR22LA374 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192728/pdf description:
Unique identifier
192728
NTSB case number
WPR22LA374
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-13T13:30:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-07-28T01:06:42.148Z
Event type
Accident
Location
Deer Park, Washington
Airport
Deer Park Airport (KDEW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the glider reported that, on a visual approach and landing he flared the nose too high. The tailwheel touched down first and the nose impacted hard, resulting in several firm oscillations. The glider sustained substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the glider that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
ICA BRASOV
Model
IS-28B2
Amateur built
false
Registration number
N213SS
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
110
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-28T01:06:42Z guid: 192728 uri: 192728 title: CEN22FA383 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105730/pdf description:
Unique identifier
105730
NTSB case number
CEN22FA383
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-13T13:31:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-08-15T19:04:46.515Z
Event type
Accident
Location
Hanna City, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
According to ADS-B data, when the airplane was abeam Garden City, Kansas, the ground speed was about 177 knots and the airplane was on a ground track of about 060°. When the wind data was applied to the track information, the tailwind component was about 7 knots, which would result in an airspeed of about 170 knots. According to the pilot’s operating handbook (POH), an altitude of 15,000 ft and at an airspeed of about 170 knots equated to about a 70% engine power setting; engine fuel consumption at 70% power can range from 10.2 gph to 12.5 gph. Fueling records indicated that the pilot added 54 gallons of 100LL the last time fuel was added. The total fuel capacity of the accident airplane was 78.6 gallons, of which 75.6 gallons were usable. The exact fuel quantity onboard when the airplane departed SAF and the cruise power setting could not be determined. According to the POH, the airplane would have been expected to consume between 5.41 and 7.58 gallons of fuel during climb. Using 54 gallons as a minimum fuel on board at the time of departure and accounting for climb fuel consumption, the endurance would be between 3.7 hrs and 4.7 hrs, depending on the engine power setting selected by the pilot for the cruise portion of the flight. If the fuel tanks were full before departure, the endurance would have been between 5.4 hrs and 6.8 hrs. A recovered Garmin 396 GPS contained an aircraft profile page that listed the accident airplane and a corresponding fuel flow of 12.5 gallons per hour. - On August 13, 2022, about 1231 central daylight time, a Mooney M20K airplane, N30EV, sustained substantial damage when it was involved in an accident near Hannah City, Illinois. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight departed Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico, about 0639 mountain daylight time, destined for Peoria International Airport (PIA), Peoria, Illinois. A fuel receipt from Jet Center at SAF indicated that 54.2 gallons of fuel was purchased for the accident airplane on August 10, 2022. A review of ADS-B data revealed that, following the fuel purchase, the airplane departed SAF and flew one time around the traffic pattern on a flight that lasted about 4 minutes. No additional fuel receipts were located that indicate the airplane was refueled following the flight on August 10th and no subsequent flights were made until the accident flight. A review of ADS-B data revealed that after departure, the airplane climbed to an altitude of 15,000 ft and remained at that altitude for the almost 5-hour flight. The data showed the flight as continuous with no stops. When the airplane was about 28 miles west of PIA, the pilot established communications with the PIA air traffic control tower and reported inbound with the current weather information. The controller advised the pilot to enter a right downwind for runway 22. When the airplane was about 10 miles west of PIA, the pilot informed the controller that the engine lost all power. When queried if they would be able to reach PIA, the pilot stated that they would be unable. The last recorded data point showed the airplane traveling west about 675 ft msl and lined up with a road. Surveillance video footage captured the airplane about one block east of the last data point. In the video, the landing gear was extended, and the propeller appeared to be windmilling. As the airplane descended it struck powerlines. A second video taken from inside a vehicle showed the airplane immediately after the powerline contact. The airplane continued the descent and touched down on the roadway. After touch down, the left wing impacted a bridge railing and then a road sign. The airplane continued eastbound, and the left wing then impacted a power pole, which separated the left wing about 6’9” outboard of the wing root. The rest of the airplane continued until it impacted a building, which resulted in substantial damage to the fuselage. - Toxicology testing performed by the FAA Forensic Sciences Laboratory detected the inactive metabolite of delta-9-tetrahydrocannabinol (THC), carboxy-delta-9-tetrahydrocannabinol (THC-COOH), in the pilot’s heart blood at 2.2 nanograms per milliliter (ng/mL) and in urine at 18.9 ng/mL. THC’s short-lived psychoactive metabolite, 11-hydroxy-delta-9-THC (11-OH-THC), was detected in his urine at 3.4 ng/mL, but not in his blood. The non-impairing high blood pressure medication chlorthalidone was detected in his heart blood and urine. Quinine was also detected in his heart blood and urine; quinine is a non-impairing medication used in the treatment of malaria and leg cramps and as an additive in tonic water. - A High Resolution Rapid Refresh (HRRR) model sounding was created for the accident time and location, with the modeled surface elevation at 2,890 ft msl. At an elevation of 15,278 ft msl, the HRRR sounding indicated the wind was from 288° at 11.1 knots. - The pilot was issued a Third Class Medical Certificate with the following limitation: “Must wear lenses for distant, have glasses for near vision,” which expired for all classes in 2018. He subsequently, applied for BasicMed and completed the BasicMed course on June 3, 2020, and the Comprehensive Medical Examination Checklist was dated January 6, 2020. The BasicMed course was valid for two years and no subsequent course completion was submitted to the FAA. - A postaccident examination revealed that the left-wing fuel tank was breached during the impact and absent of fuel. The right-wing fuel tank remained intact, and when opened only a small amount of fuel was present inside the tank. The fuel selector was positioned on the “RIGHT TANK.” The fuel strainer contained about 3 oz of fuel and the fuel line into the fuel flow divider was absent of fuel. The fuel flow divider was disassembled and no blockages were observed within the divider or fuel lines that would have prevented fuel from reaching the cylinders. A detailed examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The airplane was equipped with a Shadin Avionics MiniFlo digital fuel management system, which was designed to provide fuel management information under real time flight conditions to the flight crew. The unit was connected to the engine fuel flow transducers and did not interface with the airplane’s fuel quantity indicating system. The unit required the pilot to enter the initial fuel on board the airplane and all calculations and data provided by the unit were based on fuel flow and any provided navigational information. When power was applied to the unit, it displayed the gallons used as 64.9 gallons and the gallons remaining as 10.1 gallons. The unit did not retain data indicating the last time the system was reset to full fuel. -
Analysis
The pilot had flown about 4.8 hours and was about 10 miles from the destination airport when he reported to air traffic control that the engine lost all power and that he was not going to be able to reach the destination airport. A review of automatic dependent surveillance-broadcast (ADS-B) data showed the airplane aligned with a road with the last data point about 675 ft above mean sea level (msl). Surveillance video footage captured the airplane near the last ADS-B data point. In the video, the landing gear was extended, and the propeller appeared to be windmilling. As the airplane descended, it struck powerlines. A second video taken from inside a vehicle showed the airplane immediately after the powerline contact. The airplane continued the descent and touched down on the roadway. After touchdown, the left wing impacted a bridge railing, a road sign, and a power pole, which separated the left wing. The remainder of the airplane impacted a building, which resulted in substantial damage to the fuselage. A postaccident examination revealed that the left-wing fuel tank was breached during the impact and absent of fuel. The right-wing fuel tank remained intact, and only a small amount of fuel was present inside the tank. The fuel selector was positioned on the “RIGHT TANK.” The fuel strainer contained about 3 oz of fuel and the fuel line into the fuel flow divider was absent of fuel. No mechanical malfunctions or failures were discovered with the airframe or engine that would have precluded normal operation. The airplane was equipped with a fuel-injected engine and, as such, was not susceptible to carburetor icing. Although the pilot added 54 gallons of fuel the day before the accident, the exact amount of fuel onboard at the time of departure could not be determined. A review of airplane performance charts and wind aloft observations revealed that if the flight had departed with just the 54 gallons, the endurance would have been between 3.7 and 4.7 hours. Had the airplane departed with full fuel tanks (75.6 usable gallons), the endurance would have been between 5.4 and 6.8 hours. These calculations do not include additional fuel required to climb to altitude. Based upon the lack of fuel in the fuel lines, flow divider, and right wing fuel tank, it is likely the engine lost power due to fuel exhaustion. Toxicology testing revealed that the pilot had used cannabis as low concentrations of its inactive metabolite THC-COOH were detected in his heart blood and urine. The active, short-lived metabolite of THC, 11-OH-THC was detected in his urine, but not in his blood. While the pilot’s pattern of cannabis use is unknown, given the lack of psychoactive THC in his blood and low concentration of 11-OH-THC and THC-COOH in his urine, it is unlikely that the pilot was under the influence of THC. Thus, while the pilot was found to have cannabis in his body, the effects of the pilot’s use of cannabis did not contribute to this accident.
Probable cause
A total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY AIRCRAFT CORP.
Model
M20K
Amateur built
false
Engines
1 Reciprocating
Registration number
N30EV
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25-0708
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-15T19:04:46Z guid: 105730 uri: 105730 title: ERA22LA373 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105744/pdf description:
Unique identifier
105744
NTSB case number
ERA22LA373
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-14T12:40:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-16T18:52:43.759Z
Event type
Accident
Location
Gardiner, New York
Airport
GARDINER (5NY5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that during a landing attempt on a 2,400-ft-long runway, the airplane was not slowing enough, and he decided to perform a go around maneuver. During the go-around attempt, the airplane did not gain sufficient altitude to clear a fence at the end of the runway. Subsequently, the airplane impacted the fence and came to rest beyond the runway. The fuselage and wings were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to go-around in a timely manner which resulted in a collision with a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N33125
Operator
WESTCHESTER CO POL PILOTS ASSOC INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-7540088
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-16T18:52:43Z guid: 105744 uri: 105744 title: ERA22LA371 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105733/pdf description:
Unique identifier
105733
NTSB case number
ERA22LA371
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-14T22:00:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-08-19T23:23:29.302Z
Event type
Accident
Location
Talladega, Alabama
Airport
TALLADEGA MUNI (ASN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, during the takeoff roll, shortly after the student pilot rotated and lifted off the runway, there was a loud and noticeable impact to the right side of the airplane. The airplane pulled to the right and they elected to land straight ahead. As soon as the airplane touched back down the right wing struck the runway and the airplane skidded to a stop. Neither the flight instructor nor his student observed the deer that the airplane had collided with before the impact. Following the accident, the flight instructor noted that the right main landing gear had separated from the airplane and the deer that the airplane had impacted was near the runway centerline. A Federal Aviation Administration inspector confirmed that the airplane’s elevator was substantially damaged during the accident.
Probable cause
A collision with a deer during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N1486T
Operator
SPIVEY DARWYN D
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7225533
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-19T23:23:29Z guid: 105733 uri: 105733 title: WPR22FA304 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105737/pdf description:
Unique identifier
105737
NTSB case number
WPR22FA304
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-15T07:30:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2022-08-19T02:05:27.481Z
Event type
Accident
Location
Yellow Pine, Idaho
Airport
JOHNSON CREEK (3U2)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Federal Aviation Administration (FAA) publication H-8083-25A, Pilot's Handbook of Aeronautical Knowledge, stated that an aerodynamic stall results from a rapid decrease in lift caused by the separation of airflow from the wing's surface brought on by exceeding the critical angle of attack (AOA). AOA is defined as the acute angle between the chord line of the airfoil and the direction of the relative wind. An aerodynamic stall can occur when the airplane flies too slowly, or when higher wing loads are imposed due to maneuvers such as pull-ups or banked flight. - On July 25, 2022, an Airglas Inc., LC18H cargo pod was installed, changing the airplane’s empty weight from 1286.5 to 1357.30. The addition of the cargo pod changed the airplane’s useful load from 603.5 lbs to 532.7 lbs. Weight and balance values were calculated for the accident flight using the airplane’s weight and balance records and the weights of the two occupants. The weight of the airplane at the time of departure from 3U2 was estimated to be about 229 lbs over the maximum gross weight assuming 40 gallons of fuel, reported or measured occupant weights, and baggage. The CG was calculated using the passenger and seat locations in the most favorable position and was found to be outside the manufacturer’s tested/approved CG envelope. According to the airplane’s flight manual, the stalling speeds for the airplane with 0° flaps, 0° bank, is 51 mph (~44 kts), with 0° flaps, 30° bank, is 55 mph (~47 kts). The stalling speeds for the airplane with 30° flaps, 0° bank, is 45 mph (~39 kts), with 30° flaps, 30° bank, is 48 mph (~41 kts). - The airport manager for Johnson Creek Airport explained that it is common practice for aircraft departing from runway 35 to veer right of runway center line, about mid-field. The practice is done as an engine failure precautionary measure. - On August 15, 2022, about 0630 mountain daylight time, an Aviat Aircraft Inc., A-1A, N26HV, was substantially damaged when it was involved in an accident near Yellow Pine, Idaho. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   A witness camping at Johnson Creek Airport (3U2), Yellow Pine, Idaho, reported that on the morning of the accident flight, he observed the accident airplane taxiing to runway 35. Due to the cool weather, he returned to his tent. He recalled hearing the airplane’s engine rpm rise, like the pilot was conducting a runup. The witness stated that he then heard the airplane take off, which was followed shortly after by a sound similar to a "door slamming shut". Between 1030 to 1045, he departed runway 35 and flew to Yellow Pine, before returning to and flying over 3U2. While overflying the north end of the airport, he observed the accident airplane in the creek near the departure end of runway 35. A witness provided video of the accident flight that showed the accident airplane departing from runway 35. The airplane became airborne within the first half of the runway, then about mid-field, the airplane made a climbing right turn over the trees and out of sight. The sound of the engine was heard throughout the video consistent with an engine at high rpm. A review of data retrieved from an onboard PED showed that at 0636:45 the accident airplane departed from runway 35, climbed to a GPS altitude of 5,067 ft mean sea level (msl), with an airspeed of about 60 kts (GPS speed) and entered a climbing turn to the northeast. The data showed that the airplane continued on a northeast heading, reaching a GPS altitude of about 5,193 ft msl, with an airspeed of about 47 kts. At 0637:11, the accident airplane made a climbing left turn to the northwest, at a GPS altitude of about 5,203 ft msl, with an airspeed of about 45 kts. The data showed that the airplane continued on a northwest heading, the airspeed slowed to about 36 kts, and the airplane descended to about 5,153 ft msl until contact was lost, as seen in figure 1. Figure 1: Google Earth overly of the final portion of the accident flight. - The Valley County Coroner’s Office, McCall, Idaho, performed an autopsy of the pilot. The cause of death was multiple blunt force injuries. Toxicology testing performed at the FAA Forensic Sciences Laboratory found no drugs of abuse. - The pilot held a private pilot certificate that was issued about 9 months before the accident flight. At the time of the accident, he had accumulated about 170 total hours of flight experience, of which about 160 were in the accident airplane make and model. - Examination of the accident site revealed that the airplane impacted terrain about 265 ft northeast of the departure end of runway 35. The airplane impacted terrain in a nose-low attitude and came to rest upright in a creek, on a heading of about 116° magnetic, at an elevation of 4,892 ft msl. No visible ground scars or damaged vegetation were observed in the area near the wreckage. All major structural components of the airplane were located at the accident site. Figure 2: View of the accident site diagram. Flight control continuity was established from the cockpit to all primary flight controls. Numerous separations were noted within the flight control system with signatures consistent with overload separation or due to the recovery process. Postaccident examination of the recovered airframe and engine did not reveal evidence of any mechanical anomalies that would have precluded normal operation. -
Analysis
A video of the accident flight showed the airplane departed runway 35 and became airborne within the first half of the runway. As the airplane reached mid-field, it made a climbing right turn over the trees and disappeared from the camera view. The airplane impacted terrain shortly thereafter. The sound of the engine running can be heard throughout the video. Postaccident examination of the airplane revealed no evidence of any preexisting mechanical malfunction that would have precluded normal operation. A review of weight and balance information showed that, at the time of departure, the airplane was likely about 229 lbs over its maximum gross weight. Additionally, although the loading and seating positions could not be verified, an estimated calculation placed the airplane’s center of gravity (CG) outside of the manufacturer’s tested/approved CG envelope. Flight track data retrieved from a personal electronic device (PED), showed that the airplane’s speed decreased to 45 knots during the takeoff climb. The airplane's increased weight would have resulted in an increased stall speed. Given the increased airplane weight and the slow airspeed during the takeoff climb, it is likely that the pilot exceeded the airplane’s critical angle of attack, which resulted in an aerodynamic stall and subsequent impact with terrain.
Probable cause
The pilot's failure to maintain adequate airspeed during an initial climb, which resulted in the exceedance of the critical angle of attack, subsequent aerodynamic stall, and impact with terrain. Contributing was the pilot’s decision to operate the airplane above its maximum gross weight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1A
Amateur built
false
Engines
1 Reciprocating
Registration number
N26HV
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1410
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-19T02:05:27Z guid: 105737 uri: 105737 title: CEN22LA388 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105760/pdf description:
Unique identifier
105760
NTSB case number
CEN22LA388
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-15T11:00:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-08-18T20:46:52.313Z
Event type
Accident
Location
Lucedale, Mississippi
Airport
Sky Landings Airport (22MS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 15, 2022, about 1000 central daylight time, a Piper PA-28, N5341W, was substantially damaged when it was involved in an accident at Sky Landings Airport (22MS), Lucedale, Mississippi. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he had 30° of flaps and an approach speed of about 75 knots so he could land softly on the turf runway. After the nose came down during the landing roll the airplane started to slide to the left. The pilot corrected with right rudder and handbrake. The pilot thought his brakes had locked and attempted to keep the airplane in the center of the runway. The airplane then turned violently to the left, departed the runway, and impacted a peanut field. The airplane nosed over and came to rest inverted. The airplane sustained substantial damage to the right wing and vertical stabilizer. The pilot reported the accident landing was his first with the airplane on a turf runway. A witness reported that the runway was wet from morning dew and observed that the airplane’s speed during rollout was faster than normal. He then observed the airplane enter a skid, veer left, and exit the runway. Postaccident examination of the airplane revealed that the nosewheel tire pressure was too low to register on a tire pressure gauge. There was no visible damage to the tire. The shimmy dampener had little resistance in either direction. No other anomalies were observed with the main landing gear brake assemblies or tires that would have precluded normal operation. -
Analysis
While landing on a wet turf runway, the pilot used 30° of flaps and an approach speed of about 75 knots so he could land softly. A witness observed that the airplane’s speed during rollout was faster than normal. During the landing roll the airplane started to slide to the left. The pilot attempted to keep the airplane in the center of the runway. The airplane then turned violently to the left, departed the runway, and impacted a peanut field. The airplane nosed over and came to rest inverted resulting in substantial damage to the right wing and vertical stabilizer. A postaccident examination revealed the nosewheel tire pressure was low and the shimmy dampener had little resistance in either direction. No anomalies were observed with the main landing gear brake assemblies or tires that would have precluded normal operations. The pilot’s loss of directional control on the wet turf runway was likely due to the higher-than-normal touchdown and rollout speeds on a wet turf runway. It is possible that the low tire pressure and shimmy dampener may have contributed to the pilot’s inability to regain control of the airplane; however, investigators were not able to establish the extent that this would have contributed to the accident.
Probable cause
The pilot’s failure to maintain directional control while landing on the wet turf runway with a higher speed.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28
Amateur built
false
Engines
1 Reciprocating
Registration number
N5341W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-399
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-18T20:46:52Z guid: 105760 uri: 105760 title: ERA22LA374 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105748/pdf description:
Unique identifier
105748
NTSB case number
ERA22LA374
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-16T09:05:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-24T18:48:32.368Z
Event type
Accident
Location
Westfield, Massachusetts
Airport
WESTFIELD-BARNES RGNL (BAF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was holding short of the runway for an intersection departure and once he received takeoff clearance, he added power. After adding power, he reported losing control of the airplane, and exiting the taxiway. The right wing of the airplane impacted a sign resulting in substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control while taxiing for takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS AIRCRAFT INC
Model
RV-12
Amateur built
true
Registration number
N33EV
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
120070
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-24T18:48:32Z guid: 105748 uri: 105748 title: CEN22LA443 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106889/pdf description:
Unique identifier
106889
NTSB case number
CEN22LA443
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-17T15:15:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-14T04:44:05.923Z
Event type
Accident
Location
Owasso, Oklahoma
Airport
GUNDYS (O38)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was performing a short field landing with a designated pilot examiner in the right seat. The student pilot reported that his landing point was at the “top” of the runway numbers. After the airplane crossed over the perpendicular highway that is immediately to the south of the runway, it lost lift and the airplane impacted the edge of the runway. The main landing gear collapsed underneath both wings and the airplane came to rest upright on a grass field. The airplane sustained substantial damage to both wings. The student pilot reported that there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. The student pilot additionally reported that the accident could have been prevented by “proper inflight preparation of the approach” and “energy management.”
Probable cause
The student pilot’s failure to maintain a proper descent rate during the short field landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N3572Z
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-8016214
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T04:44:05Z guid: 106889 uri: 106889 title: ERA22LA375 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105768/pdf description:
Unique identifier
105768
NTSB case number
ERA22LA375
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-18T11:15:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2023-01-03T19:17:59.856Z
Event type
Accident
Location
Atlantic Ocean, Atlantic Ocean
Airport
POMPANO BEACH AIRPARK (PMP)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Analysis
According to the U.S. Coast Guard, they received a notification of a downed aircraft 15 nautical miles east from Pompano Beach, Florida. They responded to the location and confirmed, debris of an airplane and a deceased occupant. The Coast Guard then received a call from the wife of the pilot regarding a note that she received expressing possible suicidal intentions. She described her spouse and the airplane, which matched the recovered debris and the occupant. The wreckage of the airplane was not otherwise recovered, and the airplane was presumed destroyed. A review of Automatic Dependent Surveillance – Broadcast (ADS-B) flight track data showed that the airplane departed from Pompano Beach Airpark, Pompano Beach, Florida, before flying northwest for about 10 nautical miles. The airplane then began circling before heading west towards the Atlantic Ocean. While over the ocean, the airplane made a turn to the north before radar/ADS-B contact was lost. Following a death investigation, the Office of Medical Examiner, Palm Beach County classified the manner of death as a suicide.
Probable cause
The pilot's suicide.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Registration number
N6713A
Operator
JD Schools LLC.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28813
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-01-03T19:17:59Z guid: 105768 uri: 105768 title: WPR22LA310 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105764/pdf description:
Unique identifier
105764
NTSB case number
WPR22LA310
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-18T14:40:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2022-09-09T23:09:55.061Z
Event type
Accident
Location
Camarillo, California
Airport
CAMARILLO (CMA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On August 18, 2022, at 1340 Pacific daylight time, an experimental amateur-built Banty airplane, N995GS, was substantially damaged when it was involved in an accident near Camarillo, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Airport security video captured the airplane as it departed to the west from the ultralight runway at Camarillo Airport. The airplane became airborne and began an immediate climbing left turn. The airplane climbed to about treetop level, with an increase in bank angle to greater than 60° as the airplane completed about 90° of turn (see figure). The airplane then descended from view behind trees. The wreckage came to rest inverted on top of an airport hangar. Figure. Picture of Takeoff (Security Video Capture) The pilot, who held the repairman certificate for N995GS and was the only person authorized to sign off maintenance, told a Federal Aviation Administration (FAA) inspector that he was asked to fly the airplane and troubleshoot repair work to the flaps. However, he could not produce a record showing what work had been done or by whom. When asked specifically if he was performing a test flight on the airplane, he said he could not recall why he was there and he did not know what happened during the flight. The pilot also stated he had not flown this model airplane “for many years.” A witness to the accident, who was familiar with the airplane, said he spoke to the pilot following the accident and the pilot told him he “perceived the runway was too small,” and turned to the left after takeoff and stalled the airplane. The pilot also told him that there was nothing wrong with the airplane. The witness also assisted in the relocation of the wreckage and stated he did not [observe anything unusual or abnormal] with the airplane. A FAA inspector who responded to the accident found no airworthiness issues. A review of the pilot’s most recent logbook did not reveal any entries for flights in the accident airplane make and model between the first logbook entry in April 2020 and the date of the accident. No airplane maintenance logbooks were recovered during the investigation. -
Analysis
The accident occurred as the pilot was taking off from an ultralight runway. Portions of the takeoff and accident were captured on a security video. The airplane became airborne and, as seen in the video, it entered a climbing left turn. As the airplane ascended to about treetop level, the bank angle increased greater than 60° as the airplane turned about 90° off the runway heading. The airplane then descended out of view behind trees. The airplane came to rest inverted on top of an airport hangar and was substantially damaged. The pilot stated he had not flown the airplane for years and could not recall what happened during the flight. A witness stated that the pilot told him after the accident that he stalled the airplane and that there was nothing wrong with the airplane. Examination of the wreckage found no anomalies that would have precluded normal operation. The accident sequence is consistent with the pilot banking excessively after takeoff, which resulted in the airplane exceeding the critical angle of attack at a slow airspeed and stalling.
Probable cause
The pilot’s failure to maintain proper airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Ultralight
Make
STUCKER GARY
Model
BANTY
Amateur built
true
Engines
1 Reciprocating
Registration number
N995GS
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1285
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-09T23:09:55Z guid: 105764 uri: 105764 title: ERA22FA376 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105770/pdf description:
Unique identifier
105770
NTSB case number
ERA22FA376
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-19T11:05:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-08-21T23:27:00.452Z
Event type
Accident
Location
Glendora, Mississippi
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On August 19, 2022, about 1005 central daylight time, an Air Tractor AT-602, N602PB, was substantially damaged when it was involved in an accident near Glendora, Mississippi. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the operator’s son, the pilot had planned for three flights to spray the target field. According to onboard avionics with non-volatile memory, the airplane departed the private airstrip for the first flight at 0912. The airplane flew to the field to be sprayed, which was about 14 miles from the departure airport, performed the aerial application, and then returned to the airport at 0959. Then, at 1002, the airplane departed the private airstrip for the second flight. The airplane climbed to about 450 ft msl and flew about 5.6 miles south until the data stopped recording about 1,650 ft south of the accident location. In the final 30 seconds of data the airplane climbed from 400 ft to about 575 ft msl and slowed from 116 knots to 102 knots. Figure 1. A view of the airplane flight track. The two yellow lines on the left are the first flight to the spray field. The yellow flight track on the far right is the accident flight track, which stops near the blue airplane indicating the accident site. - According to the autopsy report from the Mississippi State Medical Examiner’s Office, Pearl, Mississippi, the pilot’s cause of death was blunt force injuries and no significant natural disease was identified. Toxicology testing detected meclizine at 21.6 nanograms per milliliter (ng/mL) in the pilot’s femoral blood and in his urine. Meclizine is an antihistamine available over the counter to prevent symptoms of motion sickness such as nausea, vomiting, and dizziness or by prescription to treat vertigo associated with diseases affecting the vestibular system. The therapeutic range of meclizine is 10 to 100 ng/mL, and its half-life is about 5 to 6 hours. Meclizine can cause drowsiness and may impair the mental or physical ability to perform potentially hazardous tasks such as driving or operating heavy machinery. The Federal Aviation Administration does not allow the use of this medication chronically or within 36 hours of flying. Based on pre-event medical records, the pilot had a history of recurrent sinusitis, high cholesterol, and high blood pressure. At his most recent visit on December 16, 2021, he reported having congestion with episodes of vertiginous dizziness. - The airplane came to rest upright in a cornfield, at an elevation of 140 ft, with the wreckage oriented on a 230° heading. All major components of the airplane were located in the vicinity of the main wreckage. The airplane struck multiple rows of corn at an angle, rather than perpendicular or parallel to the corn, before impacting the ground. The left wingtip red-light lens cover was located in the vicinity of the first ground impact scar. The first vegetation strike was about 155 ft from the main wreckage and there was an odor of fuel at the accident site. The fuselage remained intact, with the empennage attached to the fuselage. The leading edge of the left horizontal stabilizer was dented and remained attached to the empennage. The right horizontal stabilizer was bent aft and wrinkled about 1 ft from the empennage attach point. The left and right elevators remained attached to the empennage with the trim tabs attached to each elevator and both elevators moved freely by hand. The rudder and rudder trim tab remained attached to the vertical stabilizer and were undamaged. Flight control continuity was confirmed from the flight controls in the cockpit to the elevator and rudder. The right wing remained attached to the fuselage and was bent aft. The right aileron remained attached to the right wing and the outboard section was impact damaged. The left-wing tip was impact separated and was located about 140 ft before the main wreckage. The inboard section of the left wing remained attached to the fuselage with the outboard 20 ft impact-damaged and bent aft. Flight control continuity was confirmed from the ailerons to the flight controls in the cockpit through multiple overload breaks in the push/pull rods. The emergency dump handle inside the cockpit that jettisoned the load in the event of an emergency was found in the “closed” position. The engine remained attached to the airframe engine mounts. The front reduction gearbox was impact-separated and remained attached to the propeller hub. Remnants of the front reduction gearbox flange remained attached to the power section of the engine. Multiple gear teeth on the reduction gearbox exhibited rotational scoring. The exhaust stacks were removed to facilitate examination. The 2nd stage power turbine remained intact and one of the blade tips was impact-separated and located at the accident site in the vicinity of the engine. Multiple turbine blades exhibited trailing edge damage. Rotational scoring was noted on the power turbine section case. Furthermore, the sections of the exhaust duct exhibited torsional/compression damage. The airplane was equipped with a five-blade Hartzell controllable pitch propeller. Two of the five propeller blades were impact separated from the hub and located along the debris path. The other three propeller blades remained attached to the hub. Multiple blades were bent the opposite direction of travel and exhibited chordwise scratching. Furthermore, one blade exhibited leading edge gouging. -
Analysis
The pilot performed an aerial application flight without anomalies, returned to the departure airstrip, and departed on the second flight. An onboard device that recorded the flight track indicated that while en route, the airplane climbed to a maximum altitude of 575 ft above mean sea level (msl) before it began a slight right turn, and then the data ended. The data stopped recording about 1,650 ft south of the accident location. The airplane struck multiple rows of corn at an angle, rather than perpendicular or parallel to the corn which is common practice in an emergency landing. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation before the accident. The emergency chemical dump handle was in the closed position when examined at the accident site, indicating the pilot likely did not perceive an emergency during the accident sequence. The pilot’s medical records show he had a history of recurrent sinusitis. At his most recent primary care office visit, eight months before the accident, he had an acute sinus infection and complained of dizziness. Toxicology testing detected a therapeutic level of the motion sickness medication meclizine in his blood. While sinusitis can cause dizziness, there is no record of a current infection and his daughter reported he was feeling well. Although a sudden onset of vertigo or dizziness would be impairing, the meclizine should help to alleviate those symptoms. Given the available medical information, the lack of evidence that the pilot perceived an in-flight emergency, and the inconsistent way the airplane landed diagonal to the corn instead of with the rows, this investigation was unable to determine if the pilot’s medical conditions or effects from his use of meclizine contributed to this accident.
Probable cause
The collision with terrain for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-602
Amateur built
false
Engines
1 Turbo prop
Registration number
N602PB
Operator
SNOW BRAKE AIR SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
602-1233
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-21T23:27:00Z guid: 105770 uri: 105770 title: ERA22LA381 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105780/pdf description:
Unique identifier
105780
NTSB case number
ERA22LA381
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-19T16:50:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-31T20:35:26.869Z
Event type
Accident
Location
Orlando, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The accident flight was intended as a test flight after the airplane’s annual inspection. During the preflight inspection, the pilot visually checked the fuel and noted that there was less than he expected. While operating in the traffic pattern, the pilot experienced static on the radio and departed the airport area to troubleshoot. When he concluded these efforts and turned the airplane back toward the airport, the engine stopped producing power. Unable to restore engine power, the pilot performed a forced landing to a street. The pilot avoided vehicle traffic and power lines; however, the airplane struck trees and a masonry fence, resulting in substantial damage to both wings. Examination of the wreckage by a Federal Aviation Administration inspector revealed no fuel in the airplane’s fuel tanks. The pilot stated that there were no preimpact mechanical malfunctions that would have precluded normal operation.
Probable cause
The pilot's improper fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N6241A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
33041
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-31T20:35:26Z guid: 105780 uri: 105780 title: DCA22LA188 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105801/pdf description:
Unique identifier
105801
NTSB case number
DCA22LA188
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-19T20:17:00Z
Publication date
2023-07-18T04:00:00Z
Report type
Final
Last updated
2022-08-26T00:24:09.7Z
Event type
Accident
Location
Pharisburg, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
United Airlines flight 1400 encountered turbulence near Pharisburg, Ohio during descent into John Glenn Columbus International Airport (KCMH), Columbus, Ohio. One flight attendant was injured during the turbulence encounter. The airplane was not damaged. The captain was the pilot flying, and the first officer was the pilot monitoring. According to the flight crew, the flight experienced turbulence during the climb out, and areas of moderate to light chop during the first half of the flight, and it then encountered smooth air. The remainder of the cruise portion of the flight was uneventful. The flight crew began the final descent utilizing an RNAV arrival. According to the flight crew, weather conditions for the arrival were visual flight rules (VFR), no pilot reports (PIREPS) of turbulence were relayed to the flight crew by air traffic control (ATC), and no turbulence was forecasted for the arrival in the flight release weather information. The flight crew stated that during the approach, when the flight was at an altitude of about 12,000 ft-msl, they observed a scattered cloud layer with tops at around 10,000 ft-msl and could see the airport through the scattered layer. The flight crew stated they contacted the flight attendants early at around 11,000 ft-msl for final cabin checks and illuminated the seatbelt sign, since they anticipated the potential for some chop at the cloud tops during the descent. When the flight leveled at 10,000 ft-msl in the cloud tops, it encountered two strong jolts of moderate turbulence within seconds of each other. The autopilot system did not disconnect during the encounter. The flight crew stated the duration from the initial bump, followed by the second bump, then exiting the clouds entirely was approximately 8 seconds, and the flight crew requested a lower altitude to exit the turbulence. During this descent from 10,000 ft msl, the flight crew received an interphone call from the purser, stating that a flight attendant at the rear of the cabin was injured and that two medical personnel onboard were assisting. The first officer made a PIREP to ATC regarding the turbulence, then coordinated with the airport operations and control tower to ensure that an ambulance would meet the flight at their arrival gate. The flight landed uneventfully, and the flight attendant was later diagnosed with a fractured ankle.
Probable cause
The airplane’s inadvertent encounter with convective turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-824
Amateur built
false
Engines
2 Turbo fan
Registration number
N73270
Operator
United Airlines
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
31632
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-08-26T00:24:09Z guid: 105801 uri: 105801 title: ERA22LA380 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105779/pdf description:
Unique identifier
105779
NTSB case number
ERA22LA380
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-20T12:40:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2022-09-01T21:54:15.025Z
Event type
Accident
Location
Berry, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 20, 2022, about 1140 central daylight time, a Cessna 150F, N8797G, was substantially damaged when it was involved in an accident near Berry, Alabama. The flight instructor and the student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   According to the student pilot, he had the airplane configured in cruise flight when the engine lost partial power. He said, “it felt like one cylinder had quit. It didn’t vibrate like we’d broken a [connecting] rod; it was more like we lost a valve.”   The instructor stated that after the partial loss of power, he assumed control of the airplane, adjusted to best glide airspeed, performed remedial actions to restore power, and searched for a suitable forced landing site during the descent. He said he prepared for a landing in trees when, at low altitude, he saw a “cutover” in the trees that had been cleared by local loggers. The instructor maneuvered the airplane into the clearing where it collided with terrain and cut trees, substantially damaging the engine compartment, cabin, and both wings. The airplane came to rest upright in rough terrain and cut timber. It rested nose-down on the propeller and the right wing tip. The terrain and the airplane’s resting place precluded on-site examination, and the airplane was recovered from the site to a secure facility for the examination. Before the engine examination could be completed, and before the wreckage was released, the insurance carrier for the airplane sold the wreckage. The buyer, unaware that the airplane had been retained as evidence, began disassembling the airplane for the sale of its parts. Before the airplane was located and arrangements could be made for an engine examination, the airplane’s buyer had partially disassembled the engine. A Federal Aviation Administration inspector examined the partially disassembled engine. The engine was rotated by hand at the propeller flange and was found “smooth with no issues.” Compression could not be confirmed due to removal of the upper cylinder spark plugs, cylinder covers, push rods, and rocker assemblies. It could not be determined from which cylinder the spark plugs, push rods, and rocker arms had been removed. Four spark plugs were described as “oily, [with] carbon buildup, corroded and contaminated.” The left magneto was too damaged and disassembled to get it to spark. Sufficient rotation could not be applied to achieve spark on the right magneto. The carburetor was sheared off of the intake manifold. The No. 1 cylinder was cracked at the rocker box. According to the inspector, the crack extended the full length across the mounting pin section, with the bushings found loose due to the expansion from the crack. Photographs were examined by the manager of product field performance for the engine manufacturer, who stated that the exhaust valve in the No. 3 cylinder was stuck in the open position. With the rockers removed, both valves should be pressed closed by valve spring tension. The exhaust valve stuck in the open position would result in a substantial power loss. Further, he stated that bushings were not installed in the rocker boxes of the cylinders at the factory. The bushings pictured in the No. 1 cylinder rocker box reflected a repair that had been performed on the cylinder at some time in its service life. According to the manager, the loose bushing would affect the dry lifter clearance and adversely affect valve performance. The engine maintenance records were not available for review, and the maintenance history of the engine could not be determined. -
Analysis
The student pilot and flight instructor reported that the engine lost partial power during cruise flight. The instructor assumed control of the airplane, attempted to restore power, and performed a forced landing to a cleared area of wooded terrain, resulting in substantial damage to the airplane. The postaccident examination of the engine revealed that the exhaust valve in the No. 3 cylinder was stuck in the open position. Based on this finding, it is likely that the partial loss of engine power was the result of the No. 3 cylinder’s stuck exhaust valve. The engine maintenance records were not available for review, and the maintenance history of the engine could not be determined.
Probable cause
A partial loss of engine power due to the No. 3 cylinder’s stuck exhaust valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N8797G
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15062897
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-01T21:54:15Z guid: 105779 uri: 105779 title: WPR22LA371 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106232/pdf description:
Unique identifier
106232
NTSB case number
WPR22LA371
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-21T00:36:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2023-03-02T02:02:00.031Z
Event type
Accident
Location
Pacific Ocean, California
Weather conditions
Unknown
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On August 20, 2022, about 2100 Pacific standard time, a Cessna 172, N9670V, departed Watts-Woodland Airport (O41), Woodland, California, en route to an unknown destination. The airplane was registered to and operated by a private individual as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed; no flight plan was filed. The airplane was not located and is presumed to have crashed in the Pacific Ocean. On August 21, 2022, about 0750, family members reported the missing pilot and airplane to local law enforcement. Law enforcement responded to O41 and found the missing pilot’s vehicle parked next to the airplane’s wheel chocks. The Federal Aviation Administration issued an alert notice (ALNOT) about 1730. Law enforcement contacted California Office of Emergency Services Region 5, requesting assistance with the search. About 1644, the United States Air Force contacted law enforcement, advising the cell and radar team had tracked an airplane they believed to be N9670V. About 1845 the Air Force relayed that the United States Coast Guard was conducting searches where the last radar target was observed. The ALNOT was cancelled on August 22, 2022. According to uncorrelated radar data, at 2108, the United States Air Force tracked a radar target approximately 8 miles south of O41 on a westerly heading. The flight path of the presumed missing airplane continued approximately 144 miles from the California coastline over the Pacific Ocean. The last known location of the radar target at 2336 was 38 degrees 31.11 minutes north latitude and 125 degrees 55.45 minutes west longitude. The pilot’s girlfriend and son reported that the missing pilot had been depressed. About 1800 on the day he went missing, the girlfriend and the pilot had a disagreement. The pilot phoned her at 1940 and said he was upset with life, and he was not coming back. The girlfriend reported to law enforcement that during the call it sounded like the pilot was in his airplane. She received a text message about 2147 from the pilot stating “270 to infinity. I love you!” -
Analysis
Concerned parties reported the pilot missing after not returning from a flight. Multiple agencies conducted a search for the missing pilot and airplane, however, neither the pilot, airplane, nor wreckage debris was located. Radar data believed to represent the missing airplane showed a westerly track over the Pacific Ocean. The last known radar position was about 140 miles west of the Pacific shoreline.
Probable cause
Undetermined because the airplane and pilot were not located.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Registration number
N9670V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17264450
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-03-02T02:02:00Z guid: 106232 uri: 106232 title: DCA22FM038 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105777/pdf description:
Unique identifier
105777
NTSB case number
DCA22FM038
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-08-21T11:37:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-08-03T04:00:00Z
Event type
Accident
Location
Port Arthur, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the cargo vessel Damgracht and the cargo vessel AP Revelin was the Damgracht’s loss of propulsion caused by an automatic shutdown of the main engine due to a false alarm, likely triggered by water vapor sensed by the oil mist detector shortly after engine maintenance was completed to replace a failed cylinder head gasket during high humidity conditions.
Has safety recommendations
false

Vehicle 1

Callsign
PBOF
Vessel name
Damgracht
Vessel type
Cargo, Dry Bulk
IMO number
9420784
Maritime Mobile Service Identity
245955000
Port of registry
Amsterdam
Classification society
LR
Flag state
NL
Findings

Vehicle 2

Callsign
V7JV4
Vessel name
AP Revelin
Vessel type
Cargo, Dry Bulk
IMO number
9694696
Port of registry
Dubrovnik
Classification society
Other
Flag state
HR
Findings
creator: Coast Guard last-modified: 2023-08-03T04:00:00Z guid: 105777 uri: 105777 title: ERA22LA382 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105784/pdf description:
Unique identifier
105784
NTSB case number
ERA22LA382
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-21T15:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-08T18:43:30.081Z
Event type
Accident
Location
Clermont, Florida
Airport
Seminole Lake Gliderport (6FL0)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 21, 2022, about 1400 eastern daylight time, an Aeronca 7AC, N44FC, was substantially damaged when it was involved in an accident near Clermont, Florida. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while landing at the Seminole Lake Gliderport on runway 18, the airplane veered left off the runway when the tailwheel touched down and the right wing struck a tree, resulting in substantial damage to the right wing. The pilot added that the internal tailwheel centering lock spring may have been fractured or disconnected. A mechanic who examined the airplane stated that he was very familiar with the make and model tailwheel as he had over 8,000 hours of flight experience in tailwheel airplanes and has had inspection authorization for over 50 years. He further stated that the make and model tailwheel locking mechanism tend to wear after 500 to 700 hours. After it is worn, although the tailwheel is supposed to follow the rudder, the tailwheel may stay deflected to one side after the rudder is returned to neutral. The mechanic examined the accident tailwheel in December 2022. He did not disassemble it further as he could tell it was worn from external examination and had seen the issue several times in the past. The mechanic added that after he replaced the old Maule tailwheel with a new API tailwheel, the pilot noticed a significant improvement in the ground steering of the airplane. -
Analysis
The pilot reported that while landing the vintage tailwheel airplane on a turf airstrip, the airplane veered left when the tailwheel touched down. The airplane traveled off the runway and the right wing struck a tree, resulting in substantial damage to the right wing. Postaccident examination of the tailwheel revealed that the locking mechanism was worn, which likely resulted in the tailwheel not being appropriately aligned with the rudder position during the landing.
Probable cause
The pilot’s inability to maintain directional control while landing due to a worn tailwheel locking mechanism, which resulted in a runway excursion and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N44FC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-2005
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-08T18:43:30Z guid: 105784 uri: 105784 title: ERA22FA383 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105787/pdf description:
Unique identifier
105787
NTSB case number
ERA22FA383
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-23T15:47:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-09-06T22:12:59.554Z
Event type
Accident
Location
Whiteside, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On August 23, 2022, about 1447 central standard time, a Bell 206B helicopter, N770HP, was substantially damaged when it was involved in an accident near Whiteside, Tennessee. The pilot and the passenger/observer were fatally injured. The flight was conducted as a Title 14 Code of Federal Regulations Part 91 public aircraft operation. The helicopter was operated by the Tennessee Department of Safety. The pilot, who was an officer with the Tennessee Department of Safety, and the passenger/observer, who was a detective with the Marion County (TN) Sheriff’s Department, struck a marked, 1-inch diameter, energized (161K volt) aluminum high-tension powerline cable while en route to rejoin a marijuana eradication mission. The high-tension powerlines were about 430 ft tall and about 3,800 ft long. According to the Tennessee Department of Safety, the pilot and the passenger/observer had been conducting a joint-agency marijuana eradication mission that day and stopped for lunch and fuel at the Marion County Airport (APT) in Jasper, Tennessee, at 1248. The pilot purchased 48 gallons of Jet A at 1251. After lunch, a call came in requesting back up for a pursuit that the Tennessee Department of Safety was engaged in. The pilot felt the pursuit would be over before they arrived to assist. Then a call came in about a missing person case that the passenger/observer was working and was not associated with the eradication mission. The pilot and passenger/observer departed at 1401 and flew to a set of coordinates (a hotel) of where the missing person was believed to be. The missing person was not located, and the helicopter returned to join the eradication efforts. It was on this return flight that the helicopter struck the powerlines. A witness was driving eastbound on Highway 24 toward Chattanooga, Tennessee, when he observed a “dark colored helicopter” flying westbound just north of the interstate. He was talking on the phone to his wife at the time and he told her how concerned he was that the helicopter was flying so low and very close to a set of powerlines. He described the helicopter as hovering, and it did not appear to be in distress. The witness then saw the helicopter strike the powerlines and observed an “arc.” The helicopter spun a few times, and it appeared as if the pilot was trying to regain control of the helicopter. The witness said the helicopter then descended and went out of view. At the same time, a broken section of a powerline cable fell on the interstate in front of his vehicle. The pilot was not talking to air traffic control at the time of the accident and had not made any distress calls. The helicopter was not equipped with any video recording devices and was operating outside an environment that captured any radar or automatic dependent surveillance – broadcast (ADS-B) data. A handheld Garmin 496 GPS was located in the wreckage and its data was downloaded and plotted. The data revealed the helicopter was in a descending right-hand turn when it collided with the powerlines. The last fully recorded GPS position was at 1447:16, when the helicopter was at an altitude of 1,130 ft msl. AIRCRAFT INFORMATION The Bell 206B is a two-bladed, 5-seat helicopter powered by a single Rolls Royce 250-C20J turbine engine. The Tennessee Department of Safety owned and operated the helicopter as a public use aircraft. The helicopter was maintained by the Tennessee Department of Safety under a continuous inspection program. A review of the engine maintenance logbook revealed the last entry was made on August 15, 2022. At that time, a 150/300 engine inspection was completed as per the Rolls Royce Maintenance Manual. The aircraft total time (ACTT) was 5,668.0 hours and the engine total time (ETT) was also 5,668.0 hours. Each pilot was required to check into an electronic maintenance database prior to flight to record the ACTT. The last entry made for N770HP was on the day of the accident. The ACTT entered was 5,674.0 hours. WRECKAGE EXAMINATION The helicopter came to rest in heavily wooded and steep mountainous terrain on the west side of the powerlines. The nose of the helicopter was embedded in the ground on a ravine wall with the tail section pointed straight up in the air. There was no post-impact fire. The tail boom (minus the tail rotor) separated from the helicopter just aft of the horizontal stabilizer and was located downhill of the helicopter. This section of tail boom exhibited a downward slanting impact mark consistent with contact of the main rotor blade. The helicopter was equipped with aftermarket composite tail rotor blades. The tail rotor (minus one blade) was located approximately 100 ft east of where the helicopter came to rest and under the powerlines. Damage to the tail rotor and tail rotor gearbox was consistent with impact damage. The other tail rotor blade was not located. The top portion of the vertical stabilizer had also separated from the helicopter and was found under the powerlines and adjacent to a set of train tracks located north of where the helicopter came to rest. The fractured area of the vertical stabilizer exhibited striated gouging marks consistent with contact with powerlines. The cockpit area and forward fuselage sustained extensive impact damage. Only the right side (pilot seat) was equipped with a cyclic and collective; however, both sets of anti-torque pedals were installed. Both sets of pedals had separated from their respective control tubes from impact. The cyclic had separated at its base due to impact and was found in the wreckage. The collective was fractured from impact but remained partially attached at its base, and the throttle (twist grip) was loose. Examination of the flight control system from the cockpit to the main rotor and tail rotor revealed numerous impact fractures to the control tubes/linkages, but each fracture was consistent with overload from impact with terrain. Examination of the helicopter revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The two main rotor blades were marked with either a red or white dot to differentiate between the two blades. The white blade remained partially attached at the trailing edge and the spar was fractured just outboard of the doubler. This blade was cut at the trailing edge for recovery purposes. The red blade separated just outside the doubler and was found uphill of where the helicopter came to rest. Examination of the white blade revealed striated impact marks on the bottom of the blade about 2/3 outboard of the blade root. These striated marks were consistent with impact with the powerline. Striation marks were also observed on the top of the blade but were not as pronounced. The red blade exhibited arcing at the trailing edge tip of the blade. The engine remained secured to the helicopter and none of the engine mounts were damaged. Examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. -
Analysis
The pilot and the passenger/observer, who were both law enforcement personnel, were flying in a helicopter on a law enforcement mission when it struck a marked, 1-inch diameter, energized (161K volt) aluminum high-tension powerline cable. The high-tension powerlines were about 430 ft tall and about 3,800 ft long. A witness was driving on a nearby interstate when he observed the helicopter flying low and close to the powerlines. The witness reported that he was concerned the helicopter was going to hit the lines. He described the helicopter as hovering, and it did not appear to be in distress. The witness then saw the helicopter strike the powerlines and observed an “arc.” The helicopter spun a few times as it descended and went out of view. The helicopter came to rest in heavily wooded and steep mountainous terrain, which resulted in substantial damage to the fuselage, main rotor, and tail rotor. A postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions and failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from the powerlines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N770HP
Operator
TENNESSEE DEPT OF SAFETY
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
4624
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-06T22:12:59Z guid: 105787 uri: 105787 title: CEN22LA444 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106861/pdf description:
Unique identifier
106861
NTSB case number
CEN22LA444
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-23T18:30:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-03-13T22:33:50.705Z
Event type
Accident
Location
Lee's Summit, Missouri
Airport
Lee's Summit Municipal Airport (KLXT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during landing, the airplane “bounced”; however, he felt that he had “full control of the glide for the rest of the landing”. The airplane bounced again after which the propeller struck the ground and the nose landing gear collapsed when the airplane stopped. The airplane sustained substantial damage to the forward fuselage.
Probable cause
The pilot’s improper landing flare, which resulted in a bounced landing and the nose landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL INTERNATIONAL
Model
112A
Amateur built
false
Engines
1 Reciprocating
Registration number
N1462J
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
1462L
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-13T22:33:50Z guid: 106861 uri: 106861 title: WPR22LA316 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105794/pdf description:
Unique identifier
105794
NTSB case number
WPR22LA316
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-24T12:18:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-08-25T19:51:29.22Z
Event type
Accident
Location
Vacaville, California
Airport
Nut Tree Airport (VCB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On August 24, 2022, about 1118 Pacific daylight time, a Cessna 150H, N22507, was substantially damaged when it was involved in an accident near Nut Tree Airport (VCB), Vacaville, California. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, during the initial climb after takeoff from runway 20 at VCB, while the airplane was at an altitude of about 200 to 250 ft above ground level, the engine began to sputter, and the engine speed decreased to about 1,700 to 1,800 rpm. The pilot verified that the mixture and throttle were in the takeoff positions, but the airplane was no longer climbing, and the pilot had difficulty maintaining the airplane’s altitude. As a result, the pilot initiated a forced landing to an open field adjacent to the airport. During the landing roll, the airplane impacted uneven terrain and came to rest upright, resulting in substantial damage to the left wing and fuselage. Postaccident examination of the engine revealed that it was partially attached to the engine mount. The carburetor was separated from the intake spider. The upper spark plugs, and rocker box covers were removed, and the propeller was rotated by hand. Rotational continuity was established throughout the engine. Thumb compression was obtained on cylinder Nos. 1, 3, and 4. No compression was obtained on cylinder No. 2, which was removed for further examination. The No. 2 cylinder was intact and undamaged. The exhaust and intake valve springs were intact and oil coated, as were the intake and exhaust valve rocker arms. The valve springs and keepers were removed. The intake valve slid out of the valve guide freely, but the exhaust valve slid out of the valve guide with a significant amount of force. The exhaust valve stem exhibited carbon buildup along with the valve neck. White deposits were observed around the rim of the valve. The valve seat also exhibited carbon buildup. The intake valve stem exhibited carbon deposits on the neck of the valve and stem. The valve seat contact area showed no carbon buildup, but a slight amount of carbon build-up was observed on the valve rim. Examination of the airframe and engine revealed no additional evidence of pre-existing mechanical malfunction that would have precluded normal operation. -
Analysis
The pilot was conducting a personal flight. During the initial climb after takeoff, the engine lost partial power, and the airplane was unable to maintain altitude. The pilot initiated a forced landing to a nearby field; during the landing roll, the airplane impacted uneven terrain and came to rest upright, which resulted in substantial damage to the left wing and fuselage. Postaccident examination of the engine revealed that the No. 2 cylinder exhaust valve exhibited signatures consistent with a stuck valve, including a buildup of carbon deposits, and the exhaust valve could only be moved out of the valve guide with a significant amount of force. No additional evidence indicated any pre-existing mechanical malfunction or failure that would have precluded normal operation. Thus, the stuck exhaust valve likely caused the partial loss of engine power.
Probable cause
The partial loss of engine power due to a stuck exhaust valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150H
Amateur built
false
Engines
1 Reciprocating
Registration number
N22507
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15068324
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-25T19:51:29Z guid: 105794 uri: 105794 title: ERA22FA384 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105795/pdf description:
Unique identifier
105795
NTSB case number
ERA22FA384
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-24T17:39:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-08-30T01:21:45.452Z
Event type
Accident
Location
Osteen, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
Weight and Balance Calculations Weight and balance calculations were performed using weight and balance documents recovered at the accident site, the actual weights of the occupants (as determined by the medical examiner), and the weight of the parachutes. The weight and balance calculations assumed 5 gallons of fuel in each wing tank and no fuel in the header tank. The calculations revealed that the airplane weighed about 1,850 pounds, which was the maximum allowable takeoff weight for aerobatic maneuvers, and had a CG of 88.61 inches, which was close to the aft CG limit. Aerobatic Maneuvers An aerobatic pilot who flew the accident airplane model and knew the accident pilot provided a written statement in which he stated, in part that “I doubt seriously that [the accident pilot] was doing an intentional inverted spin” and was not sure that the pilot was proficient in inverted normal or flat spins. The pilot indicated that he would not perform any type of inverted spin with fuel in the wing tanks or with “a passenger weighing more than 200 [pounds]” (the weight of the passenger aboard the accident airplane). - According to the manufacturer’s website, the MX2 was an all-carbon-fiber two-seat high-performance aerobatic airplane constructed to sustain ± 12 Gs. The maximum aerobatic weight limit was 1,850 pounds, and the aerobatic center-of-gravity range (CG) was between 81.62 and 88.65 inches. According to placards near the fuel tanks, each airplane wing had a capacity of 22 gallons, and the header tank had a capacity of 17 gallons. Two fuel receipts on the day of the accident showed a fuel purchase of 18.9 gallons about 0827 (before the first demonstration flight, which lasted 22 minutes) and 7.5 gallons about 0909 (before the second demonstration flight, which lasted 23 minutes). Video from the fueling area showed the pilot adding fuel to the wing and header tanks during the first fueling of the day and to only the header tank during the second fueling. The pilot did not add fuel immediately before the accident flight. According to an interview with an aerobatic pilot of the accident airplane model, the “Typical Aerobatic Weight and Balance” information in the airplane’s Pilot’s Operating Handbook, and weight and balance forms in the accident pilot’s aerobatic binder, aerobatic flights were conducted with fuel only in the header tank. - On August 24, 2022, at 1639 eastern daylight time, an experimental amateur-built MXR Technologies MX2, N263MX, was substantially damaged when it impacted terrain in Osteen, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an aerobatic demonstration flight. According to individuals familiar with the purpose of the flight, the accident pilot organized training and demonstration flights for a group of pilots from a foreign air force. The planned flights included two 30-minute flights in the accident airplane for aerobatic demonstration and upset recovery and prevention training with a flight instructor in a different airplane. The accident flight was the first aerobatic demonstration flight for the pilot-rated passenger and the airplane’s third demonstration flight of the day. During the two previous demonstration flights earlier in the day, pilots had performed Lomcovák, half-Cuban eight, and hammerhead aerobatic maneuvers along with loops and vertical climbs with rolls. Review of Federal Aviation Administration (FAA) flight track data revealed that the airplane departed Spruce Creek Airport (7FL6), Daytona Beach, Florida, at 1632. The airplane flew south and began maneuvering to the east between 2,000 and 5,000 ft mean sea level (msl). The last data point, at 1639, showed the airplane at an altitude of 2,738 ft msl, on a track of 068°, and at a groundspeed of 15 knots. The airplane impacted a wooded marshy area almost directly under the last data point. - The Office of the Medical Examiner, District 7, Daytona Beach, Florida, performed an autopsy on the pilot. The autopsy report indicated that his cause of death was multiple blunt force injuries of the head, neck, torso, and extremities. Toxicology testing by the FAA's Forensic Sciences Laboratory detected chlorpheniramine in the pilot’s blood at 17 nanograms per milliliter (ng/mL). Hydrocodone, hydromorphone, and dihydrocodeine were detected in the pilot’s urine at 17 ng/mL, 37 ng/mL, and 16 ng/mL, respectively; these three substances were not detected in the pilot’s blood. Chlorpheniramine is an over-the-counter sedating antihistamine to treat allergy or common cold symptoms. The therapeutic range is 10 to 40 ng/mL, and it has a half-life of 12 to 43 hours. Chlorpheniramine undergoes postmortem redistribution, and central blood levels may be two to three times higher than peripheral blood levels. FAA provides guidance on wait times before flying after using this medication; post-dose observation time is 60 hours, and the medication is not for daily use. Hydrocodone is an opioid that is often used in combination with acetaminophen to treat moderate-to-severe pain; one such commonly marketed combination is Vicodin. The therapeutic range is between 10 and 50 ng/mL. As an opioid, hydrocodone carries a warning for its high risk of addiction, abuse, and misuse. Adverse reactions to the central nervous system from hydrocodone include drowsiness, mental clouding, anxiety, and impairment of mental and physical performance. Dihydrocodeine is a commonly found active metabolite of hydrocodone, with an average concentration in blood that is about 29% of the hydrocodone value. Hydromorphone is also an active metabolite of hydrocodone. Dihydrocodeine and hydromorphone have warnings and adverse reactions that are similar to those for hydrocodone. - Postcards promoting the accident pilot’s aerobatic experience were recovered from the airplane. The postcards stated in part that the accident pilot had “an impressive competition record flying aerobatics and has finished strongly in every competition he has entered since 2010.” - Accident Site Examination The airplane came to rest inverted on a 098° heading. The debris field was limited to within 1 ft of the perimeter of the airplane, and the trees and shrubs near the wreckage were not damaged, both of which were consistent with the airplane impacting the marsh in a near-vertical, inverted, and flat attitude. Airframe and Engine Examination Recovery personnel stated that a total of 10 to 15 gallons of fuel was drained from the wings and that about 0.5 gallons of fuel was drained from the right wing fuel line when the wing was turned upright. The header tank was found breached. The recovered fuel was light blue in color and absent of debris. Examination of the airframe revealed rudder and aileron control continuity that could be traced through cuts made to facilitate recovery. Elevator control continuity was confirmed from the cockpit control column to just aft of the rear pilot seat, where there was a bend fracture about 17 inches aft of the elevator torque tube end fitting, a 40-inch span of torque tube, and another fracture about 20 inches forward of the aft bellcrank. The elevator torque tube was fractured at the aft bulkhead opening, consistent with the elevator control surface in the full nose-up position at the time of impact with the ground. Examination of the fractured elevator torque tube at the National Transportation Safety Board’s Materials Laboratory revealed that the tube fractured in overload due to contact with the airframe structure during impact. Compression and suction were confirmed on all cylinders, and borescope examination of the cylinders revealed no anomalies. Examination of the engine revealed no evidence of any mechanical failures or malfunctions that would have precluded normal operation. -
Analysis
The accident flight was part of a training and demonstration flight that included a series of aerobatic maneuvers. Flight track data for the accident flight revealed that the airplane departed and maneuvered for about 7 minutes before impacting terrain almost directly under the last data point. No linear ground scar was observed at the accident site, which was indicative of the airplane having descended nearly vertically to ground impact. Additionally, the wreckage was found in an inverted orientation. Examination of the wreckage revealed no evidence of a preimpact mechanical anomaly that would have precluded normal operation of the airplane structure, the flight controls, or the engine. Estimated weight and balance calculations revealed that the airplane’s weight and its aft center of gravity were likely at or near the limit for aerobatic flight. Given the purpose of the flight, the flight track, and the orientation of the wreckage, it is likely that the pilot lost control of the airplane while performing aerobatic maneuvers and that the airplane inadvertently entered an inverted flat spin. A fracture of the elevator torque tube at the aft bulkhead opening corresponded with the elevator control surface being in the full noseup position when the airplane impacted the ground, which would have been a position consistent with the pilot attempting to recover from an inverted flat spin. The airplane’s weight and aft center of gravity likely contributed to the pilot’s inability to recover from the spin. Thus, the inverted flat spin likely continued until the airplane impacted terrain. Toxicology testing revealed subtherapeutic concentration of chlorpheniramine in the pilot’s blood, which likely did not cause significant symptoms. Hydrocodone and its active metabolites (hydromorphone and dihydrocodeine) were detected in the pilot’s urine but not in his blood, so they would not have had any therapeutic effect or side effect. Thus, the detected chlorpheniramine, hydrocodone, hydromorphone, and dihydrocodeine did not contribute to this accident.
Probable cause
The pilot’s loss of airplane control while performing aerobatic maneuvers, which resulted in the airplane entering an inverted flat spin that continued until the airplane impacted terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MXR TECHNOLOGIES
Model
MX2
Amateur built
true
Engines
1 Reciprocating
Registration number
N263MX
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
3
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-30T01:21:45Z guid: 105795 uri: 105795 title: ERA22LA385 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105803/pdf description:
Unique identifier
105803
NTSB case number
ERA22LA385
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-25T14:12:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-05T22:26:41.067Z
Event type
Accident
Location
Kissimmee, Florida
Airport
Kissimmee Gateway (ISM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot reported that, during landing, the airplane “bounced three times.” Following the third bounce the “nose wheel hit the runway in an abrupt manner.” This impact resulted in substantial damage to the forward fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare and subsequent improper recovery from a bounced landing, which resulted in the nose landing gear impacting the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N9968F
Operator
Buiqui Aerospace Corp.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17280208
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-05T22:26:41Z guid: 105803 uri: 105803 title: ERA22LA389 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105810/pdf description:
Unique identifier
105810
NTSB case number
ERA22LA389
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-27T13:37:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-08-31T22:23:28.878Z
Event type
Accident
Location
Slocomb, Alabama
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Factual narrative
On August 27, 2022, about 1315 eastern daylight time, a Cessna 140, N76527, was substantially damaged when it was involved in an accident near Slocomb, Alabama. The commercial pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after conducting his preflight and engine runup, he departed and flew near the airport for about 1 hour, landed, and checked for leaks as the engine had just been overhauled. He repeated this process “a couple more times” and then refueled the airplane with aviation fuel from several gas containers. A witness, the pilot’s son, reported that during takeoff after the refueling, the takeoff roll seemed “sluggish,” and the engine sounded “weak.” The pilot reported that the “engine wasn’t making good power” but it was too late to abort the takeoff. The witness noted that immediately after rotation during the initial climb, the airplane seemed to be climbing slower than normal as it proceeded west towards a line of trees that were about 70 ft tall. According to the pilot, as he attempted to clear the trees, he felt the airplane stall. Shortly after the airplane reached the top of the trees, the right wing dropped, and the airplane descended into the trees and disappeared from the witness’s view. The witness drove to the tree line and found that the airplane had come to rest in the tree canopy about 30 ft above ground level and that the pilot had egressed the airplane by jumping out as the airplane was catching on fire. According to the airport owner, who was also a mechanic with inspection authorization, he had recently overhauled the airplane’s engine and installed it on the airframe. After the installation of the engine, the mechanic test ran the engine for several hours with no anomalous behavior noted, and the pilot conducted “4 or 5 flights” around the airport with no discrepancies. The mechanic reported that the engine had operated about 5 hours since overhaul when the accident occurred. A Federal Aviation Administration inspector examined the wreckage and reported that the airplane impacted trees and became suspended about 30 ft off the ground on a heading of about 270° magnetic and 600 ft from the end of the turf runway. The fuel tanks were breached during impact, and a post-crash fire had consumed the cockpit and fuselage while the empennage remained in the trees. The engine was exposed to fire and thermally damaged but remained relatively free from impact damage and was subsequently examined. The carburetor heat was in the off position, and the carburetor parts and components were undamaged and clear of any water or contaminants. All spark plugs were checked and found to be in good condition. Both magnetos were damaged by postimpact fire, and the internal components were destroyed and unable to produce spark. A borescope examination was conducted on all cylinders and revealed no defects or anomalous findings. The weather at the time of the accident was not conducive to the formation of carburetor ice. -
Analysis
Following an engine overhaul, the pilot conducted several test flights around the airport traffic pattern. After landing, the airplane was fueled with aviation fuel, and the pilot began another flight. During the takeoff roll, a witness observed that the airplane seemed “sluggish,” and the engine sounded “weak.” The pilot realized the engine was not producing full power but decided it was too late to abort the takeoff. As the airplane approached the top of a 70-ft-tall tree line, the pilot exceeded the critical angle of attack; the airplane entered an aerodynamic stall and descended into trees. The airplane came to rest suspended from the tree canopy, and a postcrash fire ensued. The pilot was able to egress the airplane and jump to the ground. Postaccident examination of the engine and components, which were extensively damaged by fire, did not reveal evidence of any anomalies that would have precluded normal operation. The reason for the partial loss of engine power could not be determined based on the available evidence.
Probable cause
The partial loss of engine power during takeoff for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N76527
Operator
MALSBERGER TIM J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
10963
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-31T22:23:28Z guid: 105810 uri: 105810 title: ERA22FA386 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105806/pdf description:
Unique identifier
105806
NTSB case number
ERA22FA386
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-27T21:58:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-09-15T15:31:57.183Z
Event type
Accident
Location
French Lick, Indiana
Airport
FRENCH LICK MUNI (FRH)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On August 27, 2022, about 2058 eastern daylight time, a Beech B35, N8741A, was destroyed when it was involved in an accident near French Lick, Indiana. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot departed Fischer's Airport (6LL6), New Memphis, Illinois, about 1950, and flew to French Lick Municipal Airport (FRH), French Lick, Indiana, his home airport. A review of radar data revealed that as the airplane approached FRH, it made a right turn flying south toward the departure end of runway 26 about 500 ft above the ground (agl), then turned right flying on the south side of runway 08/26 before crossing at midfield. The airplane then made a sweeping, descending left turn onto the final approach for runway 08. The radar data stopped when the airplane was about .2 miles from the end of the runway. At that time, the airplane was traveling about 86 knots at an altitude of about 33 ft agl. Airport surveillance captured the airplane touch down on runway 08 then depart the runway surface to the left before becoming airborne and impacting trees just outside of the perimeter fence. A large explosion was also observed. PILOT INFORMATION The pilot held an airline transport pilot rating for airplane multiengine land and a commercial pilot certificate for airplane single-engine land. His last Federal Aviation Administration (FAA) first-class medical examination was conducted on January 8, 2004. At that time, he reported a total of 14,000 flight hours. AIRPLANE INFORMATION A review of the airframe maintenance logbooks revealed the last annual inspection was conducted on January 10, 2020, at a total airframe time of 5,202 hours. The engine received a 100-hour inspection on this same date. At that time, the engine had accrued a total of 3,325 hours and 1,774 hours since overhaul. WRECKAGE INFORMATION Witness marks on the runway were visible consistent with the left main wheel touching down 1,036 ft past the runway threshold. About 29 ft beyond those witness marks were additional witness marks consistent with the nose gear and right main gear touching down. Those marks remained on the runway for 165 ft until they exited the runway onto the grass, consistent with the airplane departing the runway at that point. Once in the grass the witness marks extended another 109 ft on a heading of 055° before ending, consistent with the airplane becoming airborne and impacting trees north of the perimeter fence. The airplane was located in a wooded area on a magnetic heading of 180° at an elevation of 768 ft. mean sea level (msl). The right wing impacted a tree about midspan, then impacted terrain and came to rest upright. All components of the airplane were accounted for at the accident site. A postimpact fire consumed the cabin, instrument panel, most of the fuselage, and the inboard portion of both wings by the fuel tanks. The engine also sustained extensive fire/heat damage and was partially separated from the firewall. Control cable continuity was established for all flight controls from the control surface to the cockpit. The aileron balance cable and elevator trim tab nose up cable exhibited thermal damage. The nose landing gear separated during the impact sequence. The left main landing gear was in the down and locked position. The right main landing gear was extended but not locked. The engine was removed from the airframe but the crankshaft could not be rotated due to thermal damage. The pressure carburetor, accessory housing, oil sump, fuel pump and vacuum pump were consumed by fire. The top spark plugs were removed from each cylinder for examination and were dark gray or black in color. Neither magneto could be operationally tested due to thermal damage. Both propeller blades were found at the accident site; one blade was curled aft at the tip and remained secure in the hub. The second propeller blade was separated from the hub and exhibited S-bending of the outer 1/3 of the blade. Postaccident examination of the airplane and the engine revealed no evidence of any pre-impact mechanical deficiencies or malfunctions that precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION According to the autopsy performed for the Orange County Coroner, Paoli, Indiana, the pilot’s final diagnoses included aircraft crash with flash fire eruption and smoke inhalation and severe incineration. The forensic pathologist reported that the pilot had soot in his trachea, bronchus, and lung and had 50% occlusion of his left anterior descending coronary artery. Toxicology testing performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory reported the pilot’s carboxyhemoglobin saturation in heart blood was 20%. Cyanide was also detected at 2.97 micrograms per milliliter in his heart blood and timolol was detected in his urine. Timolol is non-impairing high blood pressure medication. ADDITIONAL INFORMATION The FAA Safety Team issued a safety briefing titled Stabilized Approach and Landing in 2022. The safety briefing stated, “Focusing on establishing and maintaining a stabilized approach and landing is a great way to avoid experiencing a loss of control. A stabilized approach is one in which the pilot establishes and maintains a constant angle glidepath towards a predetermined point on the landing runway. It is based on the pilot’s judgment of certain visual clues, and depends on the maintenance of a constant final descent airspeed and configuration.” -
Analysis
The pilot was returning to his home airport at the conclusion of a cross-country flight and was attempting to make a visual approach to land at night. A review of radar data revealed the airplane overflew the airport about 500 ft above the ground before making a sweeping, descending left turn onto final approach before the data ended 0.2 miles from the end of the runway. At that time, the airplane was traveling at a groundspeed of about 86 knots at an altitude of about 33 ft above ground level (agl). Airport surveillance video captured the airplane on landing rollout. The airplane was observed departing the left side of the runway before it started a climb and impacted trees. Postaccident examination of the airplane and the engine revealed no evidence of any pre-impact mechanical deficiencies or malfunctions that precluded normal operation. The pilot’s autopsy examination and postaccident toxicological findings did not reveal any medical factors that would have resulted in the pilot becoming suddenly impaired or incapacitated. Based on the available radar data, the pilot had not stabilized the airplane during the approach to the runway and was at a critically low altitude when the airplane was .2 miles from the end of the runway. Surveillance video also suggested the airplane was not stabilized after it touched down. Visible tire marks on the runway confirmed that it departed the left side of the runway during the landing rollout. The pilot may have attempted to regain control of the airplane after the unstabilized approach, touchdown, and runway excursion by attempting to abort the landing; however, the airplane subsequently collided with trees. Based on this information it is likely that the pilot performed an un stabilized approach that resulted in a loss of directional control during landing, ultimately resulting in a runway excursion and collision with trees.
Probable cause
The pilot’s failure to make a stabilized approach, which resulted in a loss of directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B35
Amateur built
false
Engines
1 Reciprocating
Registration number
N8741A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-2254
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-09-15T15:31:57Z guid: 105806 uri: 105806 title: ERA22LA390 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105813/pdf description:
Unique identifier
105813
NTSB case number
ERA22LA390
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-27T22:10:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-08-30T15:51:09.364Z
Event type
Accident
Location
Chamblee, Georgia
Airport
DEKALB-PEACHTREE (PDK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he was attempting to land the helicopter on a portable dolly, and he was following a marshaller to land on the dolly. As he lowered the collective, the helicopter’s skids fell off the back of the dolly, and the tail rotor struck the ground. The helicopter subsequently rolled over on its left side resulting in substantial damage to the main rotor and tail rotor systems. The pilot added that there were no mechanical issues with the helicopter.
Probable cause
The pilot’s failure to ensure that the helicopter was properly positioned over a dolly before attempting to land on it, which resulted in a rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL TEXTRON CANADA LTD
Model
505
Amateur built
false
Engines
1 Turbo shaft
Registration number
N6SD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
65414
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-30T15:51:09Z guid: 105813 uri: 105813 title: CEN22LA398 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105814/pdf description:
Unique identifier
105814
NTSB case number
CEN22LA398
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-28T14:45:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2022-09-01T17:59:31.068Z
Event type
Accident
Location
Olivet, Michigan
Airport
Private (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 28, 2022, at 1345 eastern daylight time, a Cessna 172I, N46202, sustained substantial damage when it was involved in an accident near Olivet, Michigan. The student pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The student pilot was on a visual final for a low approach when he applied engine power to stabilize the descent. The engine did not respond, and the airplane continued to descend and landed hard land on the runway. The airplane nosed over and sustained substantial damage to both wings, the left wing strut, the fuselage, and the vertical stabilizer. The student pilot reported that he’d applied carburetor heat for about 10 seconds when he was about one mile from the runway. There was no engine roughness during the application. He then turned it off. Weather conditions were conducive for serious carburetor icing at glide power. A National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident Report Form 6120.1 was not received from the student pilot. Postaccident examination of the airplane revealed that the left and right wing fuel tanks contained useable fuel. Examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. -
Analysis
The student pilot was on a visual final for a low approach when he applied engine power to stabilize the descent. The engine did not respond, and the airplane continued to descend and landed hard on the runway. The airplane then nosed over and sustained substantial damage. Postaccident examination of the airplane revealed that the left and right wing fuel tanks contained useable fuel. Examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation. The student pilot stated that the engine did not respond, but it is likely that the student pilot delayed the application of engine power and when he applied engine power, it exceeded the response capability of the airplane/engine that he perceived as delayed. The student pilot also reported that he’d applied carburetor heat for about 10 seconds when he was about one mile from the runway. There was no engine roughness during the application. He then turned it off. An accident report form was not received from the student pilot. Weather conditions were conducive for serious carburetor icing at glide power.
Probable cause
The pilot’s failure to attain/maintain a proper glidepath that resulted in a hard landing and impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172I
Amateur built
false
Engines
1 Reciprocating
Registration number
N46202
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17257104
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-01T17:59:31Z guid: 105814 uri: 105814 title: ANC22FA069 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105826/pdf description:
Unique identifier
105826
NTSB case number
ANC22FA069
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-29T13:04:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-08-30T04:29:43.122Z
Event type
Accident
Location
Wasilla, Alaska
Airport
WOLF LAKE (4AK6)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
The pilot had started building the airplane about 3 years before and finished a couple of weeks before the accident. The Federal Aviation Administration DAR-F Inspector completed a Conformity Inspection of the airplane on August 13, 2022. A Special Airworthiness Certificate was issued on August 13, 2022. When the airplane passed this inspection, the next step was that a pilot must fly between 25-40 hours of test flights in specific non-populated areas to make sure all components are operating properly. Only after that test flight time was completed could the pilot fly the airplane with passengers on board. The airplane was in the test flight stage with about 3.2 hours of flight time completed. - On August 29, 2022, about 1204 Alaska Daylight Time, a Charles Brad Story TT FOX amateur-built airplane, N2723P sustained substantial damage when it was involved in an accident at the Wolf Lake Airport (4AK6), Wasilla, Alaska. The pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 test flight. Family reported that the purpose of the flight was for the pilot to complete the required flight hours during the phase I testing of the amateur-built airplane. Witnesses at the airport observed the airplane departing to the south and then heard the airplane returning towards the airport. The pilot made a call on the radio saying he was on the downwind leg of the traffic pattern for landing; no other transmissions were heard from the airplane. The flight path downloaded from an onboard Dynon Skyview D1000 showed the airplane turned crosswind after takeoff then entered a right downwind for runway 08. Once abeam the departure end of the runway, the airplane stopped its climb, began a descent, and turned toward the approach end of the gravel strip, runway 02. (Figure1) Witnesses then observed the airplane flying low and fast, heading toward the gravel strip. Witnesses reported hearing changes in the engine rpm which were described as the engine revving, going to idle, and surging. They also reported the airplane was traveling “fast,” with two witnesses reporting pitch oscillations. A witness saw the airplane “abruptly pitch down as if the airplane hit something “and impacted the hangar. Figure 1. Flight path data from the Dynon Skyview. The yellow path indicates the flight track of the accident airplane. - The pilot was the owner and builder of the airplane. The pilot had completed 4 test flights in this airplane starting on August 21. The first and second flights were logged for 0.6 hours each. The third and fourth flights were for 1 hour each. The fourth flight was on August 27th. All flights were conducted at 4AK6. - The accident was in a relatively flat, residential area next to 4AK6. All components of the airplane were located in the vicinity of the main wreckage. The airplane impacted in a nose-low attitude into the back of a hangar and came to rest inside the hangar. About 60 to 80 ft before the impact site there was evidence of an impact with a tree. The top 10 to 12 ft of the tree was broken off and laying on the ground in the direction of the flight path. Branches and parts of the tree were found scattered between the tree, the hangar, and inside the hangar. The airplane came to rest inside a hangar. The main fuselage was on the floor, with the right wing still attached to the airplane in the attic. The left wing was impact-separated and located outside the building. The flaperon handle was set to the 10° position. Flight control continuity was established in all flight controls with separation from impact damage. Examination of the engine revealed that both cylinders had compression. The spark plugs were not fouled. Engine continuity was confirmed by operating the starter pull handle and watching the propeller move. The engine was a Rotax 850 engine that was designed to be used in snowmachines and was not for aircraft use. The airplane was equipped with a three-blade composite propeller. All three blades exhibited impact damage. There were no mechanical malfunctions or anomalies with the engine that were noted that would have precluded normal operation. A Dynon Skyview system was removed from the airplane and sent for data download at the National Transportation Safety Board Recorders Laboratory. The flight data indicated that at 1203, about 8 seconds before impact, the engine rpm went from idle to max rpm 3 times. Auditory witnesses also recalled hearing the engine fluctuating rpm right before impact. -
Analysis
According to witnesses, the airplane took off on runway 08 and then turned back toward the airport. The pilot made a radio call that he was turning downwind for landing. The accident occurred during the fifth flight of the phase 1 test flights after the pilot finished building the airplane. Witnesses heard changes in the engine rpm they described as the engine revving, going to idle, and surging. They also reported that the airplane was traveling “fast,” with pitch oscillations; the airplane approached the gravel runway in a right-wing-low turn as if it was going to land. The airplane then pitched down abruptly before striking trees about 60 to 80 ft before penetrating the side of a hangar, where it came to rest. Data downloaded from an onboard device showed the airplane turned crosswind after takeoff then entered a right downwind for the runway. Once abeam the departure end of the runway, the airplane stopped its climb, began a descent, and turned toward the approach end of the intersecting gravel strip. The data also showed that the engine rpm changed from idle to maximum three times in the last 8 seconds of flight. Examination of the airplane revealed no mechanical malfunctions or anomalies that would have precluded normal operation. The reason for the rpm oscillations and pitch variations could not be determined with the available information. Given the witness statements and that the pilot was turning toward the gravel runway, it is likely that he was experiencing an issue with the airplane that could not be determined with the available information.
Probable cause
The pilot’s inability to maintain control of the airplane for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STORY CHARLES BRAD
Model
TT FOX
Amateur built
true
Engines
1 Reciprocating
Registration number
N2723P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
C9404-002
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-30T04:29:43Z guid: 105826 uri: 105826 title: DCA22LA191 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105843/pdf description:
Unique identifier
105843
NTSB case number
DCA22LA191
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-29T17:43:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-09-01T15:31:41.378Z
Event type
Accident
Location
Detroit, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
A flight attendant (FA) was injured when the flight encountered turbulence during descent. According to the captain, he conducted a preflight briefing with the FA and advised of the possibility of light to moderate chop, mainly below 12,000 feet, during the descent into the Detroit area. During the initial descent, at approximately 20,000 feet, the aircraft encountered light turbulence with a few encounters of moderate turbulence for about a minute. The captain gave the final indication (two chimes) shortly afterward and then overheard the FA give the final public address (PA) over the intercom. The remainder of the descent was mainly smooth with a little light chop. Shortly after arriving at the gate and having completed the normal shutdown procedures, the FA came to the cockpit and indicated that she had been injured and requested that the captain report it. According to the FA, she was in the forward galley when the airplane encountered turbulence; she impacted the left side of her body on the galley counter. She indicated that she took a direct hit to her ribs and then fell backward and struck the cabin door with her back. After deplaning was complete, the flight crew gathered their belongings and exited the aircraft. As they exited, the FA showed signs of being in pain; as her left side was becoming more painful. The flight crew helped her to the next gate where she sat down and was met by the paramedics who briefly evaluated her before she was transported to the local hospital where she was diagnosed with a fractured rib.
Probable cause
An encounter with moderate turbulence during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
717-200
Amateur built
false
Engines
2 Turbo fan
Registration number
N946AT
Operator
DELTA AIR LINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
55009
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-09-01T15:31:41Z guid: 105843 uri: 105843 title: ERA22LA393 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105836/pdf description:
Unique identifier
105836
NTSB case number
ERA22LA393
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-29T18:17:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-21T22:47:21.829Z
Event type
Accident
Location
Bennington, Vermont
Airport
Morse State Airport (DDH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was on approach for landing with variable wind conditions; however, METAR data showed there was a crosswind at the time of the accident. He further stated that he “flared early, got slow, attempted a go around and ended up in a full power stall.” The airplane collided with terrain near the approach end of the runway. Airport surveillance video supports the pilot’s account of the accident. The Federal Aviation Administration inspector who examined the wreckage reported that there was substantial damage to the forward fuselage and both wings. The pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operation of the airplane.
Probable cause
The pilot’s failure to maintain airspeed during a go-around, resulting in an aerodynamic stall, loss of control, and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N3768T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-30080
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-21T22:47:21Z guid: 105836 uri: 105836 title: CEN22LA402 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105830/pdf description:
Unique identifier
105830
NTSB case number
CEN22LA402
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-29T22:55:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-08-30T20:57:35.547Z
Event type
Accident
Location
Pearland, Texas
Airport
PEARLAND RGNL (LVJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 29, 2022, about 2155 central daylight time, an MD Helicopters 369E, N1576F, was substantially damaged when it was involved in an accident at the William P. Hobby Airport, Houston, TX. The flight instructor and pilot receiving instruction were not injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight was conducted by a flight instructor and a commercial pilot who was receiving instruction. The fight instructor reported that he and the pilot receiving instruction were conducting a simulated power recovery autorotation with a 90° turn. The maneuver was started at 800 ft above ground level (agl) and between 75 and 80 knots (kts) airspeed, and the instructor stated that he was commanding the throttle while the pilot receiving instruction commanded the cyclic, anti-torque, and collective controls. The instructor reduced the throttle and the pilot receiving instruction reduced airspeed to about 60-65 kts. When the helicopter descended to 300 ft agl, the flight instructor increased engine throttle and the pilot receiving instruction continued the autorotation, flared, and leveled the helicopter about 10 ft agl. The flight instructor waited for the pilot receiving instruction to increase collective, but he did not feel the collective control move, so he pulled up on the collective, but the helicopter struck the ground before it could ascend. The helicopter then slid to a stop and the flight instructor pulled the emergency fuel cutoff to shut down the engine. After exiting the helicopter, the instructor saw that the tail boom had separated from the helicopter. The pilot receiving instruction reported that he had set the helicopter up for a simulated autorotation with a 90° turn and power recovery. He counted down from 3 to begin the autorotation. The throttle was rolled to idle, and the pilot receiving instruction lowered the collective and depressed right pedal. He pitched the helicopter to maintain 60 kts while making a 90° turn to align with the runway. He maintained rotor speed by slightly raising and lowering the collective control. As the helicopter descended through about 150 ft agl, he began to flare. He felt the throttle increase but did not feel the power increase like he had felt on previous autorotations. The helicopter sank fast and struck the runway, skidding to a stop. He noted that the flight instructor pulled the fuel cutoff to stop the engine. Examination of the helicopter and a subsequent engine test run in a test cell did not reveal any anomalies that would explain a loss of engine power. -
Analysis
The flight instructor reported that he and the commercial pilot receiving instruction were practicing simulated autorotations with power recovery. During one autorotation, as the helicopter was flared at the conclusion of the autorotation, the flight instructor increased the engine throttle and waited for the pilot receiving instruction to increase collective. When he did not feel the collective control move, the flight instructor pulled up on the collective, but the helicopter struck the ground before it could ascend. The pilot receiving instruction stated that during the flare, he did not feel the engine power increase like he had felt on previous autorotations; the helicopter sank fast and struck the ground. The main rotor of the helicopter severed the tail boom during the hard landing. Examination of the helicopter and a subsequent engine test run in a test cell did not reveal any anomalies that would explain a loss of engine power. Based on the available evidence, the accident was the result of the pilot receiving instruction’s failure to increase collective at the conclusion of the autorotation and the flight instructor’s delayed remedial response, which resulted in a hard landing.
Probable cause
The pilot receiving instruction’s failure to maintain aircraft control, and the flight instructor’s delayed remedial action, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MD HELICOPTERS INC
Model
369E
Amateur built
false
Engines
1 Turbo shaft
Registration number
N1576F
Operator
CITY OF HOUSTON POLICE DEPT
Flight conducted under
Public aircraft
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
0568E
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-08-30T20:57:35Z guid: 105830 uri: 105830 title: WPR22LA323 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105831/pdf description:
Unique identifier
105831
NTSB case number
WPR22LA323
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-30T10:15:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2022-09-08T00:22:00.582Z
Event type
Accident
Location
Tooele, Utah
Airport
BOLINDER FLD-TOOELE VALLEY (TVY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On August 30, 2022, about 0915 mountain daylights time, a Cessna 182, N3094Q, was substantially damaged when it was involved in an accident near Tooele, Utah. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that, after conducting a preflight inspection, they taxied the airplane to runway 17 for a local instructional flight. While approaching the end of the taxiway, the student pilot reduced engine power to idle and applied the brakes, but the airplane did not respond to the brake application. The flight instructor assumed control of the airplane and applied the brakes, but the airplane still did not respond. While the flight instructor was attempting to mitigate the situation with the parking brake handle and rudder, the airplane exited the right side of the taxiway and impacted a ditch. Postaccident examination showed bending of the right horizontal stabilizer as well as bending of the right elevator about midspan. Flight control continuity was established from all primary flight control surfaces to the cockpit controls. Examination of the airplane’s brake system revealed that, when the brakes were activated using the rudder pedals, no resistance or pressure was felt on both sets of rudder pedals. Both brake master cylinders were void of fluid, and a liquid consistent with brake fluid was observed leaking from both main landing gear brake caliper O-ring seals. The left and right brake calipers were removed and disassembled. Both O-ring seals were flattened, consistent with excessive use and wear. According to the mechanic, the flattened O-ring seals prevented the proper seal within the brake calipers, resulting in brake fluid leaking. A review of the airplane’s maintenance records did not show that any maintenance had been performed on the brake calipers. -
Analysis
During an instructional flight, the student pilot reduced engine power to idle and applied the brakes as the airplane taxied toward the end of the runway. However, the airplane did not respond to this brake application. The flight instructor assumed control of the airplane and applied brakes, but the airplane still did not respond. While the flight instructor was attempting to mitigate the situation, the airplane exited the right side of the taxiway and impacted a ditch. Examination of the airplane’s brake system revealed a leak on both main landing gear brake caliper O-ring seals. Both brake calipers were removed and disassembled, and both O-ring seals were flattened, consistent with excessive use and wear. The flattened O-ring seals prevented the proper seal within the brake calipers, which resulted in the complete loss of brake fluid. The complete loss of brake fluid prevented the use of the airplane brakes, which caused a subsequent loss of directional control.
Probable cause
Loss of brake pressure to both sets of brakes during taxi due to failed brake caliper O-ring seals, which resulted in a loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182K
Amateur built
false
Engines
1 Reciprocating
Registration number
N3094Q
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
18258094
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-08T00:22:00Z guid: 105831 uri: 105831 title: ERA22LA392 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105833/pdf description:
Unique identifier
105833
NTSB case number
ERA22LA392
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-30T11:55:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-09-16T19:14:52.825Z
Event type
Accident
Location
Gates Mills, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Analysis
The pilot, seated in the left seat, said that the instructor pilot, seated in the right seat, asked her to perform a magneto check inflight. During the magneto check, the pilot inadvertently turned the engine ignition key to the off position resulting in a total loss of engine power. As the pilot turned the key to restart the engine, the head of the ignition key broke off. The instructor pilot transferred the controls to the pilot and attempted to move the ignition key but was also unsuccessful. The instructor pilot took the controls and performed an emergency landing into a school football field. The airplane landed hard and sustained substantial damage to the firewall, both wings, engine mount and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The instructor pilot’s decision to perform an inflight magneto check with no suitable area to land. Contributing to the accident was the pilot's failure to correctly perform a magneto check that resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N204BE
Operator
PINK SKIES INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17271338
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-16T19:14:52Z guid: 105833 uri: 105833 title: ERA22LA394 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105839/pdf description:
Unique identifier
105839
NTSB case number
ERA22LA394
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-08-31T11:35:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-06T17:33:49.922Z
Event type
Accident
Location
Hilliard, Florida
Airport
Hilliard Airpark (01J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The student pilot stated that he was practicing touch-and-go landings in the accident airplane. While approaching the runway at an altitude of about 400 feet, and while in the turn from the base to the final leg of the traffic pattern, the pilot described that he allowed the airspeed to get too slow and the airplane entered an aerodynamic stall. The airplane subsequently impacted trees and terrain, resulting in substantial damage to the fuselage and wings. The pilot reported that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain an adequate airspeed, which resulted in an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SUTPHIN JOHN E
Model
RANS S-12
Amateur built
true
Engines
1 Reciprocating
Registration number
N8028W
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
0894513
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-06T17:33:49Z guid: 105839 uri: 105839 title: ERA22LA395 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105848/pdf description:
Unique identifier
105848
NTSB case number
ERA22LA395
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-01T18:00:00Z
Publication date
2024-03-22T04:00:00Z
Report type
Final
Last updated
2022-09-12T22:15:54.335Z
Event type
Accident
Location
Orlando, Florida
Airport
Orlando Executive (ORL)
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 1 serious, 0 minor
Factual narrative
On September 1, 2022, about 1700 eastern daylight time, a Diamond Aircraft Industries DA 42 NG, N43RG, was substantially damaged when it was involved in an accident in Orlando, Florida. The commercial pilot was fatally injured and a flight instructor was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The local instructional flight was to originate at Orlando Executive Airport (ORL), Orlando, Florida. The commercial pilot, who was in the right front seat, was in the process of adding a multiengine rating to his commercial certificate. He was in the right seat because he expressed interest in eventually obtaining a flight instructor rating. The flight instructor reported that he and his student checked the weather and determined that there was a small area of precipitation, about 2 nm in diameter, over Orlando International Airport (MCO), located 7 miles south of ORL, which was slowly moving north, and would be in the vicinity of ORL after their departure. He stated that the cell did not appear to be developing significantly as shown on the radar loop. He stated that a weather briefing obtained through ForeFlight forecasted thunderstorms in the vicinity with winds up to 6 knots during the time of flight. The flight instructor reported that when they started the engines, the current weather observation at 1621 included wind from 060°at 9 knots, thunderstorms in the vicinity, and distant lightning in all quadrants. At 1640, they requested to taxi to runway 7where they performed pre-takeoff checks at the HOLD 2 pad at taxiway A7. About 1645, they completed their pre-takeoff checks. The crew observed precipitation over the departure end of the runway, so they elected to hold in place until the weather improved. During this time, the weather deteriorated further, with wind gusting to 40 knots, as advised by air traffic control, and visibility dropping to zero. They then elected to hold in place rather than attempt to taxi back to the ramp. The flight instructor reported that shortly there after, the wind gusts increased to 60 knots. The instructor applied down elevator control and moved the left aileron into the wind. He reported that the left wing was bouncing around a little more than the right wing. The airplane’s left wing then lifted and the airplane rolled to the right. The flight instructor attempted to shut down the engines, and the airplane rolled over inverted. First responders observed the airplane inverted and responded to assist the crew. - According to autopsy report from the Office of the Medical Examiner, District Nine, Orlando, Florida, the cause of death of the pilot was cervical vertebral fracture with spinal cord trauma due to blunt force of the head and neck. Testing for ethanol and drugs was negative. - At the time of the accident, the National Weather Service Surface Analysis Chart, centered over the southeastern United States, depicted a stationary frontal boundary that stretched from a low-pressure system off the South Carolina coast westward across central Georgia into another low over Alabama, and then southwestward into Louisiana. The accident site was located south of the stationary front in a warm side of the front. The surface observation for ORL at 1659 (about the time of the accident) included wind from 100° at 32 knots with gusts to 54 knots, wind varying between 060° and 130°, ¼ mile visibility, runway visual range on runway 7 varying between 400 ft and greater than 6,000 ft, thunderstorm and heavy rain, fog, scattered clouds at 1,700 ft above ground level (agl), broken ceiling at 2,900 ft agl, overcast skies at 6,000 ft agl, temperature of 23° Celsius (C), dew point temperature 21°C, and an altimeter setting of 30.00 inches of mercury (inHg). The surface observation remarks stated, automated station with a precipitation discriminator, peak wind at 1655 from 120° at 54 knots, lightning distant all quadrants, pressure rising rapidly, 0.39 inches of precipitation since 1653, temperature 22.8°C, dew point temperature 20.6°C. The ORL surface observation at 1621, while the crew were preforming preflight and engine start duties, included wind from 060°at 9 knots, thunderstorms in the vicinity, and distant lightning all quadrants. The ORL surface observation at 1641, 1 minute after the crew requested taxi clearance, included wind from 150°at 11 knots with gusts to 16 knots, thunderstorms, and distant lightning all quadrants, and thunderstorms began at 1635. Lightning data revealed 1,053 lightning flashes reported within 25 miles of the accident site within 15 minutes prior to or following the accident time with the closest lightning flash occurring 800 ft south of the accident site at the time of the accident. At 1631, MCO issued a special observation at 1631 (9 minutes before the crew requested taxi clearance) that included wind from 070° at 16 knots with gusts to 36 knots, heavy rain and thunderstorms, thunderstorms stationary and frequent lightning all quadrants. The MCO surface observation at 1606, or 54 minutes before the accident, reported wind from 090° at 6 knots with thunderstorms. There was a convective SIGMET advisory valid for the accident site at the accident time. Any convective SIGMET implies severe or greater turbulence, severe icing, and low level wind shear. SIGMET 01E, issued at 1555, included a warning of area thunderstorms moving little, with tops above flight level (FL) 450. It was superseded by SIGMET 04E at 1655, which included a warning of severe thunderstorms moving little, with tops above FL450, and wind gusts to 50 knots possible. According to Advisory Circular 00-45G, Change 2 (Aviation Weather Services), any convective SIGMET implies severe or greater turbulence, severe icing, and low-level wind shear. A convective SIGMET may be issued for any convective situation which the forecaster feels is hazardous to all categories of aircraft. Bulletins are issued hourly at Hour+55. The text of the bulletin consists of either an observation and a forecast or just a forecast. The forecast is valid for up to 2 hours. The closest Terminal Aerodrome Forecast (TAF) to ORL was issued at MCO. The MCO TAF issued at 1632, valid between 1600 and 2100, included temporary conditions for the time period between 1600 and 1900 that called for variable wind of 20 knots with gusts to 40 knots, 3 miles visibility, thunderstorms and moderate rain, and a broken ceiling of cumulonimbus clouds at 3,500 ft agl. The flight crew requested and received a weather briefing from ForeFlight at 1542, with additional MCO and ORL surface observations received at 1641, along with the updated MCO TAF from 1632. A High-Resolution Rapid Refresh (HRRR) model sounding was created for the approximate accident site coordinates for 1600. The HRRR sounding indicated an unstable atmosphere based on the Lifted Index of -7.5 and the Convective Available Potential Energy (CAPE) of 3,340 Joules/kilogram (J/kg), with the maximum vertical velocity (MVV) for this atmosphere was calculated as 82 meters/second (about 16,141 ft per minute). Outside of cumulonimbus clouds, RAOB (the complete Rawinsonde Observation program) indicated cloud cover in two layers between 4,000 ft and 12,000 ft with no icing below 14,000 ft. The strongest surface wind gusts potential, due to microburst, downburst, or outflow, indicated by the RAOB’s WindEx parameter was 56 knots or 64 miles per hour (mph). Convective clouds can produce downdrafts, outflow boundaries and gust fronts during the mature stage of their life cycle, which can create an environment favorable for unexpected changes in wind direction and speed. According to the Aeronautical Information Manual (AIM) section 7-1-2430 on microburst, they are typically relatively small area less than 1 to 2 ½ miles in diameter of strong divergent winds and downdrafts that can reach 6,000 feet per minute. Microburst can be found in convective clouds, usually embedded in heavy rain or in benign appearing virga. When there is little or no precipitation at the surface accompanying the microburst, a ring of blowing dust may be the only visual clue of its existence. The Terminal Doppler Weather Radar from Orlando (TMCO) recorded velocity data that indicated a divergent wind velocity signature to the east and above the accident site at the accident time. - The accident occurred at the HOLD 2 position, adjacent to taxiway A7. The wreckage was inverted and confined to the taxiway surface. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. Structural damage was noted on both wings, the fuselage, and the empennage. The composite tail boom fractured about 4 ft aft of the rear cabin. The horizontal stabilizer and rudder fractured from the vertical stabilizer and rudder. The wreckage was recovered to an aircraft salvage facility where an additional survival factors examination was conducted. The canopy was not attached to the fuselage when examined. There was crushing damage to the canopy, which was hinged and designed to rotate up and forward to access the cockpit. The overroll bar had fractures consistent with overload. The distance between the middle tunnel cover (at the elevator trim wheel) and the overroll bar was measured at 29.1 inches (an exemplar airplane measured 33.5 inches, or a loss of 4.4 inches). There was no damage noted to the seats or restraints. The amount of force applied to the airframe during the upset event could not be determined. -
Analysis
The commercial pilot and his flight instructor were preparing to depart on a local flight when the accident occurred. They taxied to the runway and continued the pre-takeoff and engine runup tasks. While at the holding pad, the weather deteriorated significantly to include thunderstorms, heavy rain, and high wind gusts to 54 knots. The pilots elected to hold their position to wait until the weather conditions improved. The instructor applied down elevator control and moved the left aileron into the wind. Review of available weather data indicated that a microburst caused the left wing to raise and the airplane rolled over, coming to rest inverted. The flight instructor in the left seat was seriously injured, and the commercial pilot in the right seat was fatally injured. The airplane was substantially damaged. The surviving flight instructor reported that they received a weather briefing before the flight and that there was a small area of precipitation about 7 miles to the south, slowly moving north; they expected the area of precipitation would be in the vicinity after their departure. He stated that the cell did not appear to be developing significantly when observed on their radar. An examination of meteorological data revealed that the pilots requested and received a weather briefing from a commercial flight planning service about 1 hour and 18 minutes before the accident. The briefing included convective SIGMETs for the area. The surface observations received included wind gusts to 36 knots and thunderstorms in progress to the south. If the pilots had checked the current weather at the airport 7 miles to their south before taxiing, they would have noticed that the weather there was deteriorating rapidly. The examination of the weather products revealed that the pilots were provided and reviewed the weather information that they encountered. The wreckage was examined to determine the survivability aspects of the accident. The cockpit canopy was crushed and the overroll bar was fractured. About 4.4 inches of vertical space between the middle floor tunnel cover and the overroll bar was lost. The cockpit seats and restraints were undamaged. The amount of force applied to the airframe during the upset event could not be determined. The rolling motion of the airplane likely moved the pilots out of position before impact. This change in position, in conjunction with the decrease in occupiable space from the overhead structure deformation and stretch of the seat belts, caused the injuries sustained by the occupants.
Probable cause
The flight crew’s insufficient evaluation of the deteriorating weather conditions in the area, which resulted in an encounter with a microburst.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Diamond Aircraft Industries
Model
DA 42
Amateur built
false
Engines
2 Reciprocating
Registration number
N43RG
Operator
MyFlight LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
42.N455
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-12T22:15:54Z guid: 105848 uri: 105848 title: DCA22LA196 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105884/pdf description:
Unique identifier
105884
NTSB case number
DCA22LA196
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-01T22:18:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-09-16T21:35:35.459Z
Event type
Accident
Location
Denver, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The flight crew stated that the flight was on the final stage of the arrival for landing. The seatbelt sign had been on, the flight attendants had just completed their final pre-landing preparations, and had been instructed to take their seats, when suddenly the flight experienced a sudden jolt due to clear air turbulence. When the turbulence occurred one of the flight attendants was in the process of seating herself and as she placed her hand on her jumpseat to lower it, the turbulence occurred causing her to fall and experience an abrupt and intense pressure on her left hand as her fingers were bent backwards. Her hand immediately began to swell. The injured flight attendant was assisted by another flight attendant, the flight crew was informed, and a medical emergency was declared. After landing the flight attendant was given medical care and diagnosed with a fracture of the 4th metacarpal bone in her left hand.
Probable cause
An encounter with clear air turbulence, which resulted in a serious injury as a flight attendant was lowering her jumpseat.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-824
Amateur built
false
Engines
2 Turbo fan
Registration number
N76529
Operator
UNITED AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
31652
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-09-16T21:35:35Z guid: 105884 uri: 105884 title: ERA22LA401 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105886/pdf description:
Unique identifier
105886
NTSB case number
ERA22LA401
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-03T15:09:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-17T20:00:29.316Z
Event type
Accident
Location
Wadsworth, Ohio
Airport
Wadsworth Municipal Airport (3G3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 3, 2022, about 1409 eastern daylight time, a Piper PA-28-140, N5666U, was substantially damaged when it was involved in an accident near Wadsworth Municipal Airport (3G3), Wadsworth, Ohio. The private pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that she arrived at Medina Municipal Airport (1G5), Medina, Ohio. She added 20 gallons of aviation gasoline to the airplane, resulting in a total fuel quantity of 36 gallons. The pilot then conducted a preflight inspection and an engine run-up with the fuel selector positioned to the left main fuel tank. No anomalies were noted during the engine run-up. Afterward, she switched the fuel selector to the right main fuel tank and departed about 1310. The pilot completed two full-stop landings at 1G5 performed some air work over the local area, and then switched the fuel selector to the left main fuel tank. She then flew to 3G3, which was about 10 minutes away. The pilot intended to complete a touch-and-go landing at 3G3 and return to 1G5. After the landing on runway 20 at 3G3 (a 3,530-ft-long runway), the airplane’s engine lost total power during the initial climb, when the airplane was about 50 ft above ground level. The airplane slowed, and the pilot “pushed the nose over to start regaining speed.” The airplane then landed hard, coming to rest in a grass area off the right edge of the runway. During the hard landing, the left main landing gear separated, and both wings sustained damage. Review of airport security video revealed that the airplane was in a nose-up attitude as it descended and impacted the right side of the runway with about one-third of the runway remaining. A witness (a flight instructor who worked at the airport) stated that he responded to the accident site. He noticed that the airplane’s rotating beacon was still operating and that he shut down the airplane as a safety precaution. The witness remembered that the throttle and mixture controls were fully forward and that the carburetor heat was off. He also recalled moving the fuel selector to the off position but couldn’t remember its position before moving it. A postaccident engine examination found about 2 to 4 gallons of fuel in the right fuel tank and 20 gallons in the left fuel tank. After the propeller was rotated by hand, continuity was confirmed to the rear accessory section of the engine. No anomalies were found with the spark plugs, oil filter, or fuel filter. Fuel was present in the carburetor bowl, and the air filter was dirty. A mechanic subsequently examined the airplane. He did not observe any preimpact anomalies and tried to start the engine with a battery jumper (because the battery was dead). The crankshaft turned, and the spark plugs were producing spark, but the engine did not start after multiple attempts. The mechanic thought that the airplane might need a new, fully charged battery (stronger crank) or that the carburetor might need adjustment given that it had been removed, examined, and reinstalled. Review of an FAA carburetor icing chart revealed the potential for serious icing at glide power for the reported temperature and dew point about the time of the accident. -
Analysis
During the initial climb after a touch-and-go landing, about 50 ft above the 3,530-ft-long runway, the engine lost total power. The airplane subsequently impacted the ground about 2/3 down the length of the runway and was substantially damaged. Postaccident examination of the airplane revealed that adequate fuel remained onboard and that there was no evidence of any preimpact mechanical malfunctions or failures of the engine that would have precluded normal operation. While a carburetor icing chart showed that the weather conditions were conducive to the formation of carburetor ice at glide engine power settings, because the airplane was operating at full engine power when the reported loss of engine power occurred, it was not likely that carburetor icing contributed to the loss of engine power. The reason for the loss of engine power could not be determined based on available information.
Probable cause
A total loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N5666U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-26463
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-17T20:00:29Z guid: 105886 uri: 105886 title: ERA22LA407 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105904/pdf description:
Unique identifier
105904
NTSB case number
ERA22LA407
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-03T17:23:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-14T20:49:32.138Z
Event type
Accident
Location
Mount Bethel, Pennsylvania
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The glider took off under aerotow about for a flight in the local soaring area. After flying about 45 minutes the pilot decided to reposition to a different ridge but during his transition, he encountered a loss of lift and started to lose altitude. Unable to gain sufficient lift, he was forced to make an off-airport landing. During his approach, he noticed another glider in the field and there were midfield powerlines. The pilot passed over the glider on the ground but impacted the powerlines. The impact with the powerlines and subsequent collision with terrain resulted in substantial damage to the fuselage and both wings. The pilot reported that there were no pre accident mechanical malfunctions or failures of the glider that would have precluded normal operation.
Probable cause
The glider’s encounter with atmospheric conditions, where the lift was not sufficient to maintain flight resulting in an off-airport landing and collision with powerlines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 2-33A
Amateur built
false
Registration number
N17867
Operator
AERO CLUB ALBATROSS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
280
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-14T20:49:32Z guid: 105904 uri: 105904 title: ERA22LA411 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105921/pdf description:
Unique identifier
105921
NTSB case number
ERA22LA411
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-03T17:35:00Z
Publication date
2024-03-07T05:00:00Z
Report type
Final
Last updated
2022-09-21T16:19:49.965Z
Event type
Accident
Location
Clearfield, Pennsylvania
Airport
Clearfield-Lawrence Airport (FIG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 3, 2022, about 1635 eastern daylight time, a Cessna 172M, N9619H, was substantially damaged when it was involved in an accident near Clearfield, Pennsylvania. The private pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. In a written statement provided to the National Transportation Safety Board, the pilot reported that the airplane had 42 gallons of fuel onboard. He completed a preflight inspection, and the engine run-up was normal. During initial climb, about 300 ft above ground level, the engine began shaking and lost all power. The pilot lowered the nose and saw that the airplane was still over the runway but too close to the end to land on the remaining runway. He then made a “hard” left turn in an attempt to land on the runway in the opposite direction; however, the airplane impacted a field. According to a Federal Aviation Administration (FAA) inspector, the pilot reported that the engine lost partial power, and during the 180° left turn back to the airport, he moved the fuel selector to off in preparation for an off-airport impact. The engine subsequently lost all power, and the airplane impacted a field, coming to rest upright in a wooded area at the edge of the field. The inspector examined the wreckage and observed substantial damage to both wings and the fuselage. After the wreckage was recovered, the FAA inspector further examined the engine and noted no compression on the No. 1 cylinder and 24/80 psi compression on the No. 3 cylinder; however, the compression test was done when the engine was cold. The inspector further stated that he was able to start the engine and run it at idle power, but he did not attempt to increase engine power due to a bent propeller. He subsequently removed the Nos. 1 and 3 cylinders and noted scoring on the No. 1 piston skirt and cylinder wall. The inspector and a representative from the engine manufacturer (who viewed the FAA inspector’s photographs) stated that the scoring was consistent with tappet to camshaft wearing. Review of maintenance records revealed that the most recent annual inspection was completed on August 4, 2022. At that time, the engine had accumulated 1,718 hours since its most recent major overhaul, which was performed in December 2009. -
Analysis
During initial climb, about 300 ft above ground level, the airplane’s engine began shaking and lost partial power. The pilot lowered the nose and saw that the airplane was still over the runway but too close to the end to land on the remaining runway. He made a “hard” left turn in an attempt to land on the runway in the opposite direction. He also turned the fuel selector to off in preparation for an off-airport impact. The engine subsequently lost all power (due to the fuel being turned off), and the airplane impacted a field, coming to rest upright in a wooded area at the edge of the field. A postaccident compression check performed when the engine was cold revealed no compression on the No. 1 cylinder and low compression on the No. 3 cylinder; however, the engine was subsequently started and run at idle power, with no anomalies noted. After shutdown, removal of the Nos. 1 and 3 cylinders revealed scoring on the No. 1 piston skirt and cylinder wall. The scoring was consistent with material entering the cylinder as a result of tappet to camshaft wearing, which also would have affected the intake and exhaust valves opening and closing properly. While this condition may have reduced the engine’s ability to produce full takeoff power; it would not have resulted in the sudden loss of engine performance described by the pilot. Given the engine’s subsequent normal operation postaccident, the reason for the partial loss of engine power could not be determined.
Probable cause
A sudden partial loss of engine power for undetermined reasons, which resulted in an off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N9619H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17266269
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-21T16:19:49Z guid: 105921 uri: 105921 title: ERA22FA397 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105866/pdf description:
Unique identifier
105866
NTSB case number
ERA22FA397
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-03T18:40:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-09-06T22:03:06.568Z
Event type
Accident
Location
Arthur, Kentucky
Weather conditions
Instrument Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
HISTORY OF FLIGHT On September 3, 2022, about 1740 central daylight time, an experimental, amateur-built RotorWay JetExec helicopter, N162NH, was destroyed when it was involved in an accident near Arthur, Kentucky. The pilot was fatally injured. The helicopter was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The accident pilot was a friend of the helicopter owner, who had purchased the helicopter about 1 week before the accident and asked his friend to fly the helicopter from Missouri to Tennessee. The owner of the helicopter stated that he was “worried” about the weather on the day of the accident and tried to talk the pilot into waiting to fly the helicopter to Tennessee until the weather improved. The pilot did not want to wait, and he and his wife departed on the crosscountry flight about 1030. According to the seller and previous owner, about 30 minutes later, the helicopter returned to the departure airport so that the pilot could drop off his wife. The seller stated that he tried to talk the pilot out of leaving that day because that flight would be long and rain was occurring along the route. The pilot waited “a couple of hours for the weather to improve” and then departed again. On September 5, the helicopter wreckage was located in heavily wooded, steep terrain in Mammoth Cave National State Park. Review of automatic dependent surveillance-broadcast (ADS-B) data revealed that data associated with the helicopter’s flight track ended about 40 nautical miles prior to the accident location. Additionally, the terrain became generally higher leading up to the area of the accident site. METEOROLOGICAL INFORMATION A search of archived information indicated that the accident pilot did not request weather information from Leidos Flight Service or ForeFlight. The accident pilot updated various potential flight paths and viewed airport information via ForeFlight through 1326 on the day of the accident. The available evidence did not show what, if any, weather information the accident pilot may have viewed before or during the accident flight. A convective SIGMET advisory was valid for the accident site at the accident time. The advisory, which was issued at 1655, warned of an area of thunderstorms with cloud tops above flight level 450 with the convective area moving from 210° at 15 knots. In addition, a convective SIGMET was issued at 1555 that was valid for the accident area (Figure 1). Figure 1. Aviation Weather Center graphic valid at 1700 CDT with valid convective SIGMETs, AIRMETs, and PIREPS with the accident location marked. The observations surrounding the time of the accident from the closest official weather station indicated visual flight rules to instrument flight rules conditions with moderate-to-heavy rain and thunderstorms. Radar returns (Figure 2) showed the precipitation in the vicinity of the accident area, moving from southwest to northeast. 318 lightning flashes were reported within 50 miles of the accident site within 20 minutes before or after the time of the accident (Figure 3). Figure 2. National Reflectivity Mosaic for 1740 CDT with the accident site marked with the black circle. Figure 3. Base reflectivity scan initiated at 1739:55 CDT with the accident site marked with the black circle. WRECKAGE AND IMPACT INFORMATION The helicopter came to rest on its left side on a magnetic heading of about 045°. The cabin, instrument panel, seats, and engine compartment had fractured into several pieces. The tailboom remained attached to the fuselage but was heavily damaged from impact forces. The tail rotor was wedged between two trees, and both tail rotor blades had separated and were located near the front of the helicopter. The engine was separated from the gearbox due to impact. The engine exhibited evidence of tortional twisting. The engine and main rotor gearbox rotated freely. A borescope examination of the combustion and turbine blades found no anomalies. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the State Medical Examiner, Louisville, Kentucky, performed an autopsy of the pilot. His cause of death was multiple blunt force injuries to the body. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected ethanol and propanol in the pilot’s blood but not in his urine. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. After absorption, ethanol is quickly and uniformly distributed throughout the body’s tissues and fluids. Ethanol can be produced after death by microbial activity, sometimes along with other alcohols, such as propanol. ADDITIONAL INFORMATION Title 14 CFR 91.103 states that “each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight.” Federal Aviation Administration Advisory Circular 91-92, “Pilot’s Guide to a Preflight Planning” (dated March 15, 2021), provided information on preflight self-briefings, including planning, weather interpretation, and risk identification/mitigation skills. The advisory circular further stated in part the following: Pilots adopting these guidelines will be better prepared to interpret and utilize real-time weather information before departure and en route, in the cockpit, via technology like Automatic Dependent Surveillance-Broadcast (ADS-B) and via third-party providers. -
Analysis
The helicopter pilot was flying a cross-country flight in thunderstorms. The former owner of the helicopter, its new owner, stated they were worried about the weather and tried to talk the pilot into waiting 1 day until the weather improved, however, the pilot did not want to wait and subsequently departed for his home airport. Postaccident examination revealed no anomalies with the engine or airframe that would have precluded normal operation. There was no record of the pilot obtaining a weather briefing and rising terrain led up to the area of the accident. The observations surrounding the time of the accident from the closest official weather station indicated visual flight rules to instrument flight rules conditions, with reflectivity data indicating that thunderstorms were present along the route and at the accident site at the time of the accident. Accordingly, the flight likely encountered reduced visibility and heavy rain while in thunderstorms as a result of the pilot’s decision to fly in thunderstorm conditions. Had the pilot obtained a weather briefing he likely would have had increased his awareness of the severity of the weather conditions along his route of flight and may have elected to delay the flight further until conditions improved.
Probable cause
The pilot’s decision to attempt the cross-country flight in thunderstorm conditions, which resulted in controlled flight into terrain. Contributing to the accident was the pilot’s failure to obtain a weather briefing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROTORWAY
Model
JETEXEC
Amateur built
true
Engines
1 Turbo shaft
Registration number
N162NH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
109
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-09-06T22:03:06Z guid: 105866 uri: 105866 title: DCA22MA193 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105855/pdf description:
Unique identifier
105855
NTSB case number
DCA22MA193
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-04T16:09:00Z
Publication date
2023-10-11T04:00:00Z
Report type
Final
Last updated
2022-09-14T15:35:25.908Z
Event type
Accident
Location
Freeland, Washington
Weather conditions
Visual Meteorological Conditions
Injuries
10 fatal, 0 serious, 0 minor
Factual narrative
On September 4, 2022, about 1509 Pacific daylight time, a float-equipped de Havilland DHC-3 (Otter), N725TH, was destroyed when it impacted the water in Mutiny Bay, near Freeland, Washington, and sank. The pilot and nine passengers were fatally injured. The airplane was owned by Northwest Seaplanes, Inc., and operated as a Title 14 Code of Federal Regulations (CFR) Part 135 scheduled passenger flight by West Isle Air dba Friday Harbor Seaplanes. The flight originated at Friday Harbor Seaplane Base (W33), Friday Harbor, Washington, with an intended destination of Will Rogers Wiley Post Memorial Seaplane Base (W36), Renton, Washington. Visual meteorological conditions prevailed at the time of the accident. -
Probable cause
The in-flight unthreading of the clamp nut from the horizontal stabilizer trim actuator barrel due to a missing lock ring, which resulted in the horizontal stabilizer moving to an extreme trailing-edge-down position rendering the airplane’s pitch uncontrollable.
Has safety recommendations
true

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
DHC-3
Amateur built
false
Engines
1 Turbo prop
Registration number
N725TH
Operator
West Isle Air
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
466
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-09-14T15:35:25Z guid: 105855 uri: 105855 title: DCA22LA198 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105895/pdf description:
Unique identifier
105895
NTSB case number
DCA22LA198
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-04T21:35:00Z
Publication date
2023-07-18T04:00:00Z
Report type
Final
Last updated
2022-09-11T17:10:57.528Z
Event type
Accident
Location
New York, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The flight crew stated that the flight was on the arrival for landing. The seatbelt sign had been on and the flight attendants were making their pre-landing cabin preparations. The flight then entered a small cloud that showed no precipitation on the radar and encountered light to moderate turbulence. When the turbulence occurred one flight attendant who was standing assisting a passenger was thrown to the floor, injuring her right foot. After landing the flight attendant was given medical care and diagnosed with a broken right foot.
Probable cause
An encounter with convective turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
220
Amateur built
false
Engines
2 Turbo fan
Registration number
N113DQ
Operator
Delta Air Lines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
50032
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-09-11T17:10:57Z guid: 105895 uri: 105895 title: ERA22LA406 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105902/pdf description:
Unique identifier
105902
NTSB case number
ERA22LA406
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-05T16:55:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-13T18:34:54.706Z
Event type
Accident
Location
Ivanhoe, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot was returning from a cross-country flight and planned to stop for fuel along the way; however, due to deteriorating weather conditions along his route of flight, he was unable to stop. The pilot then became distracted trying to avoid weather when the airplane’s engine lost power. The pilot further described that, “We should have landed at the nearest clear airport but got fixated on dodging rain clouds causing time consuming maneuvers to go around the storms into headwinds and unaware of fuel reserves.” He subsequently performed a forced landing to a field and struck a ditch resulting in substantial damage to the fuselage. Postaccident examination of the airplane’s intact fuel tanks revealed they were empty of useable fuel. Given this information, it is likely that during the unplanned deviations around weather, the airplane’s usable fuel supply was exhausted, which resulted in the total loss of engine power and subsequent forced landing.
Probable cause
The pilot's inadequate preflight and inflight planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177B
Amateur built
false
Engines
1 Reciprocating
Registration number
N35243
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17702287
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-13T18:34:54Z guid: 105902 uri: 105902 title: ERA22FA399 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105876/pdf description:
Unique identifier
105876
NTSB case number
ERA22FA399
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-06T14:25:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2022-09-14T22:55:00.241Z
Event type
Accident
Location
Bay City, Wisconsin
Airport
RED WING RGNL (RGK)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On September 6, 2022, at 1325 central daylight time, an experimental, amateur-built Glasair Super II SFT airplane, N11HC, was substantially damaged when it was involved in an accident near Bay City, Wisconsin. The flight instructor and a commercial pilot-under-instruction were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The flight departed from Rochester Regional Airport (RST), Rochester, Minnesota about 1218. Following some air work, the flight proceeded to Red Wing Airport (RGK), Bay City, Wisconsin and entered left traffic for the visual airport traffic pattern to runway 9. According to automatic dependent surveillance-broadcast (ADS-B) and GPS data, four circuits of the traffic pattern were flown without touching down and a fifth traffic pattern was initiated. The data indicated that the airplane turned onto the base leg of the airport traffic pattern about 0.5 to 1 mile sooner (tighter) than on the previous approaches (figure 1). The airplane impacted the ground about 1/3 nautical mile west-northwest of the approach end of runway 9.   Figure 1: Pattern Work at Red Wing Regional Airport and Wreckage Location The airplane was equipped with a Garmin G3X integrated flight instrument system. The non-volatile memory cards from the flight displays recorded data from the entire accident flight, including engine and systems performance. Speed and altitude information from the G3X revealed that the airplane departed RST, climbed to about 10,000 ft mean sea level (msl), and proceeded to the north, where airwork was performed. A series of level, 60° bank, 2 g turns were performed, and the airwork continued for about 45 minutes. The airplane then descended at about 4,400 feet per minute (fpm) toward RGK, where the traffic pattern work began. The airplane crashed on the fifth approach in the traffic pattern. The accident approach was flown at a higher descent rate, bank angle, and pitch attitude than the previous approaches. The descent rate approached 2,500 fpm, the left bank angle approached 100°, and the pitch attitude was about 15° airplane-nose-down. During the final turn, a positive normal load factor was observed, between 1 and 2 g just before the end of the recorded data, shortly before ground impact. The lateral acceleration during the final turn was about 0.3 g, which was consistent with a side slip (forward slip) maneuver. Engine data recorded by the G3X was consistent with engine operation at a reduced throttle setting at the time the data ended. The last data, at 13:24:53, revealed fuel pressure at 26.1 psi, engine speed at 1,590 rpm, and oil pressure at 61 psi. - According to autopsy report from the Office of the Medical Examiner, Pierce County, Wisconsin, the cause of death of the commercial-rated flight instructor (right seat occupant) was multiple traumatic injuries due to the airplane crash. Toxicology testing on this pilot was not performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory; however, testing was performed locally as part of the autopsy protocol. No evidence of drugs or ethanol were found. The cause of death of the commercial-rated pilot-under-instruction (left seat occupant) was multiple traumatic injuries due to the airplane crash. Toxicology testing was performed by the FAA Forensic Sciences Laboratory; no evidence of drugs or ethanol were found. - The owner, who was the airplane builder, reported that the purpose of the flight was to build time requirements for insurance purposes so that he could include the commercial pilot, who was a family friend, on his policy. This was the first flight to satisfy those requirements and the two accident pilots had not flown together previously. The flight instructor flew with the owner on September 1, 2022, and the owner stated that the flight instructor performed all tasks satisfactorily, including air work, stalls, patterns, and landings. Other than the 2-hour flight on September 1, the flight instructor had no previous experience in the Glasair. The commercial pilot had flown with the owner as a passenger; however, he had no logged time in the Glasair. - An examination of the accident site revealed that the airplane impacted terrain on a heading of about 045° and the main wreckage came to rest, upright, about 80 ft from the point of initial impact. There was no fire. All structural components of the airplane were located within the confines of the wreckage path. The wreckage was recovered to a salvage facility where additional examination was performed. The fuselage exhibited structural damage and fiberglass skin separation in several areas. The fuselage-mounted header fuel tank was breached and no fuel remained inside the tank. The cockpit fuel tank selector was found in the “HEADER” tank position. The Garmin G3X components separated from the instrument panel during the accident sequence. Both SD memory cards were undamaged and found at the scene. Both wings sustained structural damage. The airplane was equipped with extended-length wing tips. Both wing fuel tanks were breached during the impact sequence, and no fuel remained inside the tanks. The owner reported that he filled the tanks to their 50-gallon capacity before the flight. Aileron continuity was confirmed from the control surfaces to the cockpit controls. The electrically-operated wing flaps were visibly extended. The G3X data revealed that the flaps were in transit toward the extended positions when the data ended. The last position recorded on the G3X was 36° (full extension was 40°). The fiberglass dorsal transition from the vertical stabilizer to the upper fuselage was cracked and partially separated from impact forces. The vertical stabilizer skin separated and was buckled and folded down to the right. The rudder was partially separated from the vertical stabilizer. Rudder cable continuity was confirmed from the rudder attachment points to the rudder pedals. The left and right elevators remained attached to the horizontal stabilizers and aft fuselage. Elevator continuity was confirmed via the push-pull tube from the elevator attachment point to the cockpit area. The engine remained attached to the aircraft firewall. The propeller remained attached to the crankshaft flange, but the crankshaft flange had separated from the crankshaft during the impact. Oil was observed leaking from the bottom of the engine. Extensive impact damage was observed on the bottom of the engine. The oil sump was mostly missing, except for a piece towards the rear that was displaced aft. The engine was cut free from the engine mounts and hoisted for the examination. The cylinders were undamaged. The crankshaft was rotated manually via the vacuum pump drive. Thumb compression and suction were established and camshaft to crankshaft continuity was confirmed throughout the engine. Valvetrain movement was correct on all cylinders. An examination of the engine fuel system revealed normal signatures and residual fuel inside the lines and components. No obstructions or fuel contamination was found. Both magnetos remained attached to the accessory housing of the engine with minor impact damage to the harness caps. The units were removed and both units produced spark at all 4 leads when rotated. The spark plugs remained installed in their respective cylinder heads. The No. 2 bottom and No. 1 bottom plugs had impact damage to the harness end of the plugs. The plugs were removed for further examination and found to have normal coloration and wear when compared to a Champion Check-a-Plug chart. The static soaking of the Nos. 1 and 3 spark plugs was attributed to the resting position of the engine post recovery. Nothing was found during the course of the engine examination that would have precluded the powerplant from making power before the impact sequence. The propeller remained attached to the crankshaft flange. The flange of the crankshaft had separated from the remainder of the crankshaft during the impact sequence. One was bent aft approximately 15 degrees and showed polishing on the leading edge and the other blade displayed polishing and rotational scoring on the leading edge. -
Analysis
The purpose of the flight was for the commercial pilot in the left seat to build flight time with an instructor so that he could be included on the owner’s insurance policy. This was the first flight to satisfy those requirements and the two accident pilots had not flown together previously. The flight instructor had 2 hours of flight experience in the Glasair; the commercial pilot-under-instruction had no flight experience in the airplane. Recorded radar and GPS data revealed that the airplane departed the home airport and airwork was performed for about 45 minutes. The flight then proceeded to another airport for traffic pattern work. The pilots entered the visual pattern and made four approaches without the airplane touching down. On the fifth approach, the airplane turned base-to-final about ½ to 1 mile sooner (tighter) than on the previous patterns. The accident approach was flown at a higher descent rate, bank angle, and pitch attitude than the previous approaches. The descent rate approached 2,500 fpm, the left bank angle approached 100°, and the pitch attitude was about 15° airplane-nose-down. During the final turn, a positive normal load factor was observed, between 1 and 2 g just before the end of the recorded data, and shortly before ground impact, indicating that the airplane did not stall before the crash. The lateral acceleration during the final turn was about 0.3 g, which was consistent with a side slip (forward slip) maneuver, commonly used when an airplane is high on approach. An examination of the airframe and powerplant revealed no evidence of a mechanical malfunction or failure that would have precluded normal operation. The pilot flying at the time of the accident could not be determined; however, it is apparent that the flight instructor allowed an unstabilized approach to proceed beyond the point where a safe recovery was not possible. Had the instructor either discontinued the poor approach or directed the commercial pilot-under-instruction to do so, the accident would have been prevented.
Probable cause
The continuation of a poorly-flown, unstabilized approach and the flight instructor’s failure to direct a discontinuance of that approach, resulting in a collision with terrain during turn to final.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CONWAY PHILIP J
Model
Glasair Super II SFT
Amateur built
true
Engines
1 Reciprocating
Registration number
N11HC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2329
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-14T22:55:00Z guid: 105876 uri: 105876 title: CEN22LA412 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105893/pdf description:
Unique identifier
105893
NTSB case number
CEN22LA412
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-07T16:20:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-09T21:18:20.429Z
Event type
Accident
Location
Silex, Missouri
Airport
HERRMANN-FAULK AIRFIELD (54MO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On September 7, 2022, about 1520 central daylight time, a Zenith 750, N1949H, was substantially damaged when it was involved in an accident near Silex, Missouri. The pilot sustained minor injuries and the pilot-rated passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, during takeoff of the first flight after assembly, the airplane lifted off the ground about 400 ft down the 1,100-ft turf runway. During the initial climb, the pilot turned right to avoid a rural power line at the end of the runway. The airplane subsequently impacted the powerline and terrain, which substantially damaged both wings and the fuselage. The pilot reported, and a postaccident examination corroborated, that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot observed the airplane’s “Y” yoke, located between the two pilots’ knees, made pitch control more difficult, as compared to a control wheel or control stick. The airplane’s weight during the takeoff was estimated to be 1,291 lbs. The accident airplane was equipped with a Jabiru 120 HP engine and the density altitude during the accident was calculated to be 2,234 ft. Takeoff performance information for the accident airplane was not available to the pilot. At the airplane’s maximum gross weight of 1,320 lbs, the kit manufacturer’s takeoff performance information indicated a takeoff roll of 100 ft and climb rate of 1,000 ft per minute with a 100 horsepower (HP) engine at sea level. According to the pilot, takeoff performance information contained in kit manufacturer advertisements were unrealistic for most conditions. A pilot operating handbook (POH) was released in March 2009 by a company producing factory-built airplanes. The POH included takeoff performance information with turf runway corrections. At the airplane’s maximum gross weight, 3,000 ft density altitude, and equipped with a 100-horsepower engine, the POH listed the takeoff roll from a turf runway as 552 ft and the distance to clear a 50 ft obstacle as 960 ft. The pilot was not aware of takeoff performance information from this POH. The Experimental Aircraft Association (EAA) Flight Test Manual includes the following information regarding takeoff performance: Knowing your airplane’s takeoff performance is key to planning safe departures, especially on short runways and on different surfaces. To account for performance variation caused by environmental factors, such as wind or density altitude, always add a margin of safety. The pilot reflected that a better risk management decision for the initial takeoff would have been to depart solo and meet the pilot-rated passenger at another airport with a longer runway. -
Analysis
The pilot and pilot-rated passenger departed from a 1,100-ft-long turf runway on the first flight after assembling the kit-built airplane. The pilot reported that the airplane’s ground roll was about 400 ft, and after takeoff, he turned right to avoid a rural power line near the end of the runway. The airplane subsequently impacted the power line and then terrain, which damaged both wings and fuselage. The pilot reported, and a postaccident examination corroborated, that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot remarked that the airplane’s “Y” yoke, located between the two pilots’ knees, made pitch control during the takeoff more difficult, as compared to a control wheel or stick. Takeoff performance information from the kit manufacturer indicated the airplane with a 100 horsepower (HP) engine was capable of clearing the power line by a significant margin; whereas a pilot operating handbook released in 2009 for factory-built airplanes equipped with a 100 HP engine indicated significantly less margin to clear the power line. Takeoff performance information for the accident airplane, which was equipped with a 120 HP engine, was not available to the pilots. The pilot reflected that a better risk management option for the initial takeoff would have been to depart solo and meet the pilot-rated passenger at another airport with a longer runway.
Probable cause
The pilot’s failure to maintain clearance from the powerlines during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
750
Amateur built
true
Engines
1 Reciprocating
Registration number
N1949H
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-7637
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-09T21:18:20Z guid: 105893 uri: 105893 title: ERA22LA417 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105937/pdf description:
Unique identifier
105937
NTSB case number
ERA22LA417
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-08T14:20:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-30T17:39:40.059Z
Event type
Accident
Location
Meridianville, Alabama
Airport
Huntsville Executive (MDQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On September 8, 2022, about 1320 central daylight time, a Piper PA-28R-200 airplane, N29RM, was substantially damaged when it was involved in an accident near Meridianville, Alabama. The pilot under instruction and a flight instructor had minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The pilot under instruction was at the controls when the airplane entered the traffic pattern at Huntsville Executive Airport (MDQ), Meridianville, Alabama to practice takeoffs and landings. Shortly after turning onto final approach for runway 36, the engine began to run rough, as if a cylinder was “missing.” The flight instructor took over control of the airplane. He verified that the fuel boost pump was on and the throttle was advanced. The engine then stopped completely; however, the propeller continued to windmill. Unable to make it to the runway, the flight instructor landed the airplane in a bean field short of the runway. The pilots egressed the airplane and were met by first responders.   An inspector with the Federal Aviation Administration (FAA) reported that there was substantial damage to the fuselage and wings.   The wreckage was recovered to the owner’s facility, where the FAA inspector examined the engine and fuel system. The inspector reported that about 30 gallons of fuel were onboard, with no evidence of water or other contaminants in the fuel tanks. The engine contained 8 quarts of clean oil. The air induction system was unobstructed. Internal engine power and valvetrain continuity was established. Suction and compression were observed on all cylinders. Valve action was correct and there was no evidence of a stuck valve. Engine control linkages were secure with no binding observed. The magnetos and ignition leads were secure. The electric fuel boost pump was energized and pumped fuel. Fuel was observed in the line to the injector manifold. The top spark plugs were normal in color and wear. The fuel injector servo was removed; it passed a diaphragm leakage check per the Lycoming troubleshooting guide. There was no internal damage and all fuel injection nozzles were unobstructed. -
Analysis
The pilot under instruction entered the destination airport traffic pattern to practice takeoffs and landings. Shortly after turning onto final approach, the engine began to run rough, as if a cylinder was “missing.” The flight instructor took over control of the airplane, verifying that the fuel boost pump was on and the throttle was advanced. The engine then stopped completely; however, the propeller continued to windmill. Unable to make the runway, the flight instructor landed the airplane in a bean field short of the runway. An examination of the fuel-injected engine and fuel system did not reveal evidence of a preexisting mechanical malfunction or failure. There was ample fuel on board for the flight, and the fuel system was not contaminated or obstructed. The reason for the loss of engine power was not determined.
Probable cause
A loss of engine power that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N29RM
Operator
REDSTONE ARSENAL FLYING ACTIVITY
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28R-7535269
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-30T17:39:40Z guid: 105937 uri: 105937 title: CEN22LA413 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105901/pdf description:
Unique identifier
105901
NTSB case number
CEN22LA413
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-09T08:50:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-27T16:21:13.897Z
Event type
Accident
Location
Bulverde, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 9, 2022, about 0750 central daylight time, a Piper PA32RT-300T airplane, N31981, was substantially damaged when it was involved in an accident near Bulverde, Texas. The pilot and passenger were not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot reported that during the takeoff from Bulverde Airpark (1TT8), Bulverde, Texas, the airplane did not accelerate as planned. The pilot reported that he was not going to be able to stop on the remaining runway, so he continued the takeoff in order to avoid contacting a fence and vehicles at the end of the runway. The airplane cleared powerlines, trees, and a school at the end of the runway, but was nearing a stall, so the pilot performed a forced landing to a field. During the landing the airplane collided with a tree, resulting in substantial damage to the right wing and fuselage. Postaccident examination of the engine found excessive carbon deposits around the No. 4 cylinder exhaust valve. A large amount of carbon build up was found on the rocker arm, rocker shaft, and valve spring. The rotator cap also had carbon deposits and exhibited a groove wear pattern consistent with a lack of cap rotation. The exhaust valve guide had excessive wobble and movement within the guide. The No. 5 exhaust valve also displayed signatures of carbon buildup but not to the same extent as the No. 4. No other anomalies were detected with the engine or airframe. -
Analysis
The pilot reported the airplane did not accelerate as usual during the takeoff roll. To avoid obstacles at the end of the runway, the pilot continued the takeoff. The airplane cleared powerlines, trees, and a school, but was nearing a stall so the pilot decided to make a forced landing in a field. During the landing the airplane collided with a tree, resulting in substantial damage to the right wing and fuselage. Examination of the engine found excessive carbon deposits around the No. 4 cylinder exhaust valve. A large amount of carbon buildup was found on the rocker arm, rocker shaft, and valve spring. The rotator cap also had carbon deposits and exhibited a groove wear pattern consistent with a lack of cap rotation. The exhaust valve guide had excessive wobble and movement within the guide. The No. 5 exhaust valve also displayed signatures of carbon buildup but not to the same extent as the No. 4. No other anomalies were detected with the engine or airframe. The loss of engine power was likely due to at least one stuck exhaust valve.
Probable cause
The partial loss of engine power due to excessive carbon deposits that resulted in one or more stuck exhaust valves.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA32RT
Amateur built
false
Engines
1 Reciprocating
Registration number
N31981
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-7887018
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-27T16:21:13Z guid: 105901 uri: 105901 title: ERA22LA412 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105923/pdf description:
Unique identifier
105923
NTSB case number
ERA22LA412
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-09T19:45:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-10-13T20:29:47.896Z
Event type
Accident
Location
Galion, Ohio
Airport
Galion Municipal Airport (GQQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 9, 2022, about 1845 eastern daylight time, an Engineering & Research 415-C airplane, N99209, was substantially damaged when it was involved in an accident near Galion, Ohio. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The student pilot stated that before departure he performed an engine run-up that included a check of the magnetos and carburetor heat, noting normal rpm decrease for each. He initiated the takeoff noting full rpm during the takeoff roll and the airplane became airborne about the usual location along the length of the runway. On the upwind leg of the airport traffic pattern when the airplane was about 300 ft above ground level, the engine began to lose power. The pilot lowered the airplane’s nose to maintain 65 knots then made a left turn to return to the airport. When the airplane was close to the airport the engine experienced a total loss of power and the student pilot realized that the airplane was too high to land on the runway. He flew over and then north of the airport where he intended to land on an east/west oriented road. The airplane subsequently impacted a powerline pole and came to rest on the road. Postaccident examination of the airplane following recovery revealed structural damage to the fuselage and aft empennage. Examination of the engine revealed the exhaust valve of the No. 2 cylinder was stuck open. Review of the engine maintenance records revealed that a reconditioned cylinder was installed at the No. 2 position in March 1990. About 6 ½ years and 79 hours later, the No. 2 cylinder was removed and the valves were ground. Although the engine was overhauled in January 1998, the only work done to the cylinders were that they were honed, and the valves were ground and lapped. Since the engine overhaul, the No. 2 cylinder was removed in 2005 and again in 2009. The entry in 2005 specified “stuck valves” while the reason for the valve removal in 2009 was not noted. Both entries specified cleaning and/or reaming of the valve guides. In September 2019, which was before the pilot owned the airplane, a “stuck open” exhaust valve of the No. 2 cylinder was reported, with a corrective action of reaming the guide and polishing the valve stem. The engine had accrued about 63 hours and nearly 3 years since the last exhaust valve incident was logged and over 32 years and about 628 hours since the reconditioned cylinder was installed on the engine. According to the engine manufacturer Standard Practice Maintenance Manual, the expected repair for an engine experiencing a stuck valve included cleaning of the parts of the cylinder and dimensional checks of the components. The manual did not have any guidance for a repetitive issue. -
Analysis
The student pilot performed an engine run-up before departure that included a check of the magnetos and carburetor heat, noting normal rpm decreases for each. He initiated the takeoff, noting full rpm during the takeoff roll and normal takeoff distance. On the upwind leg of the airport traffic pattern, when the airplane was about 300 ft above ground level, the engine began to lose power. The pilot lowered the airplane’s nose to maintain airspeed then made a left turn to return to the airport. When the airplane was close to the airport the engine sustained a total loss of power and he realized that the airplane was too high to land on the runway. He flew over and then north of the airport, where he intended to land on an east/west oriented road. The airplane subsequently impacted a powerline pole and came to rest on the road, resulting in substantial damage to the fuselage and aft empennage. Postaccident examination of the engine revealed the loss of engine power was a result of the No. 2 cylinder exhaust valve being stuck in the open position. About 32 years before the accident, a reconditioned cylinder was installed at the No. 2 position, there were multiple maintenance record entries associated with the No. 2 cylinder citing either a stuck exhaust valve or work to the cylinder consistent valve problems, the most recent being nearly 3 years and about 63 engine hours earlier. Guidance from the engine manufacturer related to a stuck exhaust valve cited a need to clean the cylinder components and perform dimensional checks of specified components. It did not cite what to do for a repetitive problem.
Probable cause
A partial loss of engine power due to an exhaust valve that was stuck in the open position.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ENGINEERING & RESEARCH
Model
415-C
Amateur built
false
Engines
1 Reciprocating
Registration number
N99209
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1832
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-13T20:29:47Z guid: 105923 uri: 105923 title: CEN22LA423 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105951/pdf description:
Unique identifier
105951
NTSB case number
CEN22LA423
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-10T16:30:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2022-09-17T00:28:37.023Z
Event type
Accident
Location
Kingsbury, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On September 10, 2022, about 1530 central daylight time, a Luscombe 8A airplane, N25144, sustained substantial damage when it was involved in an accident near Kingsbury, Texas. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who is also the mechanic, he had not flown the airplane “for some time.” The pilot performed the preflight inspection with no anomalies noted. The fuel tank was full of fuel, the fuel vent was checked, and he “sumped” the fuel tank. The pilot started the airplane, taxied to the north end of the runway, and performed the run-up procedure with no anomalies noted. As part of the run-up procedure, both magnetos, the carburetor heat, and the fuel system were all checked. The airplane took off from the runway and the pilot noticed the engine was “performing very well.” The airplane climbed to about 400 ft agl and the pilot initiated a left turn. About halfway through the turn, the engine sustained a total loss of engine power. The pilot reported there was “no cough” or “no sputter” and the engine “just died.” The pilot attempted to troubleshoot the loss of engine power to no avail. The pilot maneuvered the airplane for a forced landing to an open field. The pilot then realized the airplane would not make the open field and maneuvered the airplane for a wooded area. The airplane came to rest in trees. The pilot was able to egress from the airplane without further incident. The pilot reported that at the time of the loss of engine power the engine was operating at full power. The pilot assessed that perhaps a short occurred in the ignition switch, that resulted in the loss of engine power. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. A postaccident examination revealed that the airplane was not equipped with a starter. The ground to the key-operated ignition switch (Bendix, part number 10-357290-1A) was found disconnected. The pilot surmised that he may have pulled off the ground lead when he removed the ignition switch from the panel. The p-leads for the left, right, and both positions were checked with a multimeter. The readings for the p-leads varied from open to closed, along with varied ohm, or resistance, readings. The ignition switch was then disassembled, and carbon tracking, a buildup of carbon that interfered with electrical continuity, was observed. A substantial amount of carbon tracking was found inside the ignition switch, particularly on the contacts. The contacts in the ignition switch were then cleaned and the ignition switch was reassembled. The p-leads were checked again with a multimeter, the varied ohm readings were no longer present, and the ignition switch appeared to function normally with the multimeter. There were no issues noted with the magnetos, the ignition harness, and the spark plugs. The magnetos are electrically independent, except at the ignition switch, and both magnetos produced spark when checked. The pilot reported that while the ignition switch was not originally installed by the manufacturer, but it had been in the airplane for over 40 years. He additionally reported that he had no previous issues with the ignition switch, the ignition switch was never overhauled, nor was he aware of an overhaul schedule for the ignition switch. According to the manufacturer, the maintenance requirements for the ignition switch are based on condition. The Federal Aviation Administration has published the Aviation Maintenance Technician Handbook – Powerplant Volume 1. This document defines carbon tracking for an ignition system and states in part: Flashover can lead to carbon tracking, which appears as a fine pencil-like line on the unit across which flashover occurs. The carbon trail results from the electric spark burning dirt particles that contain hydrocarbon materials. The water in the hydrocarbon material is evaporated during flashover, leaving carbon to form a conducting path for current. When moisture is no longer present, the spark continues to follow the carbon track to the ground. -
Analysis
The pilot reported that the airplane’s engine lost power at an altitude of about 400 ft agl after takeoff. He attempted to glide to an open field but landed in a wooded area after he realized the airplane would not reach the field. The pilot’s attempts to troubleshoot the power loss were unsuccessful. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. Postaccident examination revealed carbon tracking inside the ignition switch that interfered with the proper operation of the ignition switch as evidenced by testing using a multimeter. Once the carbon tracking was cleaned, the ignition switch operated normally. It is likely that the carbon tracking present in the ignition switch resulted in a short, that caused both magnetos to stop functioning and ultimately the engine ceased producing power. Based on the available evidence, it could not be determined how long the carbon tracking had been present inside the ignition switch.
Probable cause
A total loss of engine power due to a failure of the ignition switch from carbon tracking, which resulted in a forced landing and a subsequent impact with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LUSCOMBE
Model
8
Amateur built
false
Engines
1 Reciprocating
Registration number
N25144
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1068
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-17T00:28:37Z guid: 105951 uri: 105951 title: ERA22LA419 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105943/pdf description:
Unique identifier
105943
NTSB case number
ERA22LA419
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-11T14:30:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-15T18:25:07.791Z
Event type
Accident
Location
Jasper, Georgia
Airport
PICKENS COUNTY (JZP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he finished training and received a logbook endorsement to fly the gyroplane five days before the accident. The purpose of the accident flight was to practice touch-and-go landings. The first two were uneventful, but during the third touch-and-go, he applied power to take off again and the gyroplane rolled to the left. The pilot overcorrected and rolled the gyroplane right, resulting in the main rotor blades contacting the ground. The gyroplane slid on the runway to a stop on its right side resulting in substantial damage to main rotor blades and tail section. The pilot reported no preimpact mechanical malfunctions or failures with the gyroplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the gyroplane during a touch-and-go landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
AUTOGYRO USA LLC
Model
CALIDUS
Amateur built
false
Engines
1 Reciprocating
Registration number
N451AG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
US-C00428
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-15T18:25:07Z guid: 105943 uri: 105943 title: DCA22LA201 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105950/pdf description:
Unique identifier
105950
NTSB case number
DCA22LA201
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-11T16:50:00Z
Publication date
2023-07-18T04:00:00Z
Report type
Final
Last updated
2022-09-26T21:00:44.975Z
Event type
Accident
Location
Chicago, Illinois
Airport
Chicago O'Hare International (KORD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After landing on runway 27R at Chicago O’Hare International Airport, Southwest Airlines B737 flight 2659 (SWA2659) was cleared by ground control to taxi to gate M-14 via taxiways Z, D, TT, A, A-19. As they proceeded down taxiway A, both pilots observed an American Airlines B737 (AA1121) holding short of taxiway A-19. The pilots of SWA2659 asked ground control for permission to utilize taxiway A-20 instead and were granted permission. The captain said that as he tried to pass AA1121, he stayed left of centerline to ensure wingtip clearance. The first officer was looking out the window and informed the captain that their airplane’s wingtip was clear. However, their right winglet impacted the left elevator of AA1121. AA1121 was stationary on taxiway A and holding short of taxiway A-19 with the parking brake set, awaiting entry to gate K-20, when it was impacted by SWA2659. Figure 1. Depiction of SWA2659 taxi route and area of occurrence (Adapted from Google Earth) Post-event examination of both airplanes revealed that the right winglet of SWA2659 was damaged and sheared off by the impact and the left elevator of AA1121 was substantially damaged.
Probable cause
Southwest Airlines flight crew’s misjudgment of the distance required to safely pass the American Airlines airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-7H4
Amateur built
false
Engines
2 Turbo fan
Registration number
N963WN
Operator
SOUTHWEST AIRLINES CO
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
36676
Damage level
Minor
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
BOEING
Model
737-823
Amateur built
false
Engines
2 Turbo fan
Registration number
N909NN
Operator
American Airlines Inc
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
31159
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-26T21:00:44Z guid: 105950 uri: 105950 title: CEN22LA427 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105980/pdf description:
Unique identifier
105980
NTSB case number
CEN22LA427
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-11T20:00:00Z
Publication date
2023-12-20T05:00:00Z
Report type
Final
Last updated
2022-09-22T21:41:54.545Z
Event type
Accident
Location
Canby, Minnesota
Airport
Myers Field Airport (CNB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 11, 2022, at 1900 central daylight time, a Cessna A188A, N2122U, sustained substantial damage when it was involved in an accident near Canby, Minnesota. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot stated that, during the landing, the airplane made an immediate turn when the tailwheel touched down. The airplane spun around, the left main landing gear collapsed, and the left wing struck the ground. The airplane sustained substantial damage to the left wing. The pilot stated that the tailwheel spring cross tube broke when the tailwheel touched down. He said that the tube had a wall thickness of 0.055 inch, and the superseded tube had a wall thickness of 0.125 inch. The cross tube was examined by the National Transportation Safety Board Materials Laboratory. The tube wall at the location of the right joint was flattened and substantially deformed consistent with ductile overstress deformation of the tube, and the deformation corresponded to the upward displacement of the attach fitting right end relative to the adjacent fuselage lug. The piece of the tube that had been retained within the lug was ovalized, also consistent with overstress deformation associated with the relative displacement. The tube material was identified as alloy 4130 steel, consistent with the specified material for the part. The tube had an outside diameter of 0.873 inch and a wall thickness of 0.0481 inch. According to an engineering drawing for the tube at the time of airplane manufacture in 1970, the specified tube had a nominal outside diameter of 0.875 inch and a wall thickness of 0.049 inch. Therefore, the outside diameter of the tube was about 0.002 inch smaller than the specified nominal outside diameter of 0.875 inch, and the wall thickness was 0.0009 inch thinner than the specified nominal wall thickness of 0.049 inch for the original tube design. In 1985, the wall thickness of replacement parts (the airplane model was no longer in manufacture in 1985) was changed to 0.120 inch. The measured hardness was consistent with values for the specified material. -
Analysis
The pilot stated that the tailwheel spring cross tube broke when the tailwheel landing gear touched down. After landing, the airplane made an immediate turn and spun around. The left main landing gear collapsed, and the left wing struck the ground. The airplane sustained substantial damage to the wing. Postaccident examination of the tailwheel spring cross tube revealed that the outside diameter of the tube was about 0.002 inch smaller than the specified nominal outside diameter of 0.875 inch, and the wall thickness was 0.0009 inch thinner than the specified nominal wall thickness of 0.049 inch for the original tube design. Examination of the tube showed signatures consistent with overstress deformation. The part dimensions indicated the part could have been from original manufacture and likely had not been replaced since at least 1985, when the drawing for replacement parts was changed to have a thicker wall, 0.120 inch. An uncoated steel part of that age used in an airplane used in aerial application service would be expected to have a more corroded surface than what was observed on the accident part. The surface condition suggests it may have been recently sanded, possibly removing about 0.001 inch of material around the outside diameter. The recent change in outside diameter likely did not significantly affect the strength of the tube. The bending strength of the tube was reduced by about 2 percent relative to the nominal tube based on a comparison of the bending moments required to reach given stress at the exterior surface. Similarly, the cross-sectional area was also reduced by just 2 percent. While some increase in impact loading on the tube could be expected due to the additional clearance between the tube and the fitting, the failure is more likely attributed to loads that exceeded the maximum design load for the tailwheel. An additional margin of safety could have been achieved if the tube had been replaced with the thicker-walled replacement part rather than apparently having been cleaned up and reused. The metallurgical examination of the tailwheel spring cross tube revealed that it failed in overload, which indicates that it was not the initiating event for the loss of control. It is likely that the pilot failed to maintain airplane control during the landing sequence, which resulted in a ground loop and the substantial damage to the left wing and the fractured tailwheel spring cross tube.
Probable cause
The pilot’s failure to maintain airplane control during the landing, which resulted in an overload failure of the tailwheel cross tube and subsequent impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188A
Amateur built
false
Engines
1 Reciprocating
Registration number
N2122U
Operator
Anderson Aerial Spraying Service
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
18800672
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-22T21:41:54Z guid: 105980 uri: 105980 title: ERA22LA413 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105927/pdf description:
Unique identifier
105927
NTSB case number
ERA22LA413
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-13T12:32:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-09-15T00:42:30.909Z
Event type
Accident
Location
Chattanooga, Tennessee
Airport
LOVELL FLD (CHA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 13, 2022, about 1132 eastern daylight time, a Cessna 172, N388TC, was substantially damaged when it was involved in an accident near Chattanooga, Tennessee. The airline transport pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, during a previous off-airport landing on an unimproved surface, the right tire impacted an object and was losing air pressure. He ultimately elected to land at Lovell Field Airport (CHA), Chattanooga, Tennessee. He declared an emergency with air traffic control and advised them he intended to make multiple low passes over a grass area adjacent to runway 20 to determine the best touchdown point. He made two low passes over the area he selected, initiating a go-around after the second low pass. During climbout, with the airplane about 350 ft above ground level and at 65 mph, the engine lost power. Engine power was briefly restored before being lost again. The airplane impacted uneven terrain outside the airport fence. According to a Federal Aviation Administration inspector, an examination of the airplane revealed that the wings and forward fuselage sustained substantial damage. Fuel was drained from the wings, 7 gallons of fuel was drained from the left wing, 1/2 gallon was drained from the right wing. The carburetor contained 5 ounces of fuel. All fuel drained was free of contaminants. A postaccident examination and engine test run did not reveal any anomalies consistent with a preimpact failure or malfunction. According to the carburetor ice probability chart, the atmospheric conditions at the time of the accident were conducive to serious icing at glide power. FAA Special Airworthiness Information Bulletin (CE-09-35) – Carburetor Icing Prevention, stated that: …pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. -
Analysis
The pilot reported that the right landing gear contacted an unseen object while landing on an unimproved surface, which resulted in the tundra tire losing air pressure. After aborting the landing, he flew to an airport where he declared an emergency and advised air traffic control that he intended to land in the grass adjacent to the runway. The pilot made two low passes over a grassy area and, during climb-out from the second low pass, the engine lost all power. The pilot performed a forced landing to uneven terrain outside the airport fence, during which the airplane sustained substantial damage. A postaccident examination and engine test run did not reveal any anomalies consistent with a preimpact failure or malfunction. Weather conditions at the time of the accident were conducive for serious icing at glide power. The pilot did not report using carburetor heat. It is likely that during multiple low passes prior to landing that carburetor ice accumulated, which resulted in a loss of engine power.
Probable cause
A total loss of engine power due to of carburetor ice. Contributing to the accident was the pilot’s failure to apply carburetor heat.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N388TC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
29601
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-15T00:42:30Z guid: 105927 uri: 105927 title: ERA22LA416 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105935/pdf description:
Unique identifier
105935
NTSB case number
ERA22LA416
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-13T18:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-21T19:10:40.733Z
Event type
Accident
Location
Warrenton, Virginia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 13, 2022, about 1700 eastern daylight time, a Vans RV-7A, N40WB, sustained substantial damage when it was involved in an accident near Warrenton, Virginia. The commercial pilot was not injured. The airplane was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, who was also the owner of the airplane, he was in cruise flight at 2,500 ft mean sea level during a cross-country flight when the engine started to “sputter and surge,” followed rapidly by a total power loss. The pilot completed the emergency checklist by switching fuel tanks, turning on the fuel boost pump and adding full mixture, but was unsuccessful in his multiple attempts to regain power; he subsequently landed in a pond due to the otherwise densely populated area around him. The airplane impacted the water left-wing-low and cartwheeled before flipping over and coming to rest upside down. Photographs of the wreckage confirmed substantial damage; both wings were crushed, and the airframe was buckled. The left fuel tank was full and the fuel selector was on the left tank. A local towing company that did not specialize in aircraft recovery and salvage was asked by local authorities to recover the wreckage from the water and transport it to their yard. The wreckage was subsequently discarded before it could be examined. -
Analysis
The pilot reported that, while in cruise at 2,500 ft mean sea level during a cross-country flight, the engine started to “sputter and surge” followed rapidly by a total loss of power. The pilot completed the emergency checklist by switching fuel tanks, turning on the fuel boost pump, and richening the mixture, but was unsuccessful in his multiple attempts to regain power; he performed a forced landing to a pond due to the densely populated area around him. The airplane impacted the water left-wing-low and was substantially damaged. The wreckage was discarded before it could be further examined; therefore, the reason for the loss of engine power could not be determined.
Probable cause
A total loss of engine power for reasons that could not be determined because the airplane could not be examined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WILLIAM L BELL
Model
VANS RV-7A
Amateur built
true
Engines
1 Reciprocating
Registration number
N40WB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
71857
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-21T19:10:40Z guid: 105935 uri: 105935 title: CEN22LA421 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105939/pdf description:
Unique identifier
105939
NTSB case number
CEN22LA421
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-14T12:40:00Z
Publication date
2024-02-07T05:00:00Z
Report type
Final
Last updated
2022-09-27T16:37:28.676Z
Event type
Accident
Location
Broomfield, Colorado
Airport
ERIE MUNI (EIK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 14, 2022, about 1140 mountain daylight time, a Piper PA-28R-180, N3713T, was substantially damaged when it was involved in an accident near Broomfield, Colorado. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot recently purchased the airplane and had been flying it regularly in the three weeks before the accident. On the accident flight, the airplane departed from runway 16 at the Erie Municipal Airport (EIK), Erie, Colorado, where the airplane was based. When the airplane was about 200 ft AGL, the engine sustained a partial loss of power. The pilot reported that although the engine was still running, it was not producing enough power to climb. The pilot executed a forced landing to a residential area where the airplane nosed over and came to rest in a pond. Both wings sustained substantial damage. Postaccident examination of the airplane revealed that the interior liner of the induction air hose between the air filter and the throttle body was partially collapsed inward. The exterior of the hose did not display obvious damage. No further preimpact anomalies that would explain the reported loss of engine power were found. The airplane was equipped with a Garmin electronic flight instrument system (EFIS), but the system did not record engine parameters. Flight data recovered from the EFIS system was consistent with the pilot’s description of the flight. The engine instrumentation installed in the airplane consisted of non-recording analog gauges consistent with those installed during its manufacture in 1967. The temperature and dew point about the time of the accident was conducive for carburetor icing at glide and cruise power settings. -
Analysis
The pilot reported that shortly after takeoff, when the airplane was about 200 ft above ground level (AGL), the engine sustained a partial loss of power. He was not able to climb or maintain altitude and executed a forced landing. During the landing the airplane nosed over into a pond, resulting in substantial damage to both wings. Recorded flight data was consistent with the pilot’s description of events, but no recorded engine data was available. Postaccident examination of the airplane revealed that the interior liner of the induction air hose between the air filter and the throttle body was partially collapsed inward. The exterior of the hose did not display obvious damage. No further preimpact anomalies that would explain the reported loss of engine power were found. Weather conditions at the time of the accident were conducive for carburetor icing at glide and cruise power settings, but not at the full power setting that would be used for takeoff and initial climb. Based on the available evidence, the partially collapsed induction hose likely collapsed further, blocking airflow to the carburetor and resulting in the loss of engine power.
Probable cause
A partial loss of engine power due to a collapsed induction hose that blocked engine intake airflow.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N3713T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-30017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-27T16:37:28Z guid: 105939 uri: 105939 title: CEN22FA419 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105936/pdf description:
Unique identifier
105936
NTSB case number
CEN22FA419
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-14T13:22:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2022-09-19T17:30:19.361Z
Event type
Accident
Location
Conway, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
The airplane had been at Executive HeliJet Aviation, Myrtle Beach, South Carolina, for avionics upgrades since April 18, 2022. As part of the work being accomplished, the vacuum system was removed and replaced with electronic instrumentation. The Garmin G5 Electronic Flight Instrument Installation Manual states, in part: “The vacuum system and associated parts may be removed if there is no remaining need for vacuum. See the airplane specific maintenance manual and AC 43.13-2B for guidance when removing the vacuum system. If the vacuum pump is removed, the engine accessory port must be properly covered.” A review of the work order revealed that although a vacuum pump plate (P/N 60430) was ordered, there was no reference to the required vacuum pump drive pad gasket being ordered. Figure 1 is a copy of the lubrication schematic for the engine installed in the accident airplane. The red arrows depict the path of the oil from the oil sump to the vacuum pump plate. After the oil traveled through the oil pump, it was pressurized to normal engine operating pressure. Figure 1: Engine Lubrication Diagram from Lycoming Engine Operating Manual According to the engine operating manual, the maximum pressure for engine start, warm-up, taxi, and takeoff was 115 psi. During normal operation, the pressure would be between 55 and 95 psi. As the oil temperature increased, the viscosity is lowered, and the oil will become thin and thus more easily able to escape from non-sealed areas. - On September 14, 2022, about 1222 eastern daylight time, a Piper PA-28R-201 airplane, N62FC, was destroyed when it was involved in an accident near Conway, South Carolina. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   The flight departed Myrtle Beach International Airport (MYR), Myrtle Beach, South Carolina, about 1205, and was en route to Columbus County Municipal Airport (CPC), Whiteville, North Carolina. Shortly after departure from MYR, the pilot reported to air traffic control (ATC) that he was having problems with the compass, which resulted in difficulty maintaining assigned headings. He stated that he wanted to return to the airport and was not declaring an emergency. About 30 seconds later, the pilot reported a loss of engine power. He informed ATC that he was unable to make it back to MYR and had identified an off-field landing area.   Surveillance video captured the airplane as it flew low near trees but did not capture the accident sequence due to a power surge when the airplane impacted a powerline.   The airplane first impacted an estimated 40-ft-tall pine tree and then a powerline and came to rest against a berm along a gravel roadway. The right wing and vertical stabilizer separated during the impact with the pine tree and powerline respectively. A postcrash fire ensued that consumed much of the wreckage and back burned to the tree from the initial impact. - During the impact with the pine tree, the right wing and right horizontal stabilizer separated from the airframe. During a postaccident examination of the airframe, flight control continuity was established from the cockpit to the left aileron, stabilator, and rudder control surfaces. When the bottom of the empennage was examined, a sizeable quantity of oil was present near the tail tie down ring. A postaccident examination of the engine revealed that the Nos. 2, 3, and 4 connecting rods were separated from the crankshaft. The left engine crankcase half was fractured inboard of the No. 4 cylinder mounting pad. The Nos. 3 and 4 connecting rods were separated from their respective crankshaft rod journals and the damaged rod ends were visible through the crankcase fracture. During disassembly of the engine, a vacuum pump cover (item No. 13 in Figure 2 below from the Lycoming Parts Catalog) was removed from the vacuum pump drive pad and no gasket (item No. 11), or remnants of a gasket, were found. Other engine components were removed, and all had remnants of a gasket despite the thermal damage. Figure 2: Excerpt from Lycoming Parts Catalog, View of Engine Accessory Case A review of the aircraft maintenance records revealed that after one certificated airframe and powerplant mechanic had completed the work on the airplane, the Director of Maintenance, an airframe and powerplant mechanic with inspection authorization, signed off to return the airplane back to service. The return to service logbook entry stated that the vacuum pump had been removed but did not address the installation of the drive pad gasket or vacuum pump cover. Additionally, there was no mention of an engine runup following completion of the work. In an interview, the mechanic who completed the removal of the vacuum pump and installation of the vacuum pump cover stated that when he removed the vacuum pump, the gasket was still attached to it. He cleaned the mating surface of the cover and drive pad with Scotch-Brite and then installed the cover. He stated that he thought he had replaced the gasket. When asked about the performance of an engine runup, he stated that he ran the engine for about 30 minutes after the installation of the avionics modification. He did not recall seeing any oil leaks following the runup and said that before the runup there were about 7.5 quarts of oil in the engine and a “few days later” checked it again and the level was still above 7 quarts. When asked if there was more than one mechanic working on the modification, he said that other mechanics would come in and help complete some tasks while he concentrated on the wiring. The Director or Maintenance was asked how he reviewed completed work before returning the airplane to service, to which he replied, “I look at it all.” He stated that on larger jobs he would conduct his inspection in stages by reviewing one area when the mechanic completed an area such as the cockpit or engine and moves to another area. -
Analysis
Shortly after departure, on the first flight following maintenance, the pilot reported a loss of engine power. The pilot attempted a forced landing onto a gravel road, but the airplane impacted trees and powerlines on final approach. The airplane came to rest against a berm and a postcrash fire ensued. A postaccident examination of the engine revealed that the Nos. 2, 3, and 4 connecting rods were separated from the crankshaft. The left side of the engine crankcase was fractured. The Nos. 3 and 4 connecting rods were separated from their respective crankshaft rod journals. During disassembly of the engine, a vacuum pump cover was removed from the vacuum pump drive pad and no gasket, or remnants of a gasket, were found. Other engine components were removed, and all had remnants of a gasket despite the thermal damage. When the crankshaft was removed, discoloration was present, consistent with exposure to high heat. It is therefore likely that the gasket had not been installed following the completion of maintenance work. Additionally, when the bottom of the empennage was examined, a sizeable quantity of oil was present near the tail tie down ring. A review of the airplane maintenance records revealed that after a certificated airframe and powerplant mechanic had completed the work on the airplane, the Director of Maintenance, an airframe and powerplant mechanic with inspection authorization, signed off the paperwork to return the airplane back to service. The return to service entry stated that the vacuum pump had been removed but did not address the installation of the drive pad gasket or vacuum pump cover. In an interview, the mechanic who completed the removal of the vacuum pump and installation of the vacuum pump cover stated that that when he removed the vacuum pump, the gasket was still attached to it. He cleaned the mating surface of the cover and drive pad and then installed the cover. He stated that he thought he had replaced the gasket. A review of the work order showed that although the cover had been ordered, there was no record of a gasket being ordered. It is likely that, following the removal of the vacuum pump and system, no gasket was installed between the vacuum pump drive cover and the engine accessory case. Additionally, the Director of Maintenance likely did not review the work in detail before signing for the airplane to return to service. As the oil temperature increased, the viscosity lowered, and the oil became thin and thus more easily able to escape from non-sealed areas.
Probable cause
The mechanic’s failure to install the required gasket on the vacuum pump drive pad in accordance with the maintenance manual, which resulted in oil exhaustion and the subsequent loss of engine power. Contributing to the accident was the Director of Maintenance’s failure to verify the installation of the vacuum pump gasket before returning the airplane to service.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-201
Amateur built
false
Engines
1 Reciprocating
Registration number
N62FC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-7737039
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-09-19T17:30:19Z guid: 105936 uri: 105936 title: ERA22LA423 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105959/pdf description:
Unique identifier
105959
NTSB case number
ERA22LA423
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-14T13:30:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-09-21T21:35:07.157Z
Event type
Accident
Location
Elberta, Alabama
Airport
Shields (AL55)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot described that during the landing approach to the turf runway, while about 50 feet above the runway threshold, he reduced engine power and the airplane began to descend rapidly. He responded by increasing engine power, but the airplane impacted the ground and nosed over. The airplane’s fuselage and vertical stabilizer were substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain an appropriate descent rate during the landing approach, which resulted in a loss of control and subsequent nose over during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KUMHYR DAVID B
Model
VANS RV-8A
Amateur built
false
Engines
1 Reciprocating
Registration number
N955DK
Operator
R&V PROPERTIES LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
81538
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-21T21:35:07Z guid: 105959 uri: 105959 title: ERA22LA420 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105947/pdf description:
Unique identifier
105947
NTSB case number
ERA22LA420
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-15T08:50:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-13T17:22:16.306Z
Event type
Accident
Location
Waldo, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The private pilot stated that prior to departure of the cross-country flight he performed a preflight inspection, which included using a dipstick to check the fuel quantity, though he later reported miscalculating the amount that was on-board. The flight departed with what he thought was 15 gallons of fuel for the intended 30-minute-long flight but when about 5 miles from the intended destination, the fuel pressure gauge decreased to 0 psi and the engine lost power rapidly. He realized he would be unable to land at his intended destination due to the airplane’s altitude and distance from it, so he performed an off-airport forced landing. The airplane touched down in a shallow ditch adjacent to a road and nosed over during the landing roll. He further stated that both fuel quantity gauges indicated near 0 at the moment of the loss of engine power. Examination of the airplane revealed substantial damage to the fuselage adjacent to the left main landing gear attach point. During recovery of the airplane no fuel was noted in the wing fuel tanks and postaccident examination revealed no fuel in the fuel service tank. Given this information, it is likely that the pilot exhausted the airplane’s fuel supply, which resulted in the total loss of engine power.
Probable cause
The pilot’s inadequate preflight fuel planning and preflight inspection of the airplane, which resulted in fuel exhaustion, a total loss of engine power, and the subsequent off-airport landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
YAKOVLEV
Model
YAK-55M
Amateur built
false
Registration number
N307GS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
920607
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-13T17:22:16Z guid: 105947 uri: 105947 title: ERA22LA425 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105961/pdf description:
Unique identifier
105961
NTSB case number
ERA22LA425
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-18T12:18:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-09-23T18:29:56.216Z
Event type
Accident
Location
Great Barrington, Massachusetts
Airport
WALTER J KOLADZA (GBR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 18, 2022, about 1118 eastern standard time, a Piper PA-22-150, N6076D, was substantially damaged when it was involved in an accident near Great Barrington, Massachusetts. The student pilot and instructor were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91instructional flight. The student pilot, who was also the owner of the airplane, purchased the airplane 10 months before the accident to start his flight training. About 1015 on the day of the accident, he and the flight instructor departed Walter J Koladza Airport (GBR) Great Barrington, Massachusetts, with about 28 gallons of fuel (3 hours + endurance) and began the flight on the left tank. They flew to Columbia County Airport (1B1) Hudson, New York, and switched to the right tank. They performed three takeoffs and landings to a full stop before conducting basic private pilot maneuvers in the practice area. The student pilot reported the flight as uneventful and the total flight time when they returned to GBR was about 1 hour. The instructor reported that they checked the carburetor heat several times during the flight and switched fuel tanks back to the left tank as they entered the downwind to base leg of the airport traffic pattern. During final approach, which was high and a little fast, the student pilot attempted a go-around. Shortly after adding full throttle and initiating a climb, the engine lost power. There was “no surging, no sputtering, it just quit.” After pumping the throttle with no response, and being too low to troubleshoot, the instructor took the flight controls and performed a forced landing in a corn field. The airplane settled into the corn and immediately “dug in” and spun to the left before coming to a stop on its left side. According to the student pilot, as fuel leaked down from the right tank, the student pilot and flight instructor evacuated. During the egress, the student reported that he turned the master switch to OFF and switched the fuel tank selector handle (which was installed on the sidewall behind his left leg) into the 12 o’clock position. According to the airframe manufacturer and photographs of the wreckage, that position was the right tank position, and was not the OFF position. First responders subsequently drained about 4 gallons of fuel from the right wing. Examination of the airplane by a Federal Aviation Administration inspector revealed that the left wing was severed, and the fuselage was crushed in several locations. In addition, the left fuel tank was breached. An examination of the engine did not reveal any mechanical malfunctions or irregularities that would preclude normal operation. -
Analysis
The student pilot stated that he and a flight instructor departed on a local area instructional flight with about 28 gallons of fuel, enough for 3 or more hours of flying. With the fuel selector on the left fuel tank, they performed various training maneuvers and flew to a nearby airport where they switched to the right fuel tank. They performed three full-stop landings before returning to the practice area. After about 1 hour of flight time, they entered the traffic pattern on the downwind to base leg and switched the fuel selector back to the left fuel tank before beginning their final approach. On the final leg of the traffic pattern, they elected to perform a go-around and added full power; however, the engine lost all power without warning. Too low to troubleshoot, the instructor took the flight controls and performed a forced landing in a corn field, which resulted in substantial damage to the airplane. As fuel leaked down from the right tank, the student pilot and flight instructor evacuated. The student reported that, during the egress, he turned off the electrical master switch off and switched the fuel tank into the 12 o’clock position. Postaccident examination of the engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would preclude normal engine operation. The left fuel tank was compromised during impact, and about 4 gallons of fuel were drained out of the right wing tank by first responders. The student pilot’s description that he manipulated the fuel selector to the 12 o’clock position after the accident and during his egress would be consistent with him attempting to turn off fuel flow in order to mitigate the chances of a posaccident fire. However, the position of the fuel selector handle after the accident was actually the right fuel tank position. Given that the loss of engine power occurred shortly after switching fuel tanks, it is likely that the student pilot inadvertently placed the fuel selector in the OFF position during the flight, thus eventually starving the engine for fuel during the attempted go-around after the available fuel supply in the fuel system forward of the fuel selector had been exhausted. The flight instructor was likely unable to confirm the fuel selection because the selector handle was installed on the sidewall behind the student’s left leg.
Probable cause
The student pilot's inadvertent movement of the fuel selector to the OFF position, which resulted in fuel starvation and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N6076D
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
22-4730
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-23T18:29:56Z guid: 105961 uri: 105961 title: ERA22FA426 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105965/pdf description:
Unique identifier
105965
NTSB case number
ERA22FA426
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-19T14:48:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-09-24T00:38:21.917Z
Event type
Accident
Location
Bridgeton, New Jersey
Airport
BUCKS (00N)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
On September 19, 2022, about 1348 eastern daylight time, an Aeronca 7AC Champion, N2716E, was substantially damaged when it was involved in an accident near Bridgetown, New Jersey. The pilot and pilot-rated passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to airport security video, the pilot started the airplane’s engine at 1341 and taxied to the end of the 1,900-ft-long turf runway. About 4 minutes later, another security video showed the airplane in a steep left-turning descent and then the airplane’s impact with the ground. A witness located near the departure end of runway 18 at Bucks Airport (00N), Bridgeton, New Jersey, heard an airplane departing the runway and described that it sounded “unusual.” He observed the airplane 3 to 4 ft above the runway surface and stated that the airplane then “aggressively pulled up” in a steep climb near the end of runway. The airplane cleared power lines, but the engine sounded as if it were not accelerating or generating full power. The airplane subsequently did not appear to climb and entered a descending left turn. The witness lost sight of the airplane when it descended behind trees before hearing an impact. Another witness, the owner of the airport, observed the airplane depart the runway with about 50 ft remaining. He stated that the airplane entered a steep angle of attack and slowly leveled out again. The witness lost sight of the airplane after its slow left turn. The airplane impacted the front yard of a residential house that was about 50 ft from a road and about 500 ft from the departure end of the runway. The airframe came to rest upright oriented on a magnetic heading of about 20°. The cabin, instrument panel, seats, and engine compartment were fractured into several pieces. The forward section of the fuselage was crushed aft and upward. The Leading edges of both wings displayed relatively uniform aft crushing damage. The tail section of the airplane was not damaged. Flight control continuity was established from the controls in the cockpit to the respective flight controls. The position of the throttle, mixture, and carburetor heat controls could not be determined due to impact damage. Fuel samples were taken from the fuel tanks, fuel lines, and gascolator. The fuel was blue in color and tested negative for the presence of ethanol. The propeller was separated from the engine and one propeller blade was bent aft. The propeller blades did not display chordwise scratching or S-bending. Engine powertrain continuity was established from the propeller flange to the accessory case. The top spark plugs were removed, and thumb compression was established on all cylinders. The magnetos were removed, and spark was produced on all leads. The carburetor was removed and disassembled, and no anomalies were noted. The oil screen was clean and clear of debris. The 1354 recorded weather observation at Millville Municipal Airport (MIV), Millville, New Jersey, about 8 miles southeast of the accident location, included wind from 200° at 7 knots, 10 miles visibility, clear skies, temperature 28°C, dew point 18°C; and an altimeter setting of 29.94 inches of mercury. The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, showed a probability of serious icing at glide power at the temperature and dew point reported at the time of the accident The engine operating instructions stated that, during the pre-takeoff ground test (engine run up), the carburetor heat control should be moved “to full ‘HOT’ position and observe decrease in engine speed if air heater and control are operating properly” and then “return control to full ‘COLD’ position.” The instructions also noted, “under some conditions, ice may form in the carburetor during ground test. It must be eliminated before take-off.” Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, stated the following: Pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor…causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. -
Analysis
The pilot and pilot-rated passenger were departing on a local personal flight. Witnesses stated that the as the airplane departed the engine did not sound like it was creating full power. During the initial climb, the airplane briefly climbed at a steep angle then turned left, descended, and impacted the ground about 500 ft from the departure end of the runway. Postaccident examination of the wreckage revealed no evidence of preimpact mechanical anomalies that would have prevented normal engine operation. Given the witness statements, and the findings of the postaccident engine examination, it could not be determined whether there was a partial loss of engine power during the takeoff. Nevertheless, the conditions about the time of the accident, given the temperature and dew point, were favorable for serious carburetor icing at a glide power setting. Given this information, it is possible that during the ground operation, when the engine would typically be operating at low power, carburetor ice formed. This could have resulted in at least a partial loss of engine power during the initial climb. The available evidence for this investigation did not indicate whether or not the pilot applied carburetor heat before or during the flight. The witness reports of the airplane briefly climbing at a steep angle, the video showing the airplane in a steep descending left turn, as well as the signatures observed on the wreckage (aft crushing of the forward portion of the fuselage, the relatively uniform aft crush damage on the leading edges of both wings, and damage consistent with a relatively low energy state at the time of impact) were all consistent with the airplane encountering an aerodynamic stall before it impacted the ground. Given that there were no anomalies observed with the airplane’s flight controls during the postaccident wreckage examination, it is likely that the pilot exceeded the airplane’s critical angle of attack at an altitude too low to recover, which resulted in the subsequent loss of control and impact with terrain.
Probable cause
The pilot's exceedance of the airplane’s critical angle of attack shortly after takeoff, which resulted in an aerodynamic stall, loss of control, and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHAMPION
Model
AERONCA 7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N2716E
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-6296
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-24T00:38:21Z guid: 105965 uri: 105965 title: ERA22LA429 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105992/pdf description:
Unique identifier
105992
NTSB case number
ERA22LA429
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-21T16:20:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-18T20:41:44.704Z
Event type
Accident
Location
Ocean City, Maryland
Airport
Ocean City Muni (OXB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that the primary runway was closed for repairs, so he elected to use a runway with a 6 to 8 knot crosswind. Also, there were workers and equipment near the runway and the pilot stated that they were a distraction. After touchdown, he felt the crosswind push the airplane to the right, but he overcompensated with left rudder. The airplane was then headed toward the edge of the runway and a construction barricade. He applied brakes; however, he could not bring the airplane to a stop on the runway surface. The airplane departed the runway and nosed over in the grass. The pilot was not injured. An inspector with the Federal Aviation Administration examined the wreckage and determined that the airplane’s vertical stabilizer and rudder were substantially damaged during the accident. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane while landing with a crosswind, resulting in the runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180
Amateur built
false
Engines
1 Reciprocating
Registration number
N9359C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
31757
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-18T20:41:44Z guid: 105992 uri: 105992 title: ERA22LA428 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105988/pdf description:
Unique identifier
105988
NTSB case number
ERA22LA428
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-22T08:00:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-09-28T23:13:41.814Z
Event type
Accident
Location
Cincinnati, Ohio
Airport
Cincinnati (LUK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 22, 2022, about 0700 eastern daylight time, an experimental amateur-built Zenith CH 750, N2992W, was substantially damaged when it was involved in an accident at near Cincinnati, Ohio. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, during the takeoff roll he noticed that “something felt wrong.” He reduced power and the airplane started to “bounce” on the runway. The airplane briefly climbed before landing hard on the nosewheel. An examination of the airplane by a Federal Aviation Administration inspector revealed that the engine firewall was buckled. Further examination of the airplane revealed that a control yoke nut and bolt were missing. Both pieces of hardware were subsequently located inside the fuselage. An examination of the hardware revealed that it did not look like any of the other hardware that was attached to the control system, and review of the engineering drawings for the airplane revealed that the separated nut and bolt were not the correct type called for (bolt secured with castle nut and cotter pin). The pilot further described the findings by stating that, “There was a hardware store nut used on the wrong type bolt. Nut came off and bolt fell out [of] elevator control.” A review of the airplane’s maintenance records revealed that it had undergone three annual condition inspections since it had been completed. The records did not note that any work had been performed on the control yoke or replacement of any flight control hardware. -
Analysis
The pilot stated that, during the takeoff roll in the experimental amateur-built airplane, he noticed that “something felt wrong” with his flight controls. The airplane briefly climbed before landing hard on the nosewheel, resulting in substantial damage to the engine firewall. During a postaccident examination of the airplane, a bolt that attached the control yoke to the flight controls was missing. The missing bolt and a nut were subsequently located within the fuselage of the airplane. The “hardware store” -type nut was not the castle type nut with cotter pin -type that was called for in the airplane’s engineering drawings. Review of the airplane’s maintenance records revealed that it had undergone 3 annual condition inspections since being constructed and that no documented maintenance to, or replacement of the flight control hardware had occurred. Based on this information, it is likely the builder of the airplane used improper hardware to assemble the flight controls, which resulted in the separation of the control yoke from the flight controls and the subsequent loss of control during takeoff.
Probable cause
The airplane builder’s installation of incorrect hardware in the control yoke assembly, which resulted in a loss of control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
CH 750
Amateur built
true
Engines
1 Reciprocating
Registration number
N2992W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-8178
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-28T23:13:41Z guid: 105988 uri: 105988 title: CEN22LA429 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105986/pdf description:
Unique identifier
105986
NTSB case number
CEN22LA429
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-22T16:30:00Z
Publication date
2023-08-15T04:00:00Z
Report type
Final
Last updated
2022-09-23T16:59:21.954Z
Event type
Accident
Location
Savoy, Texas
Airport
N/A (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 22, 2022, about 1530 central daylight time, a Commander 114TC airplane, N495TC, was substantially damaged when it was involved in an accident near Savoy, Texas. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the airplane shuddered after he completed maneuvers in a local practice area. After the shudder recurred, he realized that the engine was “barely running.” The pilot’s efforts to restore engine power were not successful. He subsequently lowered the landing gear and executed a forced landing to a highway. The airplane encountered a highway median area during the landing and sustained damage to the outboard portion of the right wing and the right aileron. On-scene observation of the airplane indicated that the wing fuel tanks appeared to be full. A postrecovery examination of the engine and airframe fuel system did not reveal any anomalies that would have precluded normal engine operation. -
Analysis
The pilot reported that the airplane shuddered after he completed maneuvers in a local practice area. After the shudder recurred, he realized that the engine was “barely running.” The pilot’s efforts to restore engine power were not successful. He subsequently lowered the landing gear and executed a forced landing to a highway. The airplane encountered a highway median area during the landing and sustained damage to the outboard portion of the right wing and the right aileron. On-scene observation of the airplane indicated that the wing fuel tanks appeared to be full. A postrecovery examination of the engine and airframe fuel system did not reveal any anomalies that would have precluded normal engine operation.
Probable cause
A loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
COMMANDER AIRCRAFT CO
Model
114TC
Amateur built
false
Engines
1 Reciprocating
Registration number
N495TC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
20004
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-23T16:59:21Z guid: 105986 uri: 105986 title: ERA22LA430 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105995/pdf description:
Unique identifier
105995
NTSB case number
ERA22LA430
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-24T13:45:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-07T18:46:19.196Z
Event type
Accident
Location
Buffalo, New York
Airport
Clarence Aerodrome (D51)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The vintage tailwheel airplane was on final approach to the runway in a left crosswind. A witness, who was also president of the airport flying club, was mowing grass adjacent to the runway and saw the accident. He stated that the airplane approached the runway low and was “crabbing hard” to the left. The pilot then initiated a go-around. The engine noise increased, but the airplane attempted a go-around at a 90° left angle to the runway. The airplane cleared trees, experienced a “power on stall,” and descended nose first into a grove. The pilot reported that he was injured in the accident and did not remember anything after being 25 ft over the runway on approach; however, he reported that there were no preimpact mechanical malfunctions with the airplane. Examination of the wreckage by a Federal Aviation Administration inspector did not reveal any preimpact mechanical malfunctions. The inspector noted substantial damage to the fuselage and right wing.
Probable cause
The pilot’s failure to maintain aircraft control during initial climb after a go-around, which resulted in an aerodynamic stall and spin at low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TAYLORCRAFT
Model
BC12
Amateur built
false
Engines
1 Reciprocating
Registration number
N5619M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12019
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-07T18:46:19Z guid: 105995 uri: 105995 title: ANC22LA080 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105993/pdf description:
Unique identifier
105993
NTSB case number
ANC22LA080
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-25T14:00:00Z
Publication date
2024-02-28T05:00:00Z
Report type
Final
Last updated
2022-09-26T21:35:05.426Z
Event type
Accident
Location
Skwentna, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On September 25, 2022, about 1300 Alaska daylight time, a float-equipped Cessna 180A airplane, N9728B, was substantially damaged when it was involved in an accident near Skwentna, Alaska. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.   According to a family member, the pilot sent a text message at 1240 indicating that she was ready to taxi for departure from Whiskey Lake so the family member would know when to expect her arrival. The intended route of flight was from Whiskey Lake to Lake Hood (PALH), Anchorage, Alaska. The family member estimated that it would take about 45 minutes to get from the departure point to the destination, and when the airplane was about 15 minutes overdue, he started calling around. A friend of the family flew over Whiskey Lake and found an airplane submerged in the water.   Members from the Alaska State Troopers (AST) Search and Rescue team located the airplane and pilot about 1630. Initial on scene photographs taken by AST indicated that the left float separated from the airplane, and it was subsequently located about 175 yards away from the main wreckage. The right float remained partially attached to the submerged airplane wreckage. On October 4, 2022, members from the Alaska Dive Search Rescue and Recovery Team traveled to Whiskey Lake and recovered the submerged airplane, then moved it to the shoreline.    PERSONNEL INFORMATION The pilot’s logbooks were not located. AIRCRAFT INFORMATION According to airworthiness records the floats were installed in June 1960. There were no maintenance records available for review. WRECKAGE AND IMPACT INFORMATION On October 6, 2022, the National Transportation Safety Board investigator-in-charge, along with representatives from Cessna Aircraft and the Federal Aviation Administration, traveled to the accident site. During the on-scene wreckage examination, flight control cable continuity was established from the control inputs to the control surfaces. The right wing was damaged from the tip of the wing inward; the wing tip was not located. The left wing remained submerged. The water rudder handle was in the UP position; the flaps were retracted. The propeller remained attached to the engine crankshaft flange. One blade was curled aft at the tip; the second blade was bent aft at midspan. Damage consistent with propeller strikes was noted on the inboard portion of the right float.   The bottoms of both floats were heavily corroded and discolored.   The right float remained attached to the airframe by the fly wire. There were six patches of varying size noted on the hull of the right float. A portion of the float hull, about midspan from the tip of the float to the step, was partially separated and bent aft. No evidence of impact with a foreign object was noted. (See Figure 1.)  Figure 1 View of partially separated section on hull of the right float.   The left float separated and was also recovered to the shore. Impact damage was noted on the front tip of the float. There was one patch on the hull of the left float, with another patch on top of it. The aircraft was equipped with EDO 249-2870 floats. According to airworthiness records the floats were installed in June 1960. There were no maintenance records available for review. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed by the Alaska State Medical Examiner’s Office, Anchorage, Alaska. The cause of death was blunt force injuries and subsequent drowning. Toxicology testing performed by the Federal Aviation Administration’s (FAA) Bioaeronautical Sciences Laboratory detected diazepam in the pilot’s femoral blood at 12 ng/mL and the diazepam metabolite nordiazepam at 9 ng/mL in femoral blood. Venlafaxine and its metabolites were detected in femoral blood at 18ng/mL and 112 ng/mL, respectively. The high blood pressure medications metoprolol and timolol were detected in the pilot’s liver tissue; metoprolol was also detected in her femoral blood, while the result for timolol in her femoral blood was inconclusive. Diazepam, sometimes marketed as Valium, is a prescription benzodiazepine medication that can be used to treat a variety of conditions, including anxiety, muscle spasms, alcohol withdrawal, and seizures. Diazepam has sedative effects and can impair cognitive and psychomotor performance. The FAA considers an open prescription for diazepam disqualifying for medical certification and states that pilots using diazepam should not fly. Nordiazepam, oxazepam, and temazepam are active metabolites of diazepam. -
Analysis
The pilot was departing on a cross-country flight in a float-equipped airplane when the accident occurred. She had contacted a family member and stated she was departing; however, she did not arrive at the destination when expected. A search was initiated, and the airplane was located partially submerged in the departure lake. Postaccident examination of the wreckage revealed that both floats were heavily corroded and separated from the fuselage. There was no evidence that either float had contacted a foreign object in the water. A portion of the hull on the right float tore open and bent back. It is likely that tear in the float resulted in the airplane impacting the water during the takeoff. Maintenance records were not available for review during the investigation. Though toxicology testing of the pilot’s tissue detected diazepam and venlafaxine and their metabolites in the pilot’s system, it is unlikely that the effects of these medications contributed to this accident.
Probable cause
The failure of the landing gear float due to inadequate maintenance of the floats and corrosion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180A
Amateur built
false
Engines
1 Reciprocating
Registration number
N9728B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
50026
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-09-26T21:35:05Z guid: 105993 uri: 105993 title: ERA22LA436 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106210/pdf description:
Unique identifier
106210
NTSB case number
ERA22LA436
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-25T19:19:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-11-02T19:40:06.554Z
Event type
Accident
Location
Richmond, Kentucky
Airport
Central Kentucky Regional (RGA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the multiengine airplane reported that he had completed six touch-and-go landings uneventfully. During approach for the seventh landing, he was distracted by a low fuel caution light illuminating in the cockpit, and other traffic in the area. The pilot forgot to extend the landing gear and the airplane landed on the runway with the landing gear retracted. The airplane came to rest upright on the runway and postaccident examination of it revealed substantial damage to the fuselage stringers. The pilot further reported that there were no preimpact mechanical malfunctions with the airplane.
Probable cause
The pilot’s failure to extend the landing gear prior to landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA60
Amateur built
false
Engines
2 Reciprocating
Registration number
N711TL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
608423017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-02T19:40:06Z guid: 106210 uri: 106210 title: ERA22LA434 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106141/pdf description:
Unique identifier
106141
NTSB case number
ERA22LA434
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-26T10:00:00Z
Publication date
2024-01-30T05:00:00Z
Report type
Final
Last updated
2022-10-18T22:25:40.751Z
Event type
Accident
Location
Augusta, Georgia
Airport
Augusta Regional Airport (AGS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On September 26, 2022, about 0900 eastern daylight time, a Cessna 414 airplane, N745EP, was substantially damaged when it was involved in an accident at Augusta Regional Airport at Bush Field (AGS), Augusta, Georgia. The private pilot and passenger were not injured. The airplane was operated by the pilot as a personal flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot reported that during a visual approach to runway 35, while crossing over the runway numbers, he received a landing gear unsafe warning horn alert. He also observed a flickering nose landing gear (NLG) down light indication. He performed a go-around and, while in the traffic pattern, he cycled the landing gear up and down with the landing gear switch. The NLG light continued to flicker on and off, and the main landing gear lights were steady green, indicating they were down and locked. The pilot reported that the tower controller advised that the landing gear appeared to be down, so he continued in the traffic pattern for landing. Upon touchdown the NLG collapsed, and the airplane skidded to a stop on runway 35. The forward fuselage area sustained substantial damage. An examination of the landing gear system found that the NLG adjusting bell crank and actuator rod were connected. The NLG actuator rod was disconnected from the adjusting bell crank to facilitate recovery of the airplane. The NLG locked into place when moved into position by hand and three green lights were observed in the cockpit. There were no anomalies discovered with any linkages, bell cranks, or actuator arms, that would have resulted in the partial extension of the NLG. The landing gear system could not be otherwise functionally tested due to the airframe damage that prevented normal main and nose landing gear movement. The manual landing gear extension crank in the cockpit was found in an intermediate position, neither fully stowed nor extended. The crank was found to catch on the pilot seat when it was attempted to be stowed; however, the crank was able to be stowed when it was rotated approximately 1/4 turn. According to the Airplane Flight Manual, the landing gear emergency extension procedure stated in part: “Hand Crank – Push Button and Stow.” According to the Cessna 414 service manual, information was provided on troubleshooting the landing gear system when all three landing gear were not observed to be down and locked. Several possible issues were listed with corrective actions. The first item listed was, “manual extension crank improperly stowed” with a corrective action being “stow crank properly.” -
Analysis
The pilot reported that after an uneventful cross-country flight, while on short final approach to the runway, he received an unsafe nose landing gear (NLG) indication and performed a go-around. The pilot reported that the main landing gear indicator lights showed that the landing gear were down and locked; however, the NLG indicator light was flickering on and off. The pilot cycled the landing gear with the landing gear switch while in the traffic pattern and received confirmation from the tower controller that the landing gear appeared down. Subsequently, the pilot continued the traffic pattern to landing and, upon touchdown, the NLG collapsed and the airplane skidded to a stop on the runway. The fuselage sustained substantial damage. Examination of the landing gear system found no anomalies that would have prevented normal operation of the nose landing gear. Damage sustained to the airframe prevented the landing gear system from being tested. The manual landing gear extension crank was found in an intermediate position, which likely would have prevented the nose landing gear from fully extending and locking into place. The investigation was not able to determine whether the crank was improperly stowed, or not fully engaged, during flight, or whether the crank was moved after the accident during recovery operations.
Probable cause
The failure of the nose landing gear to fully extend and lock into position for reasons that could not be determined, which resulted in its collapse during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
414
Amateur built
false
Engines
2 Reciprocating
Registration number
N745EP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
414-0498
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-18T22:25:40Z guid: 106141 uri: 106141 title: ERA22LA435 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106142/pdf description:
Unique identifier
106142
NTSB case number
ERA22LA435
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-26T23:00:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-28T22:11:40.859Z
Event type
Accident
Location
Clearwater, Florida
Airport
CLEARWATER AIR PARK (CLW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the flight instructor, at the conclusion of the checkout flight he and the pilot were returning to the airport for landing. The instructor described that the pilot’s approach was stable until he began the landing flare too high, at an estimated altitude of about 20 feet. The flight instructor told the pilot to execute a go-around and then attempted to take over the flight controls. He was unable to recover before the airplane landed hard, resulting in substantial damage to both wings. The flight instructor stated that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper landing flare, which resulted in a hard landing. Contributing to the accident was the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28R-200
Amateur built
false
Engines
1 Reciprocating
Registration number
N1434T
Operator
Tampa Bay Aviation Inc
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28R-7235288
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-28T22:11:40Z guid: 106142 uri: 106142 title: CEN22LA434 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106010/pdf description:
Unique identifier
106010
NTSB case number
CEN22LA434
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-27T16:15:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2022-10-11T17:49:36.604Z
Event type
Accident
Location
McGregor, Texas
Airport
McGregor Executive Airport (PWG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The captain reported that the airplane was on a stabilized approach when, just before the airplane touched down, he heard a horn activate. He did not realize that the landing gear was not fully down until the nose landing gear touched down and he heard metal grinding. The airplane veered off the right side of the runway and came to rest about 20 ft from the edge. The airplane sustained substantial damage to the bottom of the fuselage. The captain’s recollection of the landing gear selection was “fuzzy” following the accident. A postaccident functional test of the landing gear system showed normal extension and retraction. No other preaccident failures or malfunctions were noted with the airplane or systems that would have precluded normal operations. The lack of anomalies indicated that the flight crew failed to ensure the landing gear was down before landing.
Probable cause
The flight crew’s failure to ensure the landing gear was down which resulted in a gear up landing and subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
550
Amateur built
false
Engines
2 Turbo fan
Registration number
N409ST
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
550-0559
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-11T17:49:36Z guid: 106010 uri: 106010 title: CEN22LA445 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192881/pdf description:
Unique identifier
192881
NTSB case number
CEN22LA445
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-28T15:50:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-09-10T22:43:53.926Z
Event type
Accident
Location
Monticello, Iowa
Airport
Monticello Regional (MXO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that the brakes were not effective during landing rollout. He allowed the airplane to depart the paved runway into the adjacent grass area to slow down. The airplane encountered a shallow ditch which damaged the fuselage immediately aft of the firewall, resulting in substantial damage to the airplane. The firewall and nose landing gear were also damaged. A mechanic completed a postaccident examination and was unable to identify any anomalies with respect to the brake system. The mechanic commented that the brake system can be affected if the parking brake is partially engaged at takeoff; however, the pilot reported that the parking brake was not used during the flight. The mechanic noted the airplane departed the pavement about 800 ft from the end of the 4,400 ft runway and encountered a drainage ditch. The airplane traveled about 600 ft past the ditch before it stopped. Based upon this distance, the pilot likely landed long and with excessive airspeed which resulted in an inability to slow the airplane sufficiently before encountering the end of the runway.
Probable cause
The pilot’s failure to maintain a proper approach airspeed and glidepath which resulted in a long landing and his inability to stop the airplane on available runway and the subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N5244R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17263458
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-10T22:43:53Z guid: 192881 uri: 192881 title: CEN22LA437 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106018/pdf description:
Unique identifier
106018
NTSB case number
CEN22LA437
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-28T17:00:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2022-10-12T16:36:12.785Z
Event type
Accident
Location
San Antonio, Texas
Airport
BOERNE STAGE FLD (5C1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While performing a landing to the runway, the student pilot lost control of the airplane, departed the runway, and collided with a glider and a hangar. The airplane sustained substantial damage to fuselage, empennage, and both wings. The student pilot reported that he did not initiate the go around in time. The student pilot did not return the National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident Report Form 6120.1.
Probable cause
The student pilot’s failure to maintain control of the airplane during the landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N93PF
Operator
BLUE SKY AVIATION MANAGEMENT LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2502
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-12T16:36:12Z guid: 106018 uri: 106018 title: ERA22LA432 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106024/pdf description:
Unique identifier
106024
NTSB case number
ERA22LA432
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-28T17:00:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-13T18:47:23.162Z
Event type
Accident
Location
Winterville, North Carolina
Airport
SOUTH OAKS AERODROME (05N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
According to the flight instructor, the student pilot was high on the approach but he allowed her to continue as he determined the landing was achievable based on visual references and cues. The student performed the landing flare, the airplane “hit hard and bounced quite high,” and the airplane pitched nose up to about a 45-degree angle. The flight instructor assumed control of the airplane, pushed the nose downward and applied full engine power to recover from the “imminent stall.” The flight instructor explained that the airplane lacked the power, airspeed, and altitude to outclimb the trees to its front and continued to fly the airplane “right at stall speed” until it settled into an area of small trees and heavy brush beyond the departure end of the landing runway, which resulted in substantial damage to the airplane’s fuselage and wings, and minor injuries to the occupants.
Probable cause
The student pilot’s improper recovery from a bounced landing. A factor in the accident was the instructor’s delayed remedial action which resulted in an inability to recover the airplane from an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N2509N
Operator
PEARCE CEDRIC J
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
12766
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-13T18:47:23Z guid: 106024 uri: 106024 title: ERA22LA431 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106021/pdf description:
Unique identifier
106021
NTSB case number
ERA22LA431
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-29T10:15:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-28T18:29:03.178Z
Event type
Accident
Location
Nashville, Tennessee
Airport
JOHN C TUNE (JWN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The student pilot reported that while hovering, the helicopter encountered a gust of wind and began to yaw to the right. The student pilot was unable to correct for the unanticipated right yaw, resulting in the forward portion of the helicopter’s right skid impacting the ground, and a subsequent dynamic rollover. The rollover resulted in substantial damage to the main rotor blades, tail boom, tail rotor, and vertical stabilizer. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
A loss of tail rotor effectiveness while hovering in crosswind conditions resulting in the student pilot's loss of control of the helicopter, impact with terrain, and dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R-22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N622MP
Operator
RJH, LLC.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
4016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-28T18:29:03Z guid: 106021 uri: 106021 title: DCA23LA008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106083/pdf description:
Unique identifier
106083
NTSB case number
DCA23LA008
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-29T11:30:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-10-11T23:46:46.3Z
Event type
Accident
Location
Denver, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
Southwest Airlines flight 48 encountered turbulence during cruise. One flight attendant sustained serious injuries. The airplane was not damaged. The regularly scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 from the Kansas City International Airport (MCI), Kansas City, Missouri, to the Denver International Airport (DEN), Denver, Colorado. According to the flight attendant, as she was pouring coffee into cups while in the front galley, the airplane encountered very light turbulence which she described as a ‘very light bump’. During the event, the coffee pot flipped over and spilled coffee onto the back of her hand, resulting in 2nd degree burns. After the event, the captain called back to the cabin to apologize for the turbulence and advised that it was unexpected. The flight attendant continued duties after the event, and there was no further turbulence. Prior to the flight, the captain discussed the possibility of turbulence during the preflight briefing, however the turbulence associated with the event was unannounced and unexpected.
Probable cause
An encounter with clear air turbulence during cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737
Amateur built
false
Engines
2 Turbo fan
Registration number
N7881A
Operator
Southwest Airlines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
35084
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-10-11T23:46:46Z guid: 106083 uri: 106083 title: CEN22LA438 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106051/pdf description:
Unique identifier
106051
NTSB case number
CEN22LA438
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-09-30T19:03:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2022-10-12T00:34:19.841Z
Event type
Accident
Location
Haskell, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that shortly after takeoff, he noticed flames coming from under the engine cowling. He maneuvered the airplane into the downwind pattern for the runway as the fire continued to develop in the airplane. Unable to make the runway, the pilot landed the airplane off field. The airplane was destroyed by the fire. After the airplane was recovered, extensive fire damage was observed with the engine. The mechanical fuel pump was completely consumed during the fire. Due to fire damage the fuel pump could not be tested or examined and the reason for the inflight fire was not determined.
Probable cause
The inflight fire for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SHIREY DAVID A
Model
FISHER CELEBRITY
Amateur built
true
Engines
1 Reciprocating
Registration number
N812TD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-10-12T00:34:19Z guid: 106051 uri: 106051 title: ERA23LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106053/pdf description:
Unique identifier
106053
NTSB case number
ERA23LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-02T11:30:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2022-10-04T19:26:16.465Z
Event type
Accident
Location
Murray, Kentucky
Airport
KYLE-OAKLEY FLD (CEY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The airplane had been in maintenance for repair work on the airplane’s tail section. On the first flight after the completed work, following a preflight inspection and engine run-up, the pilot taxied the airplane to the runway for departure. During the takeoff roll, when the pilot applied forward stick controls to raise the tail, the tail did not rise, and the airplane instead “shot straight up, stalled, then descended nose-first onto the runway.” Examination of the airplane by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted that the elevator control cables were installed incorrectly such that the elevator moved in the direction opposite to that commanded.
Probable cause
The incorrect (reverse) rigging of the elevator cables by maintenance personnel and their subsequent failure to verify that the rigging was correct during post-maintenance checks and the pilot's inadequate preflight check.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N3005E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7AC-6591
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-04T19:26:16Z guid: 106053 uri: 106053 title: CEN23LA001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106036/pdf description:
Unique identifier
106036
NTSB case number
CEN23LA001
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-02T13:48:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-10-12T18:39:29.608Z
Event type
Accident
Location
Burnet, Texas
Airport
Burnet Municipal Airport (BMQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that a gust of wind caused the tailwheel-equipped airplane to swerve left during landing roll. He was unable to regain directional control of the airplane before it departed off the left runway edge, striking a concrete pad and runway edge light which caused the airplane to nose over. The airplane’s fuselage, vertical stabilizer, and rudder were substantially damaged during the accident. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported that the surface wind was calm when he listened to the airport’s automated weather broadcast about 11 minutes before landing. A weather report issued about 5 minutes after the accident included a 4-knot surface wind from the northeast. Based on available weather information, a variable wind direction likely prevailed at the time of the accident that resulted in an unexpected left quartering tailwind during the landing.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with an unexpected quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N72794
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
9980
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-12T18:39:29Z guid: 106036 uri: 106036 title: WPR23LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106042/pdf description:
Unique identifier
106042
NTSB case number
WPR23LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-02T17:00:00Z
Publication date
2023-08-23T04:00:00Z
Report type
Final
Last updated
2022-10-04T22:23:47.02Z
Event type
Accident
Location
Clovis, New Mexico
Airport
CLOVIS RGNL (CVN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 2, 2022, about 1600 Mountain daylight time, a Piper PA-46-350P, N987PS, was substantially damaged when it was involved in an accident near Clovis, New Mexico. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he encountered “a major wind gust” while on a visual approach to runway 4 at Clovis Regional Airport (CVN). In response, he aborted the approach, applied full engine power, and retracted the landing gear and flaps; however, the airplane did not have enough speed and power to maintain flight. The pilot subsequently felt the airplane buffet and lowered the nose. The pilot maneuvered the airplane and initiated a gear-up landing to an open field adjacent to runway 4. During the landing sequence, the right horizontal stabilizer impacted an airport sign, and the airplane came to rest upright. A postaccident fire ensued. The automated weather observation station located on the airport reported that, about 4 minutes before the accident, the wind was from 180° at 11 knots. The same automated station reported that, about 56 minutes after the accident, the wind was from 160° at 10 knots. The calculated crosswind component at the time of the accident was about 7 knots, with a tailwind of about 8 knots. Postaccident examination of the airplane revealed that the fuselage undercarriage, right horizontal stabilizer, and the right elevator were substantially damaged. A subsequent examination of the recovered wreckage revealed no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. A review of the airplane’s Pilot Operating Handbook (POH), Section 4.33, “GO-AROUND,” states in part, “To initiate a go-around from a landing approach, the mixture should be set to full RICH, the propeller control should be a full INCREASE, and the throttle should be advanced to full power while the pitch attitude is increased to obtain the balked landing climb speed of 80 KIAS. Retract the landing gear and slowly retract the flaps when a positive climb is established. Allow the airplane to accelerate to the best angle of climb (81 KIAS) for obstacle clearance or to the best rate of climb speed (110 KIAS) if obstacles are not a factor.” -
Analysis
As the pilot approached the destination airport, the wind was reported as light and variable. He stated that as he flew the visual approach to runway 4 and prepared to land, he encountered a major gust of wind and elected to perform a go-around. The pilot reported that he applied full engine power, retracted the landing gear and flaps, and initiated a climb when the “stall shaker started shaking”. The pilot lowered the nose to prevent the airplane from stalling and initiated a gear-up landing to an open field adjacent to the runway. The pilot reported encountering a gust of wind; however, the wind reported at the airport 4 minutes before the accident was from 180 ° at 11 knots. The wind reported about an hour after the accident was from 160° at 10 knots. Neither weather report indicated wind gusts or significant changes in wind direction. The calculated crosswind component at the time of the accident was about 7 knots, with a tailwind of about 8 knots. Postaccident examination of the airplane revealed no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. Given the pilot’s description of the go-around and the absence of a mechanical failure or malfunction, he likely retracted the flaps before establishing the required climb airspeed and positive rate of climb. The quartering tailwind would have contributed to the loss of expected airplane performance, resulting in an incipient stall and the subsequent gear-up landing.
Probable cause
The pilot’s failure to follow the go-around procedures by prematurely retracting the flaps and not establishing a proper go-around climb speed after attempting to land with a quartering tailwind, resulting in the airplane’s inability to climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA 46-350P
Amateur built
false
Engines
1 Reciprocating
Registration number
N987PS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
46-36225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-04T22:23:47Z guid: 106042 uri: 106042 title: ERA23LA017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106116/pdf description:
Unique identifier
106116
NTSB case number
ERA23LA017
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-04T07:45:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-13T19:11:25.294Z
Event type
Accident
Location
Sanford, Florida
Airport
ORLANDO SANFORD INTL (SFB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot under instruction was flying a practice power-off 180° maneuver from the downwind leg at the accident airport. The flight instructor stated that on final approach the airplane’s airspeed was slow and the flight path was low. He stated that since the purpose of the flight was to evaluate student’s piloting skills, he allowed the approach to proceed and did not tell the student to add power or go around. The airplane landed firmly at the runway threshold and the horizontal stabilizer impacted a runway threshold light. Postaccident examination revealed that the horizontal stabilizer sustained substantial damage. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation and that a go-around maneuver should have been initiated when the approach became unstable.
Probable cause
The pilot's unstable approach, which resulted in a hard landing and impact with a runway threshold light. Also causal was the flight instructor’s failure to take remedial action to prevent the hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N455ER
Operator
EMBRY-RIDDLE AERONAUTICAL UNIVERSITY INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S11591
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-13T19:11:25Z guid: 106116 uri: 106116 title: ERA23LA005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106060/pdf description:
Unique identifier
106060
NTSB case number
ERA23LA005
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-04T13:55:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-11T17:56:46.794Z
Event type
Accident
Location
Milan, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he purchased the multiengine airplane about 3 months prior to the accident, then flew it uneventfully to another airport for an annual inspection and to have other maintenance issues addressed. After the annual inspection was completed, several engine-runs and taxi checks were performed with no anomalies noted. On the day of the accident, the pilot completed a preflight inspection and intended to fly to his home airport. The mechanic that completed the annual inspection told him that he had drained black sooty water from the fuel tanks. The pilot went out to the airplane and drained water out of the tanks until the fuel was clean and clear. About 5 to 6 minutes into the flight, the left engine began to run rough and lost partial power. When the pilot increased the power on the right engine, the right engine immediately lost all power. He set up for an off-airport landing and noticed a highway, so he lined up with the centerline of the highway and landed. During the landing rollout, the right-wing tip collided with a highway sign. The airplane subsequently rolled off the highway and came to rest upright in a field. Postaccident examination of the airplane revealed substantial damage to the right-wing spar. Two days after the accident, more water was sumped from both fuel tanks. After the water was removed, both engines ran normally. The pilot added that there were no preimpact mechanical malfunctions with the airplane. Based on this information, it is most likely that the loss of engine power the pilot experienced during the accident flight was due to fuel contamination.
Probable cause
The pilot's inadequate preflight inspection, which resulted in a total loss of engine power during cruise flight due to fuel contamination.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N7494Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-555
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-11T17:56:46Z guid: 106060 uri: 106060 title: DCA23FM001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106069/pdf description:
Unique identifier
106069
NTSB case number
DCA23FM001
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-10-04T23:41:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2023-09-21T04:00:00Z
Event type
Accident
Location
Newport News, Virginia
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire was an unknown electrical fault in the battery compartment of the crane aboard Kokosing V.
Has safety recommendations
false

Vehicle 1

Callsign
K0KOV
Vessel name
Kokosing V
Vessel type
Towing/Barge
Maritime Mobile Service Identity
368233760
Port of registry
Baltimore
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-09-21T04:00:00Z guid: 106069 uri: 106069 title: ANC23FA001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106074/pdf description:
Unique identifier
106074
NTSB case number
ANC23FA001
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-05T18:58:00Z
Publication date
2023-10-10T04:00:00Z
Report type
Final
Last updated
2022-10-11T21:36:14.857Z
Event type
Accident
Location
Fairbanks, Alaska
Airport
Chena Marina (AK28)
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
About 95 pounds of cargo was located in the left float hatch. A total of about 838 pounds of cargo was in the airplane. - On October 05, 2022, about 1758 Alaska daylight time, a Cessna 185F, N217C, was not damaged when it was involved in an accident near Fairbanks, Alaska. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness located next to the waterway stated that the pilot attempted and subsequently aborted the first takeoff. The pilot then began taxiing back to the point of the initial takeoff run. The witness stated that the engine appeared to be operating at full power during the takeoff attempt. During the taxi back following the aborted takeoff, the airplane’s attitude was nose-low and the floats were almost completely submerged underwater. Another witness on the other side of the float pond noted that the accident airplane’s floats looked almost fully submerged under water as the airplane taxied. The witness said that the airplane was using more than normal power to taxi in the water and that the elevators appeared to be in the full nose-up position. He then heard the engine power decrease, saw the airplane start to nose over, heard the power increase, and then observed the airplane completely nose over into the water. When the airplane was pulled up on the shore, a witness observed four large streams of water coming out of the front of both floats. - Unrestrained cargo in the cabin shifted forward during the event sequence and rescuers were unable to free the pilot from the cockpit. About 690 pounds of cargo had to be removed before rescuers could free the pilot from the airplane. - The airplane sustained no impact damage in the accident. All damage to the airframe was sustained during the recovery and rescue attempt of the pilot. During a postaccident examination of the floats, two unplugged holes were found under each front float bumper. The pilot’s son said that when the airplane arrived in Alaska, the standard float bumpers were not installed and a tire-type material was installed as a bumper instead. The correct smaller bumpers were installed at the time of the accident, with new-looking sealant around the bumper. 4 holes had been added to the front of each float to attach the larger, tire-type bumper; however, only the two side holes had been plugged and sealed. The two lower holes were left open. A Federal Aviation Administration inspector examined the underside of each float and found patches that did not appear to be watertight on the bottom. A witness stated that the pilot kept this airplane on the shore when it was not in use. -
Analysis
The pilot of the float-equipped airplane was departing from a pond. He aborted the first attempt and was taxiing back to attempt a second takeoff. Witnesses saw the floats almost fully submerged under the water as the airplane taxied and stated that the pitch attitude of the airplane was unusually nose-low. The pilot reduced engine power and the airplane nosed over. The airplane was not damaged; however, several hundred pounds of unsecured cargo inside the airplane shifted during the nose-over and likely resulted in the pilot’s inability to egress and his subsequent drowning. During a postaccident examination, two unsealed holes were found under the float bumpers that would have allowed water to enter the front compartment of each float. It is likely that the front compartments in both floats filled with water and resulted in the nose-over during taxi.
Probable cause
The improperly maintained floats, which allowed water to fill the front compartments and resulted in the airplane nosing over during taxi. Contributing to the fatal injury of the pilot was the improperly secured cargo, which prevented the pilot from egressing the airplane following the nose-over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N217C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18503558
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-10-11T21:36:14Z guid: 106074 uri: 106074 title: ERA23LA010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106085/pdf description:
Unique identifier
106085
NTSB case number
ERA23LA010
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-07T15:04:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-20T19:14:27.158Z
Event type
Accident
Location
ROWLESBURG, West Virginia
Airport
Cheat Island (PZ52)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
According to the pilot, he was on approach to a private turf airstrip when the accident event occurred. He said that after overflying the runway, he descended to 200 feet as he entered a tight left downwind leg of the traffic pattern over a nearby river. As he made the turn from downwind to final, he noted that his angle of attack instrument was reading well below critical angle, then within a second the plane rolled right and “slammed” into the ground. He offered the hypothesis that a sudden gust cut his lift and resulted in the stall/spin. He also stated that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation. Witnesses at the airport describe that they saw the airplane on the downwind leg of the approach, and that the airplane was closer to the airport compared to other airplanes that had been landing on the same runway. The witnesses described that the airplane was low, about 30 to 40 ft above the ground, and in a steep bank at high speed when it impacted the ground approximately 500 yards from the end of the runway. Postaccident examination of the airplane by a Federal Aviation Administration inspector confirmed that the airplane’s fuselage and wings were substantially damaged. Given this information, it is likely that the pilot failed to fly the airplane at an appropriate airspeed/angle-of-attack during the landing approach, which resulted in an aerodynamic stall, and impact with terrain.
Probable cause
The pilot's failure to maintain an appropriate airspeed/angle-of-attack during the landing approach, which resulted in an aerodynamic stall, and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GREEN L/GILNER D
Model
RV-4
Amateur built
true
Engines
1 Reciprocating
Registration number
N262DF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1969
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-20T19:14:27Z guid: 106085 uri: 106085 title: CEN23LA010 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106094/pdf description:
Unique identifier
106094
NTSB case number
CEN23LA010
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-07T17:30:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-10-12T18:37:14.851Z
Event type
Accident
Location
Libby, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was conducting a personal flight when the airplane had a total loss of engine power during cruise flight. The pilot stated that the flight departed with about 16 gallons of fuel distributed evenly between the left- and right-wing tanks, and both fuel tank gauges indicated about ¾ full before departure. About 30-45 minutes into the flight, the pilot noted that the left fuel tank gauge indicated about ¼ full while the right fuel tank gauge remained about ¾ full. The pilot decided to reposition the fuel selector valve to the right fuel tank to correct the fuel imbalance. The pilot stated that the location of his Apple iPad in the cockpit blocked his view of the right fuel tank gauge, so he made a “mental note” to check the right fuel tank gauge in about 30-45 minutes. The pilot reported that the flight continued uneventfully at 300 ft above ground level until the airplane had a total loss of engine power due to a lack of fuel in the right fuel tank. The engine did not restart after the pilot repositioned the fuel selector valve to BOTH, turned on the electric fuel boost pump, and engaged the electric starter. Both wings were substantially damaged during the subsequent forced landing in a wooded area. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The low altitude at which the loss of engine power occurred significantly reduced the amount of time available to the pilot to troubleshoot and restore engine power before the forced landing.
Probable cause
The total loss of engine power due to the pilot’s improper fuel management, which led to fuel starvation. Contributing to the accident was the low altitude at which the loss of engine power occurred.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Zenith Aircraft Company
Model
CH 750
Amateur built
true
Engines
1 Reciprocating
Registration number
N550ZF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-7677
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-12T18:37:14Z guid: 106094 uri: 106094 title: HWY23IH003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106350/pdf description:
Unique identifier
106350
NTSB case number
HWY23IH003
Transportation mode
Highway
Investigation agency
Other
Completion status
Completed
Occurrence date
2022-10-07T22:26:00Z
Publication date
2023-10-10T04:00:00Z
Report type
Final
Event type
Accident
Location
Maize, Kansas
Injuries
1 fatal, 1 serious, 0 minor
Probable cause
None
Has safety recommendations
false

Vehicle 1

Traffic unit name
2016 Dodge Charger
Traffic unit type
Single Vehicle
Units
Findings

Vehicle 2

Traffic unit name
2020 Jeep Grand Cherokee
Traffic unit type
Single Vehicle
Units
Findings
creator: Other last-modified: 2023-10-10T04:00:00Z guid: 106350 uri: 106350 title: CEN23LA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106093/pdf description:
Unique identifier
106093
NTSB case number
CEN23LA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-09T12:20:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-12T17:03:06.174Z
Event type
Accident
Location
Stanwood, Iowa
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was performing a test flight in the experimental airplane after completing a modification to the pitch control system. While on downwind to land at the private airstrip, the engine lost partial power. During the base to final turn, about 300 ft above ground level, the airplane exceeded its critical angle of attack, which resulted in an aerodynamic stall and loss of airplane control at an altitude too low to allow for recovery. The airplane impacted a cornfield short of the private airstrip and sustained substantial damage to the fuselage and both wings. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot stated that the partial loss of engine power was due to an excessive fuel pressure to the carburetor because he forgot to open a valve that bypassed fuel around the fuel pump that is used for engine priming and starting.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack in the traffic pattern, which resulted in an aerodynamic stall and loss of airplane control at too low of an altitude to recover. Contributing to the accident was the partial loss of engine power due to improper management of the fuel system.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
YATES MIKE E
Model
ROARING EAGLE
Amateur built
true
Engines
1 Reciprocating
Registration number
N181MY
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
MB5137
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-12T17:03:06Z guid: 106093 uri: 106093 title: CEN23LA286 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192566/pdf description:
Unique identifier
192566
NTSB case number
CEN23LA286
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-12T13:55:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-08-10T19:51:27.584Z
Event type
Accident
Location
Holland, Michigan
Airport
West Michigan Regional (BIV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that about 30 minutes before arrival, the crew obtained weather information which showed a left crosswind component of 25 knots (kts) for runway 26. When they flew closer to the airport, the crew requested current wind from air traffic control and determined the crosswind component to be about 17 kts. On landing, the pilot lost directional control of the airplane as it weather-vaned. Despite the use of full right rudder, the pilot could not regain control of the airplane. As the wind subsided, the pilot corrected the airplane back to the runway centerline when another gust of wind pushed the airplane off the right side of the runway. During the runway excursion, the right wing collided with a runway light which resulted in substantial damage to the forward spar lower flange. The airplane was limited to a maximum crosswind of 20 kts. Several minutes after the airplane landed, the automated weather reporting station recorded wind from 190° at 16 kts with gusts to 27 kts.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with gusty wind which exceeded the maximum crosswind of the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HONDA AIRCRAFT CO LLC
Model
HA-420
Amateur built
false
Engines
2 Turbo fan
Registration number
N704JT
Operator
Protocom Aviation
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
42000218
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T19:51:27Z guid: 192566 uri: 192566 title: CEN23LA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106117/pdf description:
Unique identifier
106117
NTSB case number
CEN23LA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-12T16:12:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-10-24T17:59:31.127Z
Event type
Accident
Location
Paola, Kansas
Airport
Miami County Airport (K81)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On October 12, 2022, at 1512 central daylight time, a Piper PA-32-300, N4171W, sustained substantial damage when it was involved in an accident near Paola, Kansas. The pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the airplane had not been flown since May 2022 due to aviation fuel prices. The pilot stated that he departed from the Johnson County Executive Airport (OJC), Olathe, Kansas, and flew about 10 miles east, then flew south, and practiced steep turns, while en route to the Miami County Airport (K81), Paola, Kansas. He planned on performing a touch-and-go landing on runway 30. He stated that during the downwind leg for landing, he switched the fuel selector to the left main wing fuel tank. He said that he touched down “pretty abruptly,” and the touchdown was probably outside the first 1/3 down runway 3. He said that the airplane lifted off the runway about 2/3 down runway 3. He said that he reconfigured the flap setting to one notch and added engine power during takeoff. He did not change the flap setting. He said that the airplane felt like it was “winding down,” and he did not know what the manifold and engine/propeller speed gauge indications were because he did not look at them. He said the engine noise never ceased after he thought there was a loss of total engine power, but he was wearing a noise cancelling aviation headset. He did not remember the engine noise getting quiet. He said the engine did not sputter like previous occasions when the engine ran out of fuel. He said that the airplane was about 100-150 ft above the runway, with no visible runway remaining, when it lost power. He decided to attempt a landing in a small clearing ahead of the airplane. He climbed the airplane to avoid a tree and then lowered the airplane pitch to increase airspeed. He then pitched the airplane up and, the airplane entered an aerodynamic stall. The airplane impacted terrain and sustained substantial damage to the wings and fuselage. The pilot stated the aural stall warning was inoperative before the accident flight, but the stall warning light was functional. The stall warning system was going to be checked during the next annual inspection since it did not function when he practiced aerodynamic stalls in May 2022. The airport manager of K81 stated that during the recovery of the airplane from the accident site, he saw at least 5 gallons of fuel that “gushed out” of the left wing. Postaccident examination of the airplane revealed the right main wing tank was full, the left outboard wing tank had about 1-2 gallons of fuel, and the right outboard wing tank was empty. The fuel selector was found in the left main fuel tank position. There was no fuel contamination from sump samples taken from the fuel system. In preparation for an engine run, the airplane was placed and secured onto a trailer and a two-blade propeller was installed due damage sustained to the original propeller from the accident. Engine control continuity from the cockpit controls to the engine fuel servo was confirmed. The right main wing fuel tank was filled with about 10 gallons of fuel. The master switch and the boost pump were selected to ON and no fuel system leaks were present. The boost pump was turned ON for about 20-30 seconds and the ignition key switch was used to engage the starter, which rotated the engine freely, but the engine did not start. The boost pump was turned ON again for about 30-45 seconds and then the engine was started using the ignition key switch. The engine ran smoothly. The engine was shut down by moving the fuel selector to OFF. The previous airplane owner stated that sometimes when switching fuel tanks, there could be an issue if the fuel selector was not placed directly in the detent. -
Analysis
The pilot stated that while the airplane was on the downwind leg for landing at the destination airport, he changed the fuel tank selection to the left main wing fuel tank. The airplane’s touchdown point was beyond a 1/3 down the runway, and the airplane lifted off about 2/3 down the runway for a touch and go. The airplane was about 100-150 ft above the runway, with no runway remaining, when the engine lost power. The pilot attempted a forced landing in a small clearing ahead of the airplane. The airplane stalled and impacted the terrain as the pilot maneuvered to clear trees along the flightpath. Both wings and the fuselage sustained substantial damage. A postaccident examination of the airplane revealed that the airplane had useable fuel and there was no fuel contamination from drained fuel tank samples. An engine test run revealed no mechanical anomalies that would have precluded normal engine operation. The previous airplane owner stated that sometimes when selecting different fuel tanks on the accident airplane with the selector, if the detent was not hit right on, it could be an issue. A lack of a positive selection of the fuel selector could have allowed engine operation for a short time, such as from downwind to landing, due to the limited fuel available downstream of the fuel selector. Also, a change in fuel system configuration while the airplane was in the traffic pattern does not mitigate the risks from an improper selection as afforded by making such a selection before reaching the traffic pattern altitude.
Probable cause
The pilot’s improper positioning of the fuel selector, which resulted in fuel starvation and a loss of engine power during a departure climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N4171W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32-40250
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-24T17:59:31Z guid: 106117 uri: 106117 title: ERA23LA018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106123/pdf description:
Unique identifier
106123
NTSB case number
ERA23LA018
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-13T10:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2022-10-25T18:03:07.128Z
Event type
Accident
Location
Middlefield, Ohio
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot departed on the fifth and final leg of the evening’s flights with no cargo and an unknown quantity of fuel. He reported that he had to deviate due to weather along the route of flight, and that the right engine began running rough after reaching cruise altitude. About 2.2 hours into the planned 2-hour flight, and about 25 miles from the destination airport, both of the airplane’s engines began “surging” and eventually “stopped producing power.” The pilot stated that he looked at the fuel gauges and they indicated empty. The pilot completed a forced landing to horse pastures, during which the airplane impacted fences, resulting in substantial damage to the wings and the fuselage. There was no evidence of fuel, fuel spillage, or odor of fuel at the scene. The pilot stated that the accident flight was longer than planned due to headwinds and weather diversions. The pilot also explained that there were known discrepancies with the fuel gauges. He also described that there had been a difference between the amount of fuel he requested at one fuel stop, what was actually dispensed, and the total amount he believed was on board when he departed on the accident flight, as he did not get a receipt, or confirm the amount dispensed. Based on the pilot’s own fuel planning numbers, full tanks at initial departure, and the fuel purchased at 2 of his 4 stops, the airplane had a fuel endurance of about 6.8 hours, of which .8 hours was for IFR reserve minimums. The total time of the 5 legs was approximately 7.2 hours.
Probable cause
The pilot’s inadequate fuel planning and inflight fuel management which resulted in exhaustion of his fuel supply and a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310
Amateur built
false
Engines
2 Reciprocating
Registration number
N62368
Operator
AIR Z FLYING SERVICES INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Ferry
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
310R0131
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-25T18:03:07Z guid: 106123 uri: 106123 title: ERA23LA020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106130/pdf description:
Unique identifier
106130
NTSB case number
ERA23LA020
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-13T18:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-09T23:03:12.145Z
Event type
Accident
Location
New Smyrna Beach, Florida
Airport
MASSEY RANCH AIRPARK (X50)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot stated that he did not perform weight and balance calculations prior to the flight in the airplane but did perform an engine run-up before departure with no issues noted. During takeoff he applied full power and rotated, initially climbing to between 20 and 30 ft above ground level. At that altitude the airplane stopped climbing and was not accelerating. He reported that while airborne with 800 ft of runway remaining, the airplane “stalled” and impacted the ground. He reported to a Federal Aviation Administration (FAA) inspector that there wasn’t anything mechanically wrong with the airplane and that the engine was producing power during the entire event. Postaccident examination of the airplane by an FAA inspector revealed that the left wing was substantially damaged. The inspector also noted evidence of binding of the left aileron, but that was attributed to be associated with impact damage to the wing. There were no other issues noted with the flight controls. Postaccident calculations revealed that for the accident flight the airplane was likely at least 24 pounds above the maximum specified gross weight of 2,250 pounds. Although the pilot initially reported the altitude loss was associated with a wind shift, according review of weather data for the time and location of the accident revealed that there were no large fronts or boundaries in the area. Further, there was no wind above 10 knots until above 10,000 ft mean seal level, there were no AIRMETS for turbulence, and the wind at multiple nearby airports was from did not exceed a velocity of about 8 knots. Given all available information, it is most likely that the pilot exceeded the airplane’s critical angle-of-attack during the takeoff, which resulted in a stall/mush during the takeoff.
Probable cause
The pilot’s exceedance of the critical angle of attack during takeoff and corresponding stall/mush. Contributing to the accident were the pilot’s operation of the airplane above the maximum specified gross weight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERO COMMANDER
Model
100
Amateur built
false
Engines
1 Reciprocating
Registration number
N3885X
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
191
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-09T23:03:12Z guid: 106130 uri: 106130 title: ERA23LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106129/pdf description:
Unique identifier
106129
NTSB case number
ERA23LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T11:27:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-18T16:04:30.098Z
Event type
Accident
Location
Knoxville, Tennessee
Airport
KNOXVILLE DOWNTOWN ISLAND (DKX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was on his first solo flight and was attempting to land. Just before touch down, a gust of wind pushed the airplane off the left side of the runway, and it struck a ditch. Subsequently, the left horizontal stabilizer sustained substantial damage. The student pilot reported that the airplane had no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The student pilot’s loss of directional control on landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AMERICAN CORP
Model
AA-5A
Amateur built
false
Engines
1 Reciprocating
Registration number
N26944
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA5A0829
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-18T16:04:30Z guid: 106129 uri: 106129 title: WPR23LA016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106155/pdf description:
Unique identifier
106155
NTSB case number
WPR23LA016
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T15:43:00Z
Publication date
2023-08-16T04:00:00Z
Report type
Final
Last updated
2022-10-18T18:11:00.207Z
Event type
Accident
Location
Laramie, Wyoming
Airport
Laramie Regional Airport (LAR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 14, 2022, about 1443 mountain standard time, an experimental amateur-built Quickie QII airplane, Canadian registration C-GDHK, was substantially damaged when it was involved in an accident near Laramie, Wyoming. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, during the climb out from the Laramie Regional Airport (LAR), Laramie, Wyoming, a partial power loss occurred. The pilot verified that the fuel system, ignition, and carburetor heat were functioning, but could not restart the engine. Unable to maintain altitude, the pilot determined that the highway was the safest location to land. Upon touchdown, the airplane bounced, veered left off the paved lane, and came to rest upright in an adjacent ditch. The right canard separated, and the fuselage sustained substantial damage. Examination of the airframe revealed no mechanical malfunctions or failures that would have precluded normal operation. Flight control continuity was confirmed from all primary flight control surfaces to the controls in the cockpit. Throttle, mixture, and carburetor heat continuity were confirmed. Examination of the engine revealed the No. 4 top spark plug insulator was cracked, and the spark plug was bent about 10°. A valvetrain continuity check revealed that the No. 1 cylinder exhaust valve was lodged in the open position despite the use of moderate force. Examination of the No. 1 cylinder exhaust valve revealed a dark colored deposit on the valve stem, consistent with carbon, and a slight bend to the stem. Examination of the engine maintenance logbooks revealed that about 5 months before the accident, new engine cylinder heads, including valves and valve guides, were installed, and an annual inspection was performed. -
Analysis
During the climb out after takeoff, the airplane’s engine lost partial power. The pilot could not maintain altitude and performed a forced landing to a highway. Upon touchdown, the airplane bounced and then veered off the paved lane into a ditch. The airplane received substantial damage to the forward canards. Examination of the engine revealed the No. 1 cylinder exhaust valve had seized in the valve guide in the open position due to the buildup of carbon on the valve stem.
Probable cause
The partial loss of engine power due to the seizure of the No. 1 cylinder exhaust valve in the valve guide.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Quickie
Model
Q2
Amateur built
true
Engines
1 Reciprocating
Registration number
C-GDHK
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
DK081082
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-18T18:11:00Z guid: 106155 uri: 106155 title: ERA23LA032 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106172/pdf description:
Unique identifier
106172
NTSB case number
ERA23LA032
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T16:15:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-25T14:33:03.022Z
Event type
Accident
Location
Lawrenceburg, Tennessee
Airport
LAWRENCEBURG-LAWRENCE COUNTY (2M2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While enroute to the destination, the pilot noted moderate turbulence and decided to land and wait until the turbulence decreased. During the first landing attempt, there was turbulence and the pilot elected to perform a abort the landing after the airplane touched down briefly. After the second landing, during the landing roll, a gust of wind raised the right wing resulting in the airplane veering to the right. The pilot applied power to increase the airflow over the rudder and recenter the airplane, however the airplane was drifting to the left. The airplane departed the left side of the runway and nosed over. During the accident sequence, the airplane sustained substantial damage to the wings and right elevator. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HOWARD AIRCRAFT
Model
DGA-15P
Amateur built
false
Engines
1 Reciprocating
Registration number
N63597
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1830
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-25T14:33:03Z guid: 106172 uri: 106172 title: ERA23LA029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106165/pdf description:
Unique identifier
106165
NTSB case number
ERA23LA029
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T17:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-20T19:43:50.431Z
Event type
Accident
Location
Montgomery, Alabama
Airport
MONTGOMERY RGNL (DANNELLY FLD) (MGM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the student pilot, the airplane “slightly ballooned up” during the landing flare. This resulted in the nose landing gear impacting the ground “harder than normal.” The impact with the ground resulted in substantial damage to the engine mounts. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper landing flare, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28
Amateur built
false
Engines
1 Reciprocating
Registration number
N11NT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7205193
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-20T19:43:50Z guid: 106165 uri: 106165 title: ERA23LA028 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106162/pdf description:
Unique identifier
106162
NTSB case number
ERA23LA028
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T17:30:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-21T20:52:53.415Z
Event type
Accident
Location
Pell City, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the experimental airplane stated that his electronic cockpit display indicated 23 gallons of fuel prior to flight, but he did not visually inspect the fuel tanks as it would have required a step ladder. About 10 minutes after takeoff, the engine lost all power, and the pilot performed a forced landing in a field. During the landing, the airplane impacted a ditch and came to rest upright. The pilot checked the fuel tanks after the accident, and they were empty. Other than the fuel gauge, the pilot reported that there were no preimpact mechanical malfunctions with the airplane. Examination of the wreckage by a Federal Aviation Administration inspector revealed that main landing gear separated and the left wing strut sustained substantial damage.
Probable cause
The pilot’s inadequate preflight inspection, which resulted in a total loss of engine power during cruise flight due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MCGLAUGHLIN RICHARD
Model
SPORTSMAN GS2
Amateur built
true
Engines
1 Reciprocating
Registration number
N302BM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7283
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-21T20:52:53Z guid: 106162 uri: 106162 title: ERA23LA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106131/pdf description:
Unique identifier
106131
NTSB case number
ERA23LA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-14T18:11:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-26T17:39:49.136Z
Event type
Accident
Location
Daytona Beach, Florida
Airport
DAYTONA BEACH INTL (DAB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was attempting to land on a mobile helipad. During the landing the helicopter landed “off center” and rolled over onto its side. The helicopter collided with the terrain and sustained substantial damage. The pilot did not report any mechanical anomalies that would preclude normal operation. The helicopter was examined by a Federal Aviation Administration inspector after the accident. The examination confirmed that the airframe and main rotor blades were substantially damaged. No flight control anomalies were discovered that would have precluded normal operation.
Probable cause
The pilot’s misjudged landing point which resulted in a loss of control and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N306MB
Operator
Joel Vela
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
true
Serial number
2439
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-26T17:39:49Z guid: 106131 uri: 106131 title: WPR23LA013 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106137/pdf description:
Unique identifier
106137
NTSB case number
WPR23LA013
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-15T13:00:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2022-10-17T22:09:05.682Z
Event type
Accident
Location
Tucson, Arizona
Airport
Ryan Field Airport (RYN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 15, 2022, about 1200 mountain standard time, a Piper PA-30, N7746Y, was substantially damaged when it was involved in an accident near Ryan Field Airport (RYN), Tucson, Arizona. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, on short final to land at RYN, the airplane yawed “hard right.” He stated that full left rudder was needed to keep the airplane straight. The pilot stated that he thought that he heard an engine surge. The airplane subsequently touched down hard and departed the right side of the runway. The pilot reported that all three landing gear collapsed and that the airplane then slid to a stop. The left wing buckled during the accident sequence. No wind gusts were reported during the approach or landing. A postaccident examination of the wreckage was conducted. Flight control continuity was verified to all flight controls, and all flight control surfaces moved freely and as commanded when the aileron, elevator, and rudder controls were manipulated in the cockpit. Engine control continuity was verified by manipulating the throttle, mixture, and propeller controls in the cockpit and observing the associated controls move at each engine. The engine control manipulation was normal except for the constantspeed propeller control for the right engine. Excessive resistance was felt while manipulating the right engine propeller control, but the control lever was able to move throughout the full range of motion. The pilot recalled no unusual resistance in the engine controls before the accident. An engine run was accomplished on both engines. Before attempting the engine run on the right engine, the propeller control cable was disconnected at the propeller governor control arm. The control arm on the propeller controller operated normally and without restriction after the cable was disconnected. The resistance remained when the propeller control lever was manipulated while disconnected. The cable was then reconnected to the propeller control on the engine. The source of the resistance was not identified. Both engines started normally using onboard battery power and ran normally as engine power was increased to about 1,700 rpm. Engine power was not increased beyond 1,700 rpm due to vibration from damaged propeller blades. Each engine responded appropriately when individual magnetos were selected, and each propeller cycled normally when commanded. No anomalies were noted with either engine. A JPI engine data monitor was recovered from the airplane. The downloaded data correlated to the accident flight. No anomalies were noted in the recovered data. -
Analysis
The pilot reported that, while on short final to land, the airplane yawed to the right. The pilot stated that full left rudder was needed to keep the airplane straight. The airplane subsequently touched down hard and departed the right side of the runway. All three landing gear collapsed and the left wing buckled, which resulted in substantial damage to the airplane. A postaccident examination of the airplane and engines was conducted, including test runs of both engines. No anomalies were noted that would have precluded normal operation or contributed to the loss of control during landing. Engine data from the accident flight were recovered, and no anomalies were noted in the data. Thus, the reason for the pilot’s loss of control during landing could not be determined based on the available evidence for this investigation.
Probable cause
The pilot’s loss of control during landing for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N7746Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-837
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-17T22:09:05Z guid: 106137 uri: 106137 title: ERA23LA026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106157/pdf description:
Unique identifier
106157
NTSB case number
ERA23LA026
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-16T10:20:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-14T20:14:07.283Z
Event type
Accident
Location
West Alexandria, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that the purpose of the flight was to practice pattern work. After two uneventful takeoffs and landings, he attempted a third takeoff. After liftoff, the right wing dipped, and he corrected with left aileron. The right wing continued to drop, and he added additional left rudder and nose down elevator to avoid a stall. The airplane enterd an aerodynamic stall/spin and impacted a cornfield to the north of the runway. The pilot was seriously injured. An inspector with the Federal Aviation Administration examined the wreckage and determined that damage to the wings and fuselage was substantial. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain airplane control after takeoff, resulting in an aerodynamic stall and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KOLB
Model
FIRESTAR II
Amateur built
true
Engines
1 Reciprocating
Registration number
N4878P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
F1067
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-14T20:14:07Z guid: 106157 uri: 106157 title: WPR23LA024 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106187/pdf description:
Unique identifier
106187
NTSB case number
WPR23LA024
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-18T12:05:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2022-11-08T02:31:03.327Z
Event type
Accident
Location
Evanston, Wyoming
Airport
EVANSTON-UINTA COUNTY BURNS FLD (EVW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was to ferry the tailwheel-equipped airplane for its new owner. The pilot initially told investigators that during the takeoff roll from a 2,300 ft asphalt runway, the skies were clear, and the wind was calm. He stated that he rotated at the 500 ft mark at an airspeed of 65 knots, and the airplane lifted off and climbed to about 50 ft agl. Shortly after, the airplane descended back onto the runway. He added that he did not hear an audible stall horn warning and that after the airplane touched down, the airplane veered off the runway. The airplane ground looped, resulting in substantial damage to the right-wing lift strut, right-wing aileron and the fuselage. The pilot’s initial statement was that the left brake failed (seized) as he saw left tire skid marks on the runway. However, he later told a Federal Aviation Administration inspector that his original statement was incorrect, and the airplane never left the ground and there must have been a brake seizure or dragging of the right brake that he overcompensated for with left rudder, resulting in the runway departure. The pilot did not respond to attempts by the NTSB investigator-in-charge to clarify the differences in his statements. Postaccident examination of the left main landing gear brake and both main gear wheel bearings revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff, resulting in a runway excursion and ground loop
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170A
Amateur built
false
Engines
1 Reciprocating
Registration number
N291JR
Operator
WILLIAM R. BENSYL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
19837
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-08T02:31:03Z guid: 106187 uri: 106187 title: ERA23LA030 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106170/pdf description:
Unique identifier
106170
NTSB case number
ERA23LA030
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-21T11:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-10-21T21:33:10.299Z
Event type
Accident
Location
Factoryville, Pennsylvania
Airport
SEAMANS FLD (9N3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a practice soft-field takeoff maneuver on a paved runway, the pilot “held the yoke fully back, ready to lower the nose when the nosewheel became airborne.” When he applied power, the airplane seemed to “take off vertically” and veer to the left. The pilot reduced power; however, the airplane veered to the left, travelled off the left side of the runway, and landed on the grass, then descended down an embankment and impacted a hangar. The airplane sustained substantial damage to the left wing. Examination of the airplane by a Federal Aviation Administration inspector revealed no preimpact mechanical malfunctions, failures or anomalies with the flight controls, brakes, or nosewheel steering, nor did the pilot report any.
Probable cause
The pilot's failure to maintain directional control while practicing a soft-field takeoff maneuver, which resulted in a runway excursion and impact with a hangar.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N658CP
Operator
CIVIL AIR PATROL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
18281658
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-21T21:33:10Z guid: 106170 uri: 106170 title: ERA23LA034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106179/pdf description:
Unique identifier
106179
NTSB case number
ERA23LA034
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-22T15:20:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-11-30T23:36:45.542Z
Event type
Accident
Location
York, Pennsylvania
Airport
YORK (THV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 22, 2022, at 1420 eastern daylight time, a Cessna A185E, N36ZN, was substantially damaged when it was involved in an accident near York, Pennsylvania. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he purchased the airplane a few days before the accident flight and was flying it back to Cottonwood Farm Airport (87VA), Crozet, Virginia. He took off from Auburn/Lewiston Municipal Airport (LEW), Auburn/Lewiston, Maine, and flew to Kingston-Ulster Airport (20N), Kingston, New York, for fuel. He stated that he topped off the fuel tanks and checked the oil before departing 20N. About 1 hour into the flight, the engine started running rough, and he noticed a drop in oil pressure. He then heard “clanking” in the engine, and it lost total power. He diverted to York Airport (THV), York, Pennsylvania, but landed short of the runway, in a field, and the airplane slid into the airport perimeter fence. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed that the airplane sustained substantial damage to the left wing. The left main landing gear separated, and the right main landing gear was bent aft 90°. Examination of the engine by an airframe and powerplant mechanic revealed that the engine oil indicated 2 quarts on the engine dipstick (the engine held 12 quarts of oil). There were small oil leaks around all cylinder push rod housings, with the leak around the No. 1 cylinder housing being the worst. All the spark plugs were dark, indicating oil burn. The No. 1 connecting rod was fractured off the crankshaft. The No. 1 crankshaft journal was black and discolored. No other anomalies were noted. The most recent annual inspection was completed on August 25, 2022. -
Analysis
The pilot had just purchased the airplane and was flying it to his home airport. He made a stop, added fuel, checked the oil, and continued to his home airport. About an hour after departure, he noticed a drop in oil pressure and then heard a clanking sound in the engine before it lost total power. He diverted to the nearest airport but landed short of the runway in a field. The airplane slid into the airport perimeter fence, resulting in substantial damage to the left wing. Postaccident examination of the engine revealed that it contained only 2 quarts of oil out of a total capacity of 12 quarts. There were oil leaks around all the cylinder pushrod housings, with the leak around the No. 1 cylinder being the worst. All spark plugs were dark, indicating oil burn. The No. 1 connecting rod was fractured and separated from the crankshaft, and the connecting rod bearings were destroyed. Heat distress signatures were found on the crankshaft connecting rod location and the No. 1 connecting rod bearings displayed significant scoring consistent with a lack of oil lubrication. Based on this information, it is likely the loss of engine power was the result of oil starvation to the connecting rod bearings.
Probable cause
Oil starvation of the number 1 connecting rod bearings, which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185E
Amateur built
false
Engines
1 Reciprocating
Registration number
N36ZN
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18501830
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-30T23:36:45Z guid: 106179 uri: 106179 title: ERA23LA167 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106966/pdf description:
Unique identifier
106966
NTSB case number
ERA23LA167
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-24T10:20:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-03-30T00:56:54.865Z
Event type
Accident
Location
Winter Haven, Florida
Airport
WINTER HAVEN RGNL (GIF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was for the pilot to practice touch-and-go landings in the tailwheel-equipped, tandem-seat airplane. Following nine uneventful landings, the pilot reported that he entered the traffic pattern at the destination airport. While on the base leg in the traffic pattern for landing he felt that the flight controls were “noticeably weird.” He aborted the landing attempt and tried to maneuver the airplane away from the airport. The pilot described that the airplane would not bank to the right and was descending, despite the engine power being at 2,200 rpm. The airplane continued in a left bank and the pilot was unable to level the wings, and despite application of aft elevator control input, he was unable to arrest the descent. The airplane continued toward a pasture and struck the ground left bank before striking trees. The airplane’s left wing sustained substantial damage during the impact. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. He added that when he was examining the airplane after the accident, he noted that the rear seat headset had become unstowed and had, “fallen onto / and around” the right rear rudder pedal. Based on this information, it is likely that the unsecured headset obstructed the movement of the rudder controls, resulting in the airplane’s uncommanded left bank.
Probable cause
The pilot’s failure to properly secure the rear seat headset, resulting in an obstruction of the airplane’s rudder controls.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHAMPION
Model
7FC
Amateur built
false
Engines
1 Reciprocating
Registration number
N6ND
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7FC-200
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-30T00:56:54Z guid: 106966 uri: 106966 title: ANC23LA005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106291/pdf description:
Unique identifier
106291
NTSB case number
ANC23LA005
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-26T17:56:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-11-21T23:33:25.68Z
Event type
Accident
Location
Kenai, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 26, 2022, about 1656 Alaska daylight time, a Piper PA-22-160, N8119D, sustained substantial damage when it was involved in an accident in Kenai, Alaska. The flight instructor and the pilot receiving instruction, who was a private pilot, sustained no injuries. The airplane was operated by the instructor pilot as a Title 14 Code of Federal Regulations Part 91 general aviation flight. The purpose of the flight was to conduct pilot training. The airplane took off from the Kenai Municipal Airport, Kenai. Shortly after takeoff, the engine lost total power and the propellor began to windmill. The flight instructor conducted emergency procedures but was unable to regain engine power. The flight instuctor informed the airport tower of their loss of engine power and was cleared to land back at the airport. He determined that they did not have sufficient altitude to make it back to the airport and landed on a road about 2 miles southeast of the airport. During the landing, to avoid a car, the flight instructor turned slightly towards the edge of the road and was pulled into a snow berm where the airplane came to rest. The airplane sustained substantial damage to the right wing and fuselage. A postaccident examination of the engine revealed that the crankshaft drive gear was missing a bolt and a broken dowel pin on the crankshaft. The missing bolt was not found during the postaccident examination. The engine was last disassembled in 1983. The accessory gearbox was opened for an oil pump rebuild in 2006. The crankshaft drive gear drives the accessory gear box and, according to the engine manufacturer, failure of the gear or the gear attaching parts would result in complete engine stoppage. -
Analysis
Shortly after takeoff, the engine lost power and the propellor began to windmill. The flight instructor conducted emergency procedures but was unable to regain engine power. The flight instructor determined that they did not have sufficient altitude to make it back to the airport and he selected a road on which to make a forced landing. To avoid a car, the pilot turned slightly towards the edge of the road and was pulled into a snow berm, where the aircraft came to a full stop. The airplane sustained substantial damage to the right wing and fuselage. A postaccident examination of the engine found the crankshaft drive gear bolt was missing and the gear alignment dowel pin on the crankshaft was broken. The missing bolt was not found during the postaccident examination. The engine was last disassembled in 1983 and the accessory gearbox was opened for an oil pump rebuild in 2006; the investigation was not able to identify how long the engine had operated with the bolt missing. The crankshaft drive gear drives the accessory gear box and, according to the engine manufacturer, failure of the gear or the gear attaching parts would result in complete engine stoppage.
Probable cause
Improper installation of the crankshaft drive gear by maintenance personnel, who failed to install all required hardware, resulting in an in-flight engine failure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N8119D
Operator
HAM KEITH W
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
22-5610
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-21T23:33:25Z guid: 106291 uri: 106291 title: ERA23LA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106213/pdf description:
Unique identifier
106213
NTSB case number
ERA23LA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-27T15:15:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-15T01:58:23.054Z
Event type
Accident
Location
Roberta, Georgia
Airport
GENTLE LANDINGS AIR PARK (0GA9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot was too high on approach to land, so he lowered the flaps and reduced power to idle. He said his groundspeed “seemed a little high” prior to touching down but he continued to land on the 3,500 ft long grass runway. The braking effectiveness on the grass was not good, but the pilot said it was “too late” to go around. The airplane went off the end of the runway and collided with a pile of logs, which resulted in substantial damage to the right-wing spar.
Probable cause
The pilot’s failure to maintain a stabilized approach speed on landing, which resulted in a runway excursion and collision with logs.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N4349R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17263100
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-15T01:58:23Z guid: 106213 uri: 106213 title: ERA23LA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106218/pdf description:
Unique identifier
106218
NTSB case number
ERA23LA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-27T16:00:00Z
Publication date
2023-11-29T05:00:00Z
Report type
Final
Last updated
2022-10-28T20:43:27.544Z
Event type
Accident
Location
Sarasota, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 27, 2022, about 1500 eastern daylight time, a Robinson R44, N442H, was substantially damaged when it was involved in an accident near Sarasota, Florida. The flight instructor and passenger were seriously injured. The helicopter was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, while en route, he saw birds in his flight path, he banked to the right to avoid striking one, and then he felt a vibration in the helicopter. He moved the collective up and down in an attempt to stop the vibration; however, it continued. The pilot performed a precautionary landing to a marshy area, and the helocopter subsequently rolled over, resulting in substantial damage to the fuselage. Examination of the helicopter by a Federal Aviation Administration inspector revealed that the tail rotor exhibited a dent. The inspector and a mechanic examined the helicopter for any anomalies and noted that there were no mechanical malfunctions that would have precluded normal operation. The dent was examined for evidence of a bird strike; however, the dented side of the tail rotor landed in the marsh water and remained there until it was recovered, and no evidence of organic material was noted. -
Analysis
While en route, the pilot saw birds in his flight path and banked the helicopter to the right to avoid striking one, after which he felt a vibration. The vibration continued, and the pilot performed a precautionary landing to a marshy area, where the helicopter rolled over, resulting in substantial damage to the fuselage. Examination of the helicopter revealed a dent in one of the tail rotor blades; no evidence of any other mechanical anomalies were noted that would have precluded normal operation. The tail rotor came to rest in marsh water and the blade did not display evidence of organic material consistent with a bird strike; however, given that the pilot identified and was maneuvering to avoid birds just before the vibration occurred, it is likely that the tail rotor was damaged during impact with a bird, resulting in the subsequent vibration.
Probable cause
An in-flight collision with a bird, which resulted in damage to a tail rotor blade, a subsequent vibration, and the pilot’s decision to conduct a precautionary landing to unsubtle terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N442H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
14185
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-28T20:43:27Z guid: 106218 uri: 106218 title: CEN23LA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106222/pdf description:
Unique identifier
106222
NTSB case number
CEN23LA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-27T21:07:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-11-10T22:25:12.138Z
Event type
Accident
Location
Burleson, Texas
Airport
FORT WORTH SPINKS (FWS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On October 27, 2022, about 2007 central daylight time (CDT), a Cessna T210M, N36X, was substantially damaged when it was involved in an accident near Fort Worth Spinks Airport (FWS), Burleson, Texas. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 corporate flight. The pilot reported that the flight initiated from the Columbus Airport, Columbus, Georgia (CSG), about 0350 CDT, with the fuel selector on the right fuel tank. About 2 hours into the flight, the fuel selector was switched to the left tank, and when the airplane was about 30 nautical miles from FWS, the fuel selector was switched back to the right tank. The pilot maneuvered the airplane onto the final approach for runway 18 at FWS, and when he was about ½ mile from the runway threshold, at an altitude of about 200 ft agl, he attempted to increase engine power, but the engine did not respond. He ensured that the fuel mixture was set to full rich and switched the fuel selector back to the left tank, but the engine still did not respond. The pilot reported that he used pitch to maintain the airplane’s approach speed and landed the airplane. During the landing, the airplane struck the localizer antenna array that was about 1,000 ft north of the runway 18 threshold. The airplane touched down in the grass area between the antenna array and the runway. The right main landing gear collapsed, the left elevator was torn from aircraft, and the right horizontal stabilizer structure was bent upward and aft during the accident sequence. According to flight track information, the flight lasted 4 hours and 10 minutes. Postaccident examination of the airplane after the accident revealed that the right fuel tank did not contain a usable quantity of fuel. No other preimpact anomalies were detected that would have prevented normal operation of the airplane. -
Analysis
The pilot reported that the airplane’s engine did not respond when he attempted to increase power while on final approach to land at the conclusion of a 4-hour flight. The airplane was about ½ mile from the runway at 200 ft above ground level (agl) at the time. He attempted to switch tanks and selected full rich mixture, but the engine did not restart. The pilot continued the landing, but the airplane struck the runway approach lighting system about 1,000 ft short of the runway and came to rest between the approach lights and the runway. A postaccident examination of the airplane did not reveal any preimpact mechanical anomalies. The right fuel tank did not contain any usable fuel at the time of the examination and the tank was not compromised. Based on the available evidence, the loss of engine power was likely due to mismanagement of the airplane’s fuel supply, which resulted in fuel starvation. Due to the low altitude the airplane’s engine likely had insufficient time to restart after the pilot switched tanks following the loss of engine power.
Probable cause
The pilot’s mismanagement of the fuel supply, which led to fuel starvation and a loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210
Amateur built
false
Engines
1 Reciprocating
Registration number
N36X
Operator
ARCHANGEL AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Executive/Corporate
Commercial sightseeing flight
false
Serial number
21061650
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-10T22:25:12Z guid: 106222 uri: 106222 title: DCA23FM003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106221/pdf description:
Unique identifier
106221
NTSB case number
DCA23FM003
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-10-28T05:36:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-12-18T05:00:00Z
Event type
Accident
Location
Chincoteague, Virginia
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the containership MSC Rita and the fishing vessel Tremont was the Tremont operator not maintaining a proper lookout and keeping the autopilot engaged while troubleshooting the vessel’s gyrocompass, which resulted in the vessel turning into the path of the MSC Rita.
Has safety recommendations
false

Vehicle 1

Callsign
WDE7314
Vessel name
Tremont
Vessel type
Fishing
IMO number
7037894
Port of registry
Boston
Flag state
USA
Findings

Vehicle 2

Callsign
3EBW6
Vessel name
MSC Rita
Vessel type
Cargo, General
IMO number
9289116
Maritime Mobile Service Identity
371245000
Port of registry
Panama City
Flag state
PM
Findings
creator: Coast Guard last-modified: 2023-12-18T05:00:00Z guid: 106221 uri: 106221 title: RRD23FR002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106217/pdf description:
Unique identifier
106217
NTSB case number
RRD23FR002
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-28T13:15:00Z
Publication date
2023-12-26T05:00:00Z
Report type
Final
Last updated
2023-12-22T05:00:00Z
Event type
Accident
Location
Beaumont, Texas
Injuries
null fatal, null serious, null minor
Probable cause
In progress
Has safety recommendations
false

Vehicle 1

Railroad name
PSC company (switching contractor)
Equipment type
Yard/switching
Train name
Switcher Train
Train number
Train 1
Train type
FRA regulated freight
Total cars
19
Total locomotive units
1
Carrying hazardous materials
true
Findings
creator: NTSB last-modified: 2023-12-22T05:00:00Z guid: 106217 uri: 106217 title: CEN23LA022 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106226/pdf description:
Unique identifier
106226
NTSB case number
CEN23LA022
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-10-30T14:58:00Z
Publication date
2023-06-28T04:00:00Z
Report type
Final
Last updated
2022-10-31T18:00:02.177Z
Event type
Accident
Location
Evansville, Indiana
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Factual narrative
On October 30, 2022, about 1358 eastern daylight time, a Piper PA-32R-300 airplane, N349SB, was substantially damaged when it was involved in an accident near Evansville Regional Airport (EVV), Evansville, Indiana. The pilot sustained serious injuries, two passengers sustained minor injuries, and one passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before departure for the cross-country flight, the airplane’s wing fuel tanks were filled (94-gallon capacity), the engine oil dipstick showed 9 quarts, and no anomalies were noted during the preflight inspection. After takeoff, the airplane climbed to 5,000 ft and flew uneventfully for about 1 hour 10 minutes. During that time, with the pilot made an altitude change to 7,000 ft and switched fuel tanks every 30 minutes. Shortly after the airplane reached 7,000 ft, the pilot felt the engine “shake” and noticed that the engine monitor showed abnormal indications for the No. 3 cylinder. The pilot turned on the fuel pump and moved the mixture control to a slightly richer position. The engine smoothed out and ran normally for a few minutes. The engine then surged momentarily to full power before returning back to its previous power setting. The pilot recognized that the airplane would not be able to fly the rest of the way to the airport, so he elected to divert to EVV and have the engine inspected. The pilot advised air traffic control that he needed to divert to EVV for an engine issue. As the airplane descended, the engine appeared to be operating normally. The controller cleared the pilot for the instrument landing system approach to runway 4. When the airplane reached an altitude of 2,500 ft and was about 8 miles southwest of EVV, the engine lost total power. The pilot reported hearing “the unmistakable sound of three thuds…and engine power was lost.” The pilot attempted to restart the engine but was unsuccessful. The pilot noted that fuel pressure, fuel quantity, voltage, and amperage were operating normally. The airplane exited instrument meteorological conditions when the airplane reached an altitude of about 1,100 ft, and the pilot decided to attempt a forced landing on a golf course. The pilot extended the landing gear and flaps, and the airplane landed hard on the golf course grass surface. Examination of the accident site revealed that the airplane traveled about 280 ft from the initial impact point to the airplane resting location. The airplane came to rest upright and sustained substantial damage to the fuselage, both wings, and horizontal stabilizer (see the figure below). Figure. Accident airplane at resting location (Source: Federal Aviation Administration). During the postaccident examination of the airplane, compressed air was applied to the fuel system at the firewall fitting, and no obstructions were noted within the system through the fuel selector valve to each wing fuel tank. No engine oil was noted on the exterior surfaces of the airframe. The Lycoming IO-540-K1G5D engine was removed from the airframe at the firewall. Examination of the engine revealed impact damage to the engine mount, vacuum pump, oil filter, oil cooler, and dual magneto. The engine exhaust was partially crushed and unobstructed. The engine crankshaft was rotated by turning the propeller by hand, and mechanical continuity was noted to the rear accessory gears and cylinder valve train. Compression and suction were observed on all six cylinders, and borescope examination of the cylinder interiors was unremarkable. Oil was noted on the exterior surfaces of the engine accessory case and rear-mounted accessories. The right oil cooler, which displayed impact damage, and the oil hose connecting the oil cooler to the oil pump were found loose on the pump side. Oil drained from the cylinder heads (when the rocker covers were removed) and the oil suction screen cover plug (when the plug was removed). No engine oil was observed on the engine dipstick. Fuel was noted in all fuel lines forward of the firewall and in the engine fuel pump, injector servo, and flow divider. The fuel nozzles, fuel screen, and oil screen were clear of debris. The magneto was rotated using an electric drill and produced spark from all 12 ignition towers. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Data from the airplane’s J.P. Instruments EDM-900 engine monitor showed no abnormalities during the flight, including at the time of the reported engine issue. -
Analysis
The pilot was conducting a personal cross-country flight. He performed a preflight inspection, and the takeoff and climb were normal. After flying for about 1 hour 10 minutes, the pilot felt the engine shake and noticed some abnormal indications on the engine monitor. He made some adjustments to the engine controls, and the engine smoothed out and ran normally. A few minutes later, the engine surged momentarily to full power and then returned to its previous power setting. The pilot diverted to a local airport, and the engine operated normally as the airplane descended. During the approach, which was conducted in instrument meteorological conditions (IMC), the engine lost total power when the airplane was about 8 miles from the airport. The pilot attempted to restart the engine but was unsuccessful. The airplane exited the IMC and subsequently landed hard on a golf course, which resulted in substantial damage to the fuselage, both wings, and horizontal stabilizer. Postaccident examination of the airplane and extracted engine data revealed no evidence of mechanical malfunctions or failures with the airplane or engine. Given the available evidence for this accident investigation, the reason for the total loss of engine power could not be determined.
Probable cause
The total loss of engine power for reasons that could not be determined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32R-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N349SB
Operator
Skyband Aviation, LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-7780480
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-10-31T18:00:02Z guid: 106226 uri: 106226 title: ERA23LA053 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106267/pdf description:
Unique identifier
106267
NTSB case number
ERA23LA053
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-02T18:26:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-20T17:45:07.01Z
Event type
Accident
Location
STATESBORO, Georgia
Airport
Statesboro-Bulloch County Airport (TBR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The private pilot just purchased the amateur-built airplane which was reportedly equipped with two fuel tanks in each wing totaling 22 gallons, or a total capacity of 44 gallons. According to the previous owner who was an airframe and powerplant mechanic, since filling the right fuel tank more than 1 month earlier, he flew the airplane on two separate flights totaling 1.3 hours. No additional flights were made by him after fueling. During an engine run before departure of the accident flight, the left and right fuel gauges indicated about one needle width from empty and 1/2 capacity, respectively. The new owner believed the depicted fuel amount was adequate for the intended short-duration flight to a nearby airport for fuel. He departed with the fuel selector on both, then shortly after takeoff moved it to the left fuel tank. About 13 minutes later the engine quit. He declared a mayday, moved the fuel selector to both and then right tank positions but that did not restore power. He flew towards a nearby airport but realized he was unable to land there. He maneuvered for a field, but about 26 minutes since departure the airplane collided with a tree adjacent to a residence, stalled, and impacted a portion of the house, the ground, and a car before coming to rest upright. Examination of the wreckage at the accident site by a Federal Aviation Administration inspector revealed no fuel remaining in either wing fuel tanks, in the airframe fuel strainer, fuel lines, or on the ground around the wreckage. Although the carburetor was impacted damaged, there were no fuel stains on or around it. Postaccident testing of the fuel quantity indicating system was not performed. The engine Operator’s Manual specified that the fuel consumption was about 9.0 gallons-per-hour at 65% power, or at economy cruise. Thus, for the approximate 30 minutes-long flight about 4.5 gallons of fuel were required. That value could have been reflected in any combination between the left and right fuel tanks, but it an extreme unbalance with no fuel in the left fuel tanks and all fuel in the right tanks would have reflected just under 1/4 capacity on the right fuel gauge. At no configuration based on the amount that was actually on-board should the right fuel gauge have indicated 1/2 capacity. Therefore, the right fuel quantity gauge likely indicated that the tanks contained more fuel than the amount that was actually on board, which resulted in inadequate fuel for the intended flight and a subsequent total loss of engine power due to fuel exhaustion. As part of the airplane’s last condition inspection performed more than 12 months earlier by the previous owner, the accuracy of the fuel gauges at empty was not performed.
Probable cause
A total loss of engine power due to fuel exhaustion. Contributing to the fuel exhaustion was the likely inaccurate right fuel quantity indicating system.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SCHMIDT RANDALL M
Model
BUSHBY MUSTANG II
Amateur built
true
Engines
1 Reciprocating
Registration number
N30RK
Operator
Toribio LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-11-804
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-20T17:45:07Z guid: 106267 uri: 106267 title: DCA23LA060 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106309/pdf description:
Unique identifier
106309
NTSB case number
DCA23LA060
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-02T22:40:00Z
Publication date
2023-06-16T04:00:00Z
Report type
Final
Last updated
2022-11-18T00:27:37.221Z
Event type
Accident
Location
New Orleans, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
According to the flight crew, the airplane was descending to land with the autopilot configured to intercept a managed flight path profile. The airplane was descending in "Vertical Speed” mode at 500 feet per minute, with the airspeed set for 300 knots. As the airplane approached the profile, the crew selected “Managed Descent” mode and the airplane nosed over rapidly to intercept the descending flight path. The first officer checked the altimeter setting and then noticed that the airspeed indicator was approaching the maximum allowable airspeed; he then deployed the speed brakes to about 50%. Simultaneously, the captain took control of the airplane, disengaged the autopilot, and pitched up to avoid an overspeed condition. The crew then reset the automation and commenced a deliberate slow down. Shortly thereafter, the cabin crew called and advised that one of the flight attendants was injured during the maneuver. A flight attendant who was securing carts in the aft galley was hoisted into the air and landed on her left foot, fracturing her ankle. The remainder of the flight continued without incident.
Probable cause
The captain’s pitch up input to avoid an overspeed condition, which resulted in a flight attendant falling and fracturing her ankle. Contributing was the airplane’s excessive airspeed during the transition to the automation-managed descent profile.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A319
Amateur built
false
Engines
2 Turbo fan
Registration number
N519NK
Operator
SPIRIT AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
2723
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-11-18T00:27:37Z guid: 106309 uri: 106309 title: CEN23LA027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106255/pdf description:
Unique identifier
106255
NTSB case number
CEN23LA027
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-05T09:21:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-11-19T01:12:27.994Z
Event type
Accident
Location
Aguilar, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 5, 2022, about 0821 mountain daylight time, a Cessna R172E, N6051U, was substantially damaged when it was involved in an accident near Aguilar, Colorado. The private pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he climbed the airplane from 9,000 ft mean sea level (msl) to 10,000 ft msl to overfly Raton Pass and Fischer Peak, Colorado. He encountered wind shear and high turbulence and simultaneously felt a pop or shudder. The airplane started to shake, and oil began to cover the windshield. He then performed a forced landing to a field, during which the airplane struck a fence. The airplane sustained substantial damage to both wings. Postaccident examination of the engine by a Federal Aviation Administration inspector revealed that the engine’s No. 2 cylinder head was cracked. The cylinder head and barrel assembly, with 358.9 hours since new, was manufactured by Engine Components International and was subject to airworthiness directive (AD) 2009-26-12, which requires initial and repetitive visual inspections and compression tests to detect cracks at the head-to-barrel interface. The last cylinder compression check was performed in July 2022 and its pressure tested at 70 psi. There were no other mechanical anomalies that would have precluded normal airplane operation. -
Analysis
The pilot of the personal flight stated that while the airplane was in cruise flight, he felt a pop or shudder. The airplane began to shake, and oil began to cover the windshield. The airplane lost engine power and the pilot then performed a forced landing to a field, during which it struck a fence. The airplane sustained substantial damage to both wings. Postaccident examination of the engine revealed that the engine’s No. 2 cylinder head was cracked. There were no other mechanical anomalies that would have precluded normal airplane operation.
Probable cause
Failure of the engine cylinder assembly, which resulted in a loss of engine power during cruise flight and an impact with a fence during the forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
R172E
Amateur built
false
Engines
1 Reciprocating
Registration number
N6051U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
R172-0183
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-19T01:12:27Z guid: 106255 uri: 106255 title: ERA23LA050 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106258/pdf description:
Unique identifier
106258
NTSB case number
ERA23LA050
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-05T14:51:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-18T00:39:02.58Z
Event type
Accident
Location
Farmingdale, New York
Airport
Republic Airport (FRG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that he was under the impression that his airplane’s inboard fuel tanks had been topped and he had 202 gallons on board prior to departure. He had a “standing order” with the airport’s fixed base operator to top the tanks; however, the fueling was not accomplished and he did not visually check the fuel level prior to departure. He entered 202 gallons in cockpit fuel computer and unknowingly commenced the flight with 61 gallons on board. Prior to reaching his destination, his fuel supply was exhausted, both engines lost all power, and he performed a forced landing in a cemetery about one mile from the airport. The pilot and his passenger had minor injuries. Inspectors with the Federal Aviation Administration examined the wreckage and determined that damage to the wings and fuselage was substantial. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper preflight inspection of the airplane’s fuel system, resulting in him commencing the flight with an inadequate fuel supply.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B-60
Amateur built
false
Engines
2 Reciprocating
Registration number
N51AL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
P-247
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-18T00:39:02Z guid: 106258 uri: 106258 title: HWY23IH002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106310/pdf description:
Unique identifier
106310
NTSB case number
HWY23IH002
Transportation mode
Highway
Investigation agency
Other
Completion status
Completed
Occurrence date
2022-11-09T10:43:00Z
Publication date
2023-12-19T05:00:00Z
Report type
Final
Event type
Occurrence
Location
Philadelphia, Pennsylvania
Injuries
null fatal, null serious, null minor
Probable cause
The PC was not determined for this case.
Has safety recommendations
false

Vehicle 1

Traffic unit name
2018 Proterra E2 Catalyst Electric Transit Bus
Traffic unit type
Single Vehicle
Units
Findings
creator: Other last-modified: 2023-12-19T05:00:00Z guid: 106310 uri: 106310 title: DCA23LA050 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106279/pdf description:
Unique identifier
106279
NTSB case number
DCA23LA050
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-10T05:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-11-14T18:02:18.147Z
Event type
Accident
Location
Miami, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
American Airlines flight 2548 encountered turbulence while descending through 18,000 ft to land at the Miami International Airport (MIA), Miami, FL, and a flight attendant (FA) fractured her spine. The flight crew reported that during descent, with the seatbelt sign illuminated and after notifying the FAs to prepare for landing, air traffic control (ATC) issued a vector for the approach at MIA with a flight path that intersected a thin cloud layer. After the airplane passed through this cloud layer about 18,000 ft, the pilot’s noticed a towering cumulus cloud directly ahead that had not been displayed on the airplane’s weather radar display. Unable to maneuver around the cloud build up, the airplane passed through the tops of the cumulus clouds, and the flight encountered moderate turbulence for about 3 seconds. The flight crew then received a call from the cabin advising them that a FA had been injured. At the time of the turbulence event, the number 4 FA was in the aft galley and was thrown to the floor. She came to rest with her back against the aft jumpseat. The injured FA was provided oxygen, helped to her jumpseat, and secured with her safety belt. Upon being notified of the injury, the flight crew requested to have paramedics meet the airplane at the gate. The injured FA was transported to the hospital where she was diagnosed with a fractured spine. Eddy dissipation rate (EDR) is a universal measure of turbulence rate. Recorded data from the airplane revealed that about 1900 to 1901 EST the EDR indicated 0.156 to 0.175 which equates to light turbulence. About 5 minutes later the EDR indicated 0.367 which equates to moderate turbulence. At the time of the flight’s arrival into MIA there were no active significant meteorological information (SIGMETs) for the area where the turbulence occurred.
Probable cause
An encounter with convective turbulence during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-8
Amateur built
false
Engines
2 Turbo fan
Registration number
N316SE
Operator
American Airlines Inc
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
44472
Damage level
None
Events
Findings
creator: NTSB last-modified: 2022-11-14T18:02:18Z guid: 106279 uri: 106279 title: ERA23LA057 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106277/pdf description:
Unique identifier
106277
NTSB case number
ERA23LA057
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-10T18:15:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-01T20:36:56.64Z
Event type
Accident
Location
Gilford, New Hampshire
Airport
LACONIA MUNI (LCI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the amphibious airplane reported that while on final approach to runway 26 he had trouble viewing the runway due to glare from the setting sun. He recalled making “…continuous efforts to block the sun glare.” He planned to make a gradual descent on the final approach to get the best forward view and peripheral views of the area. While descending, he further described that “the brightness inside the cockpit was difficult to observe instruments. I descended towards what I was convinced was the runway. I remember nothing else from that time forward.” The airplane subsequently struck the roof of a business, and the wreckage came to rest next to the building in the parking lot. The airplane’s fuselage, both wings, empennage, and floats were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Based on this information, the airplane likely struck the building after the pilot allowed the airplane to descend too low on the approach to the runway.
Probable cause
The pilot’s decision to continue the approach to land in conditions where he was unable to see in front of the airplane due to sun glare, which resulted in in a collision a building.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
175
Amateur built
false
Engines
1 Reciprocating
Registration number
N7223M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
55523
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2022-12-01T20:36:56Z guid: 106277 uri: 106277 title: CEN23LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106281/pdf description:
Unique identifier
106281
NTSB case number
CEN23LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-12T19:26:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-11-16T18:17:20.04Z
Event type
Accident
Location
Olathe, Kansas
Airport
Johnson County Executive Airport (OJC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and his student were conducting an instructional flight in night visual meteorological conditions and in the airport traffic pattern when the airplane collided with multiple geese during initial climb. The flight instructor made an uneventful landing following the bird strike. The airplane’s right-wing leading edge and main spar were substantially damaged during the bird strike.
Probable cause
The inflight collision with multiple geese during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N5258Y
Operator
T&C Aviation Enterprises Inc
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S9141
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-16T18:17:20Z guid: 106281 uri: 106281 title: CEN23LA036 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106282/pdf description:
Unique identifier
106282
NTSB case number
CEN23LA036
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-13T11:50:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2022-11-17T03:46:08.23Z
Event type
Accident
Location
Manchester, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 13, 2022, about 0950 central standard time, a Cessna 152 airplane, N222UM, sustained substantial damage when it was involved in an accident near Manchester, Michigan. The flight instructor and the student pilot were uninjured. The flight was being operated as a 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that they had been in cruise flight with the engine operating about 2,400 rpm when he “felt the power drop.” He then noticed the tachometer showed about 1,300 rpm. He stated that he took the flight controls from the student pilot, applied carburetor heat, and used the checklist to attempt to restore power. At one point, while trying different throttle and mixture settings, the rpm appeared to increase to about 1,500 for about 10 seconds before reducing back to 1,300. The instructor notified air traffic control of the power loss and diverted to the nearest airport. When it became evident they would not be able to reach the airport, he selected a field for a forced landing. During the landing, the nose wheel dug into the soft soil, and the airplane nosed over, which resulted in substantial damage to the vertical stabilizer and rudder. The student pilot stated that after the engine rpm reduced to 1,300, the flight instructor applied carburetor heat, and the engine rpm reduced and then “came back up” but only for a short time. Both pilots stated that the fuel tanks had been topped off the night before, and the airplane was placed in a hangar overnight. Before the flight, they conducted a preflight inspection, which included sumping the fuel tanks, with no anomalies noted. After engine start and taxi, a run-up was accomplished with no anomalies noted. During a postaccident examination, control continuity was established from the cockpit to all flight and engine controls. Fuel was drained from the carburetor and the left and right fuel tanks, and no contaminants were present. The carburetor venturi was inspected with no anomalies noted. The spark plugs were removed and found to be unremarkable. Following removal of the top spark plugs, thumb compression was noted on all cylinders when the propeller was rotated by hand. The magnetos were tested on the airframe and sparking was observed on all leads in firing order. The 0953 weather observation at Ann Arbor, Michigan located 17 from the accident site recorded a temperature of 32° F and a dewpoint of 25°F. Based on the FAA carburetor icing probability chart (Figure 1), the atmospheric conditions at the time of the accident were conducive to the development of serious carburetor icing at glide and cruise power. Figure 1: Carburetor Icing Probability Chart (Source: FAA SAIB CE-09-35) -
Analysis
According to the flight instructor, the airplane was in cruise flight when the engine rpm dropped from about 2,400 to about 1,300. He took the flight controls from the student pilot, turned on carburetor heat, and used the checklist in an attempt to restore power. According to the flight instructor, while trying different throttle and mixture settings, the rpm increased to about 1,500 for about 10 seconds before reducing back to 1,300. According to the student pilot, after the engine rpm reduced to 1,300, the flight instructor applied carburetor heat, and the engine rpm reduced and then increased briefly. The instructor notified air traffic control of the power loss and diverted to the nearest airport. When he realized they would not be able to reach the airport, he selected a field for a forced landing. During the landing, the nosewheel dug into the soft soil, and the airplane flipped over, which resulted in substantial damage to the vertical stabilizer and rudder. A postaccident examination of the engine and airframe revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Based on the Federal Aviation Administration (FAA) carburetor icing probability chart, the atmospheric conditions at the time of the accident were conducive to the development of serious carburetor icing at glide and cruise power. Therefore, it is likely that the loss of engine power was due to the formation of carburetor ice. Although the engine power increased briefly when the flight instructor applied carburetor heat, it is likely the amount of ice was too much for the carburetor heat to overcome.
Probable cause
A partial loss of engine power as a result of carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N222UM
Operator
UNIVERSITY OF MICHIGAN FLYERS INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15281063
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-17T03:46:08Z guid: 106282 uri: 106282 title: DCA23FM005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106286/pdf description:
Unique identifier
106286
NTSB case number
DCA23FM005
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-11-13T17:27:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-10-26T04:00:00Z
Location
Port Allen, Louisiana
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire on the bridge of the S-Trust was the thermal runaway of one of the cells in a lithium-ion battery for a UHF handheld radio.
Has safety recommendations
false

Vehicle 1

Vessel name
S-Trust
Vessel type
Cargo, Liquid Bulk
IMO number
9299771
Port of registry
Monrovia, Liberia
Classification society
DNV-GL
Flag state
LI
Findings
creator: Coast Guard last-modified: 2023-10-26T04:00:00Z guid: 106286 uri: 106286 title: ERA23LA110 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106580/pdf description:
Unique identifier
106580
NTSB case number
ERA23LA110
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-13T17:45:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-01-17T17:52:45.979Z
Event type
Accident
Location
Fulton, New York
Airport
Oswego County Airport (FZY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he just purchased the airplane that day and was going to take it for a test flight before heading back to this home airport. He stated the flight, and the landing were normal, however; during the landing rollout, he applied the brakes to slow the airplane and make the next taxiway turnoff. The nose wheel started to shimmy during the turn and applied side loads to the nose landing gear linkage and structure. The pilot continued and taxied that airplane to the hangar, where he noticed the damage to the structure. He stated there were no mechanical deficiencies with the airplane and that he should have slowed the airplane down to a taxi speed before making a turn. Th pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. Post-accident examination of the airplane revealed substantial damage to the airplane’s fuselage structure in the vicinity of the nose landing gear.
Probable cause
The pilots failure to slow the airplane down prior to turning off the runway, which resulted in damage to the airplane’s fuselage structure in the vicinity of the nose landing gear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310J
Amateur built
false
Engines
2 Reciprocating
Registration number
N3048L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310J0048
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-17T17:52:45Z guid: 106580 uri: 106580 title: ERA23LA062 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106304/pdf description:
Unique identifier
106304
NTSB case number
ERA23LA062
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-14T10:47:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-21T17:01:21.225Z
Event type
Accident
Location
Perry, Georgia
Airport
Perry-Houston County Airport (PXE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he flew an instrument approach to a 4,999-ft-long, 100-ft-wide, asphalt runway. He flared at 78 kts and the airplane touched down on centerline. After touchdown, he applied brakes and the airplane veered left. He pressed harder on the right brake pedal, but the plane did not react, so he applied full right pedal but he did not observe any response. The airplane skidded off the left side of the runway and continued skidding through grass. It subsequently struck a small embankment at the edge of a cotton field, where it came to rest upright. The pilot added that there were no preimpact mechanical malfunctions with the airplane. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the right wing, nose landing gear, and firewall. His examination, which also included observing the airplane’s left main wheel was free to rotate and that the tire did not show any abnormal wear, did otherwise note evidence of any preimpact mechanical malfunctions. The wind recorded at the airport, about the time of the accident, indicated a left crosswind to tailwind at 9 knots.
Probable cause
The pilot’s failure to maintain directional control during touchdown in a crosswind, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA32
Amateur built
false
Engines
1 Reciprocating
Registration number
N81PW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-8106002
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-21T17:01:21Z guid: 106304 uri: 106304 title: ERA23LA061 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106301/pdf description:
Unique identifier
106301
NTSB case number
ERA23LA061
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-14T19:00:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-05-17T18:08:10.381Z
Event type
Accident
Location
Lancaster, Ohio
Airport
Fairfield County (LHQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor was conducting a local instructional flight with a new student pilot. Following the preflight inspection and engine start, the flight instructor noted that the fuel selector looked to be positioned “in the right place,” and that neither he nor the student touched the fuel selector for the entirety of the accident flight. They subsequently conducted about 15 to 20 minutes of the instructional lesson on the ground, while the engine was running. During engine run-up, the flight instructor noted that “the fuel pressure indicator went to zero” so he turned on the airplane’s electric fuel pump and the fuel pressure recovered. After 1 to 2 minutes, the flight instructor turned off the electric fuel pump and the fuel pressure returned to the normal range and remained there. After takeoff, and during the initial climb, the engine started to “lose and gain power,” so the flight instructor attempted a turn back to the departure runway. Halfway through the turn, the airplane lost all engine power, and the flight instructor landed the airplane in a grassy area, but encountered uneven terrain. The airplane sustained substantial damage to the left wing during the landing. Initial postaccident examination of the airplane revealed that the fuel selector was of a configuration that the handle of the rotary valve faced away from the fuel tank being selected, while the opposite side of the handle indicated the selected tank or shutoff position. The operator had painted a gray/white stripe on the handle and fuel selector valve placard that showed the selected tank to aid pilots in correctly selecting the desired position. Following the accident, the flight instructor stated that he was confused by the white paint stripe on the fuel selector. He also stated that the airplane’s owner advised him after the accident that the fuel selector had been found in the “off” position after the accident. The wreckage was subsequently disposed of by the owner, and no additional detailed examination was conducted to determine if the fuel selector valve handle, the valve mechanism itself, or fuel selector valve placard were correctly oriented and that the internal valve mechanism was intact, nor were the engine or fuel system otherwise examined or tested. Based on this information, the reason for the loss of engine power could not be determined.
Probable cause
A loss of engine power during initial climb for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N6303J
Operator
SUNDOWNER AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-4714
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-17T18:08:10Z guid: 106301 uri: 106301 title: ERA23LA106 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106556/pdf description:
Unique identifier
106556
NTSB case number
ERA23LA106
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-18T17:05:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-11T23:51:55.294Z
Event type
Accident
Location
Mashpee, Massachusetts
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The operator reported that while enroute, the airplane encountered a flock of seagulls. The First Officer called out “birds” and the Captain attempted to take evasive action but one of the birds impacted the leading edge of the right wing, resulting in substantial damage to the right wing. Subsequently, the crew diverted to a nearby airport and landed safely. The operator reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s impact with a bird while enroute.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
402
Amateur built
false
Engines
2 Reciprocating
Registration number
N2649Z
Operator
HYANNIS AIR SERVICE INC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
402C0333
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-11T23:51:55Z guid: 106556 uri: 106556 title: ERA23FA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106324/pdf description:
Unique identifier
106324
NTSB case number
ERA23FA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-19T13:10:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2022-11-30T17:35:19.63Z
Event type
Accident
Location
Winston-Salem, North Carolina
Airport
SMITH REYNOLDS (INT)
Weather conditions
Visual Meteorological Conditions
Injuries
2 fatal, 0 serious, 0 minor
Factual narrative
FAA Special Airworthiness Information Bulletin (SAIB) CE-05-51, dated April 29, 2005, was developed to alert owners and operators of piston multi-engine airplanes of a condition in which it becomes impossible to continue level flight with one engine inoperative (OEI) with a windmilling propeller. The SAIB also indicated that a windmilling propeller was a large producer of parasitic drag and that the inability to maintain level flight would be exacerbated by a windmilling propeller. In the case of a piston multi-engine airplane, the effect of a windmilling propeller would be to increase the total drag of the airplane and induce an asymmetric drag about the yaw axis. The net result of a windmilling propeller would be that the aircraft total drag exceeded the power available, thus the aircraft would be no longer able to sustain level flight. The SAIB also indicated that the inability to feather the propeller could be due to the propeller windmilling speed falling below the start lock disengagement speed. Similar Accidents The NTSB has investigated at least 5 accidents since 2008, in addition to this accident, involving multi-engine airplanes having sustained a loss of engine power from one engine as well as a delay or failure to feather the propeller of the affected engine: ERA10LA284, ERA11FA458, ERA12FA423, CEN16FA172, and ERA19FA060. - In accordance with Airworthiness Directive (AD) 69-24-04, the airplane’s single-engine minimum control speed (Vmc) was changed from about 80 MPH calibrated airspeed (CAS) to 90 MPH CAS. The AD referenced Piper Service Bulletin 301A dated November 25, 1969. The airplane was equipped with two Garmin G5 electronic flight instruments. At the time of the accident neither unit had a memory card installed; thus, no data was available. Each engine was equipped with a single acting, constant speed, manual feathering, two-bladed Hartzell propeller. Each propeller was controlled by oil pressure from the engine-driven propeller governor that was commanded via cable by the propeller control lever on the throttle quadrant. Movement of the propeller control to the low pitch/high rpm position allowed oil pressure from the propeller governor to move the blades to low pitch/high rpm. Movement of the propeller control to the feather position diverted engine oil from the governor to the engine allowing the feathering springs and air charge to move the blades to the feather position. To prevent feathering during normal engine shutdown on the ground, the propeller incorporated spring-energized latches, or start locks. If propeller rotation was approximately 800 RPM or above, the latches were disengaged by centrifugal force, which compressed the springs. When engine RPM dropped below 800 RPM (and blade angle was typically within 7° of the low pitch stop), the springs would overcome the latch weight centrifugal force and move the latches to engage the high pitch stops, preventing blade angle movement to feather during normal engine shutdown. Following a partial loss of engine power that does not cause loss of oil pressure, if the propeller was not feathered and the engine rpm were allowed to fall below about 800 rpm, the start locks would engage and prevent the propeller from feathering if the propeller control was moved to the feather position. According to the emergency procedures contained within the airplane Owner’s Handbook, if an engine failure occurs during cruise flight, it specified to maintain airspeed and directional control. The section indicated that if the specified troubleshooting did not restore power, the propeller on the inoperative engine should be feathered. The section also indicated that best single-engine performance would be obtained by banking 3° to 5° into the operational engine and that rudder trim may be used as necessary for single-engine flight. In March 2004, the accident airplane was modified by installation of vortex generators on each wing leading edge and both sides of the vertical stabilizer in accordance with Supplemental Type Certificate (STC) SA00763SE. According to the president of the STC holder, there was no change to the published velocity air minimum control speed, thus no change in performance. Review of the maintenance records revealed the right engine fuel servo was overhauled and then installed on the right engine in April 2000. The right engine was subsequently removed from the airframe for overhaul, which was signed off in November 2001. According to the invoice/work order associated with the engine overhaul, there was no record that the right fuel servo was overhauled or repaired at that time. No record of FAA Form 8130-3 or serviceable tag for the right fuel servo was located. At the time of the last annual inspection about 6 months before the accident, the right fuel servo, which is considered an on-condition component, had accumulated about 1,035 hours and 23 years since last overhaul. The airplane was last fueled at LOZ with 29.4 gallons of 100 low lead (100LL) fuel; the fuel supplier “Incident/Accident Form” specified that since the last truck top off, there were 25 aircraft fueled from the same vehicle. Sixteen were fueled before the accident airplane and eight were fueled after. Although no fuel testing was performed, there were no reported fuel-related issues. - The INT airport was a public use, publicly owned airport equipped with runways 15/33, and 4/22. - On November 19, 2022, about 1110 eastern standard time, a Piper PA-30, N7295Y, was substantially damaged when it was involved in an accident near Smith Reynolds Airport (INT), Winston-Salem, North Carolina. The commercial pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance – broadcast (ADS-B) data, earlier that day the pilot and passenger flew from St. Louis Downtown Airport (CPS), Cahokia, Illinois, to London (Corbin) Magee Airport (LOZ), London, Kentucky, where a go-around was performed followed by an uneventful landing. After landing, the pilot reported an electrical system issue, but no maintenance was requested or performed. According to ADS-B data and air traffic control radio communication information, the airplane departed LOZ about 1004, and headed east-southeast towards INT, while air traffic control communications were transferred to several facilities appropriate for the route of flight. At 1103:39, while west-northwest of INT, air traffic control communications were transferred to INT air traffic control tower (ATCT). The pilot established contact with the INT ATCT at 1104:07, and at that time the airplane was flying at 3,450 ft pressure altitude about 8.3 nautical miles west-northwest from INT. The airplane continued on an east-southeast ground track while descending, and then at 1104:40, the local controller instructed the pilot to enter left base for runway 4. The pilot incorrectly read back the instruction, which the controller corrected, and then the pilot correctly read back the runway. At 1105:05, the pilot reported on the frequency, “that engines not ah” with the rest of the comment unfinished. The airplane turned slightly to the right flying on a southeast ground track consistent with the base leg of the airport traffic pattern for runway 4. Then, at 1106:02, when the airplane was at about 2,175 ft pressure altitude and about 4 nautical miles nearly due west from the approach end of runway 4, the pilot informed the controller, “…I got one engine that’s not making as much power as the other one we’re ok….” The controller responded by telling the pilot that he was on left base for runway 4. The airplane continued on the southeast ground track until 1106:26, and then turned left flying in an easterly direction. At 1108:05, when the airplane was east of the extended runway 4 centerline at 1,050 ft pressure altitude, the pilot asked the controller if he could land on runway 33, which was approved. The airplane continued on an east or east-southeast heading while descending. At 1109:08, when the airplane was about 4,300 ft west of the extended runway 33 centerline, the pilot asked if he could perform a right 360° turn, which was his last communication. The controller approved the pilot’s request and cleared the pilot to land runway 33. The airplane continued in an easterly direction flying east of the extended runway 33 centerline, and then turned left on northwesterly heading flying parallel to the runway. Between 1110:23 and 1110:27, which was the last ADS-B target, the flight path turned right about 20°. The accident site was located about 210 ft north-northeast from the last ADS-B target location, consistent with the turn to the right. A witness reported that the airplane, while flying in an easterly direction, banked left at about a 45° bank angle. He noted the airplane then rolled to nearly wings level but then maintained a slight left bank of about 10°. He reported hearing the engines “roaring as hard as they can go” or at full power, while flying in a nose-up attitude just above the trees. The airplane then rolled left to an inverted position and descended straight down. He did not see any smoke trailing the airplane and reported that the landing gear was extended. - Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot identified no evidence of impairing drugs. - The airplane impacted the backyard of a house at the edge of trees. The accident site was located about 4,200 ft east-northeast from the approach end of runway 33. Hazmat personnel drained an estimated 15 to 20 gallons of fuel from the right wing’s inboard and outboard fuel tanks, with the inboard tank having more fuel than the outboard or auxiliary fuel tank. During recovery of the airplane, an additional 6 gallons of fuel (blue in color consistent with 100LL) were drained from the right main fuel tank through the fuel selector after leveling the wings. No more than 1 gallon of fuel was drained from the left wing inboard and outboard fuel tanks, but fire rescue personnel reported a smell of fuel near the displaced left engine. Examination of the wreckage revealed it was upright with the empennage nearly completely separated and inverted with the upper portion resting on the top of the fuselage and the tip of the vertical stabilizer and rudder above the wing walk compound of the right wing. The left engine was displaced down, while the right engine was nearly separated from the structure and resting beneath the right wing. There was no fire present on any observed components. Flight control continuity was established from all primary flight control surfaces to the main cabin area. The stabilator trim jackscrew displayed 3 threads, which is consistent with a neutral to nose down position, and the rudder trim was neutral. Both left and right flaps were in the up or retracted position, and the landing gear jack screw transmission displayed 0 threads, consistent with the landing gear being extended. Both wings exhibited evidence of impact damage on the leading edge, with the left-wing damage nearly full span. The outboard third of the left wing was displaced aft consistent with ground contact. One vortex generator remained installed on the left wing, while four vortex generators out of a total of 20 remained installed on the right wing. The on-site investigation did not identify or document any separated vortex generators in the vicinity of the wreckage. Examination of the vertical stabilizer revealed both sides had 15 vortex generators installed with none missing on either side. Examination of the cockpit revealed the right cowl flap was full in (closed), the right engine alternate air control was in (closed), and the right throttle, mixture, and propeller controls were about midrange. The right fuel selector handle and valve were just past the auxiliary fuel tank detent position, and the valve was free of obstructions in all positions. Blue colored fuel consistent with 100LL was in the right airframe fuel strainer. Examination of both engines was performed by a representative of the engine manufacturer with NTSB oversight. No preimpact failure or malfunction was noted to the left engine or its systems, or of the right engine powertrain, lubrication, exhaust, ignition, or air induction systems. The right fuel servo was retained for operational testing, which included a test of the idle circuit, though that test was not required by the fuel servo manufacturer. The fuel servo passed all 4 test points and the regulator hysteresis check, but it failed the idle circuit test. The idle circuit test was performed with the throttle gap at the as-found setting of 0.017 inch instead of 0.006 inch as specified at overhaul, the mixture control full rich, no air flow, and the throttle moved from wide open to idle. During the testing, the highest recorded fuel flow was about 12.0 pounds-per-hour (pph), and the metering head pressure in terms of inches-of-fuel was about 45. The lowest fuel flow when performing the test and tapping the regulator was about 4.5 pph at 0.017-inch throttle valve gap, and the metering head was 3.0 inches of fuel. The test of the idle circuit was repeated numerous times; each time the metered head pressure remained much higher than specified and was inconsistent and did not result in the same repeated value. The regulator section (fuel and air) was removed as a unit from the right fuel servo. Following removal, foreign debris (several small pieces) were noted in the fuel side of the regulator section. Examination of the debris by the NTSB Materials Laboratory revealed the pieces to be similar to one another and were matched to acrylonitrile-butadiene-styrene (ABS), a thermoplastic. Following removal of the foreign material the regulator section was reassembled onto the fuel servo, which was placed back onto the test bench. Following removal of air from the fuel servo, a check of the idle circuit was performed multiple times. During each check, the fuel flow consistently decreased to 4.5 pph while the metering head pressure consistently decreased to the same value and was within limits. Disassembly examination of both propellers revealed neither was feathered at impact and there was no evidence of preimpact failure or malfunction of either propeller. There was no evidence of preimpact failure or malfunction of the right propeller governor that would have precluded normal operation, or the pilot’s ability to feather the right propeller had he commanded that within the airplane’s flight envelope. Measurements of impact marks on the preload plates of both propeller blades revealed that both propeller blade angles of the left propeller were between about 28° and 31° at impact, while both propeller blades of the right propeller were at about 18° at impact, which was about the nominal start lock blade angle. Examination of the left propeller revealed the L1 blade was rotationally loose in the propeller hub, was bent aft, and exhibited some bending at the tip opposite the direction of rotation. A wave bend was noted on the leading edge of the blade about 2 inches from the tip, and some resin was noted in that area. Chordwise and spanwise scratches were noted on the cambered side of the blade. The L2 blade was bent aft, while about 4 inches of the tip was bent forward in the thrust direction. Scoring was noted at the tip corner, and 45° angular scoring near the tip and midspan on the cambered side of the blade was noted. The blade face was unremarkable. Operational nicks were noted on the leading edge of the blade. Visual examination of the right propeller revealed one propeller blade was bent aft approximately 45° and the other blade was relatively straight with no major damage. -
Analysis
Near the conclusion of the cross-country flight, when the airplane was flying about 2,175 ft pressure altitude and about 4 nautical miles due west of the approach end of runway 4 at the destination airport, the pilot broadcast on the frequency that one engine was not making as much power as the other, but that, “we’re ok.” The controller cleared the pilot to land on runway 4; however, for reasons that were not reported by the pilot, the airplane continued past the extended runway centerline for that runway. The pilot subsequently asked to land on runway 33, which was approved. The airplane continued on an easterly heading past the extended runway 33 centerline, then turned left on northwesterly heading flying parallel to runway 33. While flying east of the airport one witness noted the airplane banking left to about 45° before the wings rolled level and then banked about 10° to the left. The same witness reported that, while flying in a nose-up attitude just above the trees with the landing gear extended, the airplane rolled to an inverted position and descended straight down. The airplane impacted terrain behind a house. Postaccident examination of the flight controls, propellers, right propeller governor, left engine and its systems, and right engine powertrain, lubrication, exhaust, ignition, and air induction systems revealed no evidence of preimpact failure or malfunction. Neither propeller was feathered at impact. The damage to the left propeller was consistent with the engine developing some power at impact while the lack of damage to the right propeller was consistent with windmilling/rotating and not developing power at impact. Additionally, although it was not determined if there were any missing vortex generators (VG’s) on either wing at the time of the accident, the airplane’s performance was not changed by the installation of the VG’s. Thus, if any were missing at the time of the accident, it likely did not contribute to the accident. Postaccident operational testing of the right engine’s fuel servo revealed that it passed all four test points and the regulator hysteresis check, but it failed testing of the idle circuit, which should result in decreased fuel flow with movement of the throttle control from wide open to idle. The fuel flow when reducing the throttle to idle was about 2.6 times higher than what it should have been. Disassembly of the right fuel servo revealed internal contamination in the fuel section of the regulator that was determined to be acrylonitrile-butadiene-styrene (ABS), a thermoplastic, though the exact source of the contamination could not be determined. Following reassembly of the regulator with the internal contamination removed, the idle circuit test was repeated multiple times, and the fuel flow was within limits. Although it could not be determined if the excessive fuel flow during the idle circuit test was caused by the internal contamination or a combination of that and misalignment of the regulator section, the additional 0.011-inch clearance of the throttle valve at idle was likely the result of maintenance personnel attempting to remedy the excessive fuel flow when moving the throttle valve to idle. Thus, it is likely that during the descent approaching the airport with both engines operating at a reduced power setting, the excessive fuel flow to the right engine likely resulted in a total loss of engine power. Although the right engine likely sustained a total loss of engine power due to a malfunction of the fuel servo, it is likely that the pilot either did not, or delayed, feathering the right propeller until the propeller rpm slowed to where the propeller blades engaged on the start locks. In that position, an attempt to feather the propeller would not be possible until the propeller rpm increased above the speed that disengaged the start locks. The increased parasitic drag from the windmilling and unfeathered right propeller likely precluded the possibility of straight and level flight. Towards the end of flight, the airspeed likely reduced below the published Velocity Minimum Control (Vmc) speed, and the airplane rolled to an inverted position. Had the pilot either turned towards runway 4 which was the nearest runway after advising the controller of an engine malfunction, or feathered the right propeller following total loss of right engine power and maintained an airspeed above the published Vmc speed while continuing towards the airport, it is likely that he could have reached the airport and landed uneventfully.
Probable cause
Contamination and/or misalignment of the regulator section of the right engine’s fuel servo, which resulted in excessive idle fuel flow and a total loss of engine power. Also causal was the pilot's failure to land immediately on the nearest runway at the destination airport, his failure to feather the right propeller following the loss of engine power while approaching the airport, and his failure to maintain airspeed while maneuvering with one engine, which resulted in a loss of control at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N7295Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-335
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-30T17:35:19Z guid: 106324 uri: 106324 title: CEN23LA053 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106374/pdf description:
Unique identifier
106374
NTSB case number
CEN23LA053
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-19T18:00:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-29T02:52:25.635Z
Event type
Accident
Location
Searcy, Arkansas
Airport
UNITY HEALTH SPECIALTY CARE (AR78)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was repositioning the helicopter on the helipad to refuel. During the maneuver, the helicopter drifted aft and the tailrotor struck an electrical box. The helicopter lost tail rotor authority and landed hard on the skids. The tailrotor driveshaft, gearbox, and driveshaft sustained substantial damage. The operator reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain clearance from the electrical box while repositioning.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N184SF
Operator
Viking Aviation LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Positioning
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
53087
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-29T02:52:25Z guid: 106374 uri: 106374 title: DCA23LA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106329/pdf description:
Unique identifier
106329
NTSB case number
DCA23LA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-19T22:51:00Z
Publication date
2023-10-16T04:00:00Z
Report type
Final
Last updated
2022-12-01T20:08:12.967Z
Event type
Accident
Location
Red Oak, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Delta Air Lines flight 2295 struck several birds while descending through 13,000 feet on approach to Eppley Airfield (OMA), Omaha, Nebraska. The bird strike occurred about 34 miles southeast of the airport, near Red Oak, Iowa, at an airspeed of 290 knots. The crew continued the approach and made a normal landing. Weather at the time of the event was night visual conditions. Birds struck the airplane and punctured the fuselage skin in two locations on the left side; one above the cockpit windows and another near the pitot tube (see figure 1). Another bird punctured the skin on the right side of the fuselage below the cockpit window. Damage was evident to the stringers and frames at each location, and the size of the punctures in total exceeded the size of the outflow valve. The damage adversely affected the structural strength and pressurization performance and required a major repair. Figure 1. Photo of two of the bird strikes on the left side of the airplane, indicated by blue circles. (Source: Delta Air Lines) The flight crew described the noise as the strike occurred as being like an “explosion.” The cabin depressurized, and the cockpit door blew open. The captain reported that the wind noise was “extreme” which made communication difficult. Soon after the strike the airplane descended though 10,000 ft and the cabin altitude matched the airplane altitude at about 9,500 ft. The crew declared an emergency, continued the approach to OMA, and landed uneventfully. The species of birds was identified as either Snow Goose or Ross’s Goose (DNA testing could not discriminate between the two) by the Smithsonian Institution Feather Identification Laboratory. According to the FAA, there were no pilot reports of bird activity in the area near the time of the accident.
Probable cause
Multiple bird strikes during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A320
Amateur built
false
Engines
2 Turbo fan
Registration number
N330NW
Operator
DELTA AIR LINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
307
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-01T20:08:12Z guid: 106329 uri: 106329 title: DCA23FM007 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106344/pdf description:
Unique identifier
106344
NTSB case number
DCA23FM007
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-11-20T05:00:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-12-19T05:00:00Z
Event type
Accident
Location
Houma, Louisiana
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the toppling of the elevated liftboat L/B Robert was gale-force winds combined with waves that exceeded the vessel’s air gap, causing vessel movement, which led to a leg sliding into an adjacent can hole in the seafloor.
Has safety recommendations
false

Vehicle 1

Callsign
WDG2290
Vessel name
L/B Robert
Vessel type
Specialty/Other
IMO number
9649809
Maritime Mobile Service Identity
367514120
Port of registry
New Orleans, LA
Classification society
ABS
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-12-19T05:00:00Z guid: 106344 uri: 106344 title: ANC23LA006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106337/pdf description:
Unique identifier
106337
NTSB case number
ANC23LA006
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-20T13:40:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2022-11-22T21:55:35.142Z
Event type
Accident
Location
Bethel, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 20, 2022, about 1140 Alaska daylight time, a Cessna 207 airplane, N23CF, was substantially damaged when it was involved in an accident near Bethel, Alaska. The commercial pilot and six passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 135 passenger flight. The flight departed from the Goodnews Bay Airport (GNU) at 1035, on a scheduled flight to the Bethel Airport (BET). While in cruise flight at 1,000 ft above ground level, about 8 minutes from BET, the engine experienced a partial loss of power. The pilot performed the emergency procedures but was unable to regain engine power. The pilot performed a forced landing to an area of ice-covered frozen tundra about 10 miles southeast of the airport. After landing the pilot contacted the operator’s dispatch for rescue. Examination of the photographs taken at the accident site revealed substantial damage to the right wing and fuselage. Examination of the airplane before recovery revealed the left fuel tank was full with about 40 gallons of fuel and the right fuel tank was empty. When power was applied to the airplane the fuel indicating system displayed the left fuel tank was almost full and the right fuel tank was empty. The airplane was recovered to the Bethel Airport for an engine examination. During the examination, no fuel was found in the fuel lines from the fuel selector in the cockpit to the engine. The damaged propeller was removed, and a serviceable propeller was installed. The engine fuel boost pump was used, and the engine started and ran normally. Visual inspection of the engine found no abnormalities. The pilot later stated he believed the engine had an engine oil pump issue and was concerned with using the fuel boost pump, fearing he was adding fuel to a possible fire. The pilot had little time to troubleshoot the engine problem and his main concern was finding a safe place to land. He said at about 75 to 100 ft above the ground, he switched the fuel selector to the left tank but did not turn on the fuel boost pump. The Cessna 207 fuel selector can only operate in the left or right fuel tank position. It is the operator’s procedure to change the selected fuel tank at the midpoint of the flight. -
Analysis
While in cruise flight, the engine experienced a loss of power at 1,000 ft above ground level. The pilot performed the emergency checklist but was unable to restore engine power. He performed a forced landing to an area of ice-covered frozen tundra. Postaccident examination of the engine and fuel system revealed that the left fuel tank was full, and the right fuel tank was empty. No fuel was present in the fuel lines from the cockpit fuel selector to the engine. During the engine examination, the engine started and ran normally. Other than the absence of fuel, no anomalies were noted with the engine that would have precluded normal operation. The airplane’s fuel selector can only operate in the left or right fuel tank position. The operator’s procedure is to change the selected fuel tank at the midpoint of the flight; however, the pilot indicated after the engine examination that he likely forgot to switch fuel tanks.
Probable cause
The total loss of engine power during cruise flight due to fuel starvation and the pilot’s mismanagement of the available fuel.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
207
Amateur built
false
Engines
1 Reciprocating
Registration number
N23CF
Operator
YR-AIRCRAFT LEASING LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
20700276
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-22T21:55:35Z guid: 106337 uri: 106337 title: CEN23LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106332/pdf description:
Unique identifier
106332
NTSB case number
CEN23LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-20T15:00:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2022-12-19T23:51:51.428Z
Event type
Accident
Location
Cypress, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Factual narrative
On November 20, 2022, at 1300 central standard time, a Cessna 150L, N10612, was substantially damaged when it was involved in an accident near Cypress, Texas. The commercial pilot and a passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, after flying for about 1.5 hours, the airplane engine began to run rough and shake violently while in cruise flight at 1,600 ft mean sea level (msl). The pilot climbed the airplane to 1,900 ft msl and diverted to the nearest airport, but the engine lost all power, and he performed a forced landing on a grass field. During the landing, the airplane struck a wood fence and sustained substantial damage that included damage to the left wing, right horizontal stabilizer, and fuselage. Postaccident examination of the engine revealed that the No. 3 cylinder exhaust valve had failed and resulted in damage to the No. 3 cylinder. At the time of the accident, the engine exceeded the engine manufacturer’s time between overhaul period specificationsIt would be helpful to note both the recommended TBO and the time since last overhaul at the time of the accident. as outlined in the Continental Motors Service Information Letter SIL98-9E, which is not mandatory for Part 91 operations. -
Analysis
The pilot stated that during cruise flight the airplane engine began to run rough and shake violently. The pilot initiated a climb to a higher altitude and diverted to the nearest airport. The engine subsequently lost power and the pilot performed a forced landing on grass field, where the airplane struck a fence and sustained substantial damage. Postaccident examination of the engine revealed that the No. 3 cylinder exhaust valve failed. At the time of the accident, the engine exceeded the engine manufacturer’s time between overhaul period specifications as outlined in the Continental Motors Service Information Letter SIL98-9E, which is not mandatory for Part 91 operations.
Probable cause
Failure of the engine exhaust valve during cruise flight, which resulted in a loss of engine power and a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150L
Amateur built
false
Engines
1 Reciprocating
Registration number
N10612
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
15074924
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-19T23:51:51Z guid: 106332 uri: 106332 title: ERA23LA074 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106379/pdf description:
Unique identifier
106379
NTSB case number
ERA23LA074
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-22T11:45:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-01T03:38:02.425Z
Event type
Accident
Location
Newnan, Georgia
Airport
Newnan Coweta County Airport (CCO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while on a downwind leg of the airport traffic pattern, abeam the runway numbers, he simulated an engine failure for the student pilot. The student pilot performed checklist items, but the airplane was getting too low and far from the runway. The flight instructor then told him to turn directly toward the runway, which he did. The student pilot stated that he wanted to go-around, but the flight instructor said to keep going. By the time the flight instructor realized the airplane was not going to reach the runway threshold, he increased power, but the tail struck a runway light. The airplane subsequently landed uneventfully. The flight instructor stated that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation. Postaccident examination of the airplane confirmed that the empennage had been substantially damaged.
Probable cause
The flight instructor’s inadequate remedial action during a simulated engine failure and low approach, which resulted in a collision with a runway light.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N407MD
Operator
Flyt Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S12764
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-01T03:38:02Z guid: 106379 uri: 106379 title: CEN23LA048 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106366/pdf description:
Unique identifier
106366
NTSB case number
CEN23LA048
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-23T15:07:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2022-12-29T02:50:54.419Z
Event type
Accident
Location
Oxford, Colorado
Airport
DURANGO-LA PLATA COUNTY (DRO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a checkride with an applicant pilot, the designated pilot examiner was demonstrating a 180° autorotation. The applicant pilot reported the descent was too quick, the examiner flared too low, and the helicopter experienced a hard landing. An airport surveillance video showed the helicopter descend at a rapid rate and impact the runway. The helicopter came to rest on its left side and sustained substantial damage to the fuselage, tail boom, and main rotor system. The operator reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The designated pilot examiner’s failure to maintain a proper descent during a practice 180° autorotation which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
369HS
Amateur built
false
Engines
1 Turbo shaft
Registration number
N668M
Operator
Colorado Highland Helicopters
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
310312S
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-29T02:50:54Z guid: 106366 uri: 106366 title: CEN23LA049 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106367/pdf description:
Unique identifier
106367
NTSB case number
CEN23LA049
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-24T12:00:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2022-11-30T03:44:59.872Z
Event type
Accident
Location
Durango, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 24, 2022, about 1000 mountain standard time, a Cessna 182A airplane, N3886D, sustained substantial damage when it was involved in an accident near Durango, Colorado. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was flying with a friend in the local area and was returning to Durango when the accident occurred. He operated the airplane with the fuel selector in the “BOTH” position. When the pilot made a turn with about 30° of bank, the engine began to “cut out.” The pilot stated that he leveled the wings and that the engine started to regain power just before it “sputtered and died.” The pilot immediately established the airplane’s best glide airspeed and selected a field for a forced landing. During the landing, the airplane impacted multiple trees, which resulted in substantial damage to the fuselage. During recovery of the airplane the pilot drained both the left and right fuel tanks, which yielded about 8 to 10 gallons of fuel per side. The wings were then removed from the airplane to facilitate transport of the wreckage to the pilot’s shop, where the National Transportation Safety Board performed a postaccident examination of the airframe and engine. The examination revealed fuel in the gascolator, with no visible contamination, and no mechanical malfunctions or failures that would have precluded normal operation. A review of weather conditions at the time of the accident showed no probability for carburetor icing. -
Analysis
According to the pilot, he was flying with a friend in the local area and was returning to the departure airport when the accident occurred. He was operating the airplane with the fuel selector in the “BOTH” position. When the pilot made a turn with about 30° of bank, the engine began to “cut out.” The pilot stated that he leveled the wings and that the engine started to regain power just before it “sputtered and died.” The pilot immediately established the airplane’s best glide airspeed and selected a field for a forced landing. During the landing, the airplane impacted multiple trees, which resulted in substantial damage to the fuselage. The left and right fuel tanks had about 8 to 10 gallons of fuel per side. A postaccident examination of the airframe and engine revealed fuel in the gascolator, with no visible contamination, and no mechanical malfunctions or failures that would have precluded normal operation. A review of weather conditions at the time of the accident showed no probability for carburetor icing. Thus, on the basis of the available evidence for this accident investigation, the cause of the loss of engine power could not be determined.
Probable cause
A complete loss of engine power for reasons that could not be determined from the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182A
Amateur built
false
Registration number
N3886D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
34586
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-30T03:44:59Z guid: 106367 uri: 106367 title: DCA23FM008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106364/pdf description:
Unique identifier
106364
NTSB case number
DCA23FM008
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-11-25T05:00:00Z
Publication date
2024-01-11T05:00:00Z
Report type
Final
Last updated
2023-12-26T05:00:00Z
Location
Jamacia Beach, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the sinking of the fishing vessel Captain Alex was uncontrolled flooding through a hole—possibly caused by steel hull plating deterioration—beneath the engine room.
Has safety recommendations
false

Vehicle 1

Callsign
WDM3066
Vessel name
Captain Alex
Vessel type
Fishing
IMO number
8940799
Maritime Mobile Service Identity
368193860
Port of registry
Biloxi
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-12-26T05:00:00Z guid: 106364 uri: 106364 title: ERA23LA072 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106372/pdf description:
Unique identifier
106372
NTSB case number
ERA23LA072
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-26T13:26:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-11-28T23:50:46.818Z
Event type
Accident
Location
Suches, Georgia
Airport
High Valley Airpark (GA87)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The gyroplane pilot reported that he initiated his takeoff midway down the runway with a tailwind. After takeoff, the angle of climb was shallower than expected and the pilot determined that he may not clear the trees beyond the runway’s departure end. He attempted to turn back toward the runway; however, the gyroplane had insufficient altitude and impacted the brush. The gyroplane sustained substantial damage to the fuselage and tail section and the passenger was seriously injured. The pilot reported that there were no preaccident mechanical failures or malfunctions with the gyroplane that would have precluded normal operation and that he gave up safety margin unnecessarily. He stated that he should have performed a full-length departure into the wind.
Probable cause
The pilot's decision to take off from the runway midpoint with a tailwind, which resulted in impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
DANIEL ANTHONY PROCTOR
Model
M24 ORION PLUS
Amateur built
false
Engines
1 Reciprocating
Registration number
N728RJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24223826
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-28T23:50:46Z guid: 106372 uri: 106372 title: ANC23LA014 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106603/pdf description:
Unique identifier
106603
NTSB case number
ANC23LA014
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-27T05:00:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-25T23:08:09.966Z
Event type
Accident
Location
Anchorage, Alaska
Airport
Merrill Field Airport (MRI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported he was on a solo cross-country flight. The airport runway conditions were reported as good, braking deceleration and directional control was normal. As the airplane crossed over the approach end of the runway, the pilot felt he needed to lose a little more airspeed and held a flare a little longer and landed further down the runway. Upon touchdown the airplane began to slide to the left of centerline. The pilot attempted a go-around maneuver by adding power. The pilot was unable to correct back to centerline, which resulted in a runway excursion. The airplane impacted taxiway signs and lights sustaining substantial damage to the left wing. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N5626U
Operator
FLY AROUND ALASKA LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-26423
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-25T23:08:09Z guid: 106603 uri: 106603 title: ERA23LA073 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106373/pdf description:
Unique identifier
106373
NTSB case number
ERA23LA073
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-27T13:30:00Z
Publication date
2024-01-31T05:00:00Z
Report type
Final
Last updated
2022-11-28T23:58:43.602Z
Event type
Accident
Location
Titusville, Florida
Airport
Space Coast Regional (TIX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On November 27, 2022, about 1130 eastern standard time, an experimental amateur-built Rotorway Exec 162-F helicopter, N8006A, was substantially damaged when it was involved in an accident near the Space Coast Regional Airport (TIX), Titusville, Florida. The flight instructor and the pilot trainee were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor, who also owned the helicopter, stated that shortly after takeoff, while about 150 ft above ground level, the engine lost partial power with “severe backfiring.” He declared an emergency, turned back to the airport, and landed on a grassy area. Upon touchdown, with a ground speed of 5-10 mph, the helicopter’s front left skid dug into the grass. The helicopter entered a dynamic rollover and came to rest on its left side, resulting in substantial damage to the tail boom and main rotor blades. Postaccident examination of the engine revealed the No. 4 exhaust valve spring retainer was missing. Review of the engine maintenance manual revealed the valve train system including the spring retainer, was to be inspected every 25 hours. The manual stated, “Note the relative depth of the keeper set in each spring retainer. You may notice a slight variance on different valves, but no keeper set should be sunk deeply into a retainer. The important thing to look for is any change in the relative position of each keeper set. If you determine that a keeper set seems to be sinking deeper into its retainer, DO NOT continue to operate the engine.” A review of the engine logbook revealed that the instructor/owner performed the 25-hour inspection on October 11, 2022, about 8.8 hours before the accident. -
Analysis
The flight instructor, who was also the owner of the experimental amateur-built helicopter, said that shortly after takeoff, while about 150 ft above ground level, the helicopter’s engine lost partial power with “severe backfiring.” He declared an emergency, turned back to the airport, and landed on a grassy area. Upon touchdown, the helicopter’s front left skid dug into the grass and the helicopter rolled over. Postaccident examination of the engine revealed the No. 4 exhaust valve spring retainer was missing. The engine maintenance manual required inspection of the valve train system, including the spring retainer, every 25 hours. A review of the engine maintenance logbook revealed that the flight instructor/owner had performed the 25-hour inspection about 8.8 hours before the accident. The reason for the separation of the valve spring retainer was not determined.
Probable cause
A failure of the No. 4 exhaust valve spring retainer, which resulted in a partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
CHILDS MICHAEL A
Model
ROTORWAY EXEC 162-F
Amateur built
false
Engines
1 Reciprocating
Registration number
N8006A
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
6708
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-11-28T23:58:43Z guid: 106373 uri: 106373 title: ERA23LA076 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106402/pdf description:
Unique identifier
106402
NTSB case number
ERA23LA076
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-27T16:30:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-02T23:53:02.538Z
Event type
Accident
Location
Trinity, North Carolina
Airport
Private (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The noncertificated pilot described that on the day of the accident flight, he thought that the winds were gusting to about 30 knots. Shortly after takeoff from the private airstrip he reported that he lost control of the airplane after encountering a gust of wind. The airplane subsequently contacted power lines and came to rest in trees, resulting in substantial damage to the fuselage and wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain control of the airplane during initial climb in gusting wind conditions, which resulted in a collision with power lines and trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Phantom Aeronautics
Model
X1
Amateur built
false
Engines
1 Reciprocating
Registration number
N5205A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
073 846
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-02T23:53:02Z guid: 106402 uri: 106402 title: DCA23RM009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106389/pdf description:
Unique identifier
106389
NTSB case number
DCA23RM009
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2022-11-29T05:00:00Z
Publication date
2024-02-10T05:00:00Z
Report type
Final
Last updated
2024-02-05T05:00:00Z
Location
At sea
Injuries
1 fatal, 0 serious, 8 minor
Probable cause
See flag state investigative report
Has safety recommendations
false

Vehicle 1

Vessel name
Viking Polaris
Vessel type
Passenger
IMO number
9863209
Port of registry
Bergen
Classification society
DNV-GL
Flag state
NO
Findings
creator: Coast Guard last-modified: 2024-02-05T05:00:00Z guid: 106389 uri: 106389 title: DCA23LA086 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106401/pdf description:
Unique identifier
106401
NTSB case number
DCA23LA086
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-11-30T01:00:00Z
Publication date
2023-10-16T04:00:00Z
Report type
Final
Last updated
2023-01-27T18:51:15.23Z
Event type
Accident
Location
Denver, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
Southwest Airlines flight 136 encountered turbulence while descending through 15,600 ft into Denver International Airport (DEN), Denver, Colorado, and a flight attendant fractured her ribs. During the brief for the flight preceding the accident flight, the captain notified FA “A” that he would be requesting that the FAs take their seats about 25 minutes before their arrival at DEN. The captain stated that this was a routine part of his briefings for flights into DEN due to the unpredictable weather. FA “A” stated that she had been busy with her duties and about 4 hours had passed since the briefing. Subsequently, she had forgot to share this information with the other FAs. About 35 minutes before landing, the captain asked the cabin crew to clean up the cabin and take their seats. All three FAs located vacant passenger seats in the cabin and were seated. When the captain “double chimed” the cabin at about 16,000 ft (indicating the cabin should be secured early), all three FAs stood up to return to their jump seats. Shortly thereafter, the airplane experienced moderate turbulence. FA “B” reported that as she was walking through the aisle, the turbulence occurred, and the airplane “dropped”. She went into the air before falling onto a row of seats. As she attempted to sit in one of the seats, the airplane dropped again, and she fell to the floor. Following the turbulence, the first officer stated that he gave a pilot report (PIREP) to air traffic control at DEN and the flight proceeded to its destination and landed without further incident. After landing, the flight crew was informed that FA “B” required medical attention. Emergency medical services arrived and transported FA “B” to the emergency room where she was diagnosed with multiple rib fractures. A post-accident review of meteorological conditions showed no significant meteorological information (SIGMETs). Upper air model data at the time of the accident revealed limited wind shear around the accident altitude. Weather radar data from the National Weather Service station located in Watkins, Colorado (located 6 nautical miles southeast of DEN) showed no reflectivity that suggested convective activity or other precipitation. There was one applicable PIREP from about 85 minutes earlier that reported moderate turbulence between 10,000 ft and 13,500 ft (MSL) about 35 miles east-southeast of the accident location near DEN. Analysis of the aggregate weather information suggested the turbulence was likely mechanical in nature and caused by significant surface winds in the vicinity of mountainous terrain.
Probable cause
The flight’s encounter with mechanical turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737
Amateur built
false
Engines
2 Turbo fan
Registration number
N946WN
Operator
SOUTHWEST AIRLINES CO
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
36918
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-01-27T18:51:15Z guid: 106401 uri: 106401 title: ERA23LA081 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106436/pdf description:
Unique identifier
106436
NTSB case number
ERA23LA081
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-01T23:08:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-19T19:54:36.063Z
Event type
Accident
Location
Guantanamo Bay, Other Foreign
Airport
GUANTANAMO BAY NAVAL AIR STATION (MUGM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight crew reported that during a civilian positioning flight to pick up a medical patient, they were cleared to land via a visual approach at night. During the base segment in the traffic pattern, the first officer, who was the pilot flying, lost sight of the runway and transferred the flight controls to the captain at an altitude of about 900 ft mean sea level. The first officer stated that after the exchange of the flight controls, the “aircraft was on short final and passed over the threshold at an angle.” Subsequently, during the captain’s landing flare and touchdown, the stick shaker activated, and the left wing dropped and impacted the runway. The captain completed the landing roll, stopped the airplane on the runway, and all of the occupants exited without incident. The impact with the runway resulted in substantial damage to the left wing. The flight crew did not report any preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The flight crew’s continuation of an unstable approach which resulted in abnormal runway contact during the landing flare and touchdown.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LEARJET
Model
35
Amateur built
false
Engines
2 Turbo fan
Registration number
N979RF
Operator
REVA, Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Flight terminal type
International
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
376
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-19T19:54:36Z guid: 106436 uri: 106436 title: PLD23FR001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106406/pdf description:
Unique identifier
106406
NTSB case number
PLD23FR001
Transportation mode
Pipeline
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-03T05:00:00Z
Publication date
2023-04-19T04:00:00Z
Report type
Final
Event type
Accident
Location
Atlanta, Georgia
Injuries
2 fatal, 0 serious, 0 minor
Pipeline operator
Atlanta Gas Light
Pipeline type
Distribution
Regulator type
GA
Probable cause
Not investigated by NTSB
Has safety recommendations
false

Vehicle 1

Findings
creator: NTSB last-modified: 2023-04-19T04:00:00Z guid: 106406 uri: 106406 title: ANC23LA016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106642/pdf description:
Unique identifier
106642
NTSB case number
ANC23LA016
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-03T16:50:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-01-28T00:46:30.679Z
Event type
Accident
Location
Anchorage, Alaska
Airport
LAKE HOOD (LHD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after applying power during the takeoff roll, the airplane veered left. She attempted to correct by reducing engine power and using opposite rudder and right brake, but the airplane exited the runway and struck a parked airplane and fuel tank resulting in substantial damage to the left wing. A Federal Aviation Administration inspector confirmed the airplane’s rudder control, braking system, and tailwheel steering mechanism functioned correctly. Postaccident examination of the airframe revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot's loss of directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHAMPION
Model
7GCBC
Amateur built
false
Engines
1 Reciprocating
Registration number
N8365V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
66
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-28T00:46:30Z guid: 106642 uri: 106642 title: DCA23LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106414/pdf description:
Unique identifier
106414
NTSB case number
DCA23LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-03T18:11:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2023-01-20T03:30:42.244Z
Event type
Accident
Location
Taneytown, Maryland
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
Mesa Airlines flight 6048 encountered turbulence at 10,000 ft during descent into Dulles International Airport (IAD), Chantilly, Virgina. As a result of the turbulence, one flight attendant sustained serious injuries. The airplane landed without further incident. The flight originated from LaGuardia International Airport (LGA), New York, New York. According to the flight crew, while descending on the HYPER EIGHT arrival, the air traffic controller advised their airplane was following a “heavy jet” and asked if a 7-mile separation would be sufficient. The captain asked for a 10-mile separation, which was granted, and the controller provided vectors to increase the spacing between the two airplanes. The crew could not see the other airplane visually, nor could they determine its location using the traffic collision avoidance system. During the descent, as the airplane crossed the HYPER intersection at 10,000 ft and 250 knots, it encountered moderate turbulence described as a “rapid jolt” while in instrument meteorological conditions. At the time, the seatbelt sign was on, and the two flight attendants along with another commuting flight attendant, were standing in the aft galley. The turbulence resulted in all three of them being “tossed about and hit the floor.” One flight attendant sustained a broken ankle. The flight crew declared a medical emergency and notified dispatch of the event. The commuting flight attendant assumed the duties for the injured flight attendant. The remainder of the fight was uneventful, and paramedics met the airplane at the gate and transported the injured flight attendant to the hospital. According to the operator, the flight crew was not aware of any forecast turbulence in the area or reports of turbulence encounters by other pilots (PIREPS).
Probable cause
An encounter with turbulence during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EMBRAER
Model
ERJ170
Amateur built
false
Engines
2 Turbo fan
Registration number
N85356
Operator
Mesa Airlines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
17000692
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-01-20T03:30:42Z guid: 106414 uri: 106414 title: ERA23LA080 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106421/pdf description:
Unique identifier
106421
NTSB case number
ERA23LA080
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-05T12:52:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-07T00:21:51.291Z
Event type
Accident
Location
Woodsfield, Ohio
Airport
MONROE COUNTY (4G5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that after touchdown, the airspeed decreased, and the tailwheel settled onto the runway. He applied brakes and recalled the airplane’s nose pulled to the left about 20 or 30 degrees. He applied right rudder and right brake to correct the direction, but the airplane exited the runway to the left, traveled up a berm and became airborne. The right wing then impacted terrain and rotated the airplane 180 degrees, before it came to rest on the main landing gear. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage and right wing. The inspector examined the airplane’s brakes and found that both functioned normally. He also examined the tires and saw that neither exhibited flat spots and that the tire marks on the runway appeared to be from a rolling (and not skidding) right tire. Based on this information, it is likely that the pilot lost directional control of the airplane during the landing.
Probable cause
The pilot's failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JAMES R DERNOVSEK
Model
KITFOX
Amateur built
true
Engines
1 Reciprocating
Registration number
N257ED
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
V95030029
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-07T00:21:51Z guid: 106421 uri: 106421 title: CEN23LA063 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106450/pdf description:
Unique identifier
106450
NTSB case number
CEN23LA063
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-06T11:30:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-12-16T02:29:07.473Z
Event type
Accident
Location
Mission, Texas
Airport
Mid-Valley Dusters Inc. Airport (43TX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
A company representative reported that the airplane impacted an unknown object during an aerial application flight. After landing, substantial damage to the left wing was discovered. Following a brief search, a damaged electrical box was found dislodged from its base with yellow paint on one side that was consistent with the color of the airplane's left wing. The operator reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot did not supply a statement regarding the collision or the circumstances.
Probable cause
The pilot's failure to maintain clearance from an electrical box.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL INTERNATIONAL
Model
S2R-G6
Amateur built
false
Engines
1 Turbo prop
Registration number
N4205X
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1968R
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-16T02:29:07Z guid: 106450 uri: 106450 title: WPR23LA059 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106430/pdf description:
Unique identifier
106430
NTSB case number
WPR23LA059
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-07T15:15:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-12-28T03:12:01.558Z
Event type
Accident
Location
Ft Worth, Texas
Airport
Bell South Airfield Airport (XS04)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, during the instructional flight practicing autorotations, the pilot receiving instruction flared the helicopter in a more pronounced nose up attitude, an aft cyclic and higher descent rate, but not excessive enough to require him to take control. During the landing, the main rotor blades contacted the tail boom. The tail rotor driveshaft and vertical fins were substantially damaged during the landing. The flight instructor reported that there were no of preaccident mechanical malfunctions or failures with the helicopter that would preclude normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a hard landing. Contributing to the accident, was the flight instructor’s inadequate supervision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206-L4
Amateur built
false
Engines
1 Turbo shaft
Registration number
N2036F
Operator
BELL TEXTRON INC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
52123
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-28T03:12:01Z guid: 106430 uri: 106430 title: ANC23LA017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106662/pdf description:
Unique identifier
106662
NTSB case number
ANC23LA017
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-08T16:00:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-02-01T00:45:14.717Z
Event type
Accident
Location
Wasilla, Alaska
Airport
Goose Bay (Z40)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The instructor pilot of the tundra tire-equipped airplane reported that, during a touch-and-go maneuver on a snow-covered runway, the airplane decelerated rapidly as the main landing gear wheels touched down into the deep snow, and he was unable to perform the go around maneuver. The airplane subsequently nosed over sustaining substantial damage to the wing lift struts and rudder. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's selection of an unsuitable landing site, which resulted in a nose over after the main landing gear wheels broke through deep snow on the snow-covered runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N3861P
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
22-3553
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-01T00:45:14Z guid: 106662 uri: 106662 title: WPR23LA062 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106441/pdf description:
Unique identifier
106441
NTSB case number
WPR23LA062
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-10T13:10:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2022-12-13T00:41:38.432Z
Event type
Accident
Location
Socorro, New Mexico
Airport
Socorro Airport (KONM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that, while on approach, the airplane encountered turbulence with wind gusts. During the flare, the airplane landed hard and bounced. A wind gust raised the right wing turning the airplane off the runway to the left side toward rising terrain. The pilot applied full power to avoid the terrain when the stall warning horn sounded. The airplane subsequently collided with terrain, substantially damaging both wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a hard bounced landing and loss of control in gusting wind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N422B
Operator
EVANS JACK J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17268342
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-13T00:41:38Z guid: 106441 uri: 106441 title: ERA23LA088 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106460/pdf description:
Unique identifier
106460
NTSB case number
ERA23LA088
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-10T17:30:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-20T00:45:41.38Z
Event type
Accident
Location
Alabaster, Alabama
Airport
Shelby County Airport (EET)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the vintage tailwheel-equipped airplane reported that he made a three-point landing on the runway centerline, aligned with the runway, in light wind. Upon touchdown, the airplane swerved left. The pilot attempted to correct with right rudder and brake application; however, the airplane departed the left side of the runway and ground looped, resulting in substantial damage to the right wing and empennage. The pilot examined the tailwheel after the accident and noted that its locking mechanism had failed. Specifically, he believed that the spindle or brass thrust ring had failed internally.
Probable cause
Failure of the tailwheel locking mechanism, which resulted in a loss of control during landing and a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
305
Amateur built
false
Engines
1 Reciprocating
Registration number
N5301G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22808
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-20T00:45:41Z guid: 106460 uri: 106460 title: ERA23LA084 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106440/pdf description:
Unique identifier
106440
NTSB case number
ERA23LA084
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-11T14:20:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2022-12-16T01:47:43.674Z
Event type
Accident
Location
Gilgo-Oak Beach-Captree, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After practicing maneuvers, autorotative approaches, and landings in the local area, the flight instructor and the student pilot were practicing autorotative landings from a hover following a simulated loss of engine power, off-airport, and over sandy terrain. While hovering about 3 ft. above the ground, the student pilot reduced engine power to enter an autorotation. Between 1 and 2 ft. above the ground, a gust of wind struck the helicopter from the right that resulted in the helicopter rolling and drifting to the left. The flight instructor then took control of the helicopter, but the left roll and drift continued, the left skid impacted the ground, and the helicopter experienced a dynamic rollover onto its left side. During the rollover, the main rotor blades impacted the ground and the tailboom and main rotor mast pylon were substantially damaged. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The flight instructor’s inadequate remedial action while supervising the student pilot’s practice autorotation in gusting wind conditions, which resulted in a dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N14HT
Operator
N7047X-R22 LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
4040
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-16T01:47:43Z guid: 106440 uri: 106440 title: WPR23LA068 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106469/pdf description:
Unique identifier
106469
NTSB case number
WPR23LA068
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-11T16:17:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-29T03:29:57.861Z
Event type
Accident
Location
Rancho Cordova, California
Airport
Mather (KMHR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that the pilot receiving instruction was practicing an offsite landing in an open area. While descending on approach to the site, the airspeed decayed to 35 kts. The flight instructor prompted for an increase in airspeed, the pilot flying acknowledged, applied forward cyclic, right pedal, and continued turning left into the wind. They encountered an uncommanded left yaw and the pilot receiving instruction added right pedal until he reached full deflection. The flight instructor then assumed control of the helicopter and pushed forward on the cyclic as he lowered the collective. The instructor attempted to recover from the uncommanded left yaw; however, but the helicopter spun several times. Unable to gain forward airspeed, the flight instructor began a descent. The helicopter subsequently landed hard substantially damaging the underside of the fuselage. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot receiving instruction’s loss of helicopter control during landing with a crosswind, and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
EC120B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N255SD
Operator
SACRAMENTO COUNTY SHERIFFS OFFICE
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1102
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-29T03:29:57Z guid: 106469 uri: 106469 title: ERA23LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106461/pdf description:
Unique identifier
106461
NTSB case number
ERA23LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-13T12:55:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-20T17:30:42.144Z
Event type
Accident
Location
Rockingham, North Carolina
Airport
RICHMOND COUNTY (RCZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, after flying for about 4 hours, the engine lost total power about 2 miles form the destination airport and the pilot performed a forced landing to a field, which resulted in substantial damage to the airplane’s fuselage and right wing. The pilot described that the fuel consumption during the accident flight was higher than he had expected based on the fuel consumption that he had calculated on previous flights. A Federal Aviation Administration inspector examined the airplane after the accident and confirmed that both of the fuel tanks were absent of fuel. In the “Recommendation” section of the NTSB Pilot/Operator Accident Report, the pilot stated that “a more accurate way to determine actual fuel on board and a higher reserve might have prevented this accident.” Based on this information, it’s likely that the loss of engine power was due to fuel exhaustion.
Probable cause
The pilot’s improper fuel management, which resulted in fuel exhaustion and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-38-112
Amateur built
false
Engines
1 Reciprocating
Registration number
N498DS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
38-79A0668
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-20T17:30:42Z guid: 106461 uri: 106461 title: ERA23LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106463/pdf description:
Unique identifier
106463
NTSB case number
ERA23LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-14T12:45:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-27T18:01:42.398Z
Event type
Accident
Location
San Juan, Puerto Rico
Airport
FERNANDO LUIS RIBAS DOMINICCI (SIG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, during the landing flare, the airplane “bounced” back into the air. The pilot attempted to regain control of the airplane but was unsuccessful. The airplane collided with the runway and “skidded” off the left side before coming to a stop in the grass. The pilot reported that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation. A Federal Aviation Administration inspector examined the airplane after the accident and conformed that the fuselage had been substantially damaged.
Probable cause
The pilot’s improper recovery from a bounced landing which resulted in a loss of control and subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N416PC
Operator
SKY WEST AVIATION INC TRUSTEE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4329
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-27T18:01:42Z guid: 106463 uri: 106463 title: ANC23LA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106474/pdf description:
Unique identifier
106474
NTSB case number
ANC23LA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-15T14:05:00Z
Publication date
2023-11-07T05:00:00Z
Report type
Final
Last updated
2022-12-23T04:47:17.562Z
Event type
Accident
Location
Lihue, Hawaii
Airport
Lihue Airport (PHLI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Factual narrative
On December 15, 2022, about 1205 Hawaii-Aleutian standard time, a Beech 77 airplane, N991AB, sustained substantial damage when it was involved in an accident at Lihue Airport (PHLI), Lihue, Hawaii. The pilot sustained serious injuries and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he conducted a preflight inspection and an engine run-up with no anomalies noted. The airplane departed from runway 21 at PHLI. The automatic terminal information service (ATIS) information reported that the wind was from 170° at 12 knots, the tower assigned him runway 21 and not runway 17. During climbout, when the airplane was about 100 to 200 ft above ground level (agl), the airplane stopped climbing. The pilot noted no change in engine noise and reported that all cockpit indications were normal except for the vertical speed indicator, which was moving between 0 and 100 ft per minute and possibly below zero. Toward the end of the runway, the airplane stalled, descended, and impacted a fence at the edge of the airport property. The airplane came to rest just past the airport fence into a storage yard. The airplane sustained substantial damage to both wings and the fuselage. In the NTSB Pilot/Operator Accident Report (Form 6120.1), the pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. The airplane was equipped with a JPI-700 engine data monitor. The data revealed engine exhaust gas temperatures and cylinder head temperatures were increasing throughout the flight with no signs of decreasing temperatures. A review of the Airport Facility Directory information for PHLI indicated no warning or notices for any potential turbulence or wind shear conditions for departures on runway 21. A review of the topography indicated an east-to-west ridge that rises to about 2,297 ft about 4 miles southwest of the centerline of runway 21; the ridge could produce downdraft conditions with strong southerly low-level wind on the departure path for runway 21. Departures on runway 17 at PHLI would not result in any turbulence or downdrafts because there is no terrain directly south of the airport. A pilot for a commercial operator departed from runway 21 about 20 minutes before the accident airplane. This pilot reported that his airplane was “always” at or above 800 ft agl at the end of the runway; on this departure, the airplane was only at 300 ft agl. The pilot also reported that downdrafts from the mountain (when using runway 21) are not detected by airport wind sensors. In addition, this pilot reported that company pilots are now required to use runway 17 and avoid runway 21. -
Analysis
The pilot reported that, during departure, he could not climb the airplane, which stalled toward the end of the runway and descended into terrain at the edge of the airport property, resulting in substantial damage to both wings and fuselage. The pilot of a commercial airplane that departed shortly before the accident airplane reported poor climb performance during departure. A review of the topography for the runway that was used for both takeoffs indicated the possibility of downdraft conditions on the departure path of the runway. It is likely that the airplane encountered a downdraft during departure that exceeded the climb capability of the airplane and resulted in the airplane exceeding its critical angle of attack, entering an aerodynamic stall, and descending into terrain.
Probable cause
The airplane’s exceedance of its critical angle of attack after encountering a downdraft during departure, which resulted in an aerodynamic stall and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
77
Amateur built
false
Engines
1 Reciprocating
Registration number
N991AB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
WA-79
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-23T04:47:17Z guid: 106474 uri: 106474 title: WPR23LA100 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106654/pdf description:
Unique identifier
106654
NTSB case number
WPR23LA100
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-15T22:45:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-02-03T07:43:30.212Z
Event type
Accident
Location
Deming, New Mexico
Airport
Deming Municipal Airport (KDMN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, the airplane does not have an electrical system and needed to be hand propped to start the engine. There were no tire chocks or tie-down ropes on the ramp, so he asked an individual at the airport, whom he believed was a pilot and said that he had experience with assisting in hand propping an airplane. The pilot instructed the individual on the procedures and with the throttle set to 1/8 inch open, and the individual in the pilot’s seat, he then positioned himself in front of the airplane and spun the propeller. The engine started as expected and the engine immediately went to a high rpm setting. The airplane began forward movement under high rpm and speed and subsequently collided with a light pole and airport hangar after the individual in the cockpit could not stop the airplane. Both wings were substantially damaged. The pilot reported that after the collision, he found the throttle positioned to the full forward high rpm position instead of the idle position and that the individual reported that he went the wrong direction with the throttle. The pilot reported that there were no mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The occupant’s improper throttle movement during the start procedure, which resulted in forward movement and loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
65-CA
Amateur built
false
Engines
1 Reciprocating
Registration number
N29447
Operator
JONES CODY
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CA10330
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-03T07:43:30Z guid: 106654 uri: 106654 title: WPR23LA074 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106496/pdf description:
Unique identifier
106496
NTSB case number
WPR23LA074
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-17T13:00:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2022-12-28T03:37:48.437Z
Event type
Accident
Location
Cottonwood, California
Airport
Flying N Ranch Airport (CA04)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that, during the takeoff, the fuel tank selector was mistakenly set to the auxiliary tank. Five minutes later the auxiliary tank ran out of gas, which resulted in a total loss of engine power. The pilot switched to the main tank; however, there was insufficient altitude available for a recovery. The airplane struck terrain about 100 ft short of the runway, which substantially damaged the left and right wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s fuel mismanagement which resulted in fuel starvation and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROYSE RALPH L
Model
GLASAIR
Amateur built
true
Engines
1 Reciprocating
Registration number
N9YA
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
582R
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-28T03:37:48Z guid: 106496 uri: 106496 title: WPR23LA070 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106476/pdf description:
Unique identifier
106476
NTSB case number
WPR23LA070
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-18T16:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-01-11T03:23:09.062Z
Event type
Accident
Location
Afton, Wyoming
Airport
Afton Municipal Airport (AFO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot was planning to complete a touch and go landing on the same runway he departed from 15 minutes earlier, which contained patches of snow and ice. When the airplane touched down, it encountered a patch of ice and skidded left. The plane collided with snow then nosed over and came to rest inverted. The airplane sustained substantial damage to the left wing. The pilot reported no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control during landing on a contaminated runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6
Amateur built
false
Engines
1 Reciprocating
Registration number
N78HJ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21043
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-11T03:23:09Z guid: 106476 uri: 106476 title: DCA23LA172 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106734/pdf description:
Unique identifier
106734
NTSB case number
DCA23LA172
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-18T16:51:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-03-22T16:48:54.698Z
Event type
Incident
Location
Kahului, Hawaii
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
United flight 1722 lost altitude about 1 minute after departure while in instrument meteorological conditions, which included heavy rain. The airplane descended from 2,100 ft to about 748 ft above the water before the crew recovered from the descent. No injuries were reported, and the airplane was not damaged. The NTSB was not originally notified of the event, since it did not meet the requirements of Title 49 Code of Federal Regulations Part 830.5. However, the NTSB learned of the event about 2 months later and chose to open an investigation. By that time, both the cockpit voice and flight data recorder durations had been exceeded. The investigation utilized flight crew statements and other records as information sources. The captain (who was the pilot flying) reported that he and the first officer had initially planned for a flaps-20 takeoff (flap setting of 20°) with a reduced-thrust setting, based on performance calculations. However, during taxi, the ground controller advised them that low-level windshear advisories were in effect. Based on this information, the captain chose a flaps-20 maximum thrust takeoff instead. He hand-flew the takeoff, with the auto throttles engaged. During the takeoff, the rotation and initial climb were normal; however, as the airplane continued to climb, the flight crew noted airspeed fluctuations as the airplane encountered turbulence. When the airplane reached the acceleration altitude, the captain reduced the pitch attitude slightly and called for the flap setting to be reduced to flaps 5. According to the first officer, he thought that he heard the captain announce flaps 15, which the first officer selected before contacting the departure controller and discussing the weather conditions. The captain noticed that the maximum operating speed indicator moved to a lower value than expected, and the airspeed began to accelerate rapidly. The captain reduced the engine thrust manually, overriding the auto throttle servos, to avoid a flap overspeed and began to diagnose the flap condition. He noticed that the flap indicator was showing 15°, and he again called for flaps 5, and he confirmed that the first officer moved the flap handle to the 5° position. The first officer stated that he “knew the captain was having difficulty with airspeed control”, and he queried the captain about it as he considered if his own (right side) instrumentation may have been in error. He did not receive an immediate response from the captain. Both pilots recalled that, about this time, the airplane’s pitch attitude was decreasing, and the airspeed was increasing. The first officer recalled that that the captain asked for flaps 1 soon after he had called for flaps 5, and when the first officer set the flaps to 1°, he then noticed the airspeed had increased further, and the control column moved forward. Both pilots recalled hearing the initial warnings from the ground proximity warning system (GPWS), and the first officer recalled announcing “pull up pull up” along with those initial GPWS warnings. The captain then pulled aft on the control column, initially reduced power to reduce airspeed, and then applied full power to “begin the full CFIT [controlled flight into terrain] recovery.” The first officer recalled that, as the captain was performing the recovery, the GPWS alerted again as the descent began to reverse trend; data showed this occurred about 748 ft above the water. After noting a positive rate of climb, the captain lowered the nose to resume a normal profile, ensured that the flaps and speed brakes were fully retracted, and engaged the autopilot. The remainder of the flight was uneventful. Figure 1 shows a perspective view of the flight track. Figure 1- Flight Track with Annotations As a result of the event, United Airlines modified one of their operations training modules to address this occurrence and issued an awareness campaign about flight path management at their training center.
Probable cause
The flight crew’s failure to manage the airplane’s vertical flightpath, airspeed, and pitch attitude following a miscommunication about the captain’s desired flap setting during the initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
777
Amateur built
false
Engines
2 Turbo jet
Registration number
N212UA
Operator
UNITED AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
30218
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-03-22T16:48:54Z guid: 106734 uri: 106734 title: CEN23LA091 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106625/pdf description:
Unique identifier
106625
NTSB case number
CEN23LA091
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-19T21:15:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-01-24T21:39:40.002Z
Event type
Accident
Location
Pocahantas, Iowa
Airport
POCAHONTAS MUNI (POH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The non-instrument rated private pilot reported that, during a night cross-country flight, the airplane encountered ice that began to accumulate on the windshield and obscured the pilot's vision. The pilot reported that during landing he had no pitch control, the airplane landed hard, and bounced. On the third bounce, the nose landing gear collapsed. The airplane came to rest upright on the runway. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation. The pilot stated in his report that he allowed external factors to influence his decision making related to the flight. He noted that he wanted to make it back home for the Christmas holiday and that he had already missed a day of work. He also stated that he did not obtain updated weather information and that if he had he may have made the decision to not start the flight.
Probable cause
The pilot’s landing flare which resulted in a bounced landing and the nose landing gear collapsing. Contributing to the accident was the airplane's encounter with adverse weather conditions which led to structural icing that affected flight characteristics and obscured the pilot's vision. Also contributing to the accident were the self-induced and external pressures that influenced the pilot’s decision to initiate and continue the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150G
Amateur built
false
Engines
1 Reciprocating
Registration number
2930J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15065730
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-24T21:39:40Z guid: 106625 uri: 106625 title: CEN23LA067 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106483/pdf description:
Unique identifier
106483
NTSB case number
CEN23LA067
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-21T16:47:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2022-12-22T23:39:15.855Z
Event type
Accident
Location
Auburn Hills, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On December 21, 2022, about 1447 eastern standard time, a Cessna 172F, N8768U, received substantial damage when it was involved in an accident near Auburn, Michigan. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the accident flight was a proficiency flight, and he was planning to perform steep turns, stalls, and two landings. Before the flight, he added Marvel Mystery Oil to the 7 quarts of engine oil that was in the engine to “thin the engine oil.” He said that the airplane hangar was close to the departure runway and that during the engine runup and takeoff roll, the engine oil temperature gauge indication was “not registering.” He did not remember whether the oil pressure gauge indication was in the normal operating range. He stated that during the departure climb to cruise altitude, the engine “coughed, shuddered, and started to run rough.” The engine speed decreased to 1,700 rpm, and the pilot then diverted the flight to the departure airport. His attempts to regain engine power were unsuccessful, and he performed an approach for an off-airport landing, during which the engine seized when he reduced engine power to idle. He said the airplane was high and fast on the approach, and it clipped trees along a road that he intended to land the airplane on. The airplane sustained substantial damage to both wings, horizontal and vertical stabilizers, fuselage, and engine mounts. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) aviation safety inspector revealed that the underside of the airplane was covered in engine oil. The No. 4 cylinder connecting rod was separated, and there were holes through the engine crankcase above the No. 4 cylinder. The externally mounted engine oil cooler exhibited fresh oil leakage that exited from the bottom engine cowl. The airplane was not equipped with a Cessna winterization kit for cold weather operations below 20o F, nor was it required to be. The FAA inspector stated there was a trail of oil leading from the airplane’s hangar down the taxiway to the runway. The pilot did not preheat the engine before start and did not warm the engine to operating temperatures before takeoff in accordance with the procedures for cold weather operations in the Airplane Owner’s Manual. In 2013, an Aviation Development Corporation remote oil filter and an externally mounted oil cooler were installed onto the engine under an FAA field approval. The engine oil was last changed by the pilot using Aeroshell 100 (SAE 50) engine oil when the airplane was based in Las Vegas, Nevada, about 3 months before the accident. Aeroshell 100 has an operating temperature range of 60o to 80o F. The Airplane Owner’s Manual states that SAE 20 oil is to be used at temperatures below 40oF. The temperature at the time of the accident was 28°F. According to Textron Aviation, Cessna and Continental Motors do not recommend the use of any additive to the oil during cold weather operations. Teledyne Continental Motors Service Information Letter (SIL) 03-1, Cold Weather Operation – Engine Preheating, issued on January 28, 2003, stated, in part: Failure to properly preheat a cold-soaked engine may result in oil congealing within the engine, oil hoses, and oil cooler with subsequent loss of oil flow, possible internal damage to the engine, and subsequent engine failure. Superficial application of preheat to a cold soaked engine can cause damage to the engine. An inadequate application of preheat may warm the engine enough to permit starting but will not de-congeal oil in the sump, lines, cooler, filter, etc. Congealed oil in these areas will require considerable preheat. The engine may start and appear to run satisfactorily but can be damaged from lack of lubrication due to the congealed oil blocking proper oil flow through the engine. The amount of damage will vary and may not become evident for many hours. However, the engine may be severely damaged and may fail shortly following application of high power. The SIL further stated that “operation of the engine above 1700 RPM before reaching minimum oil temperature may result in engine malfunction, engine failure, injury or death.” -
Analysis
The pilot reported that shortly after takeoff, as the airplane was climbing through about 3,000 feet, the engine “coughed and shuddered and started to run rough.” After unsuccessfully troubleshooting the engine, the pilot decided to conduct an emergency landing on a nearby road. During the landing the airplane’s left wing clipped trees, causing the airplane to veer left and flip over. The airplane sustained substantial damage that included damage to both wings, horizontal and vertical stabilizers, fuselage, and engine mounts. Postaccident examination revealed a trail of oil from the airplane’s hangar, down the taxiway, leading to the departure runway. The underside of the airplane was covered in engine oil, and the externally mounted engine oil cooler exhibited fresh oil leakage. The No. 4 cylinder connecting rod was separated and there were holes through the engine crankcase above the No. 4 cylinder, consistent with catastrophic failure due to a lack of lubrication. The outside air temperature at the time of the accident was about 28oF. According to the airplane manufacturer, engine oil with a viscosity of SAE 20 was to be used at temperatures below 40oF and SAE 40 was to be used for temperatures above 40oF. However, the oil in the airplane’s engine had a viscosity of SAE 50, with an operating temperature range of 60o to 80o F. Although the pilot added an oil additive to “thin the engine oil,” the aircraft manufacturer noted that the use of any oil additives during cold weather operation is not recommended. Additionally, the engine manufacturer indicated that operation of the engine without preheat could lead to oil congealing and engine failure, and operation of the engine above 1,700 rpm without first reaching minimum oil temperature could also lead to engine failure. The pilot reported that during the engine runup and takeoff roll the engine oil temperature gauge indication was “not registering,” and he did not remember whether the oil pressure gauge indication was in the normal operating range. It is likely that the pilot’s failure to preheat the engine before starting it, in combination with his failure to warm the engine to operating temperature before takeoff, resulted in the engine failure.
Probable cause
The catastrophic engine failure due to lack of oil lubrication, which resulted from the pilot’s failure to follow the airplane and engine manufacturers’ guidance for cold weather operation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172F
Amateur built
false
Engines
1 Reciprocating
Registration number
N8768U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17252691
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-22T23:39:15Z guid: 106483 uri: 106483 title: CEN23LA068 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106486/pdf description:
Unique identifier
106486
NTSB case number
CEN23LA068
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-21T21:54:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2022-12-28T01:09:26.25Z
Event type
Accident
Location
Reserve, Louisiana
Airport
Port of South Louisiana Executive Regional Airport (APS)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On December 21, 2022, about 1954 central standard time, a Grumman American AA-5B airplane, N321GD, was substantially damaged when it was involved in an accident at the Port of South Louisiana Executive Regional Airport (APS), Reserve, Louisiana. The pilot and his flight instructor were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the purpose of the night flight was to fly multiple instrument approaches at several airports before returning to APS. He observed no issues with the airplane or its engine during his preflight inspection and engine runup. The airplane had about 50 gallons of fuel available before the flight. The flight instructor obtained an instrument clearance from New Orleans Approach Control before taxiing onto runway 35 for takeoff. He reported the engine rpm, fuel flow, and engine temperatures were normal during the takeoff and initial climb; however, shortly after the airplane climbed into instrument meteorological conditions there was a sudden loss of engine power. The flight instructor reported that he felt and heard the engine lose power at least twice, and he immediately entered a left 180° turn back to the airport. The airplane was about 380 ft above the ground when it descended below the overcast cloud ceiling on a south heading. The flight instructor reported that based on the airplane’s altitude, ground speed, and the canal off the end of runway 17, he believed the safest option was to land on the taxiway versus trying to land on the remaining runway. The airplane was about 2 ft above the ground when the left wingtip impacted the ground, and the nose gear subsequently collapsed when it impacted soft terrain. After the accident, the flight instructor repositioned the fuel valve to off, leaned the fuel mixture, and turned-off the magneto and electrical master switches. The pilot receiving instruction reported that before the flight he observed his flight instructor strain the fuel system and that there was no evidence of contamination. He reported that the before-takeoff engine runup, takeoff, and the initial climb were uneventful. However, about 500 ft above the ground, the engine began “coughing/sputtering” and there was a decrease in engine rpm. The flight instructor immediately took control of the airplane and entered a left turn back to the airport. The pilot receiving instruction stated that after the airplane descended below the clouds there was not enough runway remaining to safely land on runway 17, and that the flight instructor made a left turn toward the taxiway. He reported that the airplane entered an aerodynamic stall a couple of feet above the ground and the left wing struck the ground. When interviewed by a Federal Aviation Administration operations inspector, the flight instructor stated that the engine speed decreased to about 1,400 rpm when the loss of engine power occurred during the climb. The flight instructor stated that he leaned the fuel mixture after the loss of engine power, which resulted in a 200 rpm increase in engine speed. The electric fuel pump was already turned-on for the takeoff. The flight instructor stated that he did not use carburetor heat after the loss of engine power. A postaccident examination of the engine was conducted following the accident. The engine separated from the firewall during impact. The carburetor heat valve position at the time of the accident could not be conclusively determined due to impact damage. Internal engine and valve train continuity were confirmed as the engine crankshaft was rotated, and compression and suction were noted on all cylinders. The mechanical fuel pump and oil pump discharged fuel and oil, respectively, as the crankshaft was rotated. The left magneto, equipped with an impulse coupling, produced spark as the engine crankshaft was rotated. The right magneto was not equipped with an impulse coupling, but it produced spark when removed from the engine and rotated by hand. The spark plugs exhibited features consistent with normal engine operation. Movement of the throttle arm discharged fuel from the accelerator pump into the carburetor venturi. The carburetor bowl remained intact and contained uncontaminated fuel. There were no anomalies noted with the carburetor. The propeller remained attached to the engine crankshaft flange. Both propeller blades were relatively straight and partially covered in dried mud. Neither propeller blade exhibited any chordwise burnishing or leading-edge damage. The postaccident engine examination did not reveal any evidence of mechanical malfunction that would have precluded normal operation. According to a carburetor icing probability chart contained in Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, the recorded temperature and dew point at the time of the accident were in the range of susceptibility for the formation of serious carburetor icing at cruise engine power. According to the bulletin, a pilot should use carburetor heat when operating the engine at low power settings or while in weather conditions in which carburetor icing is probable. -
Analysis
The pilot receiving instruction and his flight instructor were conducting an instructional flight in night instrument meteorological conditions when the airplane had a partial loss of engine power shortly after takeoff. The pilot-receiving-instruction reported that about 500 ft above the ground the engine began “coughing/sputtering” and there was a decrease in engine rpm. The flight instructor stated that the engine speed decreased to about 1,400 rpm, but when he leaned the fuel mixture the engine speed increased about 200 rpm. The flight instructor made a left 180° turn back toward the airport. The airplane’s left-wing tip impacted the ground, the nose gear collapsed, and the engine partially separated from the firewall when the airplane impacted the terrain during the forced landing. The postaccident engine examination did not reveal any evidence of mechanical malfunction that would have precluded normal operation. Additionally, the airplane had ample fuel available that did not contain any water or debris. The weather conditions at the time of the accident were conducive to a serious accumulation of carburetor icing with the engine operating at cruise power. According to a Federal Aviation Administration Special Airworthiness Information Bulletin, pilots should use carburetor heat while in weather conditions where carburetor icing is probable. The flight instructor stated that he did not use carburetor heat after the loss of engine power. Based on the available information, the partial loss of engine power was likely due to carburetor ice accumulation. Additionally, the low altitude at which the loss of engine power occurred significantly reduced the amount of time available to the flight instructor to troubleshoot and restore engine power before the forced landing.
Probable cause
The partial loss of engine power due to carburetor icing and the flight instructor’s failure to use carburetor heat in weather conditions conducive to serious carburetor icing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Grumman American
Model
AA-5B
Amateur built
false
Engines
1 Reciprocating
Registration number
N321GD
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA5B0461
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-28T01:09:26Z guid: 106486 uri: 106486 title: DCA23LA107 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106510/pdf description:
Unique identifier
106510
NTSB case number
DCA23LA107
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-24T05:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-01-04T22:26:29.773Z
Event type
Accident
Location
Miami, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
A Gulfstream 450 airplane encountered turbulence while in level cruise flight at 36,000 ft. and a cabin server (CS) fractured her arm and leg. The flight crew reported that after departure, while climbing through 20,000 ft, they encountered unexpected light turbulence, and the seatbelt sign was illuminated. About 30 minutes into the flight at a cruising altitude of 36,000 ft (FL360) in visual meteorological conditions with the autopilot engaged, the copilot noticed a cloud top “rising up” from under the nose of the airplane. The airplane “pitched up and down rapidly with a hard jolt;” however, the autopilot did not disengage, and the airplane returned to normal flight. A passenger notified the flight crew of injuries to the CS. At the time of the turbulence event, the CS was in the aft galley taking catering notes, when she felt a rising sensation. She attempted to get low to the floor in case turbulence was encountered. While looking over her shoulder to check on the passenger cabin, she was thrown into the air and “hurled” to the floor impacting on her left shoulder, arm, and hip. Upon being notified of the injury, the flight crew declared an emergency and diverted to Miami for medical assistance. The injured CS was transported to the hospital where she was diagnosed with a fractured left arm and multiple fractures to her left leg. At the time of the turbulence encounter there were no active convective significant meteorological information (SIGMETs), international SIGMETs, center weather advisories (CWAs) or pilot reports (PIREPs) for the area where the turbulence occurred.
Probable cause
An unanticipated encounter with convective induced turbulence from developing cumulus clouds below the flight path, which produced strong updrafts and downdrafts.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AEROSPACE
Model
GIV-X (G450)
Amateur built
false
Engines
2 Turbo fan
Registration number
N456FX
Operator
FLEXJET LLC
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
4132
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-01-04T22:26:29Z guid: 106510 uri: 106510 title: CEN23LA069 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106503/pdf description:
Unique identifier
106503
NTSB case number
CEN23LA069
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-26T14:00:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-10T03:25:43.545Z
Event type
Accident
Location
South St. Paul, Minnesota
Airport
Fleming Field (SGS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that he took off from Runway 34 and intended to practice take-offs and landings. After landing the airplane without incident, he raised the flaps and added full power to take off again; however, the airplane veered to the left during the take-off roll. The student pilot added right rudder to keep the airplane on centerline but was unsuccessful. Once airborne, the left wing struck a snowbank on the side of the runway, which caused the airplane to pivot left. The nose gear collapsed, and the airplane came to rest inverted, nose first in the snowbank. The outboard side of the right wing sustained substantial damage to the skin, ribs, and spars. The student pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, Runway 34 was covered in ice and snow.
Probable cause
The student pilot’s failure to maintain directional control during the take-off roll with a snow and ice covered runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150J
Amateur built
false
Engines
1 Reciprocating
Registration number
N51115
Operator
Condor Aviation LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
15069777
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-10T03:25:43Z guid: 106503 uri: 106503 title: ERA23LA095 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106494/pdf description:
Unique identifier
106494
NTSB case number
ERA23LA095
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-26T14:35:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-29T20:19:51.052Z
Event type
Accident
Location
Hampton, New Hampshire
Airport
-70.8301542 (7B3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that during the uneventful local flight he heard two pilots on the radio discussing the wind conditions at his destination airport and that a direct crosswind prevailed there. While approaching the runway for landing, the pilot described that the wind was “choppy” and that he applied constant inputs with the rudder and aileron controls. Near the midpoint of the runway, the pilot described that he encountered stronger than expected wind from the right. The pilot landed the airplane on both main wheels and applied left rudder to stay aligned with the runway. Despite the control input from the pilot, the airplane veered to the right, departed the right side of the runway, and nosed-over resulting in substantial damage to the wings and empennage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane while landing in crosswind conditions, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7ECA
Amateur built
false
Engines
1 Reciprocating
Registration number
N2895Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1242-78
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-29T20:19:51Z guid: 106494 uri: 106494 title: ERA23LA094 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106492/pdf description:
Unique identifier
106492
NTSB case number
ERA23LA094
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-26T22:35:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2022-12-28T19:29:06.67Z
Event type
Accident
Location
Franklin, Virginia
Airport
Franklin Regional Airport (FKN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The private pilot departed with full fuel tanks for the cross-country flight with a planned fuel stop en route. As the pilot neared the fuel stop airport, the fuel gauges indicated 3/4 capacity remaining, so he elected to continue to his destination airport. When the flight was 38 miles from the destination, with the fuel selector on the right tank position, the engine “started sputtering.” He then moved the fuel selector to the left tank position and turned the airplane towards a diversion airport. He checked the weather and NOTAMs for the diversion airport and noted nothing that concerned him. As he approached the diversion airport, he keyed the airplane’s radio transmitter 5 times and then 7 times on the common traffic advisory frequency to turn on the runway lights, but they did not turn on (the end of civil twilight had occurred about an hour prior). Concerned about the airplane’s fuel level, he landed but did not know how far down the runway he had landed. He described that the approach was “too fast” and the airplane bounced. After touching down, he applied the brakes but realized he would be unable to stop the airplane on the remaining portion of the runway. He added full power, started to climb, and thinking that the airplane had climbed higher than it actually had, he then banked left. The airplane’s left wing then collided with trees substantially damaging it and bringing the airplane to a stop. The pilot stated that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation. He also stated that had he known the runway lights were inoperative, he would have diverted to a different airport. Postaccident examination of the airplane revealed the airplane’s radios were tuned to the correct frequency to activate the runway lights. According to the airport manager the, pilot-controlled lighting system at the airport was normally checked on the 1st day of every month and had been last checked 25 days before the accident. Following the accident, he discovered that they were inoperative. Given this information, it is possible that the pilot could have performed a successful landing had the runway lights been operational.
Probable cause
The pilot’s failure to maintain clearance from trees during the initial climb following an aborted precautionary landing. Contributing to the outcome were the inoperative runway lights, which reduced the likelihood that the pilot could successfully land the airplane on the runway at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177
Amateur built
false
Engines
1 Reciprocating
Registration number
N177D
Operator
BARGER, RANDALL G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17702012
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2022-12-28T19:29:06Z guid: 106492 uri: 106492 title: WPR23LA081 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106530/pdf description:
Unique identifier
106530
NTSB case number
WPR23LA081
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-27T20:29:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-01-06T23:42:04.341Z
Event type
Accident
Location
Hawthorne, California
Airport
JACK NORTHROP FLD/HAWTHORNE MUNI (HHR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, prior to landing, she obtained weather conditions at the airport, which included calm wind and light rain. After calculating the landing performance, she determined that the destination airport was adequate, and continued the approach to landing. Upon touchdown, she realized that the runway was wetter than anticipated, and applied maximum braking efforts, which included the application of the emergency brake system. Despite the use of maximum braking, the airplane “failed to decelerate at the normal rate.” The pilot initiated a right turn to decelerate, however, the airplane exited the departure end of the runway and impacted approach lighting and the airport perimeter fence, which resulted in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The automated weather observation station located on the airport reported that, about 9 minutes before the accident, the wind was from 090° at 3 knots, 7 statute miles visibility and light rain.
Probable cause
A runway overrun due to the pilot’s failure to stop the airplane as a result of diminished braking action due to a water contaminated runway surface.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EMBRAER EXECUTIVE AIRCRAFT INC
Model
EMB-505
Amateur built
false
Engines
2 Geared turbofan
Registration number
N16DF
Operator
Solairus Aviation
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
50500167
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-06T23:42:04Z guid: 106530 uri: 106530 title: ERA23LA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106514/pdf description:
Unique identifier
106514
NTSB case number
ERA23LA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2022-12-28T13:30:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-03T19:24:28.788Z
Event type
Accident
Location
Ethel, West Virginia
Airport
LOGAN COUNTY (6L4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During landing, the airplane touched down on the runway and the pilot applied the brakes. The airplane veered to the right and the pilot attempted to correct the turn, however the airplane exited the right side of the runway. The airplane struck a berm, which resulted in substantial damage to the fuselage. Postaccident examination of the airplane revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182P
Amateur built
false
Engines
1 Reciprocating
Registration number
N8217M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18264566
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-03T19:24:28Z guid: 106514 uri: 106514 title: CEN23LA073 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106524/pdf description:
Unique identifier
106524
NTSB case number
CEN23LA073
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-01T16:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-01-09T21:46:38.234Z
Event type
Accident
Location
Conway, Arkansas
Airport
Conway Regional Airport (KCXW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that, during landing, the airplane bounced and began too “fishtail” and he lost control of the airplane. When the pilot regained control of the airplane, the right main landing gear was off the runway and the airplane exited the runway into muddy ground. The airplane nose wheel became stuck, and the airplane nosed over and came to rest inverted. The airplane sustained substantial damage to wings and vertical stabilizer. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The solo student pilot’s improper landing flare and subsequent improper recovery from a bounced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N7003G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17258703
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-09T21:46:38Z guid: 106524 uri: 106524 title: ERA23LA107 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106560/pdf description:
Unique identifier
106560
NTSB case number
ERA23LA107
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-01T21:30:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-19T00:22:39.764Z
Event type
Accident
Location
Old Bridge, New Jersey
Airport
OLD BRIDGE (3N6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was for the pilot to stay in the airport traffic pattern and make two full-stop landings to meet night currency requirements. The pilot described that shortly after takeoff he encountered an unexpected indication while retracting the landing gear and that one of the navigation radios turned off and then back on again. He then extended the landing gear and subsequently noted no abnormal indication. He continued the in the traffic pattern and while on final approach to the runway noted that he was “low,” had a clear view of the runway, and did not see any trees or other obstructions. He then increased engine power before he heard the sounds of (trees) striking the airplane. He could see the runway in front of him, so he landed the airplane and taxied uneventfully to his hangar. Both of the airplane’s wings and horizontal stabilizers were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate clearance from trees during the landing approach.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32R-301T
Amateur built
false
Engines
1 Reciprocating
Registration number
N8282K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32R-8129002
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-19T00:22:39Z guid: 106560 uri: 106560 title: ANC23LA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106557/pdf description:
Unique identifier
106557
NTSB case number
ANC23LA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-02T16:57:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-10T22:11:57.143Z
Event type
Accident
Location
Kenai, Alaska
Airport
McGahan Industrial (AK73)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that, during landing on a road in flat light conditions he drifted to the right after touching down and the right tire struck unplowed snow. The pilot was unable to correct, and the airplane continued to the right into a snow berm. Subsequently, it nosed over sustaining substantial damage to the wings, lift struts, and rudder. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control during landing in flat light conditions, resulting in the airplane to nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N94X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-7858
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-10T22:11:57Z guid: 106557 uri: 106557 title: ERA23LA104 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106551/pdf description:
Unique identifier
106551
NTSB case number
ERA23LA104
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-03T14:35:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-12T19:14:18.115Z
Event type
Accident
Location
Opa-locka, Florida
Airport
MIAMI-OPA LOCKA EXEC (OPF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that during the taxi for takeoff in a non-movement area, he and his student noticed a large multi-radial-engine airplane near their intended taxi route. The instructor told the student to deviate from the painted taxiway yellow line to provide for additional distance away from the prop wash behind the larger airplane. Subsequently, as their taxi continued behind the other airplane, the accident airplane started “violently shaking,” the right wing lifted, and the left wing contacted the taxiway surface. The nose also tipped forward, which resulted in the propeller striking the ground. The flight instructor shut off the engine, however, he estimated the airplane was pushed by the propeller blast an additional 100 ft further until eventually stopping upright on all three landing gear. The left wing sustained substantial damage. According to the pilot of the larger airplane, there had been delays for departure clearances and he had positioned his airplane into the wind while waiting, which resulted in the tail and the engines propeller blast oriented towards the taxiway the accident airplane taxied through. He stated that at the time that the event occurred, his airplane was at flight idle, and he was not performing a run-up. He did not know anything had happened to the accident airplane, until he heard of a propeller strike announced over the radio.
Probable cause
The flight instructor’s decision to taxi behind a large multi-engine airplane, which resulted in an encounter with propeller blast and a loss of airplane control on the ground.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N2354E
Operator
SKYDUO FLIGHT ACADEMY LLC.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172-72777
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-12T19:14:18Z guid: 106551 uri: 106551 title: ERA23LA101 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106542/pdf description:
Unique identifier
106542
NTSB case number
ERA23LA101
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-03T18:22:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-26T18:42:05Z
Event type
Accident
Location
Atlantic Ocean, Atlantic Ocean
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he began the accident flight with 160 gallons of fuel on board. The airplane was equipped with two main wingtip fuel tanks, two in-wing auxiliary fuel tanks, and one engine nacelle locker fuel tank. His normal procedure was to operate for 50 minutes out of the main tanks, then use most of the fuel in the auxiliary tanks, then transfer fuel out of the locker tank and use all of that fuel. While approaching the destination airport, he attempted to transfer fuel from the locker tank; however, he later noticed that fuel was not transferring from that tank. Later, the right engine lost all power, followed by the left. He subsequently ditched the airplane in the ocean about 17 miles from of the destination airport. The airplane landed on the water, and the pilot and his passengers donned life vests and egressed before the airplane sank. The occupants were rescued about 4 hours later. The airplane was not recovered from the ocean and was presumed substantially damaged. A postaccident examination of the fuel system could not be performed and the reason for the pilot’s inability to transfer fuel from the engine nacelle locker tank could not be determined.
Probable cause
A fuel system malfunction for reasons that could not be determined, which resulted in fuel starvation to both engines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
340A
Amateur built
false
Engines
2 Reciprocating
Registration number
N824BC
Operator
AONVO INVESTMENT LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
340A0306
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-26T18:42:05Z guid: 106542 uri: 106542 title: CEN23LA075 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106558/pdf description:
Unique identifier
106558
NTSB case number
CEN23LA075
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-03T19:04:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-13T02:40:01.903Z
Event type
Accident
Location
Yukon, Oklahoma
Airport
Clarence E. Page-Cimmaron-Yukon Municipal Airport (RCE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while practicing stop-and-go landings on runway 35L in a tailwheel-equipped airplane, the airplane touched down, rolled a few feet, and then veered to the left. The pilot “immediately put in right rudder” to bring the airplane back to runway centerline. The airplane nosed over and came to rest inverted in the grass. The airplane sustained substantial damage to the vertical stabilizer, and right wing. After the accident, the pilot said that he “hit the brakes too hard” when the airplane departed the side of the runway. In a separate written statement, the pilot stated that perhaps a gust of wind struck the tail during the landing roll out. Reported wind at the time of the accident was from 300° at 7 knots. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N7769E
Operator
EDWARDS SAMUEL T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17569
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-13T02:40:01Z guid: 106558 uri: 106558 title: CEN23LA076 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106562/pdf description:
Unique identifier
106562
NTSB case number
CEN23LA076
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-05T13:20:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2023-01-12T03:02:03.858Z
Event type
Accident
Location
Council Bluffs, Iowa
Airport
COUNCIL BLUFFS MUNI (CBF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 5, 2023, about 1120 central standard time, a Cessna 182M airplane, N71494, was substantially damaged when it was involved in an accident near, Council Bluffs, Iowa. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.  According to the pilot, he was flying to Council Bluffs Municipal Airport (CBF) to discuss having avionics work performed on the airplane. There was another airplane on a practice VOR-A instrument approach to CBF and the pilot recognized there was going to be a conflict, so he elected to perform a 360° turn to allow for increased spacing. At this time, he had the airplane configured with 10° flap, with the manifold pressure at 13 inches of mercury, and carburetor heat on. As the airplane entered the turn, he increased power to 17 inches of mercury and held his altitude at 1,900 ft msl. As the airplane completed about half of the 360° turn, he added power to maintain altitude and there was no response from the engine. The airplane was about 500 ft above ground level and the pilot stated that he did not have time to restart the engine. He said that he focused on locating a suitable landing area and controlling the airplane. The pilot stated that he did not turn off the carburetor heat during the turn or after the engine stopped producing power. There was about 38 gallons of fuel on-board the airplane and the fuel selector was on BOTH. The pilot executed a forced landing to a harvested soybean field. During the landing, the airplane struck a terrace in the field, which damaged the forward fuselage. After the accident a test run of the engine was conducted. The engine started normally and idled smoothly. Once warmed up, the engine was advanced to 1,500 rpm and the engine continued to run smoothly. A magneto check was performed indicating about 75 rpm drop on each magneto. The carburetor heat was activated and indicated a drop in rpm when applied. The engine rpm was not advanced above 1,500 rpm due to concerns about the bent propeller. The weather conditions at the time of the accident included a temperature of -1° C, and dewpoint of -7° C. These were in a range for potential carburetor icing at glide and cruise power. -
Analysis
The pilot reported that the airplane’s engine did not respond to a commanded power increase while maneuvering for spacing due to aircraft traffic. He subsequently made a forced landing to a field. The airplane sustained substantial damaged to the forward fuselage when it struck a terrace in the field. A postaccident engine run was conducted and although the test was limited due to the bent propeller, the engine exhibited no anomalies during the engine run. The possibility of carburetor icing existed based on the atmospheric conditions present at the time of the accident, but the pilot stated that he had carburetor heat applied during the event. The carburetor heat system worked normally during the engine run. Based on the available information, the reason for the partial loss of engine power could not be determined.
Probable cause
The partial loss of engine power for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182M
Amateur built
false
Engines
1 Reciprocating
Registration number
N71494
Operator
NEVERLAND LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18259643
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-12T03:02:03Z guid: 106562 uri: 106562 title: ERA23LA102 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106545/pdf description:
Unique identifier
106545
NTSB case number
ERA23LA102
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-05T15:19:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-08T00:44:48.839Z
Event type
Accident
Location
Calhoun, Georgia
Airport
TOM B DAVID FLD (CZL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was performing touch-and-go landings, and during the landing roll, he removed his hand from the twin-engine airplane’s throttles to turn off the electrically-powered fuel pumps. As the pilot moved his hand, his sweater sleeve caught on the right throttle handle, the right engine power increased, and the airplane veered off the runway to the left. During the runway excursion, the airplane collided with a runway marker sign and visual approach lighting equipment, which resulted in substantial damage to the fuselage and empennage. The pilot attempted to reduce the right throttle setting, but his sweater was jammed between the throttles, and he ultimately stopped the airplane by shutting down the airplane’s engines. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadvertent asymmetric throttle application, which resulted in a loss of directional control during the landing roll, runway excursion, and collision with ground equipment.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STRAY GOOSE RESEARCH LLC
Model
AIRCAM
Amateur built
true
Engines
2 Reciprocating
Registration number
N522EA
Operator
STRAY GOOSE RESEARCH LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AC-251
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-08T00:44:48Z guid: 106545 uri: 106545 title: ERA23LA105 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106552/pdf description:
Unique identifier
106552
NTSB case number
ERA23LA105
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-05T18:04:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-17T19:50:55.312Z
Event type
Accident
Location
Paris, Kentucky
Airport
WILD BLUE (31KY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot and two passengers were departing from a 2,800-ft-long turf runway and reported that prior to initiating the takeoff the wind was light and variable. During the initial climb after takeoff, and once the airplane had cleared a ridge and trees that ran parallel to the runway, the pilot reported that there was a “sudden windshear that caused a reduction in lift.” The pilot reduced the airplane’s pitch attitude in an attempt to regain lift, but the airplane continued to descend. The pilot was unable to arrest the descent and the airplane subsequently impacted the ground. The pilot reported that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation. The automated weather observation at an airport 9 miles away noted wind at 10 knots, with no gusts or other convective activity described.
Probable cause
The pilot’s loss of control after encountering changing wind conditions during the initial climb, which resulted in descent and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N6111W
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-20126
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-17T19:50:55Z guid: 106552 uri: 106552 title: ERA23LA168 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106967/pdf description:
Unique identifier
106967
NTSB case number
ERA23LA168
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-08T17:08:00Z
Publication date
2023-08-24T04:00:00Z
Report type
Final
Last updated
2023-04-12T00:25:10.727Z
Event type
Accident
Location
Ridgeland, South Carolina
Airport
Ridgeland - Claude Dean (3J1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot of the tailwheel-equipped airplane, he planned to perform a touch-and-go landing, and proceeded with a “wheel landing.” During rollout, with both main wheels on the runway, “an unpredictable and unknown force” caused the airplane to depart the right side of the runway. The airplane continued toward runway signage, and the pilot applied engine power to avoid it, which resulted in the airplane’s “ground loop to the right.” The airplane’s right wing and propeller struck the ground which resulted in substantial damage to the wing and fuselage. Weather reported 14 miles south of the accident site at the time of the accident included clear skies and calm winds. The pilot reported there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WEISS THEODORE T
Model
RV-8
Amateur built
true
Engines
1 Reciprocating
Registration number
N61TW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
80428
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-12T00:25:10Z guid: 106967 uri: 106967 title: DCA23FM012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106554/pdf description:
Unique identifier
106554
NTSB case number
DCA23FM012
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2023-01-09T04:19:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-12-28T05:00:00Z
Location
Angola, Louisiana
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the Big D tow and the Carol McManus tow was the Carol McManus pilot incorrectly recalling the agreed-upon passing arrangement, which resulted in the Carol McManus tow encroaching on the downbound Big D tow.
Has safety recommendations
false

Vehicle 1

Callsign
WDK9654
Vessel name
Carol McManus
Vessel type
Towing/Barge
IMO number
8836651
Maritime Mobile Service Identity
367532830
Port of registry
St. Louis
Flag state
USA
Findings

Vehicle 2

Callsign
WDG3181
Vessel name
Big D
Vessel type
Towing/Barge
Maritime Mobile Service Identity
367523350
Port of registry
New Orleans
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-12-28T05:00:00Z guid: 106554 uri: 106554 title: ERA23LA111 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106583/pdf description:
Unique identifier
106583
NTSB case number
ERA23LA111
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-10T18:43:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-17T22:46:44.281Z
Event type
Accident
Location
Somerville, Tennessee
Airport
FAYETTE COUNTY (FYE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During an instructional flight, while flying on the left downwind leg of the traffic pattern at an altitude of about 1,000 ft above the ground, the flight instructor and the student pilot heard a momentary grinding noise of what sounded like "metal on metal." The flight instructor described that the noise lasted no more than 2 to 3 seconds and immediately abated. The flight instructor and student did not see anything approaching the airplane or its flight path before the noise occurred, nor did they report any sensation similar to an impact. The flight instructor and student pilot subsequently landed the airplane without issue and during a postflight inspection with the airplane’s owner, the flight instructor noted damage to the right side of the engine cowling and substantial damage to the inboard aft face of one of the propellor blades. There were no visible blood or bird remains present on the propeller or cowling. The flight instructor and airplane owner postulated that the airplane may have impacted an unmanned aerial system (UAS), and the airplane owner subsequently coordinated a ground search for debris in the days following the accident; however, no UAS components was located. Review of Federal Aviation Administration (FAA) records revealed that no Low Altitude Authorization and Notification Capability authorizations were requested for the area at the time of the accident, nor had any UAS operational waivers had been filed with the FAA for operation in the area at the time of the accident. Given all available information, the reason that the airplane’s engine cowling and propeller were damaged during the flight could not be definitively determined.
Probable cause
Based on available evidence, the reason for the damage to the airplane’s propeller and engine cowling could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N5841W
Operator
First Team Pilot Training LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-2216
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-17T22:46:44Z guid: 106583 uri: 106583 title: WPR23LA088 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106595/pdf description:
Unique identifier
106595
NTSB case number
WPR23LA088
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-12T13:00:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-01-19T06:55:43.917Z
Event type
Accident
Location
Agua Caliente Springs, California
Airport
Agua Caliente Springs (L54)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he announced his position on the common traffic advisory frequency while inbound to land on his destination runway. Just prior to touchdown, the pilot observed an airplane landing directly in his path from the opposite end of the runway. To avoid a collision, the pilot added power and attempted to climb to the left, but impacted a berm, nosed over and came to rest inverted, which resulted in substantial damage to the right wing. The pilot reported no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during an aborted approach, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180K
Amateur built
false
Engines
1 Reciprocating
Registration number
N2875K
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18053111
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-19T06:55:43Z guid: 106595 uri: 106595 title: ANC23LA018 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106664/pdf description:
Unique identifier
106664
NTSB case number
ANC23LA018
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-13T14:01:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-03-16T21:40:40.667Z
Event type
Accident
Location
Glennallen, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that, before landing his wheel/ski-equipped airplane at a snow-covered airstrip, he elected to “drag” the site, which involved doing a series of touch-and-go landings to determine the snow conditions before doing a full stop landing. He said that after completing two successful drags on the untouched snow, during the third, he inadvertently allowed the airspeed to decay, and he was unable to get airborne again. The airplane subsequently passed the end of the airstrip and impacted a snow-covered gravel berm. The airplane sustained substantial damage to the left wing and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain airspeed during a drag maneuver, which resulted in an overrun and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N5373Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-8140
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-16T21:40:40Z guid: 106664 uri: 106664 title: ANC23LA013 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106592/pdf description:
Unique identifier
106592
NTSB case number
ANC23LA013
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-13T17:30:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-01-18T23:10:22.181Z
Event type
Accident
Location
Wasilla, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 13, 2023, about 1530 Alaska daylight time, a Taylorcraft BL-65 airplane, N29886, was substantially damaged when it was involved in an accident near Point Mackenzie, Alaska. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, last month after a heavy snow fall, the nose fuel tank cap was found dislodged, allowing snow to accumulate into the tank. On the day of the accident, during the airplane preflight inspection, the pilot sampled fuel from the fuel tank and found water in the fuel. He drained fuel until there was no more sign of water. He departed from Lake hood Airport (LHD) and during cruise flight the engine began to run rough. He performed a precautionary landing to a road. The pilot drained fuel from the fuel tank again and found water in the fuel. He drained fuel until there was no more sign of water. His mechanic responded to the site to assist the pilot. The mechanic drained all the fuel from the carburetor to ensure there was no water. They started the engine, and it ran smoothly for 10 minutes. The pilot departed from the road to fly back to LHD and shortly after departure the engine began to run rough again. The pilot performed a precautionary landing back on the road. During the landing roll the right wing impacted a street sign, and the airplane came to rest in a ditch. The airplane sustained substantial damage to the right wing. Postaccident examination of the engine revealed water in fuel samples drained from the gascolator and carburetor. Other than the presence of water, no anomalies were noted with the engine that would have precluded normal operation. -
Analysis
Before the day of the accident, the nose fuel tank cap had been dislodged during a snowstorm, which allowed snow to enter the fuel tank. During preflight inspection, the pilot drained fuel from the fuel tank and discovered water in the fuel. He continued to drain the fuel until no water was visible. The pilot took off and during cruise flight the engine began to run rough so he performed a precautionary landing on a road. He drained fuel from the fuel tank again and once again found water in the fuel. He continued to drain fuel until there was no more sign of water. The pilot’s mechanic responded to the site to assist the pilot. The mechanic drained all of the fuel from the carburetor to ensure there was no water. They started the engine, and it ran normally again so the pilot decided to take off. Shortly after departure from the road, the engine began to run rough again. The pilot landed back on the road. During the landing roll, the right wing impacted a street sign, and the airplane came to rest in a ditch. Postaccident examination of the engine revealed water in fuel samples drained from the gascolator and carburetor. Other than the presence of water, no anomalies were noted with the engine that would have precluded normal operation.
Probable cause
The pilot's failure to remove all water from the fuel tank, which resulted in fuel contamination and a subsequent partial loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TAYLORCRAFT
Model
BL-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N29886
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2737
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-18T23:10:22Z guid: 106592 uri: 106592 title: CEN23LA083 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106587/pdf description:
Unique identifier
106587
NTSB case number
CEN23LA083
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-15T11:30:00Z
Publication date
2023-06-22T04:00:00Z
Report type
Final
Last updated
2023-01-18T00:11:21.918Z
Event type
Accident
Location
Brashear, Texas
Airport
N/A (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On January 15, 2023, about 0930 central standard time, a Hatz Classic airplane, N1957P, was substantially damaged when it was involved in an accident near Brashear, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported a gradual loss of engine power during cruise flight. He applied carburetor heat when the engine began running rough, which seemed to make the situation worse. Eventually, the available engine power was insufficient to maintain altitude and it became clear the airplane would not be able to reach the destination airport. He executed a forced landing to a field; however, he flared “too high” and landed hard. The airframe sustained damage to both wings and the fuselage. A postaccident engine examination noted the carburetor heat ducting appeared “insufficient for proper airflow” and the carburetor heat control arm was not fully engaged. The mechanic estimated the carburetor heat installation was about 90% functional. In addition, the electric conductivity between the magneto P-lead and the cockpit ignition switch was intermittent, and 2 ignition leads exhibited minor damage. Otherwise, the engine examination was unremarkable. Meteorological conditions were conducive to the formation of carburetor icing during cruise flight. In his statement, the pilot noted the possibility of carburetor icing as the reason for the loss of engine power. -
Analysis
The pilot reported a gradual loss of engine power during cruise flight. He applied carburetor heat when the engine began running rough, which seemed to make the situation worse. Eventually, the available engine power was insufficient to maintain altitude and it became clear the airplane would not be able to reach the destination airport. The pilot executed a forced landing to a field; however, he flared too high and landed hard. The airframe sustained substantial damage to both wings and the fuselage. A postaccident engine examination revealed minor anomalies with respect to the carburetor heat system, and those anomalies may have slightly reduced the effectiveness of the carburetor heat when applied. The remaining anomalies identified during the engine examination were not consistent with a gradual loss of engine power and did not contribute to the accident. Meteorological conditions were conducive to the formation of carburetor icing during cruise flight. Based on the available information, it is likely that the formation of carburetor icing, which the carburetor heat system was unable to adequately remove, resulted in the loss of engine power. In addition, the hard landing that occurred during the forced landing may have increased the extent of damage to the airframe.
Probable cause
A partial loss of engine power due to the formation of carburetor ice, which resulted in the inability to maintain altitude and the subsequent hard forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHEEK CARROLL
Model
HATZ/CHEEK
Amateur built
true
Engines
1 Reciprocating
Registration number
N1957P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
825
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-18T00:11:21Z guid: 106587 uri: 106587 title: ANC23LA012 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106589/pdf description:
Unique identifier
106589
NTSB case number
ANC23LA012
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-16T07:15:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-02-01T01:07:04.077Z
Event type
Accident
Location
Kualapuu, Hawaii
Airport
Molokai Airport (MKK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot reported he was conducting an instrument approach in dark night conditions, and during the approach he thought the airplane was too high. The pilot performed a left turn circling procedure to lose altitude. During the turn, the pilot loss sight of the runway and the airplane impacted terrain. The airplane sustained substantial damage to the fuselage and both wings. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate altitude during a circling approach procedure in dark night visual meteorological conditions, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
208B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N236KA
Operator
KAMAKA AIR LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
208B2034
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-01T01:07:04Z guid: 106589 uri: 106589 title: WPR23LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106597/pdf description:
Unique identifier
106597
NTSB case number
WPR23LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-16T12:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-02-01T02:29:14.001Z
Event type
Accident
Location
Minidoka, Idaho
Airport
Laidlaw Corrals AIrport (U99)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he observed a thin layer of snow that covered his destination runway. He performed a normal approach and landing, but after landing he impacted a snow drift on the runway. The airplane nosed over and came to rest inverted which resulted in substantial damage to the wing and tail structure. The pilot reported no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control during landing on a contaminated runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
MX-7-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N30737
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
19019C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-01T02:29:14Z guid: 106597 uri: 106597 title: ANC23LA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106629/pdf description:
Unique identifier
106629
NTSB case number
ANC23LA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-16T16:08:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-01-24T23:48:44.876Z
Event type
Accident
Location
Anchorage, Alaska
Airport
Campbell Lake (A11)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during landing on a snow-covered frozen lake in a tundra tire-equipped airplane, the main landing gear wheels broke through the hard-packed snow, and the airplane subsequently nosed over, sustaining substantial damage to the wings, lift struts and rudder. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's selection of an unsuitable landing site, resulting in the main landing gear wheels breaking through the snow, and a subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N3904M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-2803
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-24T23:48:44Z guid: 106629 uri: 106629 title: ERA23LA116 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106617/pdf description:
Unique identifier
106617
NTSB case number
ERA23LA116
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-19T13:15:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-24T16:35:28.409Z
Event type
Accident
Location
Orlando, Florida
Airport
ORLANDO INTL (MCO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was taxiing for departure at a large international airport. As he taxied from the ramp toward the taxiway that he had been cleared to take to the departure runway, the right wing of his airplane lifted. The airplane’s left wing then contacted the ground, and the airplane began to slide across the ground. In a statement following the accident, the pilot described that he had inadvertently taxied into the jet blast of an airplane that was about 500 feet away, which he was unable to see because his view was obscured by another large airplane parked on the ramp. The pilot subsequently shut his airplane’s engine down, exited the airplane, and tried to hold its wing down and keep it from contacting the ground again. He described that the jet blast made it difficult to keep the airplane from tipping over again and that he was lifted in the air several times as he tried to hold the right wing down. After serval minutes, several individuals assisted the pilot with moving the airplane out of the jet blast. The airplane’s left wing spar was substantially damaged during the accident.
Probable cause
An inadvertent encounter with the jet blast of another airplane while taxiing, which resulted in substantial damage to the airplane’s left wing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MESAFOX LLC
Model
KITFOX
Amateur built
true
Engines
1 Reciprocating
Registration number
N915KF
Operator
MESAFOX LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
KA21118495
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-24T16:35:28Z guid: 106617 uri: 106617 title: CEN23LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106621/pdf description:
Unique identifier
106621
NTSB case number
CEN23LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-20T10:50:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-01-27T03:55:06.933Z
Event type
Accident
Location
San Antonio, Texas
Airport
Bulverde (1TT8)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that she and her student pilot were practicing landings on runway 34. The instructor stated that the student pilot compensated for a crosswind out of the east. The student reported that she compensated with right aileron and left rudder; however, upon touchdown and landing roll-out, she did not release the left rudder pressure and the airplane began to veer to the left. The instructor attempted to correct the deviation and bring the airplane back to runway centerline, but the airplane impacted a ditch on the side of the runway and flipped over. Both wings and vertical stabilizer were substantially damaged. The pilots reported there were no mechanical malfunctions or failures that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N5610U
Operator
Anderson Aviation LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-26540
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-27T03:55:06Z guid: 106621 uri: 106621 title: ERA23LA115 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106616/pdf description:
Unique identifier
106616
NTSB case number
ERA23LA115
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-20T15:40:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-24T16:44:12.67Z
Event type
Accident
Location
Benton, Tennessee
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The glider pilot reported that the day was a “good ridge day” and about 45 minutes into the flight he saw two large birds flying in a thermal. He attempted to enter the same thermal that the birds were in, turning towards a mountain ridge, the same direction the birds were circling. The pilot was carried out of the thermal and entered an area of sinking air which resulted in the glider impacting the ridge. The impact resulted in substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the glider that would have precluded normal operation.
Probable cause
The pilot’s decision to turn toward a mountain ridge in a thermal, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
EIRIAVION OY
Model
PIK-20D
Amateur built
false
Engines
1 None
Registration number
N1NZ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
20607
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-24T16:44:12Z guid: 106616 uri: 106616 title: ERA23LA114 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106615/pdf description:
Unique identifier
106615
NTSB case number
ERA23LA114
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-20T17:15:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-24T02:27:17.317Z
Event type
Accident
Location
Wauchula, Florida
Airport
WAUCHULA MUNI (CHN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot was attempting to make a crosswind landing and flared too high. He tried to recover by adding power, but it was too late, and the gyroplane landed hard on the left main landing gear. The gyroplane then bounced back and forth on both main landing gear before it rolled over and substantially damaged the main rotor blades and tail section. The pilot reported that there were no preimpact mechanical malfunctions or failures of the gyroplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a hard landing and dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEGRAW RICHARD R
Model
SUMMIT 23
Amateur built
true
Engines
1 Reciprocating
Registration number
N40DG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
9203
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-24T02:27:17Z guid: 106615 uri: 106615 title: RRD23FR004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106623/pdf description:
Unique identifier
106623
NTSB case number
RRD23FR004
Transportation mode
Railroad
Investigation agency
Other
Completion status
Completed
Occurrence date
2023-01-21T11:32:00Z
Publication date
2023-05-01T04:00:00Z
Report type
Final
Event type
Occurrence
Location
Boca Raton, Florida
Injuries
1 fatal, 0 serious, 0 minor
Probable cause
The NTSB determined that the probable cause of the incident in Boca Raton was the deliberate entry onto the track and into the path of the Brightline train by the female trespasser committing suicide.
Has safety recommendations
false

Vehicle 1

Railroad name
Brightline
Equipment type
Commuter train-pulling
Train name
Train 704
Train type
FRA regulated passenger
Total cars
4
Total locomotive units
2
Findings
creator: Other last-modified: 2023-05-01T04:00:00Z guid: 106623 uri: 106623 title: WPR23LA135 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106922/pdf description:
Unique identifier
106922
NTSB case number
WPR23LA135
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-21T17:30:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-03-21T23:47:46.356Z
Event type
Accident
Location
Skull Valley, Arizona
Airport
Yav'PE MA'Ta Airport (16AZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that he encountered a crosswind from the left during a landing attempt and the airplane drifted right. The right wing impacted tree branches that resulted in a loss of directional control. The airplane then collided with an adjacent bush, which resulted in substantial damage to the left wing. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane while landing in a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N92570
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17261586
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-21T23:47:46Z guid: 106922 uri: 106922 title: DCA23FM016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106628/pdf description:
Unique identifier
106628
NTSB case number
DCA23FM016
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2023-01-22T18:15:00Z
Publication date
2024-03-05T05:00:00Z
Report type
Final
Last updated
2024-02-21T05:00:00Z
Location
Ingleside, Texas
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the collision between the tugboat Mark E Kuebler and the tanker Nisalah was the mate maneuvering the tugboat near the starboard quarter of the tanker, which resulted in the tugboat being drawn in toward the tanker by hydrodynamic forcesthat the tugboat had insufficient reserve power to counteract due to the transit speedof the vessels.
Has safety recommendations
false

Vehicle 1

Callsign
HZFF
Vessel name
Nisalah
Vessel type
Cargo, Liquid Bulk
IMO number
9484730
Maritime Mobile Service Identity
403536000
Port of registry
Dammam
Classification society
ABS
Flag state
SA
Findings

Vehicle 2

Callsign
WDK4725
Vessel name
Mark E Kuebler
Vessel type
Towing/Barge
IMO number
9866110
Maritime Mobile Service Identity
368058110
Port of registry
Houston
Classification society
ABS
Flag state
USA
Findings
creator: Coast Guard last-modified: 2024-02-21T05:00:00Z guid: 106628 uri: 106628 title: ERA23LA118 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106640/pdf description:
Unique identifier
106640
NTSB case number
ERA23LA118
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-23T20:44:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-01-31T00:32:11.638Z
Event type
Accident
Location
Raleigh/Durham, North Carolina
Airport
RALEIGH-DURHAM INTL (RDU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot and his passenger prepared for a night flight in the flying club’s airplane to maintain the pilot’s currency. He tried to start the engine three times, priming the engine a total of 11 times, and “pumping” the throttle during one attempt, but it did not start. Concerned that he may have flooded the engine, he waited 5 minutes before attempting another start with full throttle and mixture at idle/cutoff. After this attempt, the passenger noted smoke and he realized that the engine was on fire. He told his passenger to egress and attempted to extinguish the fire with the onboard fire extinguisher; however, the fire substantially damaged the airplane’s the fuselage, engine mounts, and firewall. The pilot reported no mechanical malfunctions or failures with the airplane that would have precluded normal operation. The Pilot’s Operating Handbook for the airplane suggested priming 1 to 3 times before engine start.
Probable cause
The pilot's flooding the engine with fuel during a cold engine start, which resulted in an engine fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N747PK
Operator
RALEIGH FLYING CLUB LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-4647
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-31T00:32:11Z guid: 106640 uri: 106640 title: CEN23LA093 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106630/pdf description:
Unique identifier
106630
NTSB case number
CEN23LA093
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-24T17:39:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-01-25T22:20:43.235Z
Event type
Accident
Location
Indianapolis, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Factual narrative
On January 24, 2023, about 1539 eastern standard time, a Cirrus SR20 airplane, N99EC, was destroyed when it was involved in an accident near Indianapolis, Indiana. The pilot sustained fatal injuries. The airplane was being operated as a Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast data (ADS-B), the airplane departed the Indianapolis Executive Airport, Indianapolis, Indiana, about 1526. After takeoff, the airplane turned left, climbed to about 1,000 ft above ground level, and continued to the southeast past downtown Indianapolis. South of downtown and near the end of the data, the airplane made a 360° left turn and began a rapid descent (see Figure 1.). A residential surveillance camera captured the impact sequence and showed the airplane impact in a nose and right-wing low attitude. There were no witnesses to the accident. Figure 1. Airplane’s ADS-B flight track The airplane wreckage was located adjacent to a single railroad track and several residential homes. The initial impact point, which was consistent with the propeller, engine, forward fuselage, and both wings, was located about 20 ft from the main wreckage. The initial impact contained the propeller blades and fragmented sections of the forward fuselage. Fragmented sections of the fuselage, wings, and empennage were found forward of the main wreckage. The airplane damage was consistent with a high angle and high energy impact with terrain. Postaccident examination of the airplane revealed no mechanical malfunctions that would have precluded normal operations. An autopsy of the pilot was performed by the Marion County Coroner’s Office, Indianapolis, Indiana. The autopsy report listed the cause of death as blunt force trauma, and the manner of death as suicide. The Federal Aviation Administration Forensic Sciences Laboratory performed toxicology testing on specimens from the pilot. Testing was negative for ethanol and carbon monoxide. An unspecified level of Fentanyl was detected in the blood (cavity). -
Analysis
The airplane, rented by the pilot, departed on a reported short cross-country flight. Flight track data showed that after takeoff, the airplane climbed to an altitude of about 1,000 ft above ground level and traveled southeast. Near the end of the flight, the airplane performed a 360° turn and began a rapid descent. The highly fragmented wreckage was located adjacent to a railroad track in a residential area. The airplane damage was consistent with a high angle and high energy impact with terrain. Examination of the airplane revealed no preimpact mechanical deficiencies that would have precluded normal operation of the airplane. Following a death investigation, the coroner classified the manner of death as a suicide.
Probable cause
The pilot’s intentional flight into terrain as an act of suicide.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N99EC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2307
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-01-25T22:20:43Z guid: 106630 uri: 106630 title: WPR23LA099 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106647/pdf description:
Unique identifier
106647
NTSB case number
WPR23LA099
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-24T19:45:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-01-30T06:11:49.648Z
Event type
Accident
Location
Rich County, Utah
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that she encountered unexpected winds while flying at night. After multiple encounters with strong wind gusts and turbulence, the pilot lost control of the airplane and it started to spin downward. She was able to successfully recover from the spin, but was forced to search for a suitable landing site as she was unable to maintain altitude. The pilot executed a forced landing in an open snow-covered area and the airplane stopped abruptly, which resulted in substantial damage to the fuselage. The pilot reported no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s inability to maintain altitude following an encounter with turbulence and adverse wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C23
Amateur built
false
Engines
1 Reciprocating
Registration number
N23FD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-1663
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-01-30T06:11:49Z guid: 106647 uri: 106647 title: CEN23LA098 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106663/pdf description:
Unique identifier
106663
NTSB case number
CEN23LA098
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-25T15:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-02-06T20:06:34.074Z
Event type
Accident
Location
Eagle River, Wisconsin
Airport
Eagle River Union Airport (KEGV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during takeoff, the airplane reached an airspeed of about 35 mph and “hit an ice / snow berm”. The airplane became airborne, stalled, and impacted the terrain. The ski dug into the snow and the airplane flipped over. The airplane sustained substantial damage to the left wing and left strut. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s decision to takeoff from an unsuitable surface which resulted in collision with an object.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
120
Amateur built
false
Engines
1 Reciprocating
Registration number
N73034
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
10242
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-06T20:06:34Z guid: 106663 uri: 106663 title: WPR23LA106 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106694/pdf description:
Unique identifier
106694
NTSB case number
WPR23LA106
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-29T18:00:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-02-09T06:43:30.759Z
Event type
Accident
Location
Sandpoint, Idaho
Airport
Sandpoint (KSZT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during a landing attempt, after touchdown, he raised the flaps and the right wing lifted. He added right aileron input, but the airplane then turned about 60° to the left. The pilot was unable to correct the turn with rudder and initiated a go around, at which time the airplane collided with a snow berm, and the pilot continued. On the second landing, the airplane touched down normally, but the landing gear collapsed. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing and subsequent failure to maintain clearance from a snow berm during a go around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22
Amateur built
false
Engines
1 Reciprocating
Registration number
N1791P
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-2564
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-09T06:43:30Z guid: 106694 uri: 106694 title: ERA23LA153 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106903/pdf description:
Unique identifier
106903
NTSB case number
ERA23LA153
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-01-31T16:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-06T16:34:45.9Z
Event type
Accident
Location
Williston, Florida
Airport
Williston Municipal Airport (X60)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot stated that during takeoff from runway 23 when the flight was 20 ft above the runway, the tip-up canopy became unlatched and “flipped up” which eliminated his forward vision and made the airplane difficult to control. He returned for landing and reported the, “landing was hard.” During the landing roll the nose landing gear dug in and the airplane nosed over resulting in structural damage to the vertical stabilizer and damage to the rudder. According to a Service Letter from the airplane designer, in the event that a tip-up canopy opened in-flight, field reports indicate that the airplane will “most likely pitch nose down abruptly. The severity of the pitching moment can depend on speed, attitude, and weight and balance.” According to a Federal Aviation Administration (FAA) inspector, postaccident examination of the tip-up canopy revealed the canopy frame was distorted and the left side of the canopy frame was damaged which prevented the left aft side from latching closed. The right aft side of the canopy could be latched closed and was unable to be manually raised once closed. The airplane was equipped with a secondary canopy latch at the top rear of the canopy frame. No discrepancies of it were reported. Further, no discrepancies were reported or observed on either “catch tooth” of the latch handle or canopy latch. The airplane was not equipped with a tip-up canopy latch warning system. While the FAA inspector reported no evidence of preimpact failure or malfunction of the canopy latch system (primary or secondary), the damage to the canopy frame likely occurred during the accident sequence. It is likely that the canopy was not closed and latched on either aft side and the canopy latch handle was not fully engaged with the canopy latch during takeoff. Had the airplane been equipped with a tip-up canopy latch warning system, it is likely that the improperly closed canopy would have been detected by the pilot.
Probable cause
The hard landing and subsequent nose over during the forced landing. Contributing to the accident were the improperly secured canopy, and the distraction it created.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GREEN RICHARD H
Model
VAN'S RV7A
Amateur built
true
Engines
1 Reciprocating
Registration number
N4811E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
70455
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-06T16:34:45Z guid: 106903 uri: 106903 title: CEN23LA102 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106688/pdf description:
Unique identifier
106688
NTSB case number
CEN23LA102
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-01T18:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-02-07T20:20:27.646Z
Event type
Accident
Location
Limon, Colorado
Airport
Limon Municipal (KLIC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that he was performing touch-and-go landings. When he added power to take off, he lost control of the airplane as it veered left. He was unable to regain control before the airplane impacted a snowbank. The airplane flipped over and came to rest inverted on the side of the runway, which resulted in substantial damage to the wings, fuselage, and vertical stabilizer. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operations. At the time of the accident, the pilot was landing on Runway 34 with wind from 350°at 4 knots.
Probable cause
The pilot’s failure to maintain directional control during the takeoff roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Registration number
N5163H
Operator
EDB Air Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S8933
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-07T20:20:27Z guid: 106688 uri: 106688 title: ERA23LA123 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106675/pdf description:
Unique identifier
106675
NTSB case number
ERA23LA123
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-02T14:00:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-02-15T23:29:13.649Z
Event type
Accident
Location
Port Orange, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot reported, and airport security video confirmed, that during a takeoff attempt, the right wing contacted the runway and the pilot pulled back excessively on the yoke. The airplane pitched up, stalled, and descended back on to the runway. It subsequently travelled off the end of the runway and impacted trees, before coming to rest on its side. The pilot added that in retrospect, he should have rejected the takeoff when the right wing contacted the runway. Examination of the wreckage by a Federal Aviation Administration inspector did not reveal any preimpact mechanical malfunctions, nor did the pilot report any. The inspector noted that both wings separated, and the fuselage was substantially damaged.
Probable cause
The pilot’s failure to maintain aircraft control during a takeoff attempt, which resulted in an aerodynamic stall, runway excursion, and collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA46
Amateur built
false
Engines
1 Reciprocating
Registration number
N864JB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4608009
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-15T23:29:13Z guid: 106675 uri: 106675 title: ANC23LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106690/pdf description:
Unique identifier
106690
NTSB case number
ANC23LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-02T15:29:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-03T00:14:37.647Z
Event type
Accident
Location
Newtok, Alaska
Airport
Newtok (PAEW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot, seated in the left seat, reported that the operator’s chief pilot/check airman, seated in the right seat, was conducting an operating experience (OE) flight during a CFR Part 135 cargo flight to a remote Alaskan village. The pilot said that her approach to Runway 33, a 35-foot wide, 2,200 ft long, ice-covered runway, required a correction for a strong right crosswind. She added that the airport windsock was frozen in place, making it difficult to discern the wind velocity and direction. She reported that during the landing roll, the airplane began to veer to the left of the runway center. She said that the chief pilot/check airman then took control of the airplane to correct the veer, but the strong crosswind continued to push the airplane to the left on the ice-covered runway. The airplane subsequently collided with a snow berm on the left side of the runway, resulting in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation. During a follow up conversation with the operator’s director of operations, he said that the chief pilot/check airman was on board the accident flight to provide additional OE to a recently hired pilot due to icy runway conditions and a strong crosswind at the destination airport. This was the pilot’s first flight to the remote village.
Probable cause
The pilot’s failure to maintain directional control while landing with a crosswind on an ice-covered runway, resulting in a loss of control and subsequent impact with a snowbank. A factor was the check airman’s inadequate supervision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
207
Amateur built
false
Engines
1 Reciprocating
Registration number
N9996M
Operator
Yute Air Commuter
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
207007779
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-03T00:14:37Z guid: 106690 uri: 106690 title: CEN23LA133 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106885/pdf description:
Unique identifier
106885
NTSB case number
CEN23LA133
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-06T14:00:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-16T23:22:04.624Z
Event type
Accident
Location
Hilbert, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during initial climb through about 5,000 ft mean sea level, the engine lost power. He attempted to restart the engine, but the attempt was unsuccessful. Unable to return to the departure airport, the pilot conducted a forced landing to a field. During the forced landing, the airplane sustained substantial damage to the forward fuselage. Postaccident examination of the airplane revealed the left fuel tank contained no usable fuel, and the right fuel tank was full of fuel. After the airplane was recovered, a functional engine test run, with the right fuel tank selected, was completed with no anomalies noted. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. After the accident, the pilot stated that he should have a better understanding of engine restart procedures. The loss of engine power was attributed to fuel starvation.
Probable cause
The pilot’s inadequate fuel management, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
F33A
Amateur built
false
Engines
1 Reciprocating
Registration number
N1074W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CE-432
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-16T23:22:04Z guid: 106885 uri: 106885 title: ERA23LA140 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106837/pdf description:
Unique identifier
106837
NTSB case number
ERA23LA140
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-06T18:30:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-03-08T00:26:07.945Z
Event type
Accident
Location
Lake Katrine, New York
Airport
KINGSTON-ULSTER (20N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the pilot receiving instruction were practicing short field landings. After an initial unsuccessful approach, the pilot conducted a go-around and set up for another landing approach. The flight instructor described that after passing over obstacles while on short final approach to the runway, the flight instructor told the pilot to reduce engine power to idle so that they would not overshoot the touchdown point again. The pilot complied, and as they descend the pilot continued to increase the airplane’s pitch attitude as if engine power had not been reduced. The flight instructor noted this, directed the pilot to decrease the airplane’s pitch, and then “nudged” the control stick forward to reduce the airplane’s angle of attack. As the flight instructor released his forward pressure on the control stick, the airplane’s pitch again increased along with its descent rate, as the pilot continued to pull back on the control stick. The airplane subsequently touched down “hard” on the runway, resulting in substantial damage to the right wing. The operator reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation, nor did the pilot or flight instructor report any.
Probable cause
The pilot’s failure to maintain an appropriate pitch attitude and descent rate during landing, which resulted in a hard landing. Contributing to the accident was the flight instructor’s inadequate remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40 NG
Amateur built
false
Engines
1 Reciprocating
Registration number
N871LA
Operator
Take Flight Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
40.NC107
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-08T00:26:07Z guid: 106837 uri: 106837 title: ERA23LA125 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106732/pdf description:
Unique identifier
106732
NTSB case number
ERA23LA125
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-06T19:50:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-02-15T18:44:29.825Z
Event type
Accident
Location
Pikeville, North Carolina
Airport
WAYNE EXEC JETPORT (GWW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that during the fifth solo landing of the day the airplane began to yaw to the left of centerline after touching down. He applied right rudder but was unable to correct the yaw and the right main landing gear collapsed, which resulted in substantial damage to the main wing spar and fuselage. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA20-C1
Amateur built
false
Engines
1 Reciprocating
Registration number
N116CL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
C0016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-15T18:44:29Z guid: 106732 uri: 106732 title: CEN23LA104 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106702/pdf description:
Unique identifier
106702
NTSB case number
CEN23LA104
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-08T12:00:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-02-14T01:21:22.393Z
Event type
Accident
Location
Waukesha, Wisconsin
Airport
Waukesha County Airport (UES)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during takeoff, he heard a noise that sounded like “gravel hitting the gear,” which continued after landing gear retraction, and prompted a return to the departure airport for a precautionary landing. He stated that while on the downwind leg, the stall warning aural alert sounded, and the stick shaker activated; the pilot used the autopilot disconnect button to regain control of the airplane. During touchdown, the airplane bounced and exited the runway, which resulted in substantial damage to the lower forward fuselage. Following the accident, the pilot discovered that he had failed to remove the angle of attack vane cover. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during landing. Contributing to the accident was the pilot’s inadequate preflight inspection removal of the angle of attack vane cover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SF50
Amateur built
false
Engines
1 Turbo fan
Registration number
N426SJ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0148
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-14T01:21:22Z guid: 106702 uri: 106702 title: ANC23LA020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106728/pdf description:
Unique identifier
106728
NTSB case number
ANC23LA020
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-08T19:00:00Z
Publication date
2023-12-14T05:00:00Z
Report type
Final
Last updated
2023-02-27T23:24:07.049Z
Event type
Accident
Location
Soldotna, Alaska
Airport
Soldotna Airport (SXQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 08, 2023, about 1700 Alaska daylight time, a Piper PA-16 airplane, N5987H sustained substantial damage when it was involved in an accident in Soldotna, Alaska. The pilot was not injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Shortly after takeoff, the engine lost partial power then regained power. The pilot turned the airplane back to the airport to perform an emergency landing. While in the turn, a total loss of engine power occurred and upon landing on airport property, the airplane impacted a snowbank. The airplane sustained substantial damage to the fuselage. A postaccident examination of the engine, with oversight by a Federal Aviation Administration inspector, revealed no evidence of any preimpact mechanical malfunctions or anomalies that would have precluded normal operation. The carburetor icing chart shows the weather conditions were conducive for carburetor ice at glide or cruise power. -
Analysis
The pilot reported that on departure the engine lost then regained power. The pilot turned the airplane back toward the airport to land and, during the turn, a total loss of engine power occurred. The airplane impacted a snowbank during the landing. The airplane sustained substantial damage to the fuselage. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
A total loss of engine power for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-16
Amateur built
false
Engines
1 Reciprocating
Registration number
N5987H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
16-615
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-27T23:24:07Z guid: 106728 uri: 106728 title: ANC23LA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106730/pdf description:
Unique identifier
106730
NTSB case number
ANC23LA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-10T19:00:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-02-15T23:54:00.002Z
Event type
Accident
Location
Tok, Alaska
Airport
Tok Junction (TKJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during a landing attempt, the airplane descended below glide path and landed short of the runway. The airplane landed hard and sustained substantial damage to the firewall and engine mount. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain a proper approach glide path, which resulted in a hard landing, short of his anticipated touchdown point.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-260
Amateur built
false
Engines
1 Reciprocating
Registration number
N44782
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32-7500002
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-02-15T23:54:00Z guid: 106730 uri: 106730 title: DCA23LA170 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106723/pdf description:
Unique identifier
106723
NTSB case number
DCA23LA170
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-10T23:51:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2023-03-22T16:51:14.724Z
Event type
Accident
Location
Rushville, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
American Airlines flight 2516 encountered clear air turbulence during decent, while en route to Chicago O’Hare International airport (ORD), Chicago, Illinois. The flight was a regularly scheduled passenger flight from Orlando International Airport (MCO), Orlando, Florida to ORD. As a result of the turbulence, one flight attendant (FA) sustained serious injuries. The aircraft was not damaged, and the flight landed without further incident. The flight crew reported that while on the VEECK5 arrival at flight level (FL)290, near the top of the decent, air traffic control (ATC) advised of reports of moderate turbulence between FL240 and FL190. ATC suggested the flight begin its decent early to avoid the area, and the flight crew agreed. The flight had previously been smooth, and this was the first turbulence advisory they had received from ATC. The captain informed the cabin crew to expect moderate turbulence in about 10 minutes and advised them to prepare the cabin for landing and take their seats. The captain made an announcement for the passengers to remain seated. The seatbelt sign was on. While the cabin crew was preparing for landing, the airplane encountered severe turbulence as it descended through FL250. FA1 reached the forward jumpseat, while FA2 and FA3 reached nearby cabin seats. All 3 had difficulty reaching their seats and trouble securing their seatbelts due to the turbulence. FA4 was lifted up then down to the floor while attempting to reach a seat, injuring her left leg and ankle. She remained on the aisle floor until the turbulence ended, about 2 minutes after it began. Once FA1 confirmed it was safe to get up, she informed the captain about the injury to FA4 and went to check on the passengers with FA2. FA3 tended to FA4 and made a passenger announcement requesting medical assistance. A nurse who was a passenger on board rendered aid to FA4. The captain advised dispatch of the event and requested medical personnel meet the airplane at the gate. After landing, FA4 was transported to the hospital where she was diagnosed with multiple fractures to her left leg and ankle which required surgery. A post-accident weather analysis provided by the operator showed strong horizontal and vertical wind shear and gravity waves in the area indicating an environment conducive to clear air turbulence. Preflight weather planning predicted light to moderate turbulence between FL290 to FL360 in the area of the event. While there were no active Significant Meteorological hazards (SIGMETs) over the area of the event, a turbulence SIGMET was in effect between FL290 and FL360 for an area about 20 nautical miles southeast of the event. The Turbulence Auto-PIREP System (TAPS) had generated severe turbulence reports for altitudes between FL276 and FL244 in the hour prior to the event, and one pilot report of severe turbulence between FL200 and FL250 was issued a few minutes after the event.
Probable cause
An encounter with clear air turbulence during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737
Amateur built
false
Engines
2 Turbo fan
Registration number
N944AN
Operator
American Airlines
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
29535
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-03-22T16:51:14Z guid: 106723 uri: 106723 title: ANC23LA022 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106736/pdf description:
Unique identifier
106736
NTSB case number
ANC23LA022
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-13T17:00:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-02-23T23:26:13.006Z
Event type
Accident
Location
Chugiak, Alaska
Airport
Birchwood Airport (BCV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that the runway had about 12 inches of new snow and the runway edge lights were not visible. During the takeoff run, in flat light conditions, he was unable to determine the centerline of the runway, and the airplane subsequently drifted left of centerline. The left main landing gear impacted a snow berm along the edge of the runway and the airplane spun around 90°, which resulted in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff in flat light conditions which resulted in a loss of control and impact with a snow berm.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
U206F
Amateur built
false
Engines
1 Reciprocating
Registration number
N9572G
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
U20601772
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-23T23:26:13Z guid: 106736 uri: 106736 title: ERA23LA139 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106824/pdf description:
Unique identifier
106824
NTSB case number
ERA23LA139
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-15T12:00:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-03-06T23:24:48.95Z
Event type
Accident
Location
Keystone Heights, Florida
Airport
KEYSTONE HEIGHTS (42J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was about three miles south of the non-tower-controlled airport, inbound for landing, when he heard another pilot announce they were on the downwind leg of the traffic pattern for the same runway. He elected to perform a 360° right turn to “allow the other aircraft time to clear the pattern.” He further reported that while in the turn, he “noticed acres and acres of pristine/plush land.” The pilot then decided to perform an off-airport landing in a field. During the landing roll, livestock began to walk in front of the airplane and the pilot took action to avoid a collision. This resulted in a nose over and substantial damage to the vertical stabilizer, rudder, wings, and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper decision to perform an impromptu off-airport landing and his failure to maintain control of the airplane during the landing, which resulted in a nose-over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N2419V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
14665
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-06T23:24:48Z guid: 106824 uri: 106824 title: WPR23LA119 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106835/pdf description:
Unique identifier
106835
NTSB case number
WPR23LA119
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-15T14:40:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-15T02:04:06.238Z
Event type
Accident
Location
Fullerton, California
Airport
FULLERTON MUNI (KFUL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while practicing crosswind landings a gust of wind pushed the airplane left. The flight instructor took the controls and applied right rudder and added power to go around, but the airplane impacted a taxiway sign before it transitioned into a climb. According to the instructor, the airplane did not exhibit any abnormal flight characteristics once airborne. After confiding with the tower, they returned to the airplane base where substantial damage was found to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The student pilot's failure to maintain control of the airplane during the landing roll and the flight instructor’s delayed remedial action, which resulted in an impact with an obstacle.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N8318C
Operator
SALE REPORTED
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7615087
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-03-15T02:04:06Z guid: 106835 uri: 106835 title: CEN23LA115 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106759/pdf description:
Unique identifier
106759
NTSB case number
CEN23LA115
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-15T17:20:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-03-02T19:55:54.581Z
Event type
Accident
Location
Cahokia, Illinois
Airport
St Louis Downtown Parks (KCPS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was performing touch and go landings. On the fourth traffic pattern, the controller requested that he turn inside of the airplane that was on final approach. The pilot stated that he delayed extending the landing gear until he turned the airplane onto the final approach leg. After he reduced the airspeed, he selected flaps and extended the landing gear. During the landing, the pilot “heard the sound of metal” and realized that the landing gear was not extended. The pilot reported that when he moved the landing gear handle, he did not see the unsafe landing gear warning light, nor was there a landing gear warning horn. The airplane sustained damage to the lower fuselage. The mechanic that recovered the airplane after the accident reported that the landing gear extended normally, and the landing gear warning horn was audible. Further, the pilot reported to the responding inspector that he had just forgot to extend the landing gear.
Probable cause
The pilot’s failure to extent the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200T
Amateur built
false
Engines
2 Reciprocating
Registration number
N7681F
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
34-7770066
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-02T19:55:54Z guid: 106759 uri: 106759 title: DCA23LA175 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106744/pdf description:
Unique identifier
106744
NTSB case number
DCA23LA175
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-16T09:30:00Z
Publication date
2023-07-19T04:00:00Z
Report type
Final
Last updated
2023-02-17T18:13:51.361Z
Event type
Accident
Location
New Orleans, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Analysis
Spirit Airlines flight 641 encountered convective turbulence while descending into Louis Armstrong New Orleans International Airport (MSY), New Orleans, Louisiana. As a result of the turbulence, all three flight attendants were injured with two receiving minor injuries and one receiving a serious injury. The aircraft continued to its destination without further incident. According to the captain, the flight crew completed the approach checklist and illuminated the seat belt sign when the airplane was at about flight level (FL)180. As the airplane passed through 12,000 feet, the first officer (FO) made an announcement to the flight attendants to prepare the cabin for landing. According to the lead flight attendant, she made the landing announcement to passengers while the other two flight attendants started final checks from the aft cabin. The lead flight attendant then started the final check from the front of the aircraft. When the lead flight attendant was between rows 6 and 9, the airplane descended through a cloud layer at about 7000 feet and experienced what was described as moderate turbulence by the flight crew. This turbulence led to all three flight attendants falling to the floor. All three flight attendants agreed they needed medical attention and notified the flight crew. The FO called operations and requested for paramedics to meet the airplane. The flight continued to its destination without further incident. Upon arrival at MSY, paramedics met the airplane at the gate, and all flight attendants received medical treatment. The lead flight attendant was transported to the hospital where she was diagnosed with a fractured ankle. Another flight attendant suffered minor injuries to their back and the third suffered minor injuries to their head. Both pilots stated that the cloud layer appeared stable with no vertical development, and there were no indications on the radar that suggested the risk of turbulence. A post-accident review of the weather conditions showed no pilot reports (PIREPs) for turbulence located within a 100 nm radius from the accident location within 2 hours of the accident time. There were no airman’s meteorological information (AIRMETs), significant meteorological information (SIGMETs), or Center Weather Advisories for turbulence or thunderstorm activity for the accident location. Based on weather satellite information and upper air sounding data, the flight encountered convective activity while traversing building cumulus clouds during the descent.
Probable cause
The flight’s encounter with convective turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A319-132
Amateur built
false
Engines
2 Turbo fan
Registration number
N505NK
Operator
SPIRIT AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
2485
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-02-17T18:13:51Z guid: 106744 uri: 106744 title: CEN23LA112 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106750/pdf description:
Unique identifier
106750
NTSB case number
CEN23LA112
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-17T13:16:00Z
Publication date
2024-03-13T04:00:00Z
Report type
Final
Last updated
2023-11-16T00:28:35.721Z
Event type
Accident
Location
Houston, Texas
Airport
William Hobby Airport (HOU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On February 17, 2023, at 1116 central standard time, a Honda Aircraft HA-420 airplane, N14QB, was substantially damaged when it was involved in an accident at William P. Hobby Airport (HOU), Houston, Texas. The pilot and five passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Automated Dependent Surveillance – Broadcast (ADS-B) data obtained from the Federal Aviation Administration (FAA) and data recovered from the onboard avionics provided airplane position, altitude, and speed information. Data downloaded from the airplane Central Maintenance Function (CMF) system provided information regarding the status of the onboard systems. The flight departed Miami Executive Airport (TMB) at 0905 eastern standard time. Upon arrival into the Houston area, the pilot was provided radar vectors for an instrument landing system (ILS) approach to runway 4. The pilot was initially cleared to land; however, the tower controller instructed to the pilot to execute a go around due to another airplane on the runway. Following radar vectors for a second ILS approach to runway 4, the pilot was cleared to land and provided the current wind of 340° at 15 kts. About 2 minutes later, the tower controller issued the current wind information of 330° at 15 kts, gusting to 25 kts, to a departing airplane. The accident airplane was on a 3-mile final at that time. As the airplane crossed the runway arrival threshold, the onboard avionics recorded an altitude of 86 ft mean sea level (msl) and 125 knots indicated airspeed (IAS). The published runway 4 threshold elevation was 42 ft. The corresponding landing reference speeds published in the airplane flight manual ranged from 100 knots IAS at a landing weight of 7,500 lbs to 111 knots IAS at a landing weight of 9,500 lbs. The exact landing weight for the accident airplane was not available. The left and right weight-on-wheels (WOW) parameters transitioned from air to ground about 1116:02 consistent with initial touchdown. At that time, the airplane was about 2,000 ft from the runway arrival threshold. According to the onboard avionics, the indicated airspeed was about 108 knots, and the corresponding groundspeed was about 96 knots. The airplane tracked the runway centerline for about 4 seconds. Afterward, it drifted left and departed the pavement about 1116:09 at a groundspeed of about 75 knots. The airplane came to rest upright in the grass infield area about 150 ft north of the runway 4/runway 31L intersection. The outboard portion of the right wing was separated near midspan, and the landing gear collapsed. The pilot reported that upon touchdown, he established the aileron controls into the wind and applied the brakes. However, no braking action was observed, and the airplane drifted off the left side of the runway. He also noted that the crosswind component was near the limitation for the airplane and that he made two requests with the approach controller to land on runway 31L. He stated that those requests were denied and was instructed to expect runway 4. A detailed review of the CMF data files did not reveal any record of airplane system anomalies from the time the airplane lifted off until it touched down. Multiple system anomalies were recorded after the runway excursion consistent with airframe damage sustained during the accident sequence. Further review of CMF data revealed that, after initial touchdown, the left WOW parameter transitioned from ground back to air about 2 seconds later. It then returned to ground about 1116:16 for the remainder of the data set. The right WOW parameter remained on ground until about 1116:10 when it returned to air for the remainder of the data set. The airplane flight manual specified a crosswind limitation of 20 kts for takeoff and landing. Based on the most current wind information provided by the tower controller, the runway 4 crosswind component at the time of the accident was about 24 kts. The airplane Pilot’s Operating Manual (POM) noted that the brake system touchdown protection is intended to inhibit brake application until wheel spin-up occurs. This is to prevent a pilot from inadvertently touching down with the brakes applied and the wheels locked. After weight-on-wheels has been true for three seconds, power braking is enabled with or without a wheel speed signal. The airframe manufacturer noted that in addition to the weight-on-wheels condition, the touchdown protection will also be deactivated within one second if the average of the left and right wheel speed is at least 60 knots. Additionally, the POM noted the brake system anti-skid protection and locked wheel crossover protection are available once touchdown protection is no longer active. The airplane is not equipped with engine thrust reversers or wing-mounted speed brakes. An aft fuselage-mounted speed brake is available; although, it is not automatically deployed on touchdown. Air traffic control (ATC) tower (local control position) communications with the pilot were routine until the accident occurred. At the time, airplanes were landing on runway 4 and departing from runway 31L. A recording of communications between the pilot and terminal radar (TRACON) controller from a third-party source included multiple frequencies and some transmissions were not clearly recorded. As a result, no determination regarding any pilot request for an alternate runway due to the crosswind condition could be made. FAA regulations stated that the pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft (14 CFR 91.3). Furthermore, the regulations state that no person may operate a civil aircraft without complying with the operating limitations specified in the approved Airplane Flight Manual (14 CFR 91.9). -
Analysis
The pilot was landing at the destination airport with a gusting crosswind. Upon touchdown, he established the aileron controls for the crosswind and applied the brakes; however, no braking action was observed. The airplane subsequently drifted left and departed the runway pavement. It came to rest upright in the grass infield area adjacent to the runway. The outboard portion of the right wing separated which resulted in substantial damage. Data indicated that the airplane was 14 knots or more above the published landing reference speed when it crossed the runway threshold, and it touched down about 2,000 ft from the threshold. The left and right weight-on-wheels (WOW) parameters transitioned from air to ground consistent with initial touchdown; however, the left WOW parameter transitioned back to air about 2 seconds later. The right WOW parameter remained on ground until the airplane departed the runway pavement. A detailed review of the Central Maintenance Function (CMF) data files did not reveal any record of airplane system anomalies from the time the airplane lifted off until it touched down. Multiple system anomalies were recorded after the runway excursion consistent with airframe damage sustained during the accident sequence. The brake system touchdown protection is designed to prevent brake application until wheel spin-up occurs to avoid the possibility of inadvertently landing with a locked wheel due to brake application. After weight-on-wheels has been true for three seconds, power braking is enabled. It is likely that the lack of positive weight-on-wheel parameters inhibited brake application due to the touchdown protection function and resulted in the pilot not observing any braking action. The excess airspeed, extended touchdown, and transient weight-on-wheels parameters were consistent with the airplane floating during the landing flare and with the application of aileron controls for the crosswind conditions. The airplane was not equipped with wing-mounted speed brakes which would have assisted in maintaining weight-on-wheels during the initial portion of the landing. The most recent wind report, transmitted by the tower controller when the airplane was on a 3-mile final, presented a 70° crosswind at 15 knots, gusting to 25 knots. The corresponding crosswind gust component was about 24 knots. The airplane flight manual specified a crosswind limitation of 20 kts for takeoff and landing; therefore, the crosswind at the time of the accident exceeded the airframe crosswind limitation and would have made control during touchdown difficult. The pilot reported that he had made two requests with the approach controller to land on a different runway, but those requests were denied. The investigation was unable to make any determination regarding a pilot request for an alternate runway. Federal Aviation Regulations stated that the pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. The regulations also stated that no person may operate a civil aircraft without complying with the operating limitations. The pilot’s ultimate acceptance of the runway assignment which likely exceeded the crosswind limitation of the airplane was contrary to the regulations and to the safe operation of the airplane.
Probable cause
The pilot’s loss of directional control during landing which resulted in a runway excursion. Contributing to the accident was the pilot’s decision to land with a crosswind that exceeded the limitation for the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HONDA AIRCRAFT CO LLC
Model
HA-420
Amateur built
false
Engines
2 Turbo fan
Registration number
N14QB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
42000107
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-16T00:28:35Z guid: 106750 uri: 106750 title: ERA23LA150 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106875/pdf description:
Unique identifier
106875
NTSB case number
ERA23LA150
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-17T20:19:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-14T14:20:07.306Z
Event type
Accident
Location
Fernandina Beach, Florida
Airport
Fernendina Beach (FHB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after conducting an instrument approach, the airplane descended out of the clouds at an altitude of about 800 feet above the ground and the pilot had a clear view of the runway. The pilot described that the descent was “uneventful though blustery.” During the subsequent landing, while the airplane was slow and in a nose up pitch attitude, he encountered a sudden wind gust and the airplane subsequently struck a runway identifier sign. The airplane’s left wing and fuselage were substantially damaged during the collision. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane while landing in gusting crosswind conditions, with resulted in a runway excursion and collision with a runway identifier sign.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N740NG
Operator
ADROIT REAL ESTATE HOLDINGS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2032
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T14:20:07Z guid: 106875 uri: 106875 title: ERA23LA128 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106747/pdf description:
Unique identifier
106747
NTSB case number
ERA23LA128
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-18T19:32:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-02-27T22:35:02.947Z
Event type
Accident
Location
Buckhannon, West Virginia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was picking up the airplane for its owner after an annual inspection had been completed. During his preflight inspection he noted that both fuel tank fuel gauges indicated that they were ½ to ¾ full. While he was checking the fuel selector valve the “brittle plastic handle broke off” with the left fuel tank still selected. The pilot called the airplane owner to inform him of the situation and advised that he would add more fuel to the left fuel tank in order to make the anticipated 45-minute flight without switching fuel tanks. He subsequently had 4 gallons of fuel added to the fuel tanks and acquired a small crescent wrench that he planned to use in-lieu of the broken plastic fuel selector handle if necessary. He subsequently departed and climbed the airplane to a cruise altitude of about 6,500 feet. About 20 nautical miles from the destination, he noted that the left fuel tank quantity indication was “bouncing between ¼ and empty” and he decided to change to the right fuel tank for the remainder of the flight. He was subsequently unable to use the crescent wrench to change the fuel selector valve position after several attempts. About 2 nautical miles from the destination airport, while approaching the runway to land, the airplane’s engine lost power completely and the pilot performed a forced landing to a field. The airplane nosed over during the landing and the aft portion of the fuselage left, as well as the wing, were substantially damaged. After the accident, recovery personnel reported that after lifting the airplane upright, they noted fuel staining around the fuel caps of both wing fuel tanks, that the right fuel tank was absent of fuel, and the left fuel tank only contained only a trace amount of fuel. They also operated the fuel selector valve with their own adjustable wrench (the broken fuel selector handle and the crescent wrench used by the pilot could not be located in the wreckage) and found that it operated normally. Based on this information, it is likely that the loss of engine power was due to fuel starvation after the pilot exhausted all usable fuel from the left fuel tank and was unable to select the right fuel tank; or that the pilot had inadvertently moved the fuel selector to an intermediate position in his attempts to use a crescent wrench to adjust the fuel selector valve.
Probable cause
A total loss of engine power due to fuel starvation. Contributing was the pilot’s decision to depart on the flight with an inoperative fuel selector valve.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210
Amateur built
false
Engines
1 Reciprocating
Registration number
N6597X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
21057597
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-27T22:35:02Z guid: 106747 uri: 106747 title: CEN23LA111 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106749/pdf description:
Unique identifier
106749
NTSB case number
CEN23LA111
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-19T11:10:00Z
Publication date
2023-04-06T04:00:00Z
Report type
Final
Last updated
2023-02-27T21:22:30.236Z
Event type
Accident
Location
Moline, Illinois
Airport
QUAD CITIES INTL (MLI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot stated he was in the practice area and made the decision to return to the departure airport due to increasing winds. The pilot reported that on the landing rollout he felt a “large gust of wind” elevate the left wing making the airplane veer to the right. The pilot attempted to “pull back and brake.” The airplane exited the runway, and the left main wheel and strut impacted a runway sign which resulted in substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. A wind limitation in the flight school pre-solo packet states surface winds must be “less than 15 knot winds” and “less than 7 knot crosswind component.” The flight instructor did not list any limitations on the student’s initial solo endorsement. Five minutes before the accident, surface winds were reported from 230° at 17 knots, gusting to 26 knots. The student pilot was landing on runway 27. Runway 23 was closed at the time of the accident. According to the owner of the flight school, the student did not check in with her before launching to discuss weather and his flight plan as he was supposed to.
Probable cause
The student pilot’s failure to maintain directional control during the landing roll in gusting crosswind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N84688
Operator
Quad Cities Aero, LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17258578
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-27T21:22:30Z guid: 106749 uri: 106749 title: ERA23LA129 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106782/pdf description:
Unique identifier
106782
NTSB case number
ERA23LA129
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-19T12:15:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-02-25T01:05:47.547Z
Event type
Accident
Location
Chatham, Massachusetts
Airport
CHATHAM MUNI (CQX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
At the conclusion of an uneventful flight, the pilot entered the airport traffic pattern for landing. The pilot reported that while on the downwind leg of the traffic pattern for landing, he failed to extend the landing gear and landed with the landing gear retracted. The airplane subsequently touched down on the runway and sustained substantial damage to the underside of the fuselage. The pilot reported that there were no preaccident machinal malfunctions or failure with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to lower the landing gear before touchdown.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
TR182
Amateur built
false
Engines
1 Reciprocating
Registration number
N711PD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
R18201282
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-25T01:05:47Z guid: 106782 uri: 106782 title: WPR23LA111 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106758/pdf description:
Unique identifier
106758
NTSB case number
WPR23LA111
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-19T12:57:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-02-24T00:32:54.364Z
Event type
Accident
Location
Cal-Nev-Ari, Nevada
Airport
BLM dirt road (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that, he planned an off-airport landing on a dirt road. He performed a series of passes to confirm the road condition and decided to proceed with the landing. During the rollout, the dirt road elevation lowered with respect to the berms on either side, and the wings contacted vegetation, which damaged the left wing. The pilot and his passenger exited the airplane to inspect the damage and determined that the airplane was airworthy and able to fly to a nearby airport with only the pilot onboard. The pilot stated that for the accident takeoff, near rotation speed, the left main wheel dropped into a rut of soft sand, the airplane veered left, the left wing contacted a berm, and the airplane spun around and came to rest inverted. Substantial damage was sustained to the wings and fuselage. Witnesses reported that they saw the airplane climb before veering left and descending back to the ground. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper decision to takeoff with known damage to the wing and his failure to maintain directional control during takeoff on rough terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Glasair
Model
Sportsman
Amateur built
true
Engines
1 Reciprocating
Registration number
N2847H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7065
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-24T00:32:54Z guid: 106758 uri: 106758 title: CEN23LA116 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106764/pdf description:
Unique identifier
106764
NTSB case number
CEN23LA116
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-19T20:10:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-03-13T22:44:16.31Z
Event type
Accident
Location
Grand Prairie, Texas
Airport
Grand Prairie Municipal (GPM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he forgot to put down the landing gear and that he landed with the gear retracted. The airplane slid off the runway before it came to a rest. The airplane sustained substantial damage to the lower fuselage. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operations.
Probable cause
The pilot’s failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
G35
Amateur built
false
Engines
1 Reciprocating
Registration number
N4210D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
D-4415
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-13T22:44:16Z guid: 106764 uri: 106764 title: CEN23LA117 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106765/pdf description:
Unique identifier
106765
NTSB case number
CEN23LA117
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-20T13:00:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-02-27T21:04:39.61Z
Event type
Accident
Location
Guthrie, Oklahoma
Airport
GUTHRIE-EDMOND RGNL (GOK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The student pilot reported that, while rolling out on landing, the airplane suddenly veered to the right causing the nose to turn to the left. The student pilot attempted to correct with opposite rudder; however, the airplane exited the left side of the runway, proceeded down a terrace, and nosed over, which resulted in substantial damage to the vertical stabilizer. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident, the student pilot was landing the airplane on runway 34 with wind from 300° at 6 knots.
Probable cause
The student pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LUSCOMBE
Model
8A
Amateur built
false
Engines
1 Reciprocating
Registration number
N25342
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1218
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-27T21:04:39Z guid: 106765 uri: 106765 title: CEN23LA121 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106787/pdf description:
Unique identifier
106787
NTSB case number
CEN23LA121
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-20T14:39:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-02-27T21:48:26.08Z
Event type
Accident
Location
Oklahoma City, Oklahoma
Airport
WILEY POST (PWA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The rear seat pilot reported that he was showing the front seat passenger the “basic operation” of a tailwheel airplane. During the three-point landing, with the passenger on the flight controls, the pilot verbally “talked him through the basic steps” of the landing. The landing was unsuccessful and a go-around was initiated. The pilot then took control, stabilized the airplane, and then decided land on the remaining runway. After touchdown, the airplane “turned sharply” to the right, the airplane departed the runway, and impacted a runway sign. The airplane remained upright, and the pilot was able to taxi the airplane back to his hangar. The airplane sustained substantial damage to the left wing forward and aft lift struts. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot additionally reported that the accident could have been prevented by maintaining “aircraft control at all times.”
Probable cause
The pilot’s failure to maintain directional control during the landing, that resulted in a runway excursion, and an impact with an obstacle.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN CHAMPION AIRCRAFT
Model
8KCAB
Amateur built
false
Engines
1 Reciprocating
Registration number
N303SB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
887-2001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-27T21:48:26Z guid: 106787 uri: 106787 title: HMD23LR001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106810/pdf description:
Unique identifier
106810
NTSB case number
HMD23LR001
Transportation mode
Hazmat
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-22T20:30:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Event type
Accident
Location
Monahans, Texas
Injuries
0 fatal, 0 serious, 0 minor
Chemical released
Lithium Ion Batteries
Hazard class
Miscellaneous
Hazardous material operator
FedEx
State of material
Solid
Container type
wooden crate
Competent authority
PHMSA
Probable cause
Not determined
Has safety recommendations
false

Vehicle 1

Findings
creator: NTSB last-modified: 2023-09-29T04:00:00Z guid: 106810 uri: 106810 title: CEN23LA119 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106770/pdf description:
Unique identifier
106770
NTSB case number
CEN23LA119
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-23T13:48:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-01T23:24:46.847Z
Event type
Accident
Location
Martinsville, Indiana
Airport
Twelve Oaks Airport (II87)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot attempted a short field takeoff from a grass airstrip at the time of the accident. During the airplane’s takeoff roll, the passenger, who was seated in the left pilot seat, said that the windsock was “inconsistent.” At an airplane speed of 45-50 mph, the pilot applied control back pressure to ease the airplane into ground effect. The airplane became airborne but quickly settled back onto the runway and became airborne again. The airplane airspeed did not increase and remained at 40 mph. The pilot asked the passenger to continue to read the airspeed indications as the pilot realized that they were running out of remaining runway. The pilot reduced some of the control back pressure and pushed the airplane nose down out of fear of an aerodynamic stall and in hopes of increasing airspeed. The airplane descended and impacted the ground about 100 yds south of the departure runway and nosed over. The airplane sustained substantial damage that included damage to the right wing, aileron, and empennage. The pilot stated there was no mechanical malfunction or failure of the airplane that would have precluded normal operations. Recorded weather observations, north and northeast and 15-16 nm from the airport, indicated a quartering tailwind relative to the runway direction prevailed at the time of the accident.
Probable cause
The pilot’s inadequate weather evaluation and failure to abort the takeoff that resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N1700T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-7125017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-01T23:24:46Z guid: 106770 uri: 106770 title: WPR23LA115 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106789/pdf description:
Unique identifier
106789
NTSB case number
WPR23LA115
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-24T20:20:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-02-28T02:44:03.638Z
Event type
Accident
Location
Mulino, Oregon
Airport
MULINO STATE (4S9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, he departed with 28 gallons of fuel onboard for a cross-country flight and he used 100% power during the flight. The flight was uneventful for a little over four hours, until the pilot was approaching his destination and the engine began to run rough and sputter. The pilot was unable to reach a nearby airport and force-landed the airplane in an open field where the nose landing gear collapsed, which resulted in substantial damage to the lower fuselage. The pilot and a law enforcement examined the fuel tank and discovered that the fuel tank was empty. Fuel usage computations indicated the engine likely consumed all the fuel onboard while operating at 100% power. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate fuel planning which resulted in a loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRCRAFT MFG & DEVELOPMENT CO
Model
CH 2000
Amateur built
false
Engines
1 Reciprocating
Registration number
N8500Z
Operator
Jonathan E Kreilich
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
20-1003
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-28T02:44:03Z guid: 106789 uri: 106789 title: CEN23LA122 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106790/pdf description:
Unique identifier
106790
NTSB case number
CEN23LA122
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-25T17:00:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-02-28T01:47:34.377Z
Event type
Accident
Location
Princeton, Minnesota
Airport
Princeton Municipal Airport (PNM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during takeoff the airplane “started to slide to the left on the ice” on the snow and ice-covered runway. The pilot chose to abort the takeoff. During the abort, the airplane kept “pulling to the left” and impacted the terrain between the runway and taxiway. Upon impact, the airplane nosed over which resulted in substantial damage to the fuselage, wings, and wing struts. At the time of the accident, the pilot was taking off with a 40° right crosswind at 8 knots.
Probable cause
The pilot’s failure to maintain directional control during the takeoff roll. Contributing to the accident, was the runway condition combined with a right crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N208SP
Operator
Twin Cities Flight Training, Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
172S8208
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-02-28T01:47:34Z guid: 106790 uri: 106790 title: CEN23LA123 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106799/pdf description:
Unique identifier
106799
NTSB case number
CEN23LA123
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-26T11:15:00Z
Publication date
2023-03-30T04:00:00Z
Report type
Final
Last updated
2023-03-01T06:15:51.053Z
Event type
Accident
Location
Erie, Colorado
Airport
Eire Municipal (EIK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported executing a wheel landing in the tailwheel-equipped airplane. A “small bounce” after touch down caused the airplane to veer “slightly to the right.” The pilot subsequently over corrected and lost directional control resulting in a ground loop. The right wing was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. He noted being ready with “slight and occasional” rudder inputs would likely have been more effective than the “strong and consistent” rudder pressure applied.
Probable cause
The pilot’s loss of directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUB CRAFTERS
Model
CCX-2000
Amateur built
true
Engines
1 Reciprocating
Registration number
N840T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
CCX-2000-0150
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-01T06:15:51Z guid: 106799 uri: 106799 title: DCA23LA192 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106806/pdf description:
Unique identifier
106806
NTSB case number
DCA23LA192
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-27T20:54:00Z
Publication date
2023-08-03T04:00:00Z
Report type
Final
Last updated
2023-03-02T02:31:48.19Z
Event type
Incident
Location
Boston, Massachusetts
Airport
Boston-Logan Innternational Airport (KBOS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
JetBlue’s flight 206 (JBU206) flight crew initiated a go-around while over runway 04R due to Hop-a-Jet flight 280 (HPJ280) taking off without a takeoff clearance from runway 09 at Boston Logan International Airport (BOS). Runways 04R and 09 at BOS are intersecting runways. The BOS tower controller had instructed the pilot of HPJ280 to line up and wait (LUAW) on runway 09 while JBU206 had been cleared to land on runway 04R. HPJ280’s flight crew read back the controller’s instructions to LUAW, however they began the takeoff-roll instead. The airport surface detection equipment, model X (ASDE-X) alerted, and the controller issued go-around instructions to JBU206. JBU206’s flight crew initiated a go-around while over runway 04R, prior to reaching the intersection with runway 09. The closest proximity between both airplanes occurred when JBU206 was about 30ft AGL during the landing flare, close to the point where both runways intersected, see figure 1. A video file taken by the occupant of the flight deck observer seat was provided to the NTSB and a screen capture from the video is shown in figure 2. Figure 1. Flight tracks of both JetBlue (JBU206) and Hop-a-Jet (HPJ280) with yellow circle indicating incursion area. Figure 2: Screen capture from jump-seat occupant’s video recording showing Lear 60 crossing runway centerline. The captain of HPJ280 said that they had received clearance to cross runway 4L on taxiway E, and then take taxiway Mike, to Runway 9. On taxiway M he said, “they had heard a clearance that seems to be Line Up and Wait." He further stated that “he probably responded to the clearance, but in his mind, they were cleared for takeoff.” He said they performed the takeoff at 18:55 local time, and during cruise they received a message from ATC providing them with a phone number to call upon landing. After landing at FXE, BOS tower told them that they had taken off without authorization and caused an airplane that had been cleared to land on runway 04 to execute a go-around, passing about 400' above them. The first officer of JBU206 was the pilot flying, and they were on the ILS runway 04R approach. The captain of JBU206 said they had been cleared to land and had completed the landing checklist. On the tower frequency, they heard that an aircraft had been given LUAW instructions. As they entered the flare after crossing the threshold of runway 04R, about 30 feet above the ground, he saw an airplane cross 04R on runway 09 from his left and going to the right but could not estimate how far away the airplane was.
Probable cause
The Hop-a-Jet flight crew taking off without a takeoff clearance which resulted in a conflict with a JetBlue flight that had been cleared to land on an intersecting runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LEARJET INC
Model
60
Amateur built
false
Engines
2 Turbo fan
Registration number
N280LJ
Operator
Hop A Jet
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
60-280
Damage level
None
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
EMBRAER
Model
ERJ 190-100 IGW
Amateur built
false
Engines
2 Unknown
Registration number
N179JB
Operator
JetBlue Airways
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
19000006
Damage level
None
Findings
creator: NTSB last-modified: 2023-03-02T02:31:48Z guid: 106806 uri: 106806 title: ERA23LA134 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106814/pdf description:
Unique identifier
106814
NTSB case number
ERA23LA134
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-02-28T13:11:00Z
Publication date
2023-06-15T04:00:00Z
Report type
Final
Last updated
2023-04-02T22:31:00.175Z
Event type
Accident
Location
Labelle, Florida
Airport
La Belle Municipal Airport (X14)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a checkout flight with a flight instructor to meet flying club currency rules, the pilot flew to a nearby airport. Upon arrival at the airport they practiced landings. Immediately after the fifth landing, during the roll out, the airplane turned abruptly to the right, exited the runway onto the grass area between the runway and taxiway, and impacted a drainage ditch. The airplane’s fuselage and right wing were substantially damaged. Postaccident examination of the airplane’s wheels and braking system revealed that the right main wheel would not rotate on its axle. When pressure was applied to the top of the pilot’s side right rudder pedal, the actuator rod for the master cylinder would stick in the retracted position and would not automatically extend when the rudder pedal was released. Additionally, a gurgling sound (which indicated that air was in the system) could be heard during actuation. Further examination of the brake system revealed that the right brake assembly was not functional, displayed evidence of overheating, and was leaking fluid from around the upper piston, which was stuck in the extended position. The lower piston was also partially extended and was covered with brake fluid. The pressure plate would not move, and the anchor bolts that the pressure plate slid on displayed evidence of corrosion. Additionally, both piston O-rings appeared flat and did not stand proud from the sides of the pistons, the brake linings displayed higher than normal wear, and the brake disc displayed grooving. Based on this information, it is likely that the airplane’s right brake malfunctioned during the landing, which resulted in the loss of directional control during landing.
Probable cause
A malfunction of the airplane’s right main wheel brake, which resulted in a loss of control and runway excursion during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182S
Amateur built
false
Engines
1 Reciprocating
Registration number
N397ME
Operator
CUB CLUB INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18280876
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-02T22:31:00Z guid: 106814 uri: 106814 title: CEN23LA136 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106896/pdf description:
Unique identifier
106896
NTSB case number
CEN23LA136
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-01T08:30:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-03-18T00:47:34.178Z
Event type
Accident
Location
Hillsboro, Texas
Airport
Hillsboro Municipal Airport (KINJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that during the preflight inspection of his airplane, he discovered substantial damage to the left wing. A follow-on inspection later the same day revealed additional damage to the left main landing gear tire rim. A Federal Aviation Administration inspector examined the airplane and found additional damage to the left aileron and left elevator. Abrasion and asphalt marks on the underside of the wing tip and elevator appeared consistent with both having struck the ground. The inspector examined the ramp and runway for debris but found none. The top skin of the left wing near the tip was buckled upward. No other damage with the airplane was found. The student pilot reported that he had last flown the airplane 17 days prior to his intended flight and that when he checked the tie-down chains two days before his intended flight because of an impending storm, everything with the airplane looked okay. He surmised to the FAA inspector that maybe a fuel truck impacted the parked airplane. The damage observed was consistent with the airplane having been operated; however, based on the available information, the damage could not be conclusively associated with a specific ground operation or flight.
Probable cause
Substantial damage for reasons undetermined based on the available evidence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N3090X
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15064490
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-18T00:47:34Z guid: 106896 uri: 106896 title: WPR23LA118 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106831/pdf description:
Unique identifier
106831
NTSB case number
WPR23LA118
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-02T17:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-03-07T05:45:20.789Z
Event type
Accident
Location
Orland, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the final run for the aerial application flight, he noticed the engine spooling down. He attempted to land on a nearby road but collided with the terrain, resulting in substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter or engine that would have precluded normal operation and that the loss of engine power was due to fuel exhaustion.
Probable cause
The pilot’s inadequate fuel planning, which resulted in fuel exhaustion and a loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
UH-1B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N234SJ
Operator
PORTER FLYING SERVICES INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
388
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-07T05:45:20Z guid: 106831 uri: 106831 title: WPR23LA120 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106836/pdf description:
Unique identifier
106836
NTSB case number
WPR23LA120
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-03T14:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-14T02:07:39.354Z
Event type
Accident
Location
Vernalis, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported he was spraying near power lines during an aerial application flight. He made several passes beneath a power line; however, during a subsequent pass, the pilot became distracted and struck the power line. The airplane impacted the ground and was destroyed by post-crash fire. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain clearance from a power line during a low-level aerial application flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N48492
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
47B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T02:07:39Z guid: 106836 uri: 106836 title: RRD23LR006 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106818/pdf description:
Unique identifier
106818
NTSB case number
RRD23LR006
Transportation mode
Railroad
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-04T18:45:00Z
Publication date
2023-09-29T04:00:00Z
Report type
Final
Event type
Accident
Location
Springfield, Ohio
Injuries
null fatal, null serious, null minor
Probable cause
Not determined. Close-out
Has safety recommendations
false

Vehicle 1

Railroad name
Norfolk Southern
Equipment type
Freight train
Train name
NS- 179 of the 4th
Train number
179 of the 4th
Train type
FRA regulated freight
Total cars
212
Total locomotive units
5
Trailing tons
16000
Carrying hazardous materials
true
Findings
creator: NTSB last-modified: 2023-09-29T04:00:00Z guid: 106818 uri: 106818 title: ERA23LA152 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106900/pdf description:
Unique identifier
106900
NTSB case number
ERA23LA152
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-05T02:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-15T23:58:54.861Z
Event type
Accident
Location
Kinston, North Carolina
Airport
KINSTON REGIONAL JETPORT AT STALLINGS FIELD (ISO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while performing a touch-and-go landing at night, just prior to rotation speed, the pilot receiving instruction noticed a deer coming from the infield area. The flight instructor also saw a deer and heard a “clump” noise. The flight instructor reduced the engine power to idle and exited the runway. After taxiing to the ramp, the pilot and flight instructor noted damage to the airplane and subsequently airport operations personnel found one deceased and one injured deer near the landing runway. The deer strike resulted in substantial damage to the left horizontal stabilizer. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s impact with two deer while performing a takeoff at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N2527L
Operator
MAST AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17255727
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-15T23:58:54Z guid: 106900 uri: 106900 title: CEN23LA134 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106886/pdf description:
Unique identifier
106886
NTSB case number
CEN23LA134
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-05T20:09:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-04-12T18:44:42.635Z
Event type
Accident
Location
Buena Vista, Colorado
Airport
Central Colorado Regional Airport (KAEJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The airplane was coming into the airport to land following a cross-country flight. The pilot reported they checked the weather, entered the current conditions in the Garmin Control Unit, and received the results they expected for the RNAV approach to runway 33. The airport manager came on the radios and reported the winds as 280o at 8 knots, gusting to 19 knots. The crew captured the glidepath before the final approach fix and the co-pilot called out speeds to touchdown, the last being 115 kts. The touchdown was normal, but then the airplane experienced a strong yaw to the left from a wind gust. The pilot attempted to steer the airplane back, but the airplane went off the left side of the runway, struck a taxiway sign, and came to a stop with the nose of the airplane facing the runway. The airplane sustained substantial damage to the left inboard wing and lower left fuselage. The crew reported no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, the airplane was landing on runway 33 with reported winds 280o at 8 knots with gusts to 24 knots. Following the accident, the company put in place stricter crosswind component limits for its’ fleet of airplanes.
Probable cause
The pilot’s inability to maintain directional control during landing with a gusting left crosswind resulting in the runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HONDA AIRCRAFT CO LLC
Model
HA-420
Amateur built
false
Engines
2 Turbo jet
Registration number
N118CX
Operator
G C Aviation, Inc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
42000231
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-12T18:44:42Z guid: 106886 uri: 106886 title: CEN23LA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106881/pdf description:
Unique identifier
106881
NTSB case number
CEN23LA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-06T17:20:00Z
Publication date
2023-04-12T04:00:00Z
Report type
Final
Last updated
2023-03-14T19:11:24.111Z
Event type
Accident
Location
Tomball, Texas
Airport
DAVID WAYNE HOOKS MEML (DWH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that during an instructional flight, a large bird flew into the path of the airplane and his evasive actions were unsuccessful in avoiding the bird. The bird struck the airplane’s left wing. The flight instructor made an uneventful landing following the bird strike. The left-wing leading edge and main spar were substantially damaged during the bird strike. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
An inflight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
E-55
Amateur built
false
Engines
2 Reciprocating
Registration number
N101BM
Operator
Pour Le Martie Flying Club
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
TE-847
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T19:11:24Z guid: 106881 uri: 106881 title: ANC23LA026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106908/pdf description:
Unique identifier
106908
NTSB case number
ANC23LA026
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-06T19:00:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-03-17T21:22:45.175Z
Event type
Accident
Location
Homer, Alaska
Airport
Homer Airport (HOM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the landing roll on a dry, paved runway, the airplane veered to the right. The pilot was unable to correct, and the airplane ground looped, resulting in substantial damage to the left wing, left aileron and elevator. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane during the landing roll, which resulted in a ground loop and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N9697Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Commercial sightseeing flight
false
Serial number
18503788
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-17T21:22:45Z guid: 106908 uri: 106908 title: WPR23LA125 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106880/pdf description:
Unique identifier
106880
NTSB case number
WPR23LA125
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-06T21:45:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-16T22:14:07.414Z
Event type
Accident
Location
Bullhead City, Arizona
Airport
LAUGHLIN/BULLHEAD INTL (KIFP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that while enroute, a low fuel level annunciation occurred. The pilot subsequently prepared to divert to a nearby airport due to low fuel. Within 2 minutes the left engine shut down, followed by the right. The pilot asked air traffic control for vectors to the nearest airport. The sky conditions were clear with no moon, no horizon and no terrain feature visible. While approaching the airport at approximately 2,000 feet above the runway, the airport runway lighting turned off. The pilot was unable to turn the lights back on and subsequently used the terminal and ramp lights to maneuver the airplane to the runway. The airplane touched down and veered off the runway, which resulted in substantial damage to the fuselage. The pilot reported to a first responder that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation and that he ran out of gas.
Probable cause
The pilot’s improper fuel planning for a cross-country flight, which resulted in fuel exhaustion, a total loss of engine power and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL INTERNATIONAL
Model
AC 690A
Amateur built
false
Engines
2 Turbo prop
Registration number
N4PZ
Operator
PHILLIP R ZEECK INC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11269
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-16T22:14:07Z guid: 106880 uri: 106880 title: WPR23LA123 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106878/pdf description:
Unique identifier
106878
NTSB case number
WPR23LA123
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-07T14:04:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-03-13T20:38:09.229Z
Event type
Accident
Location
Hillsboro, Oregon
Airport
Portland-Hillsboro (HIO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that, he was taxiing on the parking row centerline and did not see that another airplane had moved and came to a stop about 5 feet into the taxiway. The left wing of the taxing airplane collided with the propeller of the other airplane, resulting in substantial damage to the left wing and aileron. The other airplane sustained minor damage to the propeller. The pilots of both airplanes reported that there were no preaccident mechanical malfunctions and failures with the airplanes that would have precluded normal operation.
Probable cause
The student pilot’s failure to see and avoid another airplane during taxi.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N25233
Operator
HILLSBORO AERO ACADEMY LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15280545
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Unknown, 1 Reciprocating
Registration number
N6460M
Operator
HILLSBORO AERO ACADEMY LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15284742
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-03-13T20:38:09Z guid: 106878 uri: 106878 title: ERA23LA145 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106851/pdf description:
Unique identifier
106851
NTSB case number
ERA23LA145
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-07T15:05:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-09T22:48:26.335Z
Event type
Accident
Location
Knoxville, Tennessee
Airport
KNOXVILLE DOWNTOWN ISLAND (DKX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll the airplane encountered a gusting and shifting crosswind. The airplane departed the left side of the runway and the pilot applied the brakes and reduced engine power. The airplane subsequently struck a culvert, the landing gear partially collapsed, and the airplane’s firewall was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control during the takeoff roll where a gusting and shifting crosswind prevailed.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22T
Amateur built
false
Engines
1 Reciprocating
Registration number
N320CA
Operator
ARMSTRONG RESOURCE MANAGEMENT CORP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
0822
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-09T22:48:26Z guid: 106851 uri: 106851 title: WPR23LA124 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106879/pdf description:
Unique identifier
106879
NTSB case number
WPR23LA124
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-09T18:15:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-17T03:03:34.59Z
Event type
Accident
Location
Van Nuys, California
Airport
Van Nuys (VNY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported she had been practicing touch and go landings. During the takeoff roll of her second touch and go, the pilot noticed the flaps were fully extended. She retracted the flaps and subsequently lost directional control of the airplane. The airplane veered and exited to the left side of the runway and struck a sign before it nosed over and came to rest inverted, which resulted in substantial damage to both wings. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilots failure to maintain directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N73726
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17267630
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-17T03:03:34Z guid: 106879 uri: 106879 title: ERA23LA146 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106856/pdf description:
Unique identifier
106856
NTSB case number
ERA23LA146
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-09T19:00:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-24T17:56:39.178Z
Event type
Accident
Location
Titusville, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that he was demonstrating a 180° autorotation for his passenger into an open field off airport grounds. Nearing the end of the maneuver, prior to touchdown, he failed to recover engine power in a timely manner which resulted in the rapid decay of the rotor rpm at low altitude; this resulted in a hard landing that subsequently caused the main rotor blades to make contact with the tail boom and severed the tail rotor driveshaft. The helicopter sustained substantial damage to the fuselage and the main rotor blades. The pilot reported that there were no pre accident mechanical malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate main rotor RPM during an autorotation which resulted in a hard landing and subsequent rotor blade strike of the tail boom.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
269A
Amateur built
false
Engines
1 Reciprocating
Registration number
N8911F
Operator
A & J Aviation Services LLC.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0230
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-24T17:56:39Z guid: 106856 uri: 106856 title: CEN23LA126 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106860/pdf description:
Unique identifier
106860
NTSB case number
CEN23LA126
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-09T19:45:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-11T02:48:11.779Z
Event type
Accident
Location
Bismark, North Dakota
Airport
Bismark Municipal Airport (BIS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The commercial pilot stated that a vehicle struck the right wing of the airplane as he was taxiing from the non-movement area for departure. Surveillance video showed a ground service vehicle drive across the ramp and into the right wing of the airplane. The driver of the ground vehicle stated that as she was starting to speed up on the ramp, the airplane came into view. The driver attempted to stop but slid on the ice and came to rest under the airplane’s right wing. A postaccident examination of the airplane revealed substantial damage to the right wing. The pilot stated there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The ground vehicle driver’s failure to see and maintain clearance from the airplane while conducting ground operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C90
Amateur built
false
Engines
2 Turbo prop
Registration number
N46CV
Operator
Executive Air Taxi Corporation
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
LJ-568
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-11T02:48:11Z guid: 106860 uri: 106860 title: DCA23FM020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106866/pdf description:
Unique identifier
106866
NTSB case number
DCA23FM020
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2023-03-09T20:08:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2024-03-07T05:00:00Z
Location
Westport, Washington
Injuries
null fatal, null serious, null minor
Probable cause
The National Transportation Safety Board determines that the probable cause of the fire on board the fishing vessel Marlins II was the failure of an extension cord used to energize galley appliances when on shore power.
Has safety recommendations
false

Vehicle 1

Callsign
WDG6090
Vessel name
F/V Marlins II
Vessel type
Fishing
IMO number
8958174
Maritime Mobile Service Identity
367553420
Flag state
USA
Findings
creator: Coast Guard last-modified: 2024-03-07T05:00:00Z guid: 106866 uri: 106866 title: ERA23LA147 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106859/pdf description:
Unique identifier
106859
NTSB case number
ERA23LA147
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-09T20:57:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-03-21T17:27:33.857Z
Event type
Accident
Location
Franklin, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Analysis
According to the pilot, prior to the flight, he determined the highest obstacle enroute was 6,100 ft with several 5,000 to 5,500 ft peaks along the route. In addition, he noted that during the flight, the end of evening nautical twilight would occur. After departure, he dialed 5,500 ft into the autopilot and leveled off. He went to don the night vision goggles and noted that they were on the copilot seat on top of an aircraft logbook. He went to move the logbook to the pilot door compartment, where it was typically stowed for flight, and decided to check the flight times against the times that maintenance was due. At that point, he noticed the cloud ceiling was lowering and dialed in 5,000 ft into the autopilot, then “went back heads down” to continue his review of the logbook. Then, the flight nurse asked for an updated estimated time enroute, and when the pilot looked up, he saw the helicopter was approaching a tree covered peak. He applied aft cyclic in order to climb; however the tail boom struck several trees, resulting in the vertical stabilizer separating from the tail boom. The pilot subsequently performed a forced landing to a road, which resulted in substantial damage to the fuselage and tail boom. The pilot reported no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s improper decision to review an aircraft logbook while enroute, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER DEUTSCHLAND GMBH
Model
EC 135 P2+
Amateur built
false
Engines
2 Turbo shaft
Registration number
N558MT
Operator
MED-TRANS CORPORATION
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Medical flight type
Medical emergency
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1073
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-21T17:27:33Z guid: 106859 uri: 106859 title: WPR23LA127 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106883/pdf description:
Unique identifier
106883
NTSB case number
WPR23LA127
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-11T13:15:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-03-14T20:35:35.317Z
Event type
Accident
Location
Lewiston, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, he planned to complete back-to-back flight lessons with two students. His students completed the preflight inspection and each tank measured about half full. The flight instructor verified that the fuel gauges indicated sufficient fuel for both lessons. During the second flight lesson with a student pilot at the controls, the airplane experienced a total loss of engine power. The flight instructor took control of the airplane and force-landed on a golf course. The airplane collided with trees during landing, resulting in substantial damage to the right wing. The flight instructor reported that the airplane ran out of fuel, and that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s inadequate fuel planning and improper in-flight decision-making, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172L
Amateur built
false
Engines
1 Reciprocating
Registration number
N7010Q
Operator
MOSMAN MATTHEW J
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17260310
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T20:35:35Z guid: 106883 uri: 106883 title: WPR23LA126 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106882/pdf description:
Unique identifier
106882
NTSB case number
WPR23LA126
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-11T13:30:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-13T21:50:44.525Z
Event type
Accident
Location
Strawberry Reservoir, Utah
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that, while flying low over a snow-covered frozen lake, the gyrocopter was closer to the surface than he realized. The pilot increased engine power to attempt to climb away from the surface, however, the nosewheel impacted snow on the surface and the gyrocopter nosed over, rolled, and came to rest on its side. The fuselage, horizontal stabilizer, and rudders were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the gyrocopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from the snow-covered lake while flying at a low altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
TRENDAK
Model
TAURUS
Amateur built
true
Engines
1 Turbo shaft
Registration number
N553AT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
T&S F26917S
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-13T21:50:44Z guid: 106882 uri: 106882 title: CEN23LA138 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106905/pdf description:
Unique identifier
106905
NTSB case number
CEN23LA138
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-11T23:33:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-03-22T01:55:03.876Z
Event type
Accident
Location
Eden Prairie, Minnesota
Airport
FLYING CLOUD (FCM)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Analysis
The pilot reported that, during a night cross country flight, the airplane encountered icing conditions while on an instrument approach. The pilot observed about 4 inches of ice had formed on the wing, running about one foot aft. The pilot reported he put the landing gear down about 5 miles from the runway. The pilot continued the approach and stated he broke out of the clouds about 300-400 ft agl and had “minimal control.” The airplane impacted snow-covered ground and came to rest about a half mile from the runway. The airplane was destroyed by a post-impact fire. In an email, the pilot stated the “airplane was in good shape.” At the time of the accident there was an icing AIRMET that covered the location of the accident. The Socata TB21 Pilot Information Manual states “Flight into known icing conditions is prohibited.”
Probable cause
The pilot’s continued flight into icing conditions in an airplane that was not equipped for icing, which led to structural icing, subsequent loss of airplane control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SOCATA
Model
TB21
Amateur built
false
Engines
1 Reciprocating
Registration number
N789TB
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1919
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-03-22T01:55:03Z guid: 106905 uri: 106905 title: ERA23LA149 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106872/pdf description:
Unique identifier
106872
NTSB case number
ERA23LA149
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-12T15:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-12T17:33:33.906Z
Event type
Accident
Location
Church Hill, Maryland
Airport
Myles Landing (27MD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that his student began the transition to flare on a normal, full stop landing. During the flare, the airplane’s nose yawed to the left. The instructor added right rudder to correct; however, the left wing pitched up. The instructor attempted to correct by applying left aileron to level the wings. He encountered resistance from the student’s flight control inputs, and the airplane touched down on the right main gear, putting a side load on it. The instructor announced that he had taken control of the airplane and initiated a go-around. The pitch trim was set to full nose up, and the instructor could not reduce the trim forces since the trim switch was set to the student’s side. The airplane pitched up and out of ground effect, and the right wing stalled and struck the ground, resulting in the nose and left wing also striking the ground. There were no injuries. An inspector with the Federal Aviation Administration examined the wreckage and determined that the damage to the fuselage and both wings was substantial. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain airplane control during the landing attempt and the flight instructor’s inadequate remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Costruzioni Aeronautiche Tecna
Model
P92
Amateur built
false
Engines
1 Reciprocating
Registration number
N562TU
Operator
Chesapeake Sport Pilot
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1562
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-12T17:33:33Z guid: 106872 uri: 106872 title: WPR23LA139 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106947/pdf description:
Unique identifier
106947
NTSB case number
WPR23LA139
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-12T16:30:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-03-24T05:23:59.755Z
Event type
Accident
Location
Sandy Valley, Nevada
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during cruise flight, he observed an increase of cylinder head temperature along with “abnormal engine operation” and decided to make a precautionary landing, off airport. During the landing roll in the tailwheel equipped airplane, the right main tire “sunk” in the soil and the tail of the airplane began to rise. Despite the pilot’s control inputs, the tail continued to rise, and the airplane nosed over coming to rest inverted. The vertical stabilizer and rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain airplane control during an off airport precautionary landing on soft soil, which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FIEDLER MARK R
Model
PA-18 REPLICA
Amateur built
true
Engines
1 Reciprocating
Registration number
N127MF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JA1906132
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-24T05:23:59Z guid: 106947 uri: 106947 title: CEN23LA132 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106884/pdf description:
Unique identifier
106884
NTSB case number
CEN23LA132
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-13T12:52:00Z
Publication date
2023-04-20T04:00:00Z
Report type
Final
Last updated
2023-03-14T02:00:33.582Z
Event type
Accident
Location
Hotchkiss, Colorado
Airport
BLM Airstrip (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot planned to land at a Bureau of Land Management backcountry landing strip he had previously visited over 100 times. After completing multiple low passes to assess the snow depth and overall conditions of the landing area, he executed a soft field landing in a 3-point, full stall attitude. During the rollout, the drag from the snow was greater than expected and he was unable to maintain control. The airplane nosed over at low speed and came to rest inverted. The vertical stabilizer, rudder, and right-wing struts sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of control during landing rollout on a snow-covered, turf airstrip.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-7-235B
Amateur built
false
Engines
1 Reciprocating
Registration number
N235TT
Operator
WILD COUNTRY AIRCRAFT LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
23031C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-14T02:00:33Z guid: 106884 uri: 106884 title: ERA23LA151 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106894/pdf description:
Unique identifier
106894
NTSB case number
ERA23LA151
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-14T11:06:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-05-02T19:50:22.05Z
Event type
Accident
Location
Scottsmoor, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot was flying to an airport that was about 33 nautical miles away from the departure airport, and after takeoff climbed to an altitude of 2,000 ft before descending to 1,500 ft. About 8 minutes into the flight the airplane’s engine "coughed and stopped running." In response, the pilot switched the fuel selector to the other tank, turned on the boost pump and wingtip fuel tank pumps, and attempted to restart the engine, but was unsuccessful. He then returned the fuel selector back to the original tank and made another attempt to restart the engine, but that effort was similarly unsuccessful. The pilot then selected a field and performed a forced landing. During the landing the airplane struck a tree, seriously injuring the pilot and substantially damaging the fuselage and left wing. A Federal Aviation Administration Inspector examined the airplane at the accident site and reported that he found the fuel selector on the right tank position and that both the right main and wingtip fuel tanks were empty. He found a small amount of fuel in the left main fuel tank (later determined to be about 2 gallons) and no fuel in the left wingtip fuel tank. The inspector otherwise found no evidence of fuel leakage at the accident site. A post recovery examination of the wreckage also found that there was no fuel in the fuel pump or fuel injector lines. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane, and in a postaccident telephone interview stated that the airplane, "…just didn’t have enough fuel."
Probable cause
The pilot’s inadequate preflight fuel planning, which resulted in fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35-B33
Amateur built
false
Engines
1 Reciprocating
Registration number
N5714K
Operator
HONOUR AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CD-784
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-02T19:50:22Z guid: 106894 uri: 106894 title: ERA23LA166 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106965/pdf description:
Unique identifier
106965
NTSB case number
ERA23LA166
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-16T18:55:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-31T22:25:17.675Z
Event type
Accident
Location
Cleveland, Tennessee
Airport
Cleveland Regional Jetport (RZR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that shortly after he exited the runway after landing, the nose landing gear collapsed. According to his written statement, “neither the flaps had been retracted yet or a command given to retract the landing gear.” He immediately shut off the mixture to the engine, took photos of the cockpit controls, and exited the airplane. Examination of the accident site and wreckage by a Federal Aviation Administration (FAA) inspector revealed that the flaps were in the down position, the nose landing gear was fully retracted, the left main landing gear was about 80% retracted, and the right main landing gear was about 50% retracted. A visual examination of the taxiway revealed a 25 ft ground scar. The airplane sustained substantial damage to the left wing. Postaccident examination of the landing gear system revealed no evidence of any preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The retraction of the landing gear after landing for unknown reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C35
Amateur built
false
Engines
1 Reciprocating
Registration number
N8702
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-3245
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-03-31T22:25:17Z guid: 106965 uri: 106965 title: WPR23LA129 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106913/pdf description:
Unique identifier
106913
NTSB case number
WPR23LA129
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-17T13:40:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-20T21:59:26.882Z
Event type
Accident
Location
Mesa, Arizona
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of a Yakovlev Yak-52 reported that he was in the number three position, off the lead airplane’s left wing while in a four-airplane formation flight. The pilot of the lead airplane initiated a left turn and the formation followed. While in the left turn, the pilot of the number three airplane felt “a bump” from underneath and observed the number four airplane pass under his right wing, and ascend toward the lead airplane. The pilot of the number three airplane realized there had been a mid-air collision, broke away from the formation to the left, and executed an emergency landing. The number three airplane’s right wing sustained substantial damage. The pilot of a Ryan Navion reported that, he was in the number four position off of the number three airplane’s left wing in the four-airplane formation flight. The pilot of the lead airplane initiated a left turn and the formation followed. When the pilot of the number four airplane “felt to level off”, his airplane collided with the number three airplane from underneath. He then executed an emergency landing. The fuselage, vertical stabilizer, and rudder were substantially damaged. The pilots of both airplanes reported that there were no preaccident mechanical malfunctions or failures with the airplanes that would have precluded normal operation.
Probable cause
The pilot of the Ryan Navion’s failure to maintain visual sight of and clearance from another airplane during a formation flight, which resulted in a mid-air collision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NAVION
Model
NAVION A
Amateur built
false
Engines
1 Reciprocating
Registration number
N610
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
NAV-4-2066
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
YAKOVLEV
Model
YAK-52
Amateur built
false
Engines
1 Reciprocating
Registration number
N2504U
Operator
TTD LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
87-8012
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-20T21:59:26Z guid: 106913 uri: 106913 title: WPR23LA132 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106916/pdf description:
Unique identifier
106916
NTSB case number
WPR23LA132
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-17T13:57:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-03-21T23:26:38.913Z
Event type
Accident
Location
Bullhead City, Arizona
Airport
Sun Valley Airport (A20)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The instructor providing instruction reported that the pilot receiving instruction aborted the first landing attempt due to crosswind conditions. During the second landing, the airplane bounced, then weather vaned and exited the runway to the right, substantially damaging the right wing tip before coming to rest. The instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane what would have precluded normal operation.
Probable cause
The flight instructors failure to take remedial action and the student pilots improper landing during crosswind conditions which resulted in a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FAY DAVID
Model
VELOCITY ELITE
Amateur built
true
Engines
1 Reciprocating
Registration number
N2214W
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Unknown
Commercial sightseeing flight
false
Serial number
V420
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-21T23:26:38Z guid: 106916 uri: 106916 title: WPR23LA133 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106917/pdf description:
Unique identifier
106917
NTSB case number
WPR23LA133
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-17T17:00:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-03-21T20:09:52.516Z
Event type
Accident
Location
Winnemucca, Nevada
Airport
Winnemucca Municipal Airport (WMC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, during an instructional flight with the student pilot at the flight controls, just prior to touchdown, the airplane started drifting left of center. The instructor told his student to go around, but the airplane had already reached the edge of the runway. When the instructor took control, the airplane had already exited the runway and came to rest on the adjacent dirt terrain, which resulted in substantial damage to the left wing. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control, and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40
Amateur built
false
Engines
1 Reciprocating
Registration number
N326AF
Operator
K2 AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
40.986
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-21T20:09:52Z guid: 106917 uri: 106917 title: WPR23LA131 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106915/pdf description:
Unique identifier
106915
NTSB case number
WPR23LA131
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-18T11:00:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-21T00:55:38.002Z
Event type
Accident
Location
Santa Ynez, California
Airport
Santa Ynez Airport (KIZA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that, while in a climb on the left crosswind leg of the airport traffic pattern, the engine stopped producing power. He made a left turn toward the airport, activated the electric fuel pump, and changed the fuel selector valve position from the left-wing fuel tank to the right-wing fuel tank. Despite the pilot’s attempts, the engine would not restart, and the pilot made a forced landing in a vineyard. The pilot stated that he believes he unported the available fuel in the left tank while in the climbing left-hand turn. The left wing and left elevator were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate fuel planning, which resulted in a loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-4-220C
Amateur built
false
Engines
1 Reciprocating
Registration number
N40635
Operator
HARTMANN PETER C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2153C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-21T00:55:38Z guid: 106915 uri: 106915 title: CEN23LA141 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106920/pdf description:
Unique identifier
106920
NTSB case number
CEN23LA141
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-19T13:15:00Z
Publication date
2023-04-27T04:00:00Z
Report type
Final
Last updated
2023-03-22T00:41:39.384Z
Event type
Accident
Location
Maple Lake, Minnesota
Airport
MAPLE LAKE MUNI-BILL MAVENCAMP SR FLD (MGG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that during landing the airplane “dipped steeply to the right” due to a gusting wind. The student pilot corrected for the dip by applying left aileron and power before touching down on the ice-covered runway. After touchdown, the airplane skidded to the left with the nose pointed to the right and departed the runway. Upon departing the runway, the nose landing gear dug into the snow which resulted in substantial damage to the engine mount. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, the student pilot was landing with an 80° right crosswind at 9 knots gusting to 14 knots.
Probable cause
The student pilot’s failure to maintain directional control during landing with a gusting crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-161
Amateur built
false
Registration number
N9088D
Operator
METRO AIRCRAFT CO
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-8616049
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-22T00:41:39Z guid: 106920 uri: 106920 title: CEN23LA140 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106910/pdf description:
Unique identifier
106910
NTSB case number
CEN23LA140
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-19T14:14:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-12T18:39:26.807Z
Event type
Accident
Location
Oklahoma City, Oklahoma
Airport
Wiley Post (KPWA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after touchdown on the runway, a gust of wind pushed the tail of the airplane to the left. The pilot was unable to maintain directional control and the airplane departed the runway and nosed over in a grassy area adjacent to the runway. The airplane sustained substantial damage to the left wing. The pilot reported that there were no pre-accident mechanical malfunctions or failures that would have precluded normal operation. The reported winds about the time of the accident were light and variable at 3 knots.
Probable cause
The pilot’s loss of directional control during landing with wind gusts, which resulted in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170A
Amateur built
false
Engines
1 Reciprocating
Registration number
N9254A
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
19015
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-12T18:39:26Z guid: 106910 uri: 106910 title: ERA23LA155 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106912/pdf description:
Unique identifier
106912
NTSB case number
ERA23LA155
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-19T17:20:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-03-22T17:37:23.855Z
Event type
Accident
Location
Sanford, North Carolina
Airport
Raleigh Executive (TTA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after the airplane touched down on the runway, it “unexpectedly” veered to the left. He tried to keep the airplane on the runway by applying full right rudder, but the airplane continued toward the left side of the runway. The pilot said that the airplane was about to pass a taxiway, and he tried to increase the turn to stay on the asphalt. But, due to the airplane’s speed, it went off the runway, into the grass and struck a ditch. This resulted in substantial damage to the left wing. Postaccident examination of the airplane’s braking and rudder system revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
A loss of directional control while landing, which resulted in a runway excursion and impact with a ditch.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N565TF
Operator
AIR THERAPY LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2881565
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-03-22T17:37:23Z guid: 106912 uri: 106912 title: ERA23LA160 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106942/pdf description:
Unique identifier
106942
NTSB case number
ERA23LA160
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-20T16:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-12T18:26:16.138Z
Event type
Accident
Location
Abbeville, South Carolina
Airport
Abbeville Airport (SC81)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot/owner of the newly-acquired tailwheel airplane reported that he hired a flight instructor to help him gain proficiency landing on short, narrow runways. He admitted that he was not proficient in this area, although he was current in tailwheel airplanes. He set up for landing on runway 8 with a left crosswind prevailing. He stated that he “arrived too high for the runway.” He stated that the flight instructor did not want him to go around, so the instructor took the controls to demonstrate a slip to lose altitude. The pilot/owner stated that the flight instructor entered a ground loop to the left after touchdown, damaging the airplane. The flight instructor provided a contrary account of the accident sequence. He reported that the pilot/owner had a bad habit of flying with his feet high on the rudder pedals, and he provided guidance prior to the flight to avoid this. Following airwork and takeoff/landing practice at another airport, the pilot attempted a landing at his home airport, which was 2,250 ft long and 40 ft wide. He reported that the pilot/owner, who was at the controls the entire time, overcontrolled the left rudder at 1 ft above the ground during landing, and this occurred so quickly that he was unable to intervene. The right wing contacted the runway, the right main landing gear separated, and the airplane skidded to a stop. A shutdown and egress were then performed. The pilot/owner reported that there was substantial damage to both wings and the fuselage. He also reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation, and the flight instructor did not report any mechanical anomalies in his written statement. A Federal Aviation Administration inspector reported that the flight instructor had no experience in the aircraft make and model prior to the accident flight.
Probable cause
A loss of directional control during landing, which resulted in a ground loop and substantial damage to the airplane. The pilot flying could not be determined since both pilots claimed that the other was at the controls during the landing. The flight instructor demonstrated poor judgement in accepting the training flight without prior experience in the airplane make and model.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-7-235C
Amateur built
false
Engines
1 Reciprocating
Registration number
N79VE
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
25118C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-12T18:26:16Z guid: 106942 uri: 106942 title: DCA23FM021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106943/pdf description:
Unique identifier
106943
NTSB case number
DCA23FM021
Transportation mode
Marine
Investigation agency
Coast Guard
Completion status
Completed
Occurrence date
2023-03-21T04:00:00Z
Publication date
2023-11-28T05:00:00Z
Report type
Final
Last updated
2023-11-14T05:00:00Z
Location
Savannah, Georgia
Injuries
0 fatal, 0 serious, 0 minor
Probable cause
The National Transportation Safety Board determines that the probable cause of sinking of the commercial fishing vessel Carol Jean was likely flooding from an unknown source while the vessel was anchored offshore and unattended. Contributing to the loss of the vessel was the captain’s inadequate planning for a tow, leading to the Carol Jean being unattended after the tow line failed and fouled its propeller.
Has safety recommendations
false

Vehicle 1

Vessel name
Carol Jean
Vessel type
Fishing
Port of registry
Darien, GA
Flag state
USA
Findings
creator: Coast Guard last-modified: 2023-11-14T05:00:00Z guid: 106943 uri: 106943 title: ERA23LA157 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106929/pdf description:
Unique identifier
106929
NTSB case number
ERA23LA157
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-21T14:30:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-24T20:23:50.979Z
Event type
Accident
Location
Livonia, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a practice autorotation with a tail wind, the pilot began the maneuver and the helicopter initially lost airspeed; the pilot immediately corrected with forward cyclic input, which also increased his descent rate. The higher than normal descent rate continued, and he began the power recovery earlier than normal. Shortly before touchdown, the pilot noticed a slope in the terrain with the rising side to his aft. The helicopter continued to descend and the helicopter’s tail rotor contacted the ground during the landing flare. The resulting impact resulted in a loss of control and substantial damage to the tail boom and tail rotor. The pilot stated that there were no preimpact malfunctions or failures of the helicopter that would have precluded normal operation.
Probable cause
The pilot’s delayed action to arrest the high descent rate during a practice autorotation in tailwind conditions which ultimately resulted in loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
47G-2A-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N73905
Operator
FROST HOLLOW HELICOPTER LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2860
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-24T20:23:50Z guid: 106929 uri: 106929 title: ERA23LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106976/pdf description:
Unique identifier
106976
NTSB case number
ERA23LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-21T16:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-01T16:17:04.014Z
Event type
Accident
Location
Cincinnati, Ohio
Airport
CINCINNATI MUNI/LUNKEN FLD (LUK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Shortly after landing, while taxing to get fuel, the pilot was being guided by a marshaller who was not using correct hand signaling techniques and appeared to wave at the pilot in a “follow me” fashion. As the pilot continued to taxi straight ahead, the marshaller stopped giving hand signals and watched the pilot continuing to taxi straight ahead before executing a sharp right turn directly into a parked airplane. During the turn, the taxiing airplane’s left wing impacted the parked airplane’s left propeller resulting in substantial damage to the taxiing airplane and minor damage to the parked airplane. The taxiing pilot reported she did not see the other airplane because her attention was focused on the marshaller.
Probable cause
The pilot’s failure to maintain an adequate visual lookout during taxi, which resulted in a collision with a parked airplane. Contributing was the marshaller’s improper marshalling techniques.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7772B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
32420
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-01T16:17:04Z guid: 106976 uri: 106976 title: DCA23LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106933/pdf description:
Unique identifier
106933
NTSB case number
DCA23LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-21T16:23:00Z
Publication date
2023-06-16T04:00:00Z
Report type
Final
Last updated
2023-03-22T21:49:33.23Z
Event type
Accident
Location
Sacramento, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
United Airlines flight 194 encountered convective turbulence while climbing through 19,000 ft after departure from San Francisco International Airport (SFO), San Francisco, CA, and a flight attendant was seriously injured. Upon being notified of the injury, the flight crew declared an emergency and diverted to Denver, Colorado for medical assistance. The flight crew reported that before departure, the purser (lead flight attendant) was asked to have the flight attendants remain seated until the 10,000 ft signal due to weather conditions at the departure airport. After departure, airspeed fluctuations and turbulence were encountered with a smooth ride once the airplane was above a cloud layer. About 12,000 ft the captain gave the 10,000 ft signal that it was safe for the flight attendants to begin the initial service. When the flight was about 32 miles northeast of SFO the flight crew established communication with Oakland Air Route Traffic Control Center (ARTCC) while climbing through flight level (FL) 175 [17,500 ft]. The controller advised them to expect occasional light turbulence up to FL 260 and instructed them to climb to FL350. Shortly thereafter, as the airplane climbed through 19,000 ft, the flight encountered unexpected turbulence for about 5 seconds. The flight crew then received a call from the cabin advising them that a flight attendant had fractured her leg. At the time of the turbulence event, one of the flight attendants was in the aft galley preparing her cart for the initial service when she felt “violent up and down jolting turbulence”. She attempted to move towards the nearest jump seat when another “intense bump” occurred. She was thrown into the air and impacted the floor fracturing her leg. Airmen’s Meteorological Information (AIRMETs) were in effect at the time of the accident for moderate turbulence below 12,000 ft and moderate turbulence from FL220 to FL360. A convective Significant Meteorological Information (SIGMET) was issued at 1455 PDT and in effect at the time of the accident for the area with areas of thunderstorms forecast with tops to FL290. A convective SIGMET implies severe or greater turbulence, severe icing, and low-level windshear. Numerous pilot reports (PIREPs) reporting moderate or greater turbulence were issued for central California (including the accident area) within two hours of the accident time.
Probable cause
An encounter with forecast convective turbulence during climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
777-224
Amateur built
false
Engines
2 Turbo fan
Registration number
N79011
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
29859
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-03-22T21:49:33Z guid: 106933 uri: 106933 title: DCA23LA221 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106964/pdf description:
Unique identifier
106964
NTSB case number
DCA23LA221
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-22T18:26:00Z
Publication date
2023-06-16T04:00:00Z
Report type
Final
Last updated
2023-04-07T20:07:10.21Z
Event type
Accident
Location
Houston, Texas
Airport
GEORGE BUSH INTCNTL/HOUSTON (IAH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
United Airlines flight 1091 sustained a tailstrike while landing at George Bush Intercontinental Airport (KIAH), Houston, TX. The flight was a regularly scheduled international passenger flight from Mexico City, Mexico to KIAH. According to the flight crew, the captain was the pilot monitoring, and the first officer (FO) was the pilot flying when they were cleared for the visual approach to runway 27 at KIAH. The airplane was in the landing configuration and on a stabilized approach at 1,000 ft. above ground level (AGL). About 60 ft AGL the captain noticed the airspeed begin to decay and stated watch your speed. The FO subsequently pitched the nose of the airplane down and added a little thrust. About 30 ft AGL, due to a higher-than-normal rate of descent the captain commanded flare, flare, flare. The FO flared the airplane which resulted in a firm landing. As the airplane rebounded from the firm landing the spoilers deployed resulting in a nose high attitude. In an effort to correct for the nose high attitude, the captain and FO pushed forward on their respective sidesticks. The FO stated that the ground spoiler deployment coinciding with the firm touchdown resulted in an airplane nose-up pitch attitude. As a result, the pitch attitude increased until the tail struck the runway. After the tailstrike, the remainder of the landing and landing rollout were normal with no risk of runway overrun or excursion. The tailstrike resulted in abrasion damage over an area of about 19 feet long by 1 foot wide along the aft lower fuselage. An inspection revealed substantial damage to the aft pressure bulkhead and frames.
Probable cause
The first officer's failure to maintain the correct airspeed and pitch attitude during landing which resulted in a tailstrike.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A320-232
Amateur built
false
Engines
2 Turbo fan
Registration number
N1902U
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
2714
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-07T20:07:10Z guid: 106964 uri: 106964 title: WPR23LA236 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192427/pdf description:
Unique identifier
192427
NTSB case number
WPR23LA236
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-24T14:32:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-06-29T03:50:30.377Z
Event type
Accident
Location
Springfield, Kentucky
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that light rain and trace clear air icing were forecast along his intended route of flight, and he encountered those conditions during climb out. As the airplane was climbing through 14,000 ft mean sea level (msl) in instrument meteorological conditions, he noticed the airspeed had decreased 10-15 knots. He checked the wings for ice and did not notice any accumulation but activated the pitot heat at that time as a precaution. After the pitot heat was activated the Primary Flight Display (PFD) and Multi-Function Display (MFD) displayed a red X and went black. Subsequently, the autopilot commanded the airplane to descend. The pilot reported that he was unable to read his standby instruments due to the violent shaking of the airplane during the descent. As the airplane emerged into VMC conditions, the airplane was in an unusual attitude. He disconnected the autopilot and was able to recover the airplane to a level attitude. At this time, the PFD and MFD operation returned. An air traffic controller reported to the pilot that he had lost about 5,000 ft in altitude and airspeed had increased over 200 kts. The pilot responded that his avionics were working again, and that the aircraft was operating normally. He continued with the flight and landed without further incident. Substantial damage was discovered to both wings following the flight. The airplane’s “Before Takeoff checklist” calls for the pitot heat to be activated for flight into icing conditions when visible moisture below +5° C, is anticipated or encountered. A Federal Aviation Administration inspector examined the airplane after the event and verified the pitot heat was operational. The circumstances of the accident are consistent with the pilot failing to activate the pitot heat in a timely manner, which allowed ice to accumulate on the pitot static system. The PFD, MFD, and autopilot subsequently malfunctioned and the pilot lost control of the airplane.
Probable cause
The pilot’s failure to activate the pitot heat in a timely manner during flight into icing conditions, which resulted in a temporary failure of the flight instruments and a subsequent loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-46-310P
Amateur built
false
Engines
1 Reciprocating
Registration number
N146MS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
46-8408032
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-29T03:50:30Z guid: 192427 uri: 192427 title: CEN23LA143 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106963/pdf description:
Unique identifier
106963
NTSB case number
CEN23LA143
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-25T19:30:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-04-03T20:55:12.644Z
Event type
Accident
Location
Hillsboro, Missouri
Airport
Private strip on owner's land (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that while on final approach, the right wing of the airplane struck the top of a tree about 40 feet above ground level. This resulted in an aerodynamic stall and loss of airplane control at an altitude too low to allow for recovery. The airplane impacted the ground, which resulted in substantial damage to the left wing. The pilot reported that there were no mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from trees during final approach to landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TAYLORCRAFT
Model
BC12-D
Amateur built
false
Engines
1 Reciprocating
Registration number
N43272
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
6931
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-03T20:55:12Z guid: 106963 uri: 106963 title: ERA23LA165 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106962/pdf description:
Unique identifier
106962
NTSB case number
ERA23LA165
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-26T12:30:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-04-07T16:11:51.464Z
Event type
Accident
Location
St. Augustine, Florida
Airport
Northeast Florida Regional Airport (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that following a local flight, the approach to landing and touchdown were normal, however, as he applied wheel brakes, the airplane veered to the right. He attempted to correct with left rudder and brake application but was unable to stop the right veer. Subsequently, the airplane exited the runway to the right and impacted a drainage ditch about 175 ft from the runway’s edge, which resulted in substantial damage to the fuselage and engine mounts. The pilot reported that this was the first landing of the flight, and no anomalies were noted with the brakes or flight controls prior to the landing. He recalled that during the runway excursion, shortly before impacting the ditch, the airplane straightened out and stopped the right turn. Shortly after the accident, the wings were removed for recovery which prevented the investigation from determining whether air was present in the brake lines. Photographs of the main landing gear wheels, brakes, and brake lines revealed no evidence of catastrophic mechanical failures or evidence that brake lines had become disconnected. Review of maintenance records found no evidence of recent brake work, and the endorsements showed that the brake fluid reservoir was serviced routinely. The operator and pilot both submitted a National Transportation Safety Board Aircraft Accident Incident Report (6120.1) and neither party reported that there were mechanical malfunctions or failures with the airplane. About the time of the accident, the automated weather observing system reported wind 220° at 9 knots, gusting to 15 knots, which was a direct crosswind for the landing runway 13. It is likely that the airplane encountered a crosswind gust during the landing roll, which resulted in the airplane veering right toward the direction of the crosswind. This conclusion is further supported by the pilot’s report that the airplane straightened out, once the crosswind became a headwind, shortly before its collision with the ditch.
Probable cause
The pilot’s failure to maintain directional control during the landing roll in gusting crosswind conditions, which resulted in a runway excursion and an impact with a ditch.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-151
Amateur built
false
Engines
1 Reciprocating
Registration number
N541SP
Operator
Florida Aviation Career Training Inc.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-7415570
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-07T16:11:51Z guid: 106962 uri: 106962 title: CEN23LA146 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106986/pdf description:
Unique identifier
106986
NTSB case number
CEN23LA146
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-27T12:38:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-11T18:58:26.477Z
Event type
Accident
Location
Telluride, Colorado
Airport
Telluride Regional Airport (KTEX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that the airplane encountered a crosswind gust during the landing roll and subsequently departed the right side of the runway pavement onto snow covered terrain adjacent to the runway. The nose landing gear sunk into the soft ground adjacent to the runway and the airplane nosed over coming to rest inverted. The airplane sustained substantial damage to the empennage and left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. According to the pilot, at the time of the accident, the airplane was landing on runway 27 with winds 18 knots gusting to 48 knots from a south-southwest direction.
Probable cause
The pilot’s failure to maintain directional control during the landing roll in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
35
Amateur built
false
Engines
1 Reciprocating
Registration number
N3233V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
D-676
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-11T18:58:26Z guid: 106986 uri: 106986 title: CEN23LA148 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106997/pdf description:
Unique identifier
106997
NTSB case number
CEN23LA148
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-27T13:26:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-07T00:44:14.402Z
Event type
Accident
Location
Oklahoma City, Oklahoma
Airport
WILEY POST (PWA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he had recently completed his initial training, and the accident flight was his first flight in the airplane. The pilot entered the traffic pattern with the autopilot engaged and was told by the co-pilot to “keep it tight.” The autopilot did not command a steep enough bank, and the pilot disconnected the autopilot in an attempt to align with the runway centerline. On final approach about 50 ft above ground level (agl), the airplane was aligned to the right of the runway centerline. The airplane landed hard, bounced multiple times, exited the runway, and impacted a runway sign. The pilot then executed a go-around and landed without further incident at an alternate airport. The airplane sustained substantial damage to the right wing spar. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported that prior to and during the flight, challenge-response checklist reading was not utilized between he and the co-pilot, and callouts were not used below 1,000 ft agl.
Probable cause
The pilot’s improper landing flare, which resulted in a hard, bounced landing, runway excursion, and subsequent collision with a runway sign. Contributing to the accident was the pilot’s lack of experience in the airplane, the unstabilized approach, and inadequate crew resource management.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
550
Amateur built
false
Engines
2 Turbo fan
Registration number
N550DW
Operator
XCEED MANAGEMENT GROUP LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
550-0487
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-07T00:44:14Z guid: 106997 uri: 106997 title: ERA23LA169 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106968/pdf description:
Unique identifier
106968
NTSB case number
ERA23LA169
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-27T16:50:00Z
Publication date
2023-06-23T04:00:00Z
Report type
Final
Last updated
2023-04-10T16:52:01.821Z
Event type
Accident
Location
Mattituck, New York
Airport
MATTITUCK (21N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated he went flying in windy conditions and that during landing, a crosswind “blew” the airplane to the left side of runway 19. He attempted to realign the airplane with the runway centerline, however, the nose “dropped sharply.” The pilot tried to bring the nose up again, but the nose landing gear struck the runway “hard.” The nose landing gear collapsed and the airplane came to rest off the left side of the runway. During the accident sequence, the main wing spar was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. The recorded wind 9 nautical miles southwest of the airport, three minutes after the accident was from 120° at 4 kts.
Probable cause
The pilot’s failure to maintain control of the airplane during the landing, which resulted in a hard landing and runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150H
Amateur built
false
Engines
1 Reciprocating
Registration number
N50133
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15069081
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-10T16:52:01Z guid: 106968 uri: 106968 title: WPR23LA144 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106996/pdf description:
Unique identifier
106996
NTSB case number
WPR23LA144
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-27T17:40:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-04-03T22:59:42.977Z
Event type
Accident
Location
Rigby, Idaho
Airport
RIGBY (U56)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor of the tailwheel-equipped airplane reported that the airplane swerved slightly to the left during landing roll on an instructional flight with a pilot receiving instruction at the controls. After the tailwheel touched the ground, the pilot receiving instruction attempted to control the left swerve with the right rudder. This resulted in the airplane veering to the right side of the runway and colliding with a snowbank. The airplane subsequently nosed over substantially damaging the fuselage, right wing strut and vertical stabilizer. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot receiving instruction’s failure to maintain directional control during landing and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KESKIMAKI CHARLES A
Model
KITFOX
Amateur built
false
Engines
1 Reciprocating
Registration number
N89CK
Operator
BALER CALEB
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
311
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-03T22:59:42Z guid: 106996 uri: 106996 title: ERA23LA170 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106975/pdf description:
Unique identifier
106975
NTSB case number
ERA23LA170
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-29T10:17:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-05T00:19:34.319Z
Event type
Accident
Location
Lakeland, Florida
Airport
LAKELAND LINDER INTL (LAL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he performed a wheel landing in the tailwheel-equipped airplane. As he lowered the tailwheel, the airplane turned right, and he applied left rudder to continue straight. As soon as he applied the rudder pressure, he “felt something pop” and the airplane continued to turn right, resulting in a ground loop. In the accident sequence, the left main landing gear collapsed, resulting in substantial damage to the left wing. Post accident examination of the tailwheel steering system noted that the left tailwheel steering cable separated.
Probable cause
A loss of control on the ground as a result of left tailwheel steering cable separation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
T-6G
Amateur built
false
Engines
1 Reciprocating
Registration number
N791MH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
5114791
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-05T00:19:34Z guid: 106975 uri: 106975 title: CEN23LA147 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106987/pdf description:
Unique identifier
106987
NTSB case number
CEN23LA147
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-29T10:23:00Z
Publication date
2023-05-04T04:00:00Z
Report type
Final
Last updated
2023-04-05T19:26:45.6Z
Event type
Accident
Location
Wade, Oklahoma
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
While maneuvering during an aerial application flight, the engine lost power, and the pilot conducted an autorotation to a field. During the autorotation, the helicopter landed hard, rolled over, and sustained substantial damage. Postaccident examination of the helicopter revealed a foamy cream-colored liquid in the airframe fuel filter and fuel line. The pilot reported that before the accident flight the helicopter was fueled from the operator’s support truck fuel tank. Initial examination of the tank showed no visible signs of fuel contamination. A subsequent visual examination, several days later, showed the same cream-colored contamination that was identified in the helicopter fuel system. The pilot reported that the truck’s fuel tank was filled the day before from his on-site fuel storage tank. The reason for the fuel contamination in the operator’s on-site fuel storage or the helicopter fuel system could not be determined. The loss of engine power was attributed to fuel contamination.
Probable cause
The total loss of engine power due to fuel contamination.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
OH-58A
Amateur built
false
Engines
1 Turbo shaft
Registration number
N82851
Operator
Prentice Aviation, Inc
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
72-21118
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-05T19:26:45Z guid: 106987 uri: 106987 title: ERA23LA172 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106977/pdf description:
Unique identifier
106977
NTSB case number
ERA23LA172
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-29T13:15:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-04T18:18:49.871Z
Event type
Accident
Location
Clarksville, Tennessee
Airport
Outlaw Field (CKV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The flight instructor of the helicopter reported that the student pilot was taking his second lesson, learning to hover over a grass area at the airport. The flight instructor was operating the collective and anti-torque pedals, while the student pilot was operating the cyclic. The student pilot made an abrupt rearward movement with the cyclic. The flight instructor increased throttle and raised the collected to gain height; however, the right rear skid contacted the ground, resulting in a dynamic rollover. The flight instructor added that there were no preimpact mechanical malfunctions with the helicopter and that in the future, he should initiate hover training at a higher height. Examination of the helicopter by a Federal Aviation Administration inspector revealed substantial damage to the main rotor blades, fuselage, and tailboom.
Probable cause
The flight instructor’s inadequate remedial action following an abrupt control input by the student pilot, which resulted in abnormal contact with the ground and a dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HELICOPTERES GUIMBAL
Model
CABRI G2
Amateur built
false
Engines
1 Reciprocating
Registration number
N242JL
Operator
Austin Peay State University
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1319
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-04T18:18:49Z guid: 106977 uri: 106977 title: ERA23LA177 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106995/pdf description:
Unique identifier
106995
NTSB case number
ERA23LA177
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-03-31T17:49:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-04-06T16:59:29.344Z
Event type
Accident
Location
Leesburg, Florida
Airport
Leesburg International Airport (LEE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While on approach for a short field landing, the flight instructor reported that the pilot undergoing instruction added power to arrest an excessive rate of descent at his instruction but removed it when the flight descended below 100 ft. The airplane began to descend rapidly and during the flare touched down first on the nose landing gear. The flight instructor took control of the airplane and added power to abort the landing, but he reported the nose dropped and the airplane began to, “…porpoise down the runway while the stall warning was sounding.” He attempted to keep the nose level but the airplane bounced about 5 or 6 times before coming to rest at the edge of the runway near the midpoint. The pilot reported that the approach was, “…a bit steep and fast due to gusty conditions.” He also reported the canopy became unlatched during the porpoising, and he held it down to prevent getting hit by debris kicked up by the propeller. A review of pictures of the airplane revealed it came to rest with the right main landing gear partially collapsed. The top center portion of the fuselage was substantially damaged during the accident. The pilots reported that there were no mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s delayed remedial action, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND GMBH
Model
DA 42 NG
Amateur built
false
Engines
2 Reciprocating
Registration number
N306ER
Operator
EMBRY-RIDDLE AERONAUTICAL UNIVERSITY INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
42.N206
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-06T16:59:29Z guid: 106995 uri: 106995 title: WPR23LA145 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106998/pdf description:
Unique identifier
106998
NTSB case number
WPR23LA145
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-01T09:23:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-04-07T04:47:19.322Z
Event type
Accident
Location
Elko, Nevada
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was aerial animal control. The pilot reported that while flying at about 30kts and 50 ft above the ground and during a sweeping turn to avoid the effects of an estimated 30 kt tailwind at low altitude, a strong wind gust occurred in the path of the tailwind, which led to an uncontrolled descent rate. Unable to arrest the descent rate, the pilot executed a run-on landing. Environmental conditions weakened the pilot’s depth perception, which resulted in a tail strike that sheared off the tail boom. The main rotor blades contacted the ground and the helicopter rolled on its side, substantially damaging the fuselage and tail boom. The pilot reported that there were no mechanical failures or malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain sufficient altitude and airspeed in gusting tailwind conditions that resulted in an unrecoverable descent and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N462BA
Operator
ELKHORN AVIATION INC
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
12265
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-07T04:47:19Z guid: 106998 uri: 106998 title: WPR23LA146 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106999/pdf description:
Unique identifier
106999
NTSB case number
WPR23LA146
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-01T14:43:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-04-10T23:34:32.18Z
Event type
Accident
Location
Santa Ana, California
Airport
John Wayne/Orange County Airport (KSNA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while practicing crosswind landings with his student, the tower advised the pilot of wake turbulence from a commercial airliner on the parallel runway. They flew a steeper approach but noticed a moderate right quartering headwind on the windsock. At about 100 feet above ground level the airplane encountered wake turbulence and banked sharply to the right. Both pilots added full left aileron and applied backpressure to the yoke as the airplane contacted the terrain. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s failure to maintain clearance from a medium category commercial airliner which resulted in an encounter with wake turbulence and subsequent loss of control resulting in impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N1399U
Operator
OC 172 GROUP LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17267070
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-10T23:34:32Z guid: 106999 uri: 106999 title: ERA23LA176 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106991/pdf description:
Unique identifier
106991
NTSB case number
ERA23LA176
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-01T20:37:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-04T00:25:07.341Z
Event type
Accident
Location
Wall Township, New Jersey
Airport
MONMOUTH EXECUTIVE AIRPORT (BLM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight crew of the business jet reported that after touching down on runway centerline the airplane was struck by a gust of wind from the right. They were able to keep the airplane on the runway centerline but were subsequently struck by another more powerful gust, which pushed the airplane off the left side of the runway. The runway excursion resulted in substantial damage to the fuselage and left wing. A posaccident review of weather radar data showed that a severe thunderstorm (for which a tornado warning had been issued) was present to the west of the airport and was rapidly moving east. There was a convective SIGMET valid for the airport at the time of the accident. The pilot-in-command reported checking relevant weather information before the flight, that the airplane was equipped with an operational onboard weather radar system, and that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilots’ loss of directional control while landing in gusting wind conditions which resulted in a runway excursion. Also contributing was the flight crew’s decision to land at an airport where there was a rapidly approaching severe thunderstorm.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
750
Amateur built
false
Engines
2 Turbo fan
Registration number
N85AV
Operator
USAC Airways 693, LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
7500085
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-04T00:25:07Z guid: 106991 uri: 106991 title: ERA23LA178 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107006/pdf description:
Unique identifier
107006
NTSB case number
ERA23LA178
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-02T12:50:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-11T18:07:24.424Z
Event type
Accident
Location
Canton, Georgia
Airport
CHEROKEE COUNTY RGNL (CNI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
While on approach to land, the pilot reported that the airplane descended faster than he had wanted it to, so he increased the engine throttle in response. The airplane bounced during the subsequent landing attempt, and during the next touch down the pilot was unable to control the airplane’s direction and it veered off the runway to the left. The airplane crossed a grass median and a taxiway before encountering a steep drop off of the terrain where the airplane nosed over. The airplane’s fuselage, empennage, and left wing sustained substantial damage. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control following a bounced landing, which resulted in a runway excursion and a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N6301W
Operator
KAP TITLE INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-20344
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-11T18:07:24Z guid: 107006 uri: 107006 title: ANC23LA029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107023/pdf description:
Unique identifier
107023
NTSB case number
ANC23LA029
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-02T17:20:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-04-07T22:32:58.152Z
Event type
Accident
Location
Wasilla, Alaska
Airport
Wasilla Airport (PAWS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that he was providing flight instruction to the pilot who had recently purchased the tailwheel-equipped airplane, and during takeoff, a crosswind pushed the airplane to the left. He attempted to correct for the left drift to no avail. Subsequently, the airplane continued to the left, exited the runway, impacted a snowbank, and nosed over, resulting in substantial damage to the wings. The flight instructor reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot’s failure to maintained directional control and the instructor pilot's inadequate supervision, which resulted in a loss of control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170
Amateur built
false
Engines
1 Reciprocating
Registration number
N4464B
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
26808
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-07T22:32:58Z guid: 107023 uri: 107023 title: WPR23LA182 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/122570/pdf description:
Unique identifier
122570
NTSB case number
WPR23LA182
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-02T17:30:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-05-10T18:51:56.063Z
Event type
Accident
Location
Marana, Arizona
Airport
EL TIRO (AZ67)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
This report was modified on November 15, 2023. Please see the docket for this accident to view the original report. The pilot of the glider reported that, during the landing flare, a dust devil pushed the glider to the ground, causing a hard landing. The glider bounced and then stalled, making another hard impact on the runway, which resulted in substantial damage to the fuselage cage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the glider that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a hard bounced landing in a dust devil.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHEMPP-HIRTH
Model
DISCUS-2B
Amateur built
false
Registration number
N774JP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
97
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-05-10T18:51:56Z guid: 122570 uri: 122570 title: ERA23LA186 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107028/pdf description:
Unique identifier
107028
NTSB case number
ERA23LA186
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-03T16:30:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-10T17:57:17.341Z
Event type
Accident
Location
White Plains, New York
Airport
WESTCHESTER COUNTY (HPN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot landed in gusting wind. He reported that after touchdown the airplane veered to the left. He attempted to correct with aileron and rudder; however, the airplane departed the runway, the left wing struck the ground, and the airplane nosed over. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control during the landing rollout in gusting wind, which resulted in a runway excursion and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA22
Amateur built
false
Engines
1 Reciprocating
Registration number
N8500D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-5727
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-10T17:57:17Z guid: 107028 uri: 107028 title: ANC23LA028 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107018/pdf description:
Unique identifier
107018
NTSB case number
ANC23LA028
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-04T10:00:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-04-06T19:27:40.574Z
Event type
Accident
Location
Palmer, Alaska
Airport
Wick Air (14AK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while landing on the 1,300 ft. long, gravel-covered runway, he inadvertently touched down with excess airspeed and did not have enough braking action to stop the airplane. The airplane subsequently impacted a snow berm at the end of the airstrip and nosed over which resulted in substantial damage to the left-wing struts. The pilot stated that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's delayed decision to execute a go-around maneuver while landing with excess airspeed into a short strip, which resulted in a runway overrun and subsequent loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-5-235C
Amateur built
false
Engines
1 Reciprocating
Registration number
N5644W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
7350C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-06T19:27:40Z guid: 107018 uri: 107018 title: WPR23LA151 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107034/pdf description:
Unique identifier
107034
NTSB case number
WPR23LA151
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-05T12:30:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-04-11T01:08:55.694Z
Event type
Accident
Location
Susanville, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, while flying low to observe the unusual water flows from mountains, he noted abnormal engine behavior. He elected to perform a precautionary landing on flat terrain due to nearby rising terrain. Upon touchdown, the airplane experienced a slight ballooning effect, leading the pilot to apply maximum braking upon touchdown. The tires grabbed harder than expected due to soft terrain and the airplane nosed over and came to rest inverted, which resulted in substantial damage to the fuselage. A postaccident engine test run by the pilot revealed no anomalies or an explanation for the abnormal engine behavior.
Probable cause
The pilot’s braking technique during an off airport precautionary landing on unforeseen soft terrain, which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LOWE BRUCE
Model
SKYSTR KTFX IV-1200
Amateur built
true
Engines
1 Reciprocating
Registration number
N1641E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1854
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-11T01:08:55Z guid: 107034 uri: 107034 title: ERA23LA180 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107014/pdf description:
Unique identifier
107014
NTSB case number
ERA23LA180
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-05T15:00:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-04-29T00:09:49.774Z
Event type
Accident
Location
Leesburg, Virginia
Airport
LEESBURG EXEC (JYO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was landing the airplane and reported that as the main landing gear touched down on the runway the airplane immediately veered to the left. The pilot applied right rudder control input but was unable to control the airplane’s direction. The left main landing gear then collapsed as the airplane departed the runway surface and the airplane came to a stop off the left side of the runway. The airplane’s left wing was substantially damaged during the accident. A Federal Aviation Administration inspector examined the airplane after the accident. He observed that the left main landing gear trunnion was cracked and that the strut had separated from the trunnion. The inspector also found that the hardware connecting the scissor link was missing and that the scissor link did not display damage consistent with a shearing action or other abnormal stress. Given this information it is likely that the hardware securing the scissor was not present at the time of the landing, which allowed the left main landing gear wheel to freely castor about the strut, resulting in the loss of directional control at touchdown.
Probable cause
Separation of the left man landing gear scissor hardware, which resulted in a loss of directional control and subsequent runway excursion during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
421C
Amateur built
false
Engines
2 Reciprocating
Registration number
N880JS
Operator
BRAVO AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Executive/Corporate
Commercial sightseeing flight
false
Serial number
421C-0489
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-29T00:09:49Z guid: 107014 uri: 107014 title: WPR23LA152 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107035/pdf description:
Unique identifier
107035
NTSB case number
WPR23LA152
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-05T16:00:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-04-11T02:25:59.827Z
Event type
Accident
Location
Los Alamos, New Mexico
Airport
Los Alamos Airport (KLAM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Both pilots reported that during the takeoff roll, the pilot receiving instruction lost directional control of the airplane and it veered off the runway. The airplane subsequently collided with a parked unoccupied airplane. The left horizontal stabilizer and elevator sustained substantial damaged. The flight instructor reported that the airplane was not equipped with brakes at the right seat position. Both pilots reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot receiving instruction’s failure to maintain directional control during the takeoff roll, resulting in a runway excursion and ground collision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN
Model
G-44A
Amateur built
false
Engines
2 Reciprocating
Registration number
N444M
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1411
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-11T02:25:59Z guid: 107035 uri: 107035 title: ERA23LA183 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107020/pdf description:
Unique identifier
107020
NTSB case number
ERA23LA183
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-06T13:10:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-04-21T18:34:41.099Z
Event type
Accident
Location
Foley, Alabama
Airport
COLLIER AIRPARK (2AL1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the experimental amateur-built helicopter reported that he had hovered around the airport for about 20 minutes without issue and then initiated a takeoff to remain in the traffic pattern. During the initial climb, about 20 to 30 ft above ground level, the engine suddenly lost power and the helicopter yawed to the right. The pilot entered an autorotation and performed a run-on landing on a grass surface. During the landing, the right skid dug into uneven terrain, the helicopter rolled over onto its right side, and a post-crash fire quickly ignited. The pilot was able to extract himself from the helicopter without injury, however, the helicopter was destroyed by the post-impact fire. The pilot reported that after the accident, he discovered an undamaged turbocharger air intake hose clamp directly in his departure path in the grass. Photographs of the turbocharger revealed that the air intake clamp was not installed, and the intake hose had been consumed by fire. The pilot reported that about a week prior to the accident, while the helicopter was being transported on a trailer, he personally adjusted this clamp and intake hose, and he may have forgotten to tighten the clamp. During the initial climb, it is likely that the turbocharger intake hose and clamp separated from its installation area, and as a result, engine power was lost.
Probable cause
The loss of engine power during the initial climb due to the disconnection of the turbocharger air intake hose and clamp, and the pilot’s inadequate servicing and preflight inspection of the turbocharger air intake clamp.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
PETERSON MARK G
Model
PETERSON A600
Amateur built
true
Engines
1 Reciprocating
Registration number
N272AM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6600
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-04-21T18:34:41Z guid: 107020 uri: 107020 title: ERA23LA187 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107029/pdf description:
Unique identifier
107029
NTSB case number
ERA23LA187
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-07T18:30:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-04-14T16:04:04.03Z
Event type
Accident
Location
Cedar Key, Florida
Airport
GEORGE T LEWIS (CDK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot stated that he entered the traffic pattern at the destination airport and conducted a “stabilized” approach until just prior to touchdown, when the airplane experienced “mechanical turbulence which destabilized the approach.” The pilot initiated a go-around when a wind gust “lifted the right wing.” The airplane departed the left side of the runway and struck trees 100 ft left of the landing surface. The pilot reported there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate compensation for gusting wind conditions while landing, which resulted in a loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LEWIS/URMSTON
Model
RV 4 200
Amateur built
true
Engines
1 Reciprocating
Registration number
N8DU
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1960
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-14T16:04:04Z guid: 107029 uri: 107029 title: ERA23LA199 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107078/pdf description:
Unique identifier
107078
NTSB case number
ERA23LA199
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-08T09:55:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-18T17:26:55.345Z
Event type
Accident
Location
Somerset, Kentucky
Airport
LAKE CUMBERLAND RGNL (SME)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot was taking off in gusting wind and described that shortly after rotation, he saw the stall warning light illuminate. He reported that although the engine was developing full power and he leveled off to regain airspeed, the airplane settled back onto the runway and “pulled left.” Despite the pilot’s attempt to keep the airplane on the runway, it departed the runway, impacted an instrument landing system antenna, crossed a taxiway, and then came to rest. The left wing was substantially damaged. The pilot reported that there were no preimpact mechanical failures or malfunctions of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane during the takeoff, which resulted in a runway excursion and collision with an airport navigation antenna.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N2448R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-5624
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-18T17:26:55Z guid: 107078 uri: 107078 title: ERA23LA211 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107163/pdf description:
Unique identifier
107163
NTSB case number
ERA23LA211
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-08T12:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-05-26T20:51:04.253Z
Event type
Accident
Location
Vero Beach, Florida
Airport
NEW HIBISCUS AIRPARK (X52)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The student pilot departed from the turf runway at his home airport, which he described as “extremely rough,” for a solo flight in the airport traffic pattern. The pilot stated that the first 300 feet of the runway past the displaced threshold was “a very soft area” and a cone had been placed there, so he landed the airplane about 700 feet from the displaced threshold. The airplane bounced back into the air to a height of about 7 to 8 feet and the pilot added power and increased back pressure on the control wheel to hold the nose wheel off the runway. The airplane then touched down again on the main landing gear and the nose wheel again touched down on the runway. The nose wheel then contacted 3 to 5 “bumps” before settling into the turf, the lower portion of the nose landing gear separated, and the airplane nosed over, coming to rest inverted. The student pilot received minor injuries and the airplane’s fuselage and empennage were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation. Review of the student pilot’s logbook revealed that his presolo aeronautical knowledge endorsement indicated that he was aware of the flight characteristics and operational limitations of the airplane, as well as the airspace rules and procedures for the airport, which he had flown the airplane in and out of and landed at on at least 18 separate occasions. He therefore should also have been aware of the runway conditions. Given this information, it is likely that the student pilot’s landing technique was not appropriate for the condition of the turf runway, and that the techniques he used to recover from the bounced landing resulted in subsequent nose landing gear collapse and noseover.
Probable cause
The pilot's improper recovery from a bounced landing, which resulted in a nose landing gear collapse and subsequent noseover. Contributing was the rough condition of the runway, as described by the pilot, and his decision to operate from it.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AEROPILOT S R O
Model
LEGEND 600
Amateur built
false
Engines
1 Reciprocating
Registration number
N600LD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1531
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-26T20:51:04Z guid: 107163 uri: 107163 title: WPR23LA147 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107030/pdf description:
Unique identifier
107030
NTSB case number
WPR23LA147
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-08T13:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-04-10T19:39:09.633Z
Event type
Accident
Location
Midway, Utah
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that during an instructional flight, he and his student were approaching a ridge line to conduct a practice pinnacle landing. The student pilot stated that as they were over the ridge line, the helicopter was struck by a wind gust, and it yawed to the right. He added left anti-torque pedal to correct the yaw, then the low RPM horn sounded, and the instructor took the flight controls. He lowered the collective and added forward cyclic to move away from terrain, however the helicopter landed hard in the snow and rolled onto its right side. The tail boom was substantially damaged. The instructor reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during a pinnacle landing that resulted in a hard landing and subsequent roll over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N7530D
Operator
UTAH STATE UNIVERSITY
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
3619
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-10T19:39:09Z guid: 107030 uri: 107030 title: WPR23LA148 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107031/pdf description:
Unique identifier
107031
NTSB case number
WPR23LA148
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-08T18:45:00Z
Publication date
2023-05-11T04:00:00Z
Report type
Final
Last updated
2023-04-10T20:25:22.108Z
Event type
Accident
Location
Mesa, Arizona
Airport
Falcon Field Airport (KFFZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that during a solo flight, shortly after touchdown, he applied brakes and it felt like the airplane started to skid. He attempted to correct, but the airplane veered to the left and hit a taxiway sign, sustaining substantial damage to the left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N9366J
Operator
Red Rock Flight School
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-3465
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-10T20:25:22Z guid: 107031 uri: 107031 title: ERA23LA193 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107051/pdf description:
Unique identifier
107051
NTSB case number
ERA23LA193
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-10T20:20:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-17T18:09:21.606Z
Event type
Accident
Location
West Mifflin, Pennsylvania
Airport
ALLEGHENY COUNTY (AGC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot stated that this was her second solo flight. During takeoff, the airplane lifted off the runway but she felt it was not accelerating like it should and she elected to abort the takeoff. She landed the airplane on the remaining portion of runway, however it continued off the departure end, down an embankment, and came to rest in some bushes. The leading edges of the wings, fuselage, and the stabilator were all substantially damaged. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s decision to abort the takeoff and land on the runway without sufficient runway remaining, which resulted in a runway overrun.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N476TA
Operator
ATP TAA LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2881318
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-17T18:09:21Z guid: 107051 uri: 107051 title: CEN23LA154 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107050/pdf description:
Unique identifier
107050
NTSB case number
CEN23LA154
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-11T17:12:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-13T20:52:29.033Z
Event type
Accident
Location
Terrell, Texas
Airport
Terrell municipal Airport (TRL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that the student pilot was landing the airplane with a left crosswind. On touchdown, the airplane bounced, pitched up, and drifted toward the right side of the runway. The flight instructor told the student pilot to go around and then attempted to take control of the airplane. The airplane touched down in the grass, nosed over and came to rest inverted. The airplane sustained substantial damage to the forward fuselage, vertical stabilizer and rudder, and right wing strut. At the time of the accident, the airplane was landing on runway 18 with wind 100o at 7 knots.
Probable cause
The student pilot’s failure to maintain directional control during landing and the flight instructor’s delayed remedial response
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Registration number
N1221U
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17266918
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-04-13T20:52:29Z guid: 107050 uri: 107050 title: CEN23LA157 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107055/pdf description:
Unique identifier
107055
NTSB case number
CEN23LA157
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-11T22:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-04-14T23:32:36.712Z
Event type
Accident
Location
Skiatook, Oklahoma
Airport
SKIATOOK MUNI (2F6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he had just purchased the airplane and the accident flight was his first flight in it. While performing a touch-and-go-landing with a left gusting crosswind, the airplane veered right, departed the runway, and struck a runway light. The left main landing gear separated, and the airplane came to rest in the grass next to the taxiway. The airplane sustained substantial damage to the fuselage and lower wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operations. At the time of the accident, the airplane was landing on runway 18 with wind variable at 12 knots with gusts to 21 knots. The pilot reported that he did not look at the windsock before the landing.
Probable cause
The pilot's failure to maintain directional control during landing in a gusting crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Acro Sport
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N39GC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
AS123
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-14T23:32:36Z guid: 107055 uri: 107055 title: CEN23LA153 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107047/pdf description:
Unique identifier
107047
NTSB case number
CEN23LA153
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-11T22:13:00Z
Publication date
2023-09-27T04:00:00Z
Report type
Final
Last updated
2023-04-17T22:11:12.434Z
Event type
Accident
Location
New Waverly, Texas
Airport
Estates Airpark (XS09)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Factual narrative
On April 11, 2023, about 2113 central daylight time, a Ryan Navion A airplane, N4229K, sustained substantial damage when it was involved in an accident near New Waverly, Texas. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, after a night cross-country flight, he overflew his private airport at 1,500 ft above mean sea level (msl) to see if the solar lights were working. Unable to see the lights, he climbed to 2,000 ft msl and turned left towards Conroe. He stated that while in the turn, “the engine started to cut out,” and he initiated the emergency procedures checklist. Unable to get the engine power restored, he initiated a forced landing. He lowered the landing gear at 500 ft msl and turned on the landing lights, but at 400 ft msl, a tree appeared in front of his right wing. The airplane impacted several trees before impacting the ground, which resulted in substantial damage to the fuselage, empennage, and both wings. The pilot stated that on the flight before the accident leg, the airplane had about 89.5 gallons of fuel distributed between a main tank (39.5 gallons), tip tanks (40 gallons), and an auxiliary baggage compartment tank (10 gallons). At the conclusion of that flight, about 45 gallons of fuel remained. He stated that before the accident flight, he added 52 additional gallons, which brought the total fuel on board to about 100 gallons. When the airplane was recovered from the wreckage location, the fuel tanks were drained and a small fuel sample was captured in a clear glass jar. After allowing time for any particulates to settle, it was discovered that a dark green sediment was present in the fuel sample. During a postaccident examination, a material consistent with the sediment from the jar was located in the fuel manifold distributor. No other preimpact mechanical malfunctions or failures were noted that would have precluded normal operation. -
Analysis
The pilot reported that, after a night cross-country flight, he overflew his private airport to see if the solar lights were working. Unable to see the lights, he began a climb and initiated a left turn towards an alternate airport. He stated that while in the turn, “the engine started to cut out,” and he initiated the emergency procedures checklist. Unable to restore the engine power, he initiated a forced landing. The airplane impacted several trees during the approach before impacting the ground, which resulted in substantial damage to the fuselage, empennage, and both wings. During a postaccident examination, sediment was found in fuel that was drained from the fuel tanks and the fuel manifold distributor. The amount of sediment in the distributor likely reduced the fuel flow to the engine, which resulted in a total loss of engine power.
Probable cause
A total loss of engine power as a result of fuel contamination.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RYAN
Model
NAVION A
Amateur built
false
Engines
1 Reciprocating
Registration number
N4229K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
NAV-4-1229
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-17T22:11:12Z guid: 107047 uri: 107047 title: CEN23LA156 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107054/pdf description:
Unique identifier
107054
NTSB case number
CEN23LA156
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-13T11:45:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-04-14T21:04:43.419Z
Event type
Accident
Location
Evansville, Indiana
Airport
EVANSVILLE RGNL (EVV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while performing a three-point landing on runway 18, during the roll out the airplane veered left, exited the runway to the left, and ground looped in the counter-clockwise direction. During the ground loop, the right wing struck the ground and the airplane came to rest upright on the main landing gear. The right aileron sustained substantial damage. After the accident sequence the pilot noted that the tailwheel lock was not fully in the locked position. The pilot was able to taxi the airplane to parking without further incident. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to engage the tailwheel lock before landing which resulted in the loss of control and ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
A75N1(PT17)
Amateur built
false
Engines
1 Reciprocating
Registration number
N50142
Operator
EVANSVILLE P-47 FOUNDATION INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-962
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-14T21:04:43Z guid: 107054 uri: 107054 title: ERA23LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107202/pdf description:
Unique identifier
107202
NTSB case number
ERA23LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-13T17:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-03T20:33:43.966Z
Event type
Accident
Location
West Mifflin, Pennsylvania
Airport
ALLEGHENY COUNTY (AGC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that at about 8 to 10 ft above the ground the flight instructor shouted “FLARE, FLARE, FLARE!” The volume and intensity of the command startled the student pilot who pulled back sharply on the yoke and the airplane stalled. The flight instructor subsequently took control of the airplane and before he could take corrective action the airplane impacted the ground resulting in substantial damage to the lower fuselage. The flight instructor’s account of the event was similar to the student pilot’s. The operator reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper landing flare, and the flight instructor’s delayed remedial action, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N544TH
Operator
Pittsburgh Flight Training Center
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S12257
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-03T20:33:43Z guid: 107202 uri: 107202 title: WPR23LA161 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107096/pdf description:
Unique identifier
107096
NTSB case number
WPR23LA161
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-14T17:00:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-04-27T03:32:15.228Z
Event type
Accident
Location
Concord, California
Airport
Buchanan Field Airport (CCR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during a touch and go landing, he experienced a wind gust that turned the airplane to the right and then to the left. The was unable to correct the airplane’s heading and the airplane exited the runway which resulted in substantial damage to both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane during a landing in gusty wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GLOBE
Model
GC-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N80922
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1115
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-04-27T03:32:15Z guid: 107096 uri: 107096 title: WPR23LA155 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107069/pdf description:
Unique identifier
107069
NTSB case number
WPR23LA155
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-14T18:00:00Z
Publication date
2023-08-24T04:00:00Z
Report type
Final
Last updated
2023-04-19T01:52:05.193Z
Event type
Accident
Location
North Las Vegas, Nevada
Airport
NORTH LAS VEGAS (KVGT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The Certified Flight Instructor reported that, while practicing stop-and-go landings with his student, the airplane touched down hard and immediately veered left. The pilot attempted to correct with opposite rudder; however, the airplane continued off the runway and hit a taxiway sign with the left wing and landing gear struts. The airplane sustained substantial damage to the left-wing strut. The pilot reported to the duty officer that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control of the airplane during the landing roll resulting in collision with taxiway sign.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N734NJ
Operator
FLYRIGHT AVIATION INC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17268981
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-19T01:52:05Z guid: 107069 uri: 107069 title: ERA23LA196 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107066/pdf description:
Unique identifier
107066
NTSB case number
ERA23LA196
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-15T15:50:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-18T20:26:33.536Z
Event type
Accident
Location
Gilford, New Hampshire
Airport
LACONIA MUNICIPAL AIRPORT (LCI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing flare a gust of wind pitched the nose of the airplane up. He then attempted to add power and go around, but the maneuver was unsuccessful with the pilot stating, “I believe both wings had stalled.” The airplane impacted the runway in a nose low attitude, which resulted in substantial damage to the fuselage and right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane during an attempted go-around, which resulted in an aerodynamic stall and impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ICP SRL
Model
SAVANNAH S
Amateur built
false
Engines
1 Reciprocating
Registration number
N5400S
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-10-54-0221
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-18T20:26:33Z guid: 107066 uri: 107066 title: ERA23LA207 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107132/pdf description:
Unique identifier
107132
NTSB case number
ERA23LA207
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-15T16:11:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-04-25T20:22:52.549Z
Event type
Accident
Location
Wake Forest, North Carolina
Airport
CROOKED CREEK (7NC5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
According to the student pilot of the glider, another glider was still on the runway as he was entering the downwind leg of the airport traffic pattern for landing. He decided to land short of the turf runway and entered the glider into a forward slip in order to touch down in the intended area. He reported that, upon removing the slip, he noted that the airspeed decayed “from 60 to 30,” and about 40 to 45 ft above the ground, he realized that the glider was “stalled” and that he “had no control over the aircraft.” The glider impacted a parked tow airplane and terrain, resulting in substantial damage to the leading edge of the left wing and the aft fuselage. The student pilot reported no preimpact mechanical malfunctions or failures with the glider that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain airspeed during the landing approach, which resulted in an exceedance of the glider’s critical angle of attack, an aerodynamic stall, and a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 1-26E
Amateur built
false
Registration number
N33873
Operator
NORTH CAROLINA SOARING ASSOCIATION
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
615
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-25T20:22:52Z guid: 107132 uri: 107132 title: CEN23LA159 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107086/pdf description:
Unique identifier
107086
NTSB case number
CEN23LA159
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-17T10:45:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-04-21T21:04:33.702Z
Event type
Accident
Location
Fredericksburg, Texas
Airport
Gillespie County (T82)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that when she checked the weather inbound to the airport, the wind was reported as calm. However, the wind may have shifted resulting in a tailwind on final approach. When it became apparent that the airplane was going to land long, she added full power to attempt a go-around. However, the airplane porpoised, the nose landing gear struck the runway and collapsed, and the airplane veered left and departed the runway. The airplane sustained substantial damage to the forward fuselage. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation. She noted that initiating the go-around earlier may have prevented the accident.
Probable cause
The pilot stated that when she checked the weather inbound to the airport, the wind was reported as calm. However, the wind may have shifted resulting in a tailwind on final approach. When it became apparent that the airplane was going to land long, she added full power to attempt a go-around. However, the airplane porpoised, the nose landing gear struck the runway and collapsed, and the airplane veered left and departed the runway. The airplane sustained substantial damage to the forward fuselage. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation. She noted that initiating the go-around earlier may have prevented the accident.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
3 Unknown, 1 Reciprocating
Registration number
N478SP
Operator
Archimedes Aviation LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S8023
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-21T21:04:33Z guid: 107086 uri: 107086 title: WPR23LA159 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107084/pdf description:
Unique identifier
107084
NTSB case number
WPR23LA159
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-18T17:35:00Z
Publication date
2023-08-17T04:00:00Z
Report type
Final
Last updated
2023-04-20T17:53:20.389Z
Event type
Accident
Location
Upland, California
Airport
CABLE Airport (KCCB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while on short final during a normal approach, he accidently pulled the engine mixture control to idle-cutoff and the engine shut down. He was unable to restart the engine and landed short of the runway. The airplane then impacted the airport boundary fence, which resulted in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper selection of the mixture control, which resulted in a total loss of engine power and a collision with the airport boundary fence during a forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VASHON AIRCRAFT
Model
RANGER R7
Amateur built
false
Engines
1 Reciprocating
Registration number
N349VR
Operator
CKD ENGINEERING LLC DBA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
10202
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-20T17:53:20Z guid: 107084 uri: 107084 title: ERA23LA210 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107155/pdf description:
Unique identifier
107155
NTSB case number
ERA23LA210
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-18T20:20:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-04-27T05:32:42.34Z
Event type
Accident
Location
St. Augustine, Florida
Airport
Northeast Florida Regional Airport (SGJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that as he entered the airport environment for landing, while on about a 3-mile final approach, the air traffic control tower controller instructed him to perform a left 360° turn. The pilot completed the turn, and the controller cleared him to continue the approach and land. As the pilot continued the final approach to land, the sun was in his eyes, and he noticed two objects on the runway. He inquired the tower about what was on the runway, but before the controller could respond, he identified the objects as two F-18 fighter aircraft departing. Subsequently, during the landing flare he heard “gear gear gear” over the radio and then touched down with the landing gear retracted. The airplane skidded to a stop on the runway. The fuselage sustained substantial damage. The pilot reported that he omitted completing his mental landing checklist of “gear, propeller, mixture, pumps, speed, stable.” The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N751WW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30-1449
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-27T05:32:42Z guid: 107155 uri: 107155 title: ANC23LA030 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107116/pdf description:
Unique identifier
107116
NTSB case number
ANC23LA030
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-22T13:45:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-04-24T22:56:40.579Z
Event type
Accident
Location
Soldotna, Alaska
Airport
Soldotna Airport (SXQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, to avoid excessive wear on the airplane’s Bushwheels, he decided to not land on the paved runway and instead he landed on the snow-covered gravel runway. During landing, the airplane decelerated rapidly as the main wheels touched down into the snow. The airplane subsequently nosed over sustaining substantial damage to the right-wing lift struts and rudder. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s selection of an unsuitable landing site, which resulted in the main landing gear wheels breaking through the snow and the airplane nosing over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
BEAVER DHC-2 MK.1
Amateur built
false
Engines
2 Reciprocating
Registration number
N454FU
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1193
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-24T22:56:40Z guid: 107116 uri: 107116 title: WPR23LA164 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107121/pdf description:
Unique identifier
107121
NTSB case number
WPR23LA164
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-22T15:00:00Z
Publication date
2023-06-06T04:00:00Z
Report type
Final
Last updated
2023-04-25T18:38:14.863Z
Event type
Accident
Location
Mesa, Arizona
Airport
Falcon Field (FFZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, during an instructional flight with the student pilot at the flight controls, they realized the airplane was high while they were on the base leg of the airport traffic pattern. After turning onto final approach, the student pilot conducted a forward slip to decrease altitude and intercept the glideslope. When over the runway, the student pilot had applied too much left rudder, and on touchdown the airplane immediately veered left. The student pilot then overcorrected to the right. The flight instructor stated, he then took control of the airplane and attempted to correct back to the left, however he was unable to regain directional control. The airplane departed the runway surface impacting a runway sign, resulting in substantial damage to the left wing. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control, and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N4402A
Operator
CAE OXFORD AVIATION ACADEMY PHOENIX INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2881241
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-25T18:38:14Z guid: 107121 uri: 107121 title: ERA23LA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107307/pdf description:
Unique identifier
107307
NTSB case number
ERA23LA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-24T10:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-04T21:41:28.512Z
Event type
Accident
Location
Good Hope, Alabama
Airport
NONE (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the agricultural airplane was landing on a private runway that was about 24 feet wide and surrounded by wheat crop. The pilot described that, during the landing, the airplane was closer to the edge of the runway than he thought, and the airplane’s right spray boom caught on the wheat after touchdown. The airplane subsequently veered off the runway and into the wheat field, resulting in substantial damage to the airplane’s empennage and left wing. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation and that he should have checked the runway conditions before landing and considered the possible impact of the growing wheat on his operation from the runway.
Probable cause
The pilot’s decision to land on a runway where there was insufficient clearance from obstructions (wheat crop) to operate safely.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-402A
Amateur built
false
Engines
1 Turbo prop
Registration number
N623LA
Operator
Pitts Aerial Services
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
402A-1127
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T21:41:28Z guid: 107307 uri: 107307 title: WPR23LA165 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107122/pdf description:
Unique identifier
107122
NTSB case number
WPR23LA165
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-24T14:45:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-04-26T18:48:23.655Z
Event type
Accident
Location
Tracy, California
Airport
TRACY MUNI (TCY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the takeoff roll, the airplane drifted to the left, and he corrected with right brake input. The airplane began drifting left again, and the pilot was unable to correct with right rudder or brake. The airplane briefly became airborne and then landed in the grass to the left of the runway. The airplane sustained substantial damage to the engine mount. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the takeoff roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ONEAL J R/ONEAL R C
Model
EDI EXPRESS
Amateur built
true
Engines
1 Reciprocating
Registration number
N92734
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
166
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-04-26T18:48:23Z guid: 107122 uri: 107122 title: WPR23LA168 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107154/pdf description:
Unique identifier
107154
NTSB case number
WPR23LA168
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-25T20:00:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-04-27T05:16:38.923Z
Event type
Accident
Location
Nyssa, Oregon
Airport
home-unregistered (none)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that during takeoff, the airplane “seemed to lift off ok”, however, within a few seconds, the left wing stalled and impacted trees. During the accident sequence, the airplane descended into bushes and came to rest on its nose. Both wings and the fuselage sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate airspeed on takeoff that resulted in an aerodynamic stall and subsequent impact with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N140D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
8395
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-27T05:16:38Z guid: 107154 uri: 107154 title: WPR23LA169 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107156/pdf description:
Unique identifier
107156
NTSB case number
WPR23LA169
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-26T19:00:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-04-27T18:50:34.713Z
Event type
Accident
Location
Glendale, Arizona
Airport
GLENDALE MUNI (GEU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, during a practice power-off landing with a student pilot at the controls, he recommended using flaps to provide some additional lift to the airplane as it approached the runway. The airplane rapidly lost airspeed and lift, and subsequently landed hard. The student pilot applied full power with the intention of executing a go-around. The flight instructor then took control and promptly pulled the throttle, because he believed the propellor struck the runway. The airplane veered to the right and subsequently collided with terrain, resulting in substantial damage to the fuselage. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper landing flare, which resulted in a hard landing and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
REMOS ACFT GMBH FLUGZEUGBAU
Model
REMOS GX
Amateur built
false
Engines
1 Reciprocating
Registration number
N76GX
Operator
Eagle Sport LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
279
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-04-27T18:50:34Z guid: 107156 uri: 107156 title: ERA23LA216 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107809/pdf description:
Unique identifier
107809
NTSB case number
ERA23LA216
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-27T10:30:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-04T21:43:17.383Z
Event type
Accident
Location
Stratford, Connecticut
Airport
IGOR I SIKORSKY MEML (BDR)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot/owner was landing the experimental, amateur-built airplane at the conclusion of a night cross-country flight. The pilot described that he flared the airplane slightly high and that it, “skipped and then settled.” The landing roll seemed normal until the left main landing gear collapsed and the airplane departed the runway. The pilot further characterized that the touchdown wasn’t particularly hard, compared to landings he had previously made in other airplanes. The airplane’s horizontal stabilizer and elevator were substantially damaged during the runway excursion. Following the accident, the pilot had the airplane repaired by its original builder, which included replacing a section of threaded rod on the left main landing gear that had broken, which was part of the landing gear down-locking mechanism. Based on this information, it is likely that the failure of the threaded rod resulted in the landing gear collapse and subsequent runway excursion.
Probable cause
A failure of the left main landing gear down locking mechanism, which resulted in a collapse of that landing gear and a subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GILBERT R. RINGER
Model
GP4
Amateur built
false
Engines
1 Reciprocating
Registration number
C-GPEX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
GP4-438
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T21:43:17Z guid: 107809 uri: 107809 title: CEN23LA218 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192286/pdf description:
Unique identifier
192286
NTSB case number
CEN23LA218
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-27T15:00:00Z
Publication date
2024-03-20T04:00:00Z
Report type
Final
Last updated
2023-06-02T02:55:15.552Z
Event type
Incident
Location
Romeoville, Illinois
Airport
LEWIS UNIVERSITY (LOT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On April 27, 2023, about 1400 central daylight time, a Piper J3C-65 airplane, N6384H, sustained minor damage when it was involved in an incident near Romeoville, Illinois. The pilot sustained no injuries. The airplane was operated as a Title 14 CFR Part 91 personal flight. The pilot reported that during the preflight inspection of the airplane, no anomalies were noted. The pilot decided to use runway 09 for the departure at the Lewis University Airport (LOT), Romeoville, Illinois, for the local area flight. During the takeoff, about 650 ft agl, the airplane began to shake “very violently.” The pilot closed the throttle, issued an emergency transmission to the LOT air traffic control tower, and executed a 180° turn to the left to land back on the departure runway. About halfway through turn, the pilot turned off the engine as he felt the airplane could successfully make the landing. The pilot was able to land the airplane on the runway without further incident. After the pilot exited the airplane, he noticed that about 5 inches of the outboard portion of one of the aluminum propeller blades had separated. The separated blade segment was not recovered. The propeller sustained minor damage. There was no other damage sustained to the propeller, the engine, and the airframe. The airplane was equipped with a McCauley 1B90/CM7144 fixed pitch propeller. Postincident examination revealed features consistent with fatigue cracking initiating at the midpoint of the cambered face of the propeller blade. These initiation sites exhibited corrosion pits consistent with those found on the cambered face of the propeller, which had been present underneath the paint and primer. An annual inspection was performed on the airplane on October 25, 2022. A review of the airplane’s maintenance records revealed that the airplane had accumulated 0.7 hours since the annual inspection was performed. The propeller was overhauled on January 28, 2015, and the total time since new was listed as “unknown.” The propeller was installed on the airplane on August 18, 2015. The propeller had about 223 total hours since its installation. The maintenance records did not show any overhaul work performed on the propeller since it was installed on the airplane. According to McCauley, this propeller is to be overhauled at 2,000 hours or 72 calendar months, whichever occurs first. The FAA does not mandate that propellers be overhauled for 14 CFR Part 91 operations. -
Analysis
The pilot reported that no anomalies were noted during the preflight inspection of the airplane. During the takeoff, about 650 ft agl, the airplane began to shake “very violently.” The pilot closed the throttle, issued an emergency transmission to the air traffic control tower, and executed a 180° turn to the left to land back on the departure runway. About halfway through turn, the pilot turned off the engine as he felt the airplane could successfully make the landing. The pilot was able to land the airplane on the runway without further incident. After the pilot exited the airplane, he noticed that about 5 inches of the outboard portion of one of the aluminum propeller blades had separated. The airplane sustained minor damage to the propeller. Postincident examination revealed features that were consistent with fatigue cracking initiating at the midpoint of the cambered face of the propeller blade. These initiation sites exhibited corrosion pits consistent with those found on the cambered face of the propeller, which had been present underneath the paint and primer. On closer examination, these pits exhibited higher amounts of chlorine than the rest of the blade surfaces. It is unclear as to the origin of the pitting corrosion, which was likely due to chlorine species. Chlorine is a common element known to cause pitting of aluminum alloys in service. Many chemicals, locales, and substances can impart chlorine (as well as sulfur, phosphorus, and alkali metals) onto metal parts. These constituents can diffuse through a variety of coatings and materials, though their effectiveness resisting potentially aggressive chemicals in this case is unknown. The propeller was overhauled on January 28, 2015, and the total time since new was listed as “unknown.” The propeller was installed on the airplane on August 18, 2015. The maintenance records did not show any overhaul work performed on the propeller since it was installed on the airplane. According to the propeller manufacturer, this propeller is to be overhauled at 2,000 hours or 72 calendar months, whichever occurs first. The Federal Aviation Administration (FAA) does not mandate that propellers be overhauled for Title 14 Code of Federal Regulations (CFR) Part 91 operations. Cracks in propellers can grow to fracture in just a few flights once started. At overhaul, the paint, primer, and any coatings would likely be removed, and the surfaces refinished. These processes would likely remove surface stress concentrators like pitting and other imperfections, along with detecting any visible cracks. With the blade being 2.5 years outside of a recommended overhaul, the chances of cracks initiating would be higher.
Probable cause
The inflight failure of the propeller blade due to fatigue cracking from corrosion pits, initiating at the midpoint of the cambered face.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C
Amateur built
false
Engines
1 Reciprocating
Registration number
N6384H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
19565
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-06-02T02:55:15Z guid: 192286 uri: 192286 title: ERA23LA212 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107169/pdf description:
Unique identifier
107169
NTSB case number
ERA23LA212
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-28T11:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-12T17:39:29.554Z
Event type
Accident
Location
Dulles, Virginia
Airport
WASHINGTON DULLES INTERNATIONAL (IAD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The flight attendant reported that after informing the flight crew that the cabin was secure, she was making her way back to her seat when the flight began to take off. During the takeoff the flight attendant fell and was seriously injured. The flight continued to its destination where the flight attendant was checked by medical personnel. She then elected to return to the airport of origin, and once there was transported to the hospital where it was discovered that her ankle was fractured. Following the accident, the operator modified their procedures to require that the flight deck crew verify that cabin crew are seated prior to taxi.
Probable cause
The initiation of the takeoff while before the flight attendant had returned to her seat, which resulted in a serious injury during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AEROSPACE CORP
Model
GVII-G500
Amateur built
false
Engines
2 Turbo fan
Registration number
N507GD
Operator
GENERAL DYNAMICS CORP
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Executive/Corporate
Commercial sightseeing flight
false
Serial number
72107
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-05-12T17:39:29Z guid: 107169 uri: 107169 title: CEN23LA176 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114704/pdf description:
Unique identifier
114704
NTSB case number
CEN23LA176
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-28T15:11:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-10T17:48:50.592Z
Event type
Accident
Location
Nacogdoches, Texas
Airport
NACOGDOCHES A L MANGHAM JR RGNL (OCH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot stated he touched down and began to porpoise. The airplane began to slide to the right towards the runway edge. The student pilot’s attempt to stop was unsuccessful and the airplane exited the runway. During the runway excursion, the airplane nosed over which resulted in substantial damage to the right wing. The student pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Registration number
N52602
Operator
HUTCH AVIATION INC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17274562
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-10T17:48:50Z guid: 114704 uri: 114704 title: WPR23LA170 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107165/pdf description:
Unique identifier
107165
NTSB case number
WPR23LA170
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-28T16:26:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-05-02T04:14:44.112Z
Event type
Accident
Location
Van Nuys, California
Airport
Van Nuys Airport (KVNY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while picking up to reposition, the helicopter initiated a roll to the left. While attempting to recover, the helicopter impacted the ground and the left skid collapsed, which resulted in substantial damage to the tail rotor. The pilot reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain lateral control of the helicopter, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N549TS
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11075
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-02T04:14:44Z guid: 107165 uri: 107165 title: WPR23LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107166/pdf description:
Unique identifier
107166
NTSB case number
WPR23LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-04-29T10:30:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-05-04T19:45:55.439Z
Event type
Accident
Location
Queen Creek, Arizona
Airport
Pegusas Airpark (5AZ3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported encountering a dust devil (also called a whirlwind) during rollout following a full stall landing maneuver. The airplane did not have any aileron authority due to the low airspeed at the time of the encounter. The left wing subsequently impacted the ground and the airplane departed the runway. It continued to roll down a hill before flipping and coming to rest inverted, resulting in substantial damage to the empennage and both wings. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation.
Probable cause
The airplane’s encounter with a dust devil after landing, which resulted in a loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170B
Amateur built
false
Engines
1 Reciprocating
Registration number
N2207D
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
20359
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T19:45:55Z guid: 107166 uri: 107166 title: WPR23LA174 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107203/pdf description:
Unique identifier
107203
NTSB case number
WPR23LA174
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-01T19:15:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-05-02T21:54:20.408Z
Event type
Accident
Location
San Luis Obispo, California
Airport
San Luis Obispo (KSBP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll, the airplane “pulled hard right.” He added engine power “to try to get some rudder control” and the airplane veered across the runway to the left. The airplane exited the left side of the runway and impacted airport equipment, which resulted in substantial damage to both wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident, the pilot was landing runway 29, with wind from 310° at 14 knots, gusting to 21 knots.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210N
Amateur built
false
Engines
1 Reciprocating
Registration number
N29TR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21064570
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-02T21:54:20Z guid: 107203 uri: 107203 title: WPR23LA176 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107309/pdf description:
Unique identifier
107309
NTSB case number
WPR23LA176
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-02T12:33:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-05-04T20:05:04.89Z
Event type
Accident
Location
Santa Barbara, California
Airport
Santa Barbara Municipal Airport (KSBA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the experimental airplane reported that after a normal landing, during rollout the local air traffic controller advised him that they saw flames or smoke under the fuselage. After coming to a stop, the pilot egressed and dispensed a handheld fire extinguisher, successfully extinguishing a fire that had developed in the area of the front seat. The pilot stated he then saw liquid venting from the main tank vent that was igniting on the ground. Because his fire extinguisher was emptied, he pushed the airplane away from the fire, and by the time emergency response personnel arrived it had extinguished itself. The fuselage sustained substantial damage from the fire. According to the pilot, the fuel system consisted of two wing tanks and a main center tank in the fuselage. When a wing tank is selected for fuel delivery a distributor delivers fuel under constant pressure to the engine and returns excess to the main tank. The pilot stated that he typically switches fuel tanks during flight to manage the level in the main tank, and that landings, and takeoffs are typically performed with the main tank selected and partially full. However, for the accident flight, weather conditions caused an unplanned diversion, and he had to land the airplane with a full main tank. Due to the fuel configuration at the time of the landing, the main tank fuel quantity level was above the vent inlet line and combined with the landing flare attitude, the fuel began to vent. The vent line was located near the engine exhaust stack, and it is likely that high temperature exhaust gasses ignited misted or vaporized fuel as it exited the vent line. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation, and the accident could have been avoided if the fuel vent was extended to vent into the relative wind at all speeds.
Probable cause
A fire that resulted from venting fuel coming into contact with hot exhaust surfaces or exhaust gases. Contributing to the fire was the design and location of the main tank fuel vent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AkroTech Aviation
Model
Giles G-202
Amateur built
true
Engines
1 Reciprocating
Registration number
C-GXGS
Operator
MKT Aerobatics LTD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
61
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T20:05:04Z guid: 107309 uri: 107309 title: CEN23LA180 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/127504/pdf description:
Unique identifier
127504
NTSB case number
CEN23LA180
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-02T20:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-11T18:45:38.643Z
Event type
Accident
Location
Pottsboro, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the amphibious airplane reported that during a water landing, he forgot to retract the landing gear, and the airplane touched down with the landing gear extended. The airplane subsequently nosed over and sustained substantial damage to both wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to retract the landing gear before a water landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SEAREY
Model
LSX
Amateur built
true
Engines
1 Reciprocating
Registration number
N40SR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1LK618C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T18:45:38Z guid: 127504 uri: 127504 title: CEN23LA172 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107813/pdf description:
Unique identifier
107813
NTSB case number
CEN23LA172
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-03T14:29:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-05-08T23:48:09.944Z
Event type
Accident
Location
Coldspring, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Factual narrative
On May 3, 2023, about 1329 central daylight time, a Piper PA-34-200 airplane, N28HE, sustained substantial damage when it was involved in an accident near Coldspring, Texas. The pilot examiner and flight instructor sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 pilot certification flight. According to the pilot examiner, following steep turn maneuvers, they heard a “loud metallic bang” from the tail of the airplane and the control yoke abruptly went to the full nose-up position. He stated the nose of the airplane pitched up rapidly, and the stall warning went off as they entered an accelerated stall. He took control of the airplane and applied full power to recover from the stall, at which time they heard another loud bang from the tail and the nose of the airplane pitched abruptly down. He reduced power to idle, there was another bang, and once again the airplane pitched up uncontrollably. This time he did not add power and the nose of the airplane pitched down, but not as severely and he was able to use the engine power to dampen the pitch oscillations. Unable to maintain full control of the airplane, he elected for an emergency, off-airport landing. While on the final approach, as the airplane clipped the tops of trees, the pilot examiner pulled the mixture controls to cutoff. Upon touchdown, the airplane bounced then slid through a rough, muddy field, which resulted in substantial damage to both wings, the fuselage, and empennage. A postaccident examination revealed that the bolt (item 49 in figure 1) which connects the stabilator trim rod assembly (item 12) to the stabilator link assembly (item 13) was missing. (Figure 2) Figure 1. Illustrated Parts Catalog (Part Nos. 753-816) Figure 2. Photo of the stabilator trim assembly (Photo courtesy of the FAA) A review of applicable maintenance records revealed two maintenance logbook entries for the elevator trim wheel cable becoming unspooled, the first on March 14, 2023, and the second on March 23, 2023. After each repair, a functional check flight was accomplished with no discrepancies noted. In an interview with the mechanic from the March 23 repair, he stated that he did not disconnect or otherwise perform maintenance on the affected control rod or linkage. The pilot examiner stated that during the preflight inspection, no anomalies were noted with the trim linkage assembly. Following the accident, the flight school inspected all PA-34 airplanes in their fleet and replaced the affected bolt on each airplane. -
Analysis
According to the pilot examiner, following steep turn maneuvers, they heard a loud “pop” from the tail of the airplane, the nose abruptly pitched up, and the airplane entered an accelerated stall. He took control of the airplane and added power to recover from the stall, at which time they heard another loud bang and the nose of the airplane pitched abruptly down. He reduced power to idle, there was another bang, and once again, the airplane pitched up uncontrollably. This time he did not add power and the nose of the airplane pitched down, but not as severely and he was able to use the engine power to dampen the pitch oscillations. Unable to maintain full control of the airplane, he elected for an emergency, off-airport landing. The airplane contacted trees while on approach to the field. The airplane landed hard, bounced, and slid through a rough, muddy field, which resulted in substantial damage to both wings, the fuselage, and empennage. A postaccident examination revealed that the bolt that connects the stabilator trim rod assembly to the stabilator link assembly was missing and not located. Since the bolt was not recovered, the reason for the separation could not be determined. Without being able to determine the reason for the separation, the flight school proactively inspected all same model airplanes in their fleet and replaced the bolt on each of them.
Probable cause
The stabilator trim rod assembly separated from the stabilator link assembly due to a missing connecting bolt, which resulted in the pilot’s inability to maintain pitch control of the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200
Amateur built
false
Engines
2 Reciprocating
Registration number
N28HE
Operator
WINGS OVER TEXAS HOLDINGS LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
34-7350278
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-08T23:48:09Z guid: 107813 uri: 107813 title: CEN23LA171 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107812/pdf description:
Unique identifier
107812
NTSB case number
CEN23LA171
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-03T20:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-04T23:04:48.551Z
Event type
Accident
Location
Gretna, Nebraska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while taking off from an off-airport site, he turned too early before gaining enough altitude, and the right wing contacted the ground. The pilot lowered the left wing and the airplane’s left tire “contacted the ground sideways.” The wheel sheared off and the left wing contacted the ground which resulted in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation
Probable cause
The pilot’s failure to maintain clearance from terrain during a turn immediately after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Kitfox
Model
IV
Amateur built
true
Engines
1 Reciprocating
Registration number
N440RS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1440
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T23:04:48Z guid: 107812 uri: 107812 title: ERA23LA217 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/107814/pdf description:
Unique identifier
107814
NTSB case number
ERA23LA217
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-04T13:15:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-04T22:54:52.089Z
Event type
Accident
Location
Defuniak Springs, Florida
Airport
DeFuniak Springs Airport (54J)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot listened to the recorded weather information then took off on the airport’s only paved runway with a direct crosswind of about 5 kts. He described that during the initial climb, the airplane encountered either a downdraft or increasing wind over trees next to the runway that resulted in the airplane rolling left. The pilot attempted to counteract the roll; however, the airplane settled off the sloped left side of the runway, impacted a berm, bounced up, and came to rest on the taxiway. The left wing was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation. Postaccident communication with the Federal Aviation Administration revealed that the airport manager’s weather reporting system included gusting wind that was not reported by the automated weather system.
Probable cause
The pilot's failure to maintain directional control while taking off in a crosswind, which resulted in a runway excursion and impact with a berm. Contributing was the automated weather briefing which failed to include accurate wind information.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28R
Amateur built
false
Engines
1 Reciprocating
Registration number
N3796T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28R-30109
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-04T22:54:52Z guid: 107814 uri: 107814 title: ERA23LA227 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/139289/pdf description:
Unique identifier
139289
NTSB case number
ERA23LA227
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-04T15:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-11T19:08:00.419Z
Event type
Accident
Location
Knoxville, Tennessee
Airport
KNOXVILLE DOWNTOWN ISLAND (DKX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was departing on her third solo flight. During the takeoff the airplane began drifting to the left and the pilot attempted to correct with right rudder application. The pilot said that it then felt as if the airplane encountered a gust of wind that pushed it to the left off the runway and into the grass. The airplane’s left wing struck a runway approach light and was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AMERICAN CORP
Model
AA-5A
Amateur built
false
Engines
1 Reciprocating
Registration number
N26941
Operator
Fast Track Flight Training
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
AA5A0839
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T19:08:00Z guid: 139289 uri: 139289 title: CEN23LA177 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/122568/pdf description:
Unique identifier
122568
NTSB case number
CEN23LA177
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-04T18:01:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-23T01:24:42.018Z
Event type
Accident
Location
Longville, Minnesota
Airport
LONGVILLE MUNI (XVG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during his landing roll the airplane encountered an unexpected wind shift with quartering tailwind gusts as he decelerated to about 45 miles per hour. The pilot had not yet retracted his flaps and lost directional control of the airplane. The airplane departed the left side of the runway, traversed through the grass, and came to rest in a swale, resulting in substantial damage to the fuselage and engine mount. The pilot did not report any mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with an unexpected windshift, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
17-30A
Amateur built
false
Engines
1 Reciprocating
Registration number
N8210R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30421
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T01:24:42Z guid: 122568 uri: 122568 title: CEN23LA175 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114702/pdf description:
Unique identifier
114702
NTSB case number
CEN23LA175
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-04T19:30:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-11T18:45:08.897Z
Event type
Accident
Location
Brookings, South Dakota
Airport
Brookings Regional (KBKX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The check instructor reported that during a soft field takeoff for an end-of-course test, the student pilot did not correct for an increasing nose up attitude and struck the tail on the runway surface. The student was then instructed to abort the take-off several times, to which the student did not immediately respond. During the abort, the student pilot lost directional control and the instructor took control of the airplane. However, the instructor reported that he was unable to regain full control before the airplane left the runway surface. The airplane struck a runway sign which resulted in substantial damage to the fuselage.
Probable cause
The student pilot’s failure to maintain pitch and directional control during the takeoff roll. Contributing to the accident, was the student pilot’s delay in relinquishing control of the airplane and the instructor's delayed reaction before the loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N1674E
Operator
South Dakota State University
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S9915
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T18:45:08Z guid: 114702 uri: 114702 title: DCA23LA278 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/135369/pdf description:
Unique identifier
135369
NTSB case number
DCA23LA278
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-05T05:54:00Z
Publication date
2023-07-18T04:00:00Z
Report type
Final
Last updated
2023-05-11T16:12:58.84Z
Event type
Accident
Location
Charlotte, North Carolina
Airport
CHARLOTTE/DOUGLAS INTL (CLT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
American Airlines flight 1753 sustained a tailstrike while landing at Charlotte Douglas International Airport (CLT), Charlotte, NC. The flight was a regularly scheduled domestic passenger flight from Fort Lauderdale, FL to CLT. According to the flight crew, the captain was the pilot flying, and the first officer (FO) was the pilot monitoring when they were cleared to land on runway 18L at CLT. The airplane was in the landing configuration and on a stabilized approach at 1,000 ft. above ground level (AGL). While crossing the runway’s threshold the wind shifted from a 6 -7 knot headwind component to a 6–7 knot tailwind component, the airspeed began to decay, and the airplane’s sink rate increased. In an effort to correct for the sink rate the captain applied back sidestick. The airplane touched down firmly and bounced, coincidentally the ground spoilers deployed which resulted in a nose high attitude. The airplane touched down a second time decelerated and taxied uneventfully to the gate. The captain stated that the ground spoiler deployment coinciding with the bounced touchdown resulted in an airplane nose-up pitch attitude. As a result, the pitch attitude increased until the tail struck the runway. After the tailstrike, and subsequent touchdown the remainder of the landing and landing rollout were normal with no risk of runway overrun or excursion. The tailstrike resulted in abrasion damage along the aft lower fuselage, over an area of about 14 feet long by 2 feet wide. An inspection revealed substantial damage to several frames.
Probable cause
The captain’s failure to maintain the appropriate airspeed and pitch attitude during landing which resulted in a tailstrike.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A321-231
Amateur built
false
Engines
2 Turbo fan
Registration number
N921US
Operator
AMERICAN AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
6523
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T16:12:58Z guid: 135369 uri: 135369 title: WPR23LA179 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114706/pdf description:
Unique identifier
114706
NTSB case number
WPR23LA179
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-05T10:45:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-05-09T19:29:03.034Z
Event type
Accident
Location
North Las Vegas, Nevada
Airport
NORTH LAS VEGAS (VGT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, during the landing rollout, he encountered a gusting right crosswind that lifted the right wing. As the airplane weathervaned to the right, the pilot applied left rudder input, but was unable to maintain directional control. The airplane veered off the runway to the right and subsequently ground looped, resulting in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing in gusting wind conditions, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ELY JOHN M
Model
VANS ACFT RV-8
Amateur built
false
Engines
1 Reciprocating
Registration number
N83SE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
81685
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-09T19:29:03Z guid: 114706 uri: 114706 title: WPR23LA181 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114708/pdf description:
Unique identifier
114708
NTSB case number
WPR23LA181
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-06T08:30:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-05-10T00:23:58.018Z
Event type
Accident
Location
Moorpark, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that during a series of take offs and landings, the “A line red light” for the engine’s fuel pump illuminated, twice. Both times, he shut down the engine to reset the engine’s computer and restarted the engine. The pilot reported knowledge of a potential mechanical malfunction prior to leaving the airport environment, during the accident flight. He continued the flight to a remote area where the A line red light illuminated again, followed by the low-pressure fuel warning light. The pilot elected to land the airplane on a deserted dirt road. While landing, the sun impeded his vision and the airplane landed beside the road, on rough terrain. During the landing roll, the airplane’s main landing gear collapsed, and the airplane impacted terrain, resulting in substantial damage to the left wing.
Probable cause
The pilot’s failure to maintain control of the airplane during an off airport precautionary landing. Contributing to the accident was the pilot’s decision to continue the flight with a possible mechanical malfunction.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STEVEN RADENBAUGH
Model
JA35 SUPERSTOL
Amateur built
true
Engines
1 Reciprocating
Registration number
N799CP
Operator
EMERALD ISLE APARTMENTS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
JA622-03-21
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-10T00:23:58Z guid: 114708 uri: 114708 title: CEN23LA179 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/122574/pdf description:
Unique identifier
122574
NTSB case number
CEN23LA179
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-06T10:40:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-24T19:11:35.738Z
Event type
Accident
Location
Englewood, Colorado
Airport
CENTENNIAL (APA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he attempted to adjust his seat while taxing the airplane. The seat slid aft, and he was unable to reach the rudder pedals. The airplane traversed across a taxiway, impacted a swale, then continued onto a runway before the pilot was able to regain control. The airplane’s rudder and lower aft fuselage were substantially damaged. The pilot reported there were no pre-accident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s decision to adjust his seat during taxi, which resulted in his seat sliding aft, and subsequent loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N34BL
Operator
AMERICAN ASSET LEASING LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
172S12468
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-24T19:11:35Z guid: 122574 uri: 122574 title: CEN23LA186 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174540/pdf description:
Unique identifier
174540
NTSB case number
CEN23LA186
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-06T15:00:00Z
Publication date
2023-06-29T04:00:00Z
Report type
Final
Last updated
2023-05-22T20:05:01.918Z
Event type
Accident
Location
Tahlequah, Oklahoma
Airport
TAHLEQUAH MUNI (TQH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot stated that after he started the airplane engine, he realized that the wheel chocks were still in place on the nose landing gear tire. He set the parking brake and exited the airplane with the engine still running. As the pilot removed the chocks, they inadvertently hit the propeller and pulled his arm into the propeller arc. The pilot sustained a serious injury to his right arm. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The airplane sustained minor damage to the propeller.
Probable cause
The pilot’s failure to remove the wheel chocks before engine start which resulted in the inadvertent contact with the propeller while the engine was running.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
F33A
Amateur built
false
Engines
1 Reciprocating
Registration number
N2294L
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CE-676
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-05-22T20:05:01Z guid: 174540 uri: 174540 title: WPR23LA178 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114703/pdf description:
Unique identifier
114703
NTSB case number
WPR23LA178
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-07T14:40:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-05-09T19:05:01.891Z
Event type
Accident
Location
Belen, New Mexico
Airport
BELEN RGNL (BRG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while taking off, the wind shifted to a strong quartering tailwind. The airplane settled to the ground and the propeller contacted the runway before the landing gear could be extended by the pilot. The pilot and passenger exited the airplane unharmed. The airplane was destroyed by the postcrash fire. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The airplane’s encounter with downdraft on takeoff, which resulted in a loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
UNIVERSAL
Model
GLOBE GC-1A
Amateur built
false
Engines
1 Reciprocating
Registration number
N80892
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
295
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-05-09T19:05:01Z guid: 114703 uri: 114703 title: WPR23LA180 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114707/pdf description:
Unique identifier
114707
NTSB case number
WPR23LA180
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-07T20:30:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-05-08T21:47:07.081Z
Event type
Accident
Location
Ariel, Washington
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that he was attempting to land in a field, adjacent to a friend’s house. During the landing roll, the airplane hit an unexpected bump and the tail lifted into the air. The pilot applied brakes in tall grass, and the airplane nosed over and came to rest inverted. The right-wing strut, vertical stabilizer, and rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during the landing roll, resulting in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N6058D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-4711
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-08T21:47:07Z guid: 114707 uri: 114707 title: ERA23LA222 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/114705/pdf description:
Unique identifier
114705
NTSB case number
ERA23LA222
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-07T22:35:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-09T18:45:22.338Z
Event type
Accident
Location
Hernando, Florida
Airport
TWELVE OAKS (5FL7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot stated that he and the pilot-rated passenger were practicing full-stop landings from the turf runway on a dark, moonless night. The passenger had already completed three full-stop landings and he had completed two. The accident flight was going to be his last landing. During a takeoff, he lost visual reference of the tree line along the side of the runway and contacted some treetops. The airplane subsequently impacted the ground and the leading edges of the wings, and fuselage were substantially damaged. The pilot and the passenger were seriously injured. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate clearance from obstacles during takeoff at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N150VL
Operator
FLYING LOW ENGINEERING INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15076672
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-09T18:45:22Z guid: 114705 uri: 114705 title: CEN23LA185 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174535/pdf description:
Unique identifier
174535
NTSB case number
CEN23LA185
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-09T09:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-18T19:19:28.089Z
Event type
Accident
Location
Midland, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that when he was about 6 miles from the destination airport, the engine began running very rough. The pilot turned 180° toward an alternate airport that he had just flown over and declared an emergency. He attempted to troubleshoot the engine roughness, but was unsuccessful, and the engine lost total power. Unable to reach the runway, the pilot conducted a forced landing to a rough field. During the forced landing, the airplane sustained substantial damage to the horizontal stabilizer. Postaccident examination of the airplane revealed the right fuel tank contained no usable fuel, and the left fuel tank contained about 25 gallons of fuel. The fuel selector was found in the right fuel tank position. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. After the accident, the pilot stated that he had no memory of changing tanks during the flight.
Probable cause
The pilot’s inadequate fuel management which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR22
Amateur built
false
Engines
1 Reciprocating
Registration number
N433CF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0710
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-18T19:19:28Z guid: 174535 uri: 174535 title: ERA23LA226 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/139288/pdf description:
Unique identifier
139288
NTSB case number
ERA23LA226
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-09T12:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-11T19:07:38.125Z
Event type
Accident
Location
Frenchville, Maine
Airport
NORTHERN AROOSTOOK RGNL (FVE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that after making a 3-point landing on the airport’s paved runway a gust of wind, “turned [the airplane] towards a ditch.” The pilot pressed on the brakes “hard” to prevent going into the ditch and the airplane nosed over, resulting in substantial damage to the left wing and vertical stabilizer. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain control of the airplane while landing in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SILVAIRE
Model
LUSCOMBE 8F
Amateur built
false
Engines
1 Reciprocating
Registration number
N1885B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6312
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T19:07:38Z guid: 139288 uri: 139288 title: ANC23LA032 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/139291/pdf description:
Unique identifier
139291
NTSB case number
ANC23LA032
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-09T13:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-11T20:33:43.452Z
Event type
Accident
Location
Skwentna, Alaska
Weather conditions
Unknown
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that, he was flying uphill over an area of snow-covered, mountainous terrain, when he encountered flat light and whiteout conditions, which made it difficult to discern topographical features. In an attempt to maintain visual reference with the ground, he turned the helicopter to the right to fly back down the hill. Subsequently, the right landing gear skid contacted terrain and the helicopter entered a dynamic rollover to the right, resulting in substantial damage to the fuselage, tail boom, and powertrain system. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot's failure to maintain adequate altitude/clearance from terrain while maneuvering in adverse weather conditions, which resulted in a dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N704T
Operator
Willow Creek Aviation
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
10343
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-11T20:33:43Z guid: 139291 uri: 139291 title: ANC23LA033 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/162754/pdf description:
Unique identifier
162754
NTSB case number
ANC23LA033
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-10T14:10:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-05-23T21:50:09.863Z
Event type
Accident
Location
Soldotna, Alaska
Airport
Soldotna Airport (SXQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was conducting touch-and-go landings in a tailwheel-equipped airplane during gusting crosswind conditions. The pilot reported that after landing, a gust of wind turned the airplane into the wind. When the pilot corrected for the turn, another gust of wind lifted the left wing and the airplane nosed over. The airplane sustained substantial damage to the left wing and rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll in gusting crosswind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-7-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N30AG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4131C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T21:50:09Z guid: 162754 uri: 162754 title: ERA23LA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174542/pdf description:
Unique identifier
174542
NTSB case number
ERA23LA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-10T14:40:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-05-20T23:04:08.085Z
Event type
Accident
Location
Akron, Ohio
Airport
None (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot/owner was operating the unregistered experimental helicopter in his back yard, when he attempted to lift the skids off the ground “a few inches.” When the pilot set the helicopter back down on the ground, it rolled over onto its left side resulting in substantial damage to the fuselage. The main rotor system, including the controls for the cyclic were also damaged from impact. Though the pilot held a private pilot certificate with a rating for airplane single-engine land, he was not certificated to act as a pilot in helicopters.
Probable cause
The non-certificated pilot’s failure to maintain control of the unregistered helicopter during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROTORWAY
Model
EXEC
Amateur built
true
Engines
1 Reciprocating
Registration number
UNREG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
None
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-20T23:04:08Z guid: 174542 uri: 174542 title: ERA23LA228 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/149067/pdf description:
Unique identifier
149067
NTSB case number
ERA23LA228
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-11T10:27:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-18T20:03:47.252Z
Event type
Accident
Location
Bradenton, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the helicopter reported that while he was on approach to land, he attempted to slow his descent by pulling aft on the cyclic and increased the collective pitch. The low rotor rpm horn sounded as he was beginning to hover in ground effect, and he then began to fly forward slowly. At 20 knots, the low rotor rpm horn sounded again, and his altitude increased to 40 ft above ground level. The rotor speed did not recover, and the helicopter descended until it landed on an uneven berm. The helicopter then pitched forward, the main rotor blades impacted the ground, and the helicopter rolled onto its left side. The helicopter’s tail boom was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate rotor rpm during landing which resulted in a premature landing on uneven ground and a subsequent rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N62HT
Operator
REGISTRATION PENDING
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
13709
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-18T20:03:47Z guid: 149067 uri: 149067 title: ANC23LA034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/162755/pdf description:
Unique identifier
162755
NTSB case number
ANC23LA034
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-11T18:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-05-23T21:52:42.096Z
Event type
Accident
Location
Sterling, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During an interview, the non-certificated pilot reported that he departed from a private airstrip without conducting a preflight inspection and was unaware of how much fuel was in the airplane. After departure the engine lost all power. The pilot turned the airplane back to the airstrip but did not have the altitude, and subsequently the airplane impacted trees along a road. The airplane sustained substantial damage to the wings and empennage during the accident sequence. The non-certificated pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. During recovery of the airplane the non-certificated pilot reported that there was no fuel in either fuel tank and he suspected the airplane ran out of fuel.
Probable cause
The pilot's inadequate preflight inspection and fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DENNIS D DOWNS
Model
CCK-1865
Amateur built
true
Engines
1 Reciprocating
Registration number
N3151
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CCK-1865-0106
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T21:52:42Z guid: 162755 uri: 162755 title: WPR23LA190 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174532/pdf description:
Unique identifier
174532
NTSB case number
WPR23LA190
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-12T11:45:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-05-17T04:54:01.129Z
Event type
Accident
Location
Elko, Nevada
Airport
Elko Regional (EKO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, prior to commencing his approach to land the reported wind at the airport was variable at 5kts. During landing the tail of the airplane rose and shifted to the left at touchdown. The pilot attempted to recover, but the airplane ground looped, resulting in substantial damage to the left and right ailerons. Upon exiting the aircraft, the pilot observed the windsock indicating a quartering tailwind. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing with a quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1C-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N12HD
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3401
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-17T04:54:01Z guid: 174532 uri: 174532 title: CEN23LA184 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174534/pdf description:
Unique identifier
174534
NTSB case number
CEN23LA184
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-13T16:42:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-16T01:44:24.906Z
Event type
Accident
Location
Gardner, Kansas
Airport
GARDNER MUNI (K34)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot was in the front seat and a passenger, who is a flight instructor, was in the rear seat. Due to his injuries, the pilot was unable to recall what happened during the accident sequence. The passenger reported that during the takeoff, the airplane began to drift to the right. The airplane came near another airplane that was on the grass and the pilot “pitched up” to avoid the other airplane. The airplane exceeded its critical angle of attack, which resulted in an aerodynamic stall and loss of airplane control at an altitude too low to allow for recovery. The passenger estimated the aerodynamic stall occurred at 50 ft agl. The airplane impacted terrain, came to rest upright, and a postimpact fire ensued. The airplane sustained substantial damage to the fuselage and both wings. The passenger reported that the engine was producing full power until the time of impact, and he did not hear any abnormal engine noises during the accident flight. A postaccident examination confirmed flight control continuity for the airframe.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack during the takeoff, which resulted in an aerodynamic stall and loss of airplane control at too low of an altitude to recover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RANS
Model
S7
Amateur built
true
Engines
1 Reciprocating
Registration number
N8932L
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0318630
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-16T01:44:24Z guid: 174534 uri: 174534 title: WPR23LA189 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174531/pdf description:
Unique identifier
174531
NTSB case number
WPR23LA189
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-13T18:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-05-16T03:06:28.587Z
Event type
Accident
Location
Twisp, Washington
Airport
TWISP MUNI (2S0)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while demonstrating touch and go landings, he completed a normal touchdown. On rollout, the airplane began to veer to the right. The pilot attempted to correct with full left rudder and brake; however, the airplane exited the right side of the runway and bounced up a small dirt embankment. The airplane completed a full rotation and the left wing impacted terrain, which resulted insubstantial damage to the left aileron. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing, which resulted in a runway excursion and ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N185MG
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
18502902
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-16T03:06:28Z guid: 174531 uri: 174531 title: CEN23LA189 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/174545/pdf description:
Unique identifier
174545
NTSB case number
CEN23LA189
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-16T15:50:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-30T17:56:50.327Z
Event type
Accident
Location
Grand Junction, Colorado
Airport
Grand Junction Regional Airport (GJT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while performing a 3-point landing, a wind gust from the right caused the airplane to “balloon” and bounce during the initial touchdown. During the attempted bounce recovery, the tundra tires firmly grabbed the grooved runway resulting in a ground loop. During the ground loop, the left wing struck the ground which resulted in substantial damage to the wing. The pilot reported that there were no preaccident malfunctions or failures with the airplane which would have precluded normal operation. At the time of the accident, the pilot was landing the airplane on runway 29 with wind from 330° at 7 knots gusting to 17 knots. The pilot stated that he was unfamiliar flying this airplane with large tundra tires.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with gusting wind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185f
Amateur built
false
Engines
1 Reciprocating
Registration number
N4742E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18503853
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-30T17:56:50Z guid: 174545 uri: 174545 title: ANC23LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192217/pdf description:
Unique identifier
192217
NTSB case number
ANC23LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-17T11:55:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-05-23T02:26:35.851Z
Event type
Accident
Location
Anchorage, Alaska
Airport
TED STEVENS ANCHORAGE INTL (ANC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after landing, while in a high-speed taxi, air traffic control asked him to exit on a taxiway prior to the taxiway he intended to use. He applied brakes and the airplane nosed over and the airplane came to rest inverted. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's excessive braking during the landing roll, resulting in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA22
Amateur built
false
Engines
1 Reciprocating
Registration number
N7741D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-5419
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T02:26:35Z guid: 192217 uri: 192217 title: ANC23LA036 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192218/pdf description:
Unique identifier
192218
NTSB case number
ANC23LA036
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-17T13:22:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-05-23T23:34:34.378Z
Event type
Accident
Location
Point Thomson, Alaska
Airport
POINT THOMSON AIRSTRIP (37AA)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while established on an RNAV GPS instrument approach to a remote airport, flat light conditions made it difficult to decern topographical features of the snow-covered terrain below. Prior to reaching the decision height altitude, the pilot said he looked outside for the runway environment, but the flat light condition caused him to spend more time looking outside and he became disorientated. When he looked back at the airplane’s instruments, he noticed the airplane was below the glide path and initiated a go-around maneuver; however, the airplane subsequently impacted snow-covered terrain. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadvertent descent below the published minimum descent altitude, while operating in flat light conditions, which resulted in controlled flight into terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA31
Amateur built
false
Engines
2 Reciprocating
Registration number
N34WM
Operator
JuniPogo LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
31-7305125
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T23:34:34Z guid: 192218 uri: 192218 title: WPR23LA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192782/pdf description:
Unique identifier
192782
NTSB case number
WPR23LA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-17T16:59:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-08-08T19:39:06.31Z
Event type
Accident
Location
Tracy, California
Airport
TRACY MUNI (TCY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll a wind gust caused the left wing to raise. The pilot was unable to maintain directional control and came to rest adjacent to the runway. The airplane sustained substantial structural damage to its wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll after encountering a wind gust.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170B
Amateur built
false
Engines
1 Reciprocating
Registration number
N2771C
Operator
KENMORE CREW LEASING INC TRUSTEE
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
26315
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-08T19:39:06Z guid: 192782 uri: 192782 title: ERA23LA237 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/180446/pdf description:
Unique identifier
180446
NTSB case number
ERA23LA237
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-18T12:59:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-05-23T01:48:42.577Z
Event type
Accident
Location
PETERSBURG, West Virginia
Airport
Grant County Airport (W99)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot and the flight instructor were performing flight training in the turbo-propeller-powered, multi-engine airplane. After completing two uneventful takeoffs and landings, the instructor and the pilot briefed that they would next perform a no-flap landing. While on the downwind leg of the traffic pattern, the pilot called for the before landing checklist. The instructor began reading the checklist, the pilot pushed the propeller controls fully forward, and the flight instructor mentioned that the pilot needed to hold the airplane’s attitude in order to slow the airplane to the desired airspeed. The flight instructor further described, “I was coaching the [pilot] on centerline and speed and neither of us realized that we had not completed the landing checklist.” During the landing flare, the flight instructor heard a metallic scraping sound, and began to abort the landing, about which time the pilot noted that the landing gear was not extended. After two attempts to increase engine power and climb, the flight instructor realized that the airplane was not controllable and decided to land on the grass next to the runway with the landing gear retracted. The airplane’s right wing was substantially damaged during the landing. The operator reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation, nor did either of the flight crew report any, with the exception that neither crewmember recalled hearing the landing gear position warning system horn activate at any point. Maintenance personnel tested the system following the accident and noted no anomalies.
Probable cause
The flight crew’s failure to ensure that the landing gear were properly configured before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
65-A90-1
Amateur built
false
Engines
2 Turbo prop
Registration number
N80Y
Operator
DYNAMIC AVIATION GROUP, INC.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
LM-79
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T01:48:42Z guid: 180446 uri: 180446 title: CEN23LA191 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192209/pdf description:
Unique identifier
192209
NTSB case number
CEN23LA191
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-18T15:00:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-05-22T20:48:03.098Z
Event type
Accident
Location
Genoa, Illinois
Airport
Aero Lake Estates Airport (30IS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported, that while landing, a “huge downdraft hit the plane” and “dropped the plane quickly and very low.” She attempted a go-around; however, the airplane was not “able to generate enough lift”, and she lost control. The airplane landed in the grass next to the runway, which resulted in substantial damage to the left wing. She also recalled hearing the stall warning before contacting the ground. The pilot reported a loss of electrical power to the radios. She added there were no anomalies or malfunctions with respect to the flight controls or engine that would have precluded a normal go-around maneuver.
Probable cause
The pilot’s failure to maintain airplane control during a go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N6840F
Operator
C747 LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
15063440
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-22T20:48:03Z guid: 192209 uri: 192209 title: ERA23LA242 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192233/pdf description:
Unique identifier
192233
NTSB case number
ERA23LA242
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-19T16:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-30T16:21:38.79Z
Event type
Accident
Location
Kingston, Tennessee
Airport
WOLF CREEK (2TN7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that the airplane bounced upon landing and the nose landing gear impacted the turf runway. Subsequently, the nose landing gear dug into the runway and the airplane nosed over resulting in substantial damage to the fuselage, vertical stabilizer, and rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare and subsequent improper recovery from a bounced landing which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GARY R BREARLEY
Model
RV-9A
Amateur built
true
Engines
1 Reciprocating
Registration number
N105GS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
91280
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-30T16:21:38Z guid: 192233 uri: 192233 title: CEN23LA193 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192212/pdf description:
Unique identifier
192212
NTSB case number
CEN23LA193
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-19T17:45:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-22T20:12:10.628Z
Event type
Accident
Location
DeKalb, Illinois
Airport
DE KALB TAYLOR MUNI (DKB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that the pilot was receiving landing training in his airplane. As the airplane touched down on the runway, a gust of wind caused it to balloon. The flight instructor ordered the pilot to go around, and the airplane accelerated to 85 kts in a slight climb. About 25 feet above the ground the airplane abruptly and rapidly pitched over to about 20° nose low. The flight instructor immediately came on the control yoke and pulled but received no response to his pull. The airplane impacted the runway about 10o nose low and slid off the left side into the grass where it came to a stop. The pilot, flight instructor, and a passenger egressed the airplane without incident. The airplane sustained substantial damage to both wings. The flight instructor reported there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident the airplane was landing on runway 27 with wind 290o at 14 kts gusting to 19 kts. The pilot reported that the nose dropped dramatically and that neither he nor the flight instructor had time to react with additional back pressure on the control yoke. The pilot said during the pitch over that his hands never left the control yoke. The flight instructor further reported that light clear air turbulence was present at the time and “windshear caused our demise.”
Probable cause
The pilot’s failure to maintain aircraft control during a go-around in gusting winds. Contributing was the presence of windshear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA32RT
Amateur built
false
Engines
1 Reciprocating
Registration number
N442TM
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
32R-7887225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-22T20:12:10Z guid: 192212 uri: 192212 title: ANC23LA037 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192219/pdf description:
Unique identifier
192219
NTSB case number
ANC23LA037
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-19T18:02:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-05-23T02:09:08.928Z
Event type
Accident
Location
Hunter Creek, Alaska
Airport
Palmer Municipal (PAQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll from a remote gravel bar in a tundra tire-equipped airplane, a gusting crosswind banked the airplane to the right, and it subsequently came to rest inverted and sustained substantial damage to the wings and empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of takeoff, the pilot reported the winds to be gusting about 45 to 50 knots, which he said exceeded rudder and aileron authority.
Probable cause
The pilot’s loss of directional control during takeoff roll in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N4231Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-8457
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T02:09:08Z guid: 192219 uri: 192219 title: CEN23LA192 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192210/pdf description:
Unique identifier
192210
NTSB case number
CEN23LA192
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-20T12:05:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-31T17:56:04.295Z
Event type
Accident
Location
Ankeny, Iowa
Airport
Ankeny municipal Airport (KIKV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported he completed the landing checklist on the downwind leg and confirmed that the landing gear was extended via the cockpit landing gear indicator lights. Additionally, he saw that the landing gear locking pins were engaged. On final approach, the pilot intended to move the flap control lever to the “full down” position; however, he inadvertently moved the landing gear control lever from the “down” position. The pilot did not perform a visual gear down check on short final. The airplane touched down with its main landing gear retracted and came to a stop on the runway. The pilot and his passenger exited the airplane and a post-accident fire ensued. The fuselage and left wing were substantially damaged by the fire. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadvertent retraction of the landing gear control lever, resulting in a gear-up landing on the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN-BUEHN
Model
T-6G
Amateur built
false
Engines
1 Reciprocating
Registration number
N42JM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
182-735
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-31T17:56:04Z guid: 192210 uri: 192210 title: WPR23LA193 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192211/pdf description:
Unique identifier
192211
NTSB case number
WPR23LA193
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-20T13:30:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-05-23T18:49:19.819Z
Event type
Accident
Location
American Falls, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
According to the pilot the engine lost all power immediately after switching fuel tanks inflightduring initial climb. The pilot performed a forced landing in a field, which resulted in the airplane nosing over and substantial damage to the fuselage. The pilot told investigators that she may have inadvertently moved the fuel selector to the OFF position and that she observed the fuel selector in the OFF position following the accident. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s inadvertent selection of the off position of the fuel tank selector inflight, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N77J
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11489
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T18:49:19Z guid: 192211 uri: 192211 title: CEN23LA213 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192280/pdf description:
Unique identifier
192280
NTSB case number
CEN23LA213
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-20T13:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-09T07:35:37.384Z
Event type
Accident
Location
Ray, Michigan
Airport
RAY COMMUNITY (57D)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor demonstrated a simulated engine failure to his student while the airplane was on the crosswind leg in the traffic pattern. He reported that he attempted to land on the opposite runway from which they departed. He reported that while maneuvering to final approach the airplane was pushed to the left of the runway over a grassy area by a “sudden downward draft.” The flight instructor stated that he thought the airplane encountered “windshear coming down between the trees.” He landed the airplane in the wet grass between the taxiway and the runway, which resulted in a propeller strike. Post-accident examination revealed substantial damage to the engine mount. The flight instructor reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. The flight instructor reported that the wind at the time of the accident was 300° at 10 knots. The landing was made toward runway 10 which resulted in a 9-knot tailwind.
Probable cause
The flight instructor’s failure to maintain airplane control during simulated engine-out procedures. Contributing to the accident was the flight instructor’s decision to land with a tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N586SB
Operator
KAREON CONSULTING LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-10781
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-09T07:35:37Z guid: 192280 uri: 192280 title: WPR23LA195 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192216/pdf description:
Unique identifier
192216
NTSB case number
WPR23LA195
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-21T09:33:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-05-23T03:29:31.192Z
Event type
Accident
Location
Mobile, Arizona
Airport
Motown (5AZ6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that during a wheel landing, the airplane touched down and bounced. He added a “slight bump of power” and decided to turn the landing into a three-point landing. The airplane was higher above the ground than he realized, and it stalled. During the second touchdown, the airplane landed hard, and the left main landing gear collapsed. The airplane bounced a second time, then settled onto the runway and veered off the runway to the left. The airplane crossed a berm and nosed over. The left-wing struts, vertical stabilizer, and rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, resulting in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N108AM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2136
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-23T03:29:31Z guid: 192216 uri: 192216 title: WPR23LA194 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192213/pdf description:
Unique identifier
192213
NTSB case number
WPR23LA194
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-21T13:38:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-05-24T02:38:58.698Z
Event type
Accident
Location
Spanish Fork, Utah
Airport
Spanish Fork Municipal Airport/Woodhouse Field (KSPK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while attempting a “jump” takeoff, which he had only practiced with an instructor two years prior, the airplane assumed a nose high attitude and turned sharply to the left. The pilot pushed the stick forward and used rudder and ailerons to straighten the airplane, but his attempt to decrease the angle of attack was unsuccessful. He then retracted the flaps to “lower the nose,” and the airplane descended and impacted the top of a hangar, which resulted in substantial damage to the fuselage and left and right wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's decision to attempt an unfamiliar takeoff technique, his failure to maintain pitch control during takeoff, and his subsequent decision to retract flaps at a low altitude, which resulted in a descent into a building.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUBCRAFTERS
Model
CCX-2300
Amateur built
true
Engines
1 Reciprocating
Registration number
N668LD
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CCX-2300-0055
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-24T02:38:58Z guid: 192213 uri: 192213 title: ANC23LA038 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192262/pdf description:
Unique identifier
192262
NTSB case number
ANC23LA038
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-21T16:40:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-02T01:28:12.53Z
Event type
Accident
Location
Honolulu, Hawaii
Airport
Daniel K. Inouye International Airport (PHNL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot receiving instruction and instructor pilot completed a Part 135 recurrent training flight, which included, in part, autorotations, hovering autorotations, and sloping ground landings. A post-flight inspection revealed substantial damage to the tail boom that was consistent with a hard landing. The pilots reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The instructor pilot’s inadequate supervision of the pilot receiving instruction, which resulted in a hard landing, and substantial damage to the tail boom.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
AEROSPATIALE
Model
AS350B2
Amateur built
false
Engines
1 Turbo shaft
Registration number
N745RH
Operator
Novictor Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2047
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-06-02T01:28:12Z guid: 192262 uri: 192262 title: CEN23LA196 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192224/pdf description:
Unique identifier
192224
NTSB case number
CEN23LA196
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-22T10:47:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-24T16:53:48.872Z
Event type
Accident
Location
Kansas City, Missouri
Airport
CHARLES B WHEELER DOWNTOWN (MKC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was performing his seventh solo takeoff, when the tower controller cleared him for takeoff and told him to expedite due to other traffic. He added full throttle and looked down to check his airspeed; however, when he looked back up to the runway the airplane was left of the runway centerline. The student pilot applied right rudder and the airplane veered to the right. He then removed the right rudder input and the airplane “darted” to the left, exited the runway, and impacted a ditch and a runway sign. The airplane came to rest in the grass alongside of the runway. The airplane sustained substantial damage to the left and right wings. The student pilot reported no preaccident mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The student pilot's failure to maintain directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N227XY
Operator
ATP Flight School
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2881571
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-24T16:53:48Z guid: 192224 uri: 192224 title: CEN23LA197 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192225/pdf description:
Unique identifier
192225
NTSB case number
CEN23LA197
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-22T11:00:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-30T21:19:03.853Z
Event type
Accident
Location
Gueydan, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The two airplanes were conducting agricultural operations at a private airstrip. The pilot of the landing airplane reported that, while airborne, he noticed the departing airplane was being loaded at the tender truck. The pilot of the landing airplane estimated that he would have enough time to land and clear the runway before the departing airplane was finished loading. The pilot of the departing airplane reported that after loading, he positioned his airplane on the runway and began his takeoff roll. Meanwhile, the pilot of the landing airplane touched down in the opposite direction of the departing airplane. The pilot of the landing airplane reported that while he was slowing down on the landing roll, he looked over his airplane’s hopper and noticed the departing airplane rolling toward him. The pilot of the landing airplane attempted to veer out of the way of the departing airplane but was unsuccessful. The left wing of the landing airplane struck the left wing of the departing airplane. The landing airplane sustained substantial damage to both left wings, the fuselage, the horizontal stabilizer, and the elevator. The departing airplane sustained substantial damage to all four wings and the fuselage. Both pilots reported that there were no preimpact mechanical failures or malfunctions with the airplanes that would have precluded normal operation. Both pilots reported that neither made a radio call announcing their intentions.
Probable cause
The failure of both pilots to see and avoid each other resulting in a collision on the airstrip. Contributing was the pilots’ failure to announce their intentions over their radios as they were taking off and landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM-SCHWEIZER A/C CORP
Model
GULFSTREAM AM G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N8337K
Operator
Vincent Flying Service
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
17D
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
GULFSTREAM-SCHWEIZER A/C CORP
Model
GULFSTREAM AM G-164D
Amateur built
false
Engines
1 Turbo prop
Registration number
N8331K
Operator
Vincent Flying Service
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
16D
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-30T21:19:03Z guid: 192225 uri: 192225 title: CEN23LA256 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192428/pdf description:
Unique identifier
192428
NTSB case number
CEN23LA256
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T10:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-29T22:39:33.202Z
Event type
Accident
Location
Romeoville, Illinois
Airport
Lewis University Airport (LOT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot stated that during her initial solo flight, she attempted three landings. The first and second landing attempts resulted in go-arounds. During the third landing attempt, there was a “severe porpoise,” and she felt the airplane “rushing down the runway uncontrollably.” She “pushed down” to stop the porpoise because she felt that she was never going to be able to land. The airplane then impacted the runway surface and sustained substantial damage, which included damage to the fuselage. The pilot stated that the accident could have been prevented by performing a go-around instead of forcing the airplane onto the runway. There was no mechanical malfunction/failure of the airplane reported that would have precluded normal operation.
Probable cause
The student pilot’s failure to attain/maintain a proper landing flare and failure to perform a go-around that resulted in an impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172R
Amateur built
false
Engines
1 Reciprocating
Registration number
N674MA
Operator
Lewis University
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17280742
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-29T22:39:33Z guid: 192428 uri: 192428 title: CEN23LA199 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192228/pdf description:
Unique identifier
192228
NTSB case number
CEN23LA199
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T11:15:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-24T02:00:52.687Z
Event type
Accident
Location
Abbeville, Louisiana
Airport
ABBEVILLE CHRIS CRUSTA MEML (IYA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The check pilot and the pilot receiving instruction were performing initial new hire training for the commercial operator. The pilot previously performed three practice 180° autorotations, terminating with a power recovery. The pilot then performed a practice, straight-in, full down autorotation to touchdown on the sod area parallel to the runway. During the touchdown, the two pilots heard a “loud bang.” The helicopter came to rest upright on the sod area and both pilots were able to egress from the helicopter without further incident. A postflight inspection revealed that the main rotor blades struck the tail boom, severing the tail rotor driveshaft. The main rotor blades, the tail boom, and the tail rotor system sustained substantial damage. The operator reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. According to another helicopter manufacturer, main rotor blowback occurs when the forward portion of the helicopter’s main rotor disk is displaced upward, while the rear portion of the main rotor disk is displaced downward. If the resulting blowback is excessive, the main rotor blades may impact the tail boom. A review of the accident helicopter rotorcraft flight manual (RFM) found no information listed to provide awareness to pilots about the main rotor blowback condition.
Probable cause
The pilot’s failure to maintain proper helicopter control during autorotation that resulted in an abnormal ground contact which caused the subsequent main rotor strike on the tail boom that severed the tail rotor driveshaft. Contributing to the accident was the main rotor blowback condition, due to the aft tilting of the main rotor disk.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
407
Amateur built
false
Engines
1 Turbo shaft
Registration number
N451PH
Operator
PHI AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
54127
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-24T02:00:52Z guid: 192228 uri: 192228 title: ERA23LA244 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192236/pdf description:
Unique identifier
192236
NTSB case number
ERA23LA244
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T13:45:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-26T23:16:22.12Z
Event type
Accident
Location
Reidsville, North Carolina
Airport
Rockingham County (SIF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The solo student pilot described that, during the landing approach, there was a crosswind from the right. When the airplane touched down, it drifted to the left. The pilot attempted to correct by applying right rudder, but the airplane departed the left side of the runway and continued through a ditch, resulting in substantial damage to the empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane while landing in a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N8992J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-3016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-26T23:16:22Z guid: 192236 uri: 192236 title: CEN23LA198 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192227/pdf description:
Unique identifier
192227
NTSB case number
CEN23LA198
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T14:45:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-05-30T17:57:05.508Z
Event type
Accident
Location
Wichita, Kansas
Airport
Col. James Jabara (KAAO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported that, during taxi on taxiway A1 in a Cessna 172, a nearby turbine-powered Embraer Phenom airplane parked in the run-up area for taxiway blocked his path to the runway. After completing his pre-takeoff checklist, the student pilot radioed the Phenom crew and asked “if [he] could proceed and sneak behind them to the runway”. The Phenom crew replied, “that should be fine” and the pilot then proceeded to taxi behind the Phenom. As the Cessna taxied behind the Phenom, the jet blast lifted the airplane onto its propeller and left wing which resulted in substantial damage to the left wing. The Phenom maintenance crew reported they were conducting a high-power engine run and did not know that an airplane was trying to taxi behind them on taxiway A1. During the student pilot’s initial radio call, a turbine powered Beechjet airplane was taxiing the opposite direction on the taxiway and because the student pilot of the accident airplane did not identify himself with the airplane’s callsign, the maintenance crew assumed the radio call came from the Beechjet.
Probable cause
The pilot’s failure to maintain a safe taxi distance from a turbine-powered airplane, resulting in an encounter of the turbine-powered airplane’s jet blast while taxiing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N49RH
Operator
Wichita State University Campus of Applied Sciences and Technology
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S12932
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-30T17:57:05Z guid: 192227 uri: 192227 title: CEN23LA207 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192254/pdf description:
Unique identifier
192254
NTSB case number
CEN23LA207
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T18:00:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-09T07:37:18.388Z
Event type
Accident
Location
Fort Worth, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while enroute to his destination, a large bird impacted the airplane’s left wing, which resulted in substantial damage to the wing structure. The pilot declared an emergency and landed the airplane uneventfully at the closest airport.
Probable cause
An inflight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN
Model
AA-5
Amateur built
false
Engines
1 Reciprocating
Registration number
N1972G
Operator
Eugene L. Capone
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
AA5-0157
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-09T07:37:18Z guid: 192254 uri: 192254 title: WPR23LA200 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192242/pdf description:
Unique identifier
192242
NTSB case number
WPR23LA200
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-23T23:10:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-06T00:45:48.973Z
Event type
Accident
Location
San Diego, California
Airport
BROWN FLD MUNI (SDM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the helicopter reported that he had completed an operational mission, during which he was wearing Night Vision Goggles (NVGs), and returned to the airport. While hover taxiing to parking using the NVGs, an aircraft approaching the airport to land triggered the Traffic Collision Avoidance System (TCAS), causing the helicopter’s strobing “wig-wag” lights to activate and impact the pilot’s visibility. The pilot looked down to locate the light switch and removed his hand from the collective to deactivate the lights. The helicopter descended and contacted the ground before the pilot could stop the descent. The helicopter subsequently became airborne again and the pilot was able to regain control and continue hover taxiing to parking. Substantial damage to the tail boom was discovered after the flight. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain altitude during a hover taxi due to distraction resulting from the unanticipated activation of strobing lights while using night vision googles.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
EUROCOPTER
Model
AS 350 B3
Amateur built
false
Engines
1 Turbo shaft
Registration number
N791AM
Operator
US DEPARTMENT OF HOMELAND SECURITY
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Public aircraft - federal
Commercial sightseeing flight
false
Serial number
4335
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-06-06T00:45:48Z guid: 192242 uri: 192242 title: ERA23LA243 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192234/pdf description:
Unique identifier
192234
NTSB case number
ERA23LA243
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-25T08:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-25T22:38:52.787Z
Event type
Accident
Location
Limington, Maine
Airport
LIMINGTON-HARMON (63B)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that despite the winds being calm at the surface, shortly after departing for the accident flight he encountered gusty wind above the trees near the airport. He continued around the traffic pattern and planned to land in an area of grass next to the paved runway. During the final approach to land, a sudden gust of wind pushed the airplane to the right of the runway toward trees and a hangar. The pilot described that there was not enough time to initiate a go around before the airplane contacted a tree and then the hangar. The airplane came to rest upside down on the ground and the fuselage and both wings were substantially damaged. The pilot reported that there no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate compensation for the gusty crosswind conditions, which resulted in a collision with a tree during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
THOMPSON EDWARD
Model
LM-5X-W
Amateur built
true
Engines
1 Reciprocating
Registration number
N970CE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-25T22:38:52Z guid: 192234 uri: 192234 title: CEN23LA202 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192239/pdf description:
Unique identifier
192239
NTSB case number
CEN23LA202
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-25T10:20:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-05-26T19:48:41.149Z
Event type
Accident
Location
Wright, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that before his 12th aerial application flight of the day, the airplane was overloaded with fertilizer due to faulty ground loading equipment. Knowing the airplane was overloaded the pilot decided to dump some of the fertilizer over the grass strip during takeoff. As the airplane reached the point on the grass strip that he felt he could safely stop, the “airplane felt like it was wanting to fly” so he continued the takeoff. As the pilot turned toward the field that he intended to apply the fertilizer to, the airplane settled and impacted in a field. The airplane sustained substantial damage to both wings, empennage, and fuselage, and the engine separated from the airframe. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. No Title 14 Code of Federal Regulations Part 137 certificate was found for the operator and there was no record of a knowledge and skill test for the pilot as required by 14CFR 137.19.
Probable cause
The pilot's decision to takeoff with the airplane overloaded which resulted in the airplane settling and subsequently impacting terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164B
Amateur built
false
Engines
1 Reciprocating
Registration number
N6699Q
Operator
S & S Aviation LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
214B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-26T19:48:41Z guid: 192239 uri: 192239 title: CEN23LA203 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192240/pdf description:
Unique identifier
192240
NTSB case number
CEN23LA203
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-25T13:24:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-31T00:34:21.304Z
Event type
Accident
Location
Windsor, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While on initial climb, a bird impacted the leading edge of the vertical stabilizer. The leading edge of the stabilizer sustained substantial damage. The airplane was controllable, and the pilot executed an uneventful landing.
Probable cause
An inflight collision with a bird while on initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NANCHANG
Model
CJ6
Amateur built
false
Engines
1 Reciprocating
Registration number
N443LM
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3151214
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-31T00:34:21Z guid: 192240 uri: 192240 title: ERA23LA378 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193127/pdf description:
Unique identifier
193127
NTSB case number
ERA23LA378
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-25T18:20:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-10-17T18:20:46.119Z
Event type
Accident
Location
Savannah, Georgia
Airport
SAVANNAH/HILTON HEAD INTL (SAV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot was conducting touch-and-go takeoffs and landings. He reported that during his second landing and subsequent takeoff, he felt a vibration in the nose landing gear and decided that he would make the next landing a full stop and taxi back to the fixed base operator. During the third landing attempt the airplane touched down, the pilot heard a “snap,” as the nose landing gear settled onto the runway, and the nose landing gear then collapsed. Security video of the landing showed that the airplane landed normally, and after several seconds of landing roll, the nose landing gear collapsed and the airplane came to a stop on the runway. The airplane’s firewall, engine mounts, and lower fuselage structure were substantially damaged. The airplane was subsequently removed from the runway and stored in a hangar at the airport. The hangar later caught fire and the airplane was destroyed. An examination of the nose landing gear components could not accomplished.
Probable cause
Failure and collapse of the nose landing gear during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N177EM
Operator
AERO DAVIS LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1045
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-17T18:20:46Z guid: 193127 uri: 193127 title: WPR23LA207 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192281/pdf description:
Unique identifier
192281
NTSB case number
WPR23LA207
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-26T04:50:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-09T22:47:14.559Z
Event type
Accident
Location
Kingman, Arizona
Airport
Kingman Airport (IGM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that on a night landing the airplane touched down smoothly on the main landing gear. During the landing roll, when the nose gear touched down, the airplane’s roll out became rough and bumpy. When the airplane came to a stop, the pilot and passenger discussed that they probably had a flat nose wheel tire. Subsequently, the passenger exited the airplane to examine the nose wheel tire and observed it to be flat. The pilot told the passenger to keep clear and then attempted to taxi clear of the runway. However, at a high-power setting, the airplane only moved a few feet, and the pilot elected to discontinue the taxi. The pilot was deciding what his next move would be when the passenger approached the airplane from the front. The pilot tried to warn the passenger but subsequently, the propeller struck the passenger and resulted in a serious injury.
Probable cause
The failure of the passenger to adequately maintain a safe distance from the airplane’s propeller and the determination to let the passenger exit the airplane with the engine running.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182Q
Amateur built
false
Engines
1 Reciprocating
Registration number
N94599
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
18266458
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-06-09T22:47:14Z guid: 192281 uri: 192281 title: ERA23LA248 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192247/pdf description:
Unique identifier
192247
NTSB case number
ERA23LA248
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-26T10:58:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-06-01T15:59:04.184Z
Event type
Accident
Location
Melbourne, Florida
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the multiengine turboprop airplane was flying over the ocean at FL340 when he heard an “explosion.” He quickly donned his oxygen mask, declared an emergency with air traffic control, and descended to 12,000 ft. The pilot subsequently diverted the flight and landed the airplane uneventfully. After landing he observed that the airstair door had completely separated from the fuselage. The inflight separation of the airstair door and resulting depressurization of the airplane’s cabin constituted substantial damage to the airframe. Post accident examination of the airplane revealed that portions of the airstair door hinges remained attached to the fuselage, the airstair door handle anchor had failed, and the door damper support was bent and its upper bolt sheared. The six door plate strikers on the fuselage were undamaged. The airstair door was not recovered and the condition of its securing mechanisms could not be examined. Given this information, the reason for the inflight separation of the door could not be determined.
Probable cause
An inflight separation of the airplane’s airstair door for undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RAYTHEON AIRCRAFT COMPANY
Model
B300
Amateur built
false
Engines
2 Turbo prop
Registration number
N680CB
Operator
DALKS LEASING INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
FL-499
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-06-01T15:59:04Z guid: 192247 uri: 192247 title: CEN23LA303 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192622/pdf description:
Unique identifier
192622
NTSB case number
CEN23LA303
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-27T13:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-07-14T02:26:19.191Z
Event type
Accident
Location
Ulysses, Kansas
Airport
Ulysses Airport (ULS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while spraying a pasture at low altitude, the airplane struck a zipline cable, which resulted in substantial damage to the vertical stabilizer and rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation and that he needed to be more alert to obstacles.
Probable cause
The pilot’s failure to maintain clearance from a cable during spray operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AYRES CORPORATION
Model
S2R-G6
Amateur built
false
Engines
1 Turbo prop
Registration number
N4182G
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
G6-155
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-14T02:26:19Z guid: 192622 uri: 192622 title: WPR23LA205 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192276/pdf description:
Unique identifier
192276
NTSB case number
WPR23LA205
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-27T16:17:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-06-09T22:36:08.097Z
Event type
Accident
Location
Sugar Land, Texas
Airport
SUGAR LAND RGNL (SGR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll, shortly after rotation, he cycled the gear up. The airplane then descended and contacted the runway, which resulted in substantial damage to the lower fuselage. The flap control lever and the flaps were found in the “UP” position following the accident. Review of the Airplane Flight Manual (AFM) directed the flaps to be set to MID during the before taxi check and to check flaps MID during the before takeoff check. The AFM ALSO stated, in part, “No takeoff authorized without flaps, or with non-symmetrical flap configuration or annunciated flap asymmetry.” The pilot said he could not recall setting the flaps to “MID” position prior to takeoff. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to complete required preflight checklist items and properly configure the flaps for takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIAGGIO AERO INDUSTRIES SPA
Model
P180
Amateur built
false
Engines
2 Turbo prop
Registration number
N327A
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1158
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-09T22:36:08Z guid: 192276 uri: 192276 title: CEN23LA234 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192337/pdf description:
Unique identifier
192337
NTSB case number
CEN23LA234
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-28T13:40:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-09T01:13:37.877Z
Event type
Accident
Location
Grand Forks, North Dakota
Airport
GRAND FORKS INTL (GFK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and his student were performing a soft field take off following a touch-and-go landing. The operator reported that the airplane started to drift to the left with a “higher than normal” pitch attitude and the airplane encountered a wind gust. The right wing dropped and contacted the runway surface. According to the flight instructor, during the take-off, the student “instantly” applied right aileron, instead of right rudder, to maintain the runway centerline. The flight instructor took over controls and continued the takeoff. While in the traffic pattern, the flight instructor noticed an “abnormality” on the right wing and landed the airplane without further incident. A visual inspection found that the right aileron sustained substantial damage. The operator stated that there were no mechanical malfunctions or failures that would have precluded normal operation. About the time of the accident wind was recorded as 160° at 17 knots with gusts to 29 knots.
Probable cause
The student pilot’s failure to attain a proper takeoff attitude while demonstrating a soft field takeoff and his improper control inputs resulting in a dragged wing. Contributing to the accident were the gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N771ND
Operator
UNIVERSITY OF NORTH DAKOTA
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
2881036
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-09T01:13:37Z guid: 192337 uri: 192337 title: ANC23LA041 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192349/pdf description:
Unique identifier
192349
NTSB case number
ANC23LA041
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-28T17:00:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-11T19:20:16.36Z
Event type
Accident
Location
McGrath, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was attempting to depart from an off-airport location. He normally departed downhill into the wind, but the wind direction had shifted. He elected to depart up the hill into the wind. At the end of the runway the airplane lifted off the ground but was not climbing fast enough to avoid the rising terrain. The pilot chose to land, the airplane touched down on the tundra and nosed down. The airplane sustained substantial damage to the wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s delayed decision to abort the takeoff, which resulted in a forced landing and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N7712H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-604
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-06-11T19:20:16Z guid: 192349 uri: 192349 title: WPR23LA204 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192268/pdf description:
Unique identifier
192268
NTSB case number
WPR23LA204
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-28T17:43:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-02T01:07:34.801Z
Event type
Accident
Location
Enterprise, Utah
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The airplane departed a private dirt strip in mountainous terrain with a left quartering headwind. During the initial climb, the pilot retracted the flaps from to 20º to 10º to improve the airplane’s acceleration. There was no change in airspeed, so he retracted the flaps completely and the airplane began a descent. He then extended the flaps back to 10º and initiated a shallow right turn to maneuver away from rising terrain, but the airplane did not climb. The pilot applied a nose down attitude to prevent a stall and the airplane impacted terrain and nosed over, in which the right wing sustained substantial damage. The pilot suspected he had flown into a downdraft after taking off and reported there were no mechanical failures or malfunctions to the airplane or engine that would have precluded normal operation.
Probable cause
The pilot’s inability to maintain altitude during an initial climbout in mountainous terrain after encountering a suspected downdraft.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
175A
Amateur built
false
Engines
1 Reciprocating
Registration number
N5089
Operator
GIFFORD DAVID M
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
56756
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-02T01:07:34Z guid: 192268 uri: 192268 title: ANC23LA039 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192272/pdf description:
Unique identifier
192272
NTSB case number
ANC23LA039
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-29T09:30:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-08T21:05:52.885Z
Event type
Accident
Location
Fairbanks, Alaska
Airport
Chena River Seaplane Base (2Z5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during approach in a float-equipped airplane, she encountered a strong gust of wind and the airspeed decreased, so she increased engine power. Before touchdown, she felt the airspeed was too fast, she selected full flaps and reduced engine power. The airplane veered left, and the pilot attempted to correct with opposite rudder and increased engine power; however, the airplane water looped to the left and impacted a riverbank, which resulted in substantial damage to the right wing. The pilot landed the airplane with a right quartering tailwind. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing with a quartering tailwind, which resulted in a water loop and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N4488Z
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
18-8843
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-08T21:05:52Z guid: 192272 uri: 192272 title: CEN23LA209 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192259/pdf description:
Unique identifier
192259
NTSB case number
CEN23LA209
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-29T12:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-05-31T20:33:04.624Z
Event type
Accident
Location
Lodi, Wisconsin
Airport
Lodi Lakeland (9WN5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during takeoff from a grass runway, a sudden wind gust from the rear caused the airplane to weathervane to the right and lose lift. The pilot was unable to correct for the gust before the airplane impacted the ground and nosed over. Both wings and the empennage were substantially damage during the nose over. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident, the pilot was taking off on runway 27 with wind from 150° at 6 knots.
Probable cause
The pilot’s failure to maintain control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KOLB
Model
Firestar SS
Amateur built
true
Engines
1 Reciprocating
Registration number
N994TA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
456
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-31T20:33:04Z guid: 192259 uri: 192259 title: CEN23LA212 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192278/pdf description:
Unique identifier
192278
NTSB case number
CEN23LA212
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-29T12:30:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-01T21:01:45.792Z
Event type
Accident
Location
Light, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that on departure, the airplane settled to the ground and struck a levee. The airplane came to rest upside down in a field about 100 feet from the point of impact. The airplane sustained substantial damage to the wings, fuselage, horizontal stabilizer, and vertical stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The accident occurred shortly after takeoff from a private turf/dirt strip used only for agricultural operations. The pilot reported that the airplane was about 320 pounds below its maximum gross weight of 6,070 lbs., that the density altitude at the time of the accident was about 2,000 feet msl, and that he turned “a little premature” after taking off with a full load of fertilizer.
Probable cause
The pilot exceeding the climb capability of the airplane during takeoff which led to it settling into the ground.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164B
Amateur built
false
Engines
1 Reciprocating
Registration number
N6678Q
Operator
HDS INC
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
199B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-01T21:01:45Z guid: 192278 uri: 192278 title: WPR23LA206 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192279/pdf description:
Unique identifier
192279
NTSB case number
WPR23LA206
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-29T13:00:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-06-02T00:04:15.567Z
Event type
Accident
Location
Santa Teresa, New Mexico
Airport
Dona Ana County International Jetport Airport (DNA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported winds at the airport were 6 gusting to 13 knots, 30 degrees from runway heading during the approach to landing. Upon touchdown, the airplane began to bounce, and she felt a strong crosswind pushing her to the right. She elected to initiate a go-around, however, the right wing lifted, and the left wing impacted the ground. The left main landing gear collapsed, and the airplane ground looped. The left wing and aileron sustained substantial damage. The pilot reported there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot stated the airport experiences dust devils frequently and often they are not visible. A review of the Federal Aviation Administration (FAA) Weather Handbook (FAA-H-8083-28) and the FAA Aeronautical Information Manual found no detailed information listed about dust devils or the potential hazards of flying through dust devils.
Probable cause
The pilot’s loss of control after encountering a dust devil during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140A
Amateur built
false
Engines
1 Reciprocating
Registration number
N1126D
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15675
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-02T00:04:15Z guid: 192279 uri: 192279 title: CEN23LA210 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192271/pdf description:
Unique identifier
192271
NTSB case number
CEN23LA210
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-30T08:44:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-05-31T23:42:49.582Z
Event type
Accident
Location
St. Anthony, North Dakota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that while conducting wildlife damage management activities under contract with the U.S. Department of Agriculture, he entered a right 180-degree turn in order to reverse direction and position the airplane. The airplane heading prior to the turn was into a slight right quartering headwind and required a climb due to up-sloping terrain. About 160 degrees into the right turn, the right quartering headwind became a left quartering tailwind. The airplane descended and contacted the ground. On contact, the nose of the airplane pitched forward and struck the ground. The airplane then bounced, cartwheeled, and came to rest approximately 105 ft from the initial ground contact, resulting in substantial damage to the fuselage, both wings, and the empennage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from terrain while maneuvering at low attitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N7343L
Operator
AIR DAKOTA FLITE INC
Second pilot present
false
Flight conducted under
Public aircraft
Flight operation type
Public aircraft - federal
Commercial sightseeing flight
false
Serial number
18-7509049
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-05-31T23:42:49Z guid: 192271 uri: 192271 title: ERA23LA259 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192325/pdf description:
Unique identifier
192325
NTSB case number
ERA23LA259
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-30T11:07:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-06-07T18:51:02.783Z
Event type
Accident
Location
Miami, Florida
Airport
MIAMI EXEC (TMB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was conducting his first solo flight and the airplane was high on the final leg of the approach to land. He attempted to correct by reducing the engine power to idle. When he initiated the landing flare, the airplane bounced on initial touchdown and then porpoised on the runway. The underside of the fuselage sustained substantial damage during the landing. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper landing flare, which resulted in substantial damage the airplane’s fuselage.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N2447B
Operator
SILVER EXPRESS CO
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17280801
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-07T18:51:02Z guid: 192325 uri: 192325 title: WPR23LA209 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192303/pdf description:
Unique identifier
192303
NTSB case number
WPR23LA209
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-30T15:05:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-06-06T04:07:36.835Z
Event type
Accident
Location
Santa Fe, New Mexico
Airport
Santa Fe Municipal Airport (SAF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he experienced severe turbulence within about 10 miles of the airport as he was approaching to land. He further reported that during the landing, the airplane encountered a downdraft and bounced on touchdown. The airplane exited the runway to the left onto adjacent grass area and nosed over, resulting in substantial damage to the right wing. The pilot reported there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation during landingPlease ensure you take into account the entirety of the pilot’s statement. Your initial narrative was not wrong, but it lacked the details necessary to paint a complete picture of what happened. The pilot’s narrative was pretty clear that nothing was wrong with the airplane during the landing. However, he checked the “yes” box on the 6120 that there was a mechanical issue. That was probably due to the loss of engine power that he corrected. If you see this kind of contradiction in a 6120 you should either reinterview the pilot and verify that nothing was wrong at the time of the accident or ask him to resubmit a 6120 with the box checked NO. .
Probable cause
An encounter with a downdraft during landing that resulted in the pilot’s loss of control.As stated above, the initial PC was not incorrect, but it didn’t paint an accurate picture of what really happened.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPISTREL DOO AJDOVSCINA
Model
VIRUS SW
Amateur built
false
Engines
1 Reciprocating
Registration number
N69PV
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
709 SWN 100
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-06-06T04:07:36Z guid: 192303 uri: 192303 title: CEN23LA219 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192275/pdf description:
Unique identifier
192275
NTSB case number
CEN23LA219
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-31T14:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-12T17:41:58.981Z
Event type
Accident
Location
Pontiac, Michigan
Airport
OAKLAND COUNTY INTL (PTK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
A flight instructor and a private pilot receiving instruction were performing a hovering maneuver as part of a flight lesson. During an exchange of the flight controls, a gust of wind moved the helicopter backward. The flight instructor reassumed control of the helicopter, but the tail rotor assembly struck the ground and separated from the helicopter. He then performed a hovering autorotation, the helicopter landed upright on its skids and the occupants egressed the helicopter without injury. The ground strike resulted in substantial damage to the tailboom assembly. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The flight crew’s inadequate compensation for gusting wind, and the flight instructor’s delayed remedial action, which resulted in impact with the ground.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N7102Z
Operator
MICHIGAN HELICOPTERS LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2309
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-12T17:41:58Z guid: 192275 uri: 192275 title: CEN23LA228 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192317/pdf description:
Unique identifier
192317
NTSB case number
CEN23LA228
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-05-31T18:30:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-06-06T17:51:13.804Z
Event type
Accident
Location
Saffell, Arkansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that shortly after takeoff on an aerial application flight to apply fertilizer to rice fields in a remote area the airplane unknowingly flew through a dust devil (also called a whirlwind), and subsequently lost lift. The pilot estimated the dust devil was between 8 to 10 ft in diameter and reported no visible debris. The airplane subsequently impacted a dirt ditch, nosed over, and came to rest inverted. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the engine mount, the fuselage, both wings, and the empennage. The operator reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. The pilot reported that he had encountered several dust devils in earlier flights that day for the operating area. The pilot did not perform a hopper load dump during the accident sequence, as he reported flying the airplane was the priority. A review of the Federal Aviation Administration Aviation (FAA) Weather Handbook (FAA-H-8083-28) and the FAA Aeronautical Information Manual found no detailed information listed about dust devils or the potential hazards of flying through dust devils.
Probable cause
The airplane’s encounter with a dust devil after takeoff, which resulted in a loss of lift, and a subsequent loss of control. Contributing to the accident was the presence of a dust devil in the airplane’s flight path.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164
Amateur built
false
Engines
1 Turbo prop
Registration number
N8405K
Operator
MJ AVIATION INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
688B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-06T17:51:13Z guid: 192317 uri: 192317 title: CEN23LA216 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192284/pdf description:
Unique identifier
192284
NTSB case number
CEN23LA216
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-01T08:28:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-06-13T18:20:24.398Z
Event type
Accident
Location
Sugar Grove, Illinois
Airport
Aurora Municipal Airport (ARR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and student pilot intended to complete a cross-country flight. During the takeoff roll, the student pilot pitched the nose up to 15° then lowered it to 5° upon request of the instructor. As the takeoff roll continued, the student abruptly applied right rudder and again increased the pitch attitude. The airplane veered to the right and became airborne off the right side of the runway. The instructor took control of the airplane as it began to stall about 20 ft. above ground level. The airplane bounced and the propeller struck the ground, then it porpoised, and came to rest in a field about 1,000 ft. from the runway. The landing gear collapsed, and the elevator sustained substantial damage. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper flight control inputs and the flight instructor’s delayed remedial action during takeoff, which resulted in a runway excursion and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
REMOS AIRCRAFT GMBH
Model
G-3/600
Amateur built
false
Engines
1 Reciprocating
Registration number
N133LS
Operator
Simply Fly
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
217
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-13T18:20:24Z guid: 192284 uri: 192284 title: CEN23LA215 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192283/pdf description:
Unique identifier
192283
NTSB case number
CEN23LA215
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-01T11:03:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-02T00:22:33.716Z
Event type
Accident
Location
Forest Lake, Minnesota
Airport
FOREST LAKE (25D)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported on that he deliberately flew a high approach to land as he had experienced a high sink rate on previous flights. About 1/3 the way down the runway and despite being “ready for it” the pilot experienced a high sink rate as the airplane was about 30 feet off the ground. The airplane impacted the runway and bounced, upon impacting the runway a second time, the airplane remained on the ground, but the pilot reported a “total loss” of rudder control and the aircraft veered off the left side on the runway and came to rest into a ditch. The landing gear collapsed and the forward fuselage was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during the approach to land that resulted in an excessive descent rate and impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ZENITH
Model
750
Amateur built
true
Engines
1 Reciprocating
Registration number
N827LC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
11167
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-02T00:22:33Z guid: 192283 uri: 192283 title: DCA23LA304 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192290/pdf description:
Unique identifier
192290
NTSB case number
DCA23LA304
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-01T17:32:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-06-13T17:18:54.707Z
Event type
Accident
Location
Houston, Texas
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
A flight attendant was seriously injured when United Airlines flight 1288 encountered low-topped convectively-induced turbulence during a descent into the George Bush Intercontinental Houston Airport (IAH), Houston, Texas. Flight 1288 originated from Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland. The captain was the pilot monitoring, and the first officer was the pilot flying. The flight crewmembers reported that during preflight planning, the weather briefing and dispatch-provided flight papers were normal, with no turbulence concerns or convective weather issues noted. The captain briefed the flight attendants that the ride was expected to be good, and normal inflight service could be expected. During the flight, the flight crewmembers observed some weather building up along their route along the Kentucky-Tennessee border. To avoid this weather, they planned a different route, consulted with their dispatcher, and received a new route south of the building storms. As the flight was approaching the Houston terminal area, the flight crew briefed the descent and anticipated approach into IAH including a review of the weather. They indicated there were no pilot reports (PIREPS), significant meteorological information (SIGMETS), or other warnings issued for the area approaching IAH. After starting the descent, they turned the seatbelt sign on at 18,000 feet and advised the passengers via the passenger announcement (PA) system to remain seated for the rest of the flight. The flight crewmembers reported that they were in visual flight rules (VFR) conditions for the descent with a scattered cumulus layer below them around 10,000 - 13,000 feet mean sea level (MSL). No buildups were towering over them and the visibility above the scattered cumulus layer below them was good. They hadn’t received any reports of turbulence and fully expected their descent to be normal. At this time, they had not yet given the final double bell signal (indicating that the flight was approaching 10,000 feet) to the flight attendants. Just as they entered the cumulus area around 13,000 MSL it became apparent they were going to go directly through one of the cumulus clouds. Entering the cloud layer, the flight encountered brief turbulence. The flight crew classified the turbulence as being moderate and indicated that it only lasted for a few seconds. When the turbulence was encountered, two flight attendants in the aft galley, who were preparing to begin their initial descent procedures, were knocked to the floor. As one FA propped herself up into a seated position so she could get up and take her jump seat, a second encounter with turbulence occurred and she was tossed into the air. She landed directly on her tailbone, injuring her spine, and resulting in severe pain in her lower back. Shortly thereafter, the captain made a PA for the flight attendants to take their Jump seats. He did not use the phrase, “flight attendants be seated immediately,” because the event was over before he could grab the PA to make that announcement. Approaching 10,000 feet, the flight crew received a call from the cabin advising them that two of the flight attendants might have been injured. Passing through 10,000 feet, the captain rang the double chime and heard the purser make a passenger announcement that the flight attendants would remain seated for the rest of the flight and asked the passengers to stow all items and return their seats to the upright positions. Shortly thereafter, the flight crew received another call from the cabin advising them that one of the Flight Attendants' injuries was more severe and may require paramedics to meet the flight at the gate. Emergency medical personnel met the airplane at the gate and treated the injured flight attendant. A post-flight medical evaluation revealed that the flight attendant was diagnosed with a “spinal compression fracture.” Based on a review of weather radar (KHGX), satellite (GOES-16), and upper air model data (HRRR), the turbulence encounter was generally coincident in time and location with low-topped convective activity that reached heights above 12,000 feet. Based on the Automatic dependent surveillance-broadcast (ADS-B) data at the time of the accident, the aircraft did not look to be inside a convective updraft but was operating close to the updrafts. There was no other source of turbulence (e.g., clear-air turbulence, mountain wave turbulence) present.
Probable cause
An encounter with convectively-induced turbulence (CIT).
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS INDUSTRIE
Model
A320-232
Amateur built
false
Engines
2 Turbo fan
Registration number
N479UA
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
1538
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-06-13T17:18:54Z guid: 192290 uri: 192290 title: DCA23LA305 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192293/pdf description:
Unique identifier
192293
NTSB case number
DCA23LA305
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-01T18:06:00Z
Publication date
2023-10-16T04:00:00Z
Report type
Final
Last updated
2023-06-13T17:18:10.335Z
Event type
Accident
Location
Chicago, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
A flight attendant was seriously injured when United Airlines flight 1734 encountered convectively-induced turbulence during the descent into the Chicago O'Hare International Airport (ORD), Chicago, Illinois. Flight 1734 originated from the San Francisco International Airport (SFO) and the captain was the pilot monitoring and the first officer was the pilot flying. The flight crewmembers reported that they were not aware of any adverse reports of turbulence from either air traffic control (ATC), or other aircraft and they found the route along the arrival path to be generally smooth. Their weather radar was on and showed some cells located to the west of ORD, but none were along either their arrival route, the airport itself, or the area east of ORD where they conducted their approach to landing. When they first checked in with the Chicago approach controller, they were assigned runway 27R. However, they preferred a longer runway due to their landing weight and were therefore assigned runway 28C which they had to load into the flight management computer and re-brief. The captain indicated that the seat belt sign had been turned on early in the descent during the “arrival” passenger announcement. About 13,000 ft, the captain gave the cabin crew the “double chime” indicating that they should prepare the cabin for landing and then take their seats. The flight crewmembers reported that as the aircraft was descending through an isolated overcast layer, they observed a small cloud buildup with the top of the buildup slightly above their altitude. They contacted ATC and requested and were approved to make a left turn to avoid the cloud build-up. Although they attempted to avoid the cloud, the aircraft penetrated the left outermost area of the cloud buildup at an altitude of approximately 12,100 ft. The flight crewmembers indicated that as they went through this area, they experienced about 5 seconds of light to borderline moderate turbulence. As soon as they exited the area, the air was once again smooth. Shortly after the encounter, the flight crewmembers received a call from the cabin crew informing them that one of the flight attendants had fallen in the rear galley and had injured her foot. According to the cabin crew, shortly after they heard the double chime, there was a big bump of turbulence, and a flight attendant lost her balance, twisted her ankle, and hit her back on the corner of her jump seat. A physician who was onboard the airplane assisted her and helped move her to a passenger seat for the remainder of the flight. Emergency medical personnel met the airplane at the gate and a post-flight medical evaluation revealed that the flight attendant had a fracture injury to her metatarsal bone in the left foot. Based on a review of WSR-88Dweather radar (KMKX), satellite (GOES-16), and upper air model (HRRR) data, the turbulence encounter appeared generally coincident in time and location with a convective updraft that reached heights above 12,100 ft.
Probable cause
An encounter with convectively-induced turbulence (CIT).
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-924ER
Amateur built
false
Engines
2 Turbo fan
Registration number
N28457
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
41744
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-06-13T17:18:10Z guid: 192293 uri: 192293 title: CEN23LA225 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192312/pdf description:
Unique identifier
192312
NTSB case number
CEN23LA225
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-02T09:20:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-06T01:31:59.651Z
Event type
Accident
Location
Flippin, Arkansas
Airport
MARION COUNTY RGNL (FLP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll, the airplane veered toward the left edge of the runway. The pilot attempted to abort the takeoff and reduced engine power to idle; however, the pilot continued to hold the aircraft in a nose-high attitude and the airplane became airborne. The airplane flew over the taxiway and impacted terrain adjacent to the taxiway. The impact collapsed the main and nose gear and caused the right wingtip to strike the ground. Post accident examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector noted tire marks on the runway that veer to the left and are in-line with the aircraft’s direction, with a darker mark on the left. The inspector examined the airplane’s brakes and found that both functioned normally. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's loss of directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SKYKITS CORP
Model
SAVANNAH VGW
Amateur built
true
Engines
1 Reciprocating
Registration number
N341JD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
08-11-51-788
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-06T01:31:59Z guid: 192312 uri: 192312 title: CEN23LA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192334/pdf description:
Unique identifier
192334
NTSB case number
CEN23LA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T10:00:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-06-13T00:49:24.399Z
Event type
Accident
Location
Carrington, North Dakota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 3, 2023, about 0900 central daylight time, a Piper PA-25-235 airplane, N8843L, was substantially damaged when it was involved in an accident near Carrington, North Dakota. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. According to the pilot, after engine start, he taxied to the end of the runway to perform an engine run-up and allow the oil temperature to rise. During the run-up, the pilot checked the magnetos and turned on the carburetor heat. During the carburetor heat check, he noted an expected drop in rpm and then turned off the carburetor heat. He stated that he remained on the ground about 10 minutes at idle power waiting for a rise in oil temperature and reduction in oil pressure since it was the first flight of the day and the engine was cold. The pilot stated that shortly after departure while turning onto the crosswind leg of the traffic pattern, the engine lost power, and he executed a forced landing to a gravel road. During landing, the airplane impacted a drainage ditch, which resulted in substantial damage to both wings. During a postaccident examination, no preimpact mechanical malfunctions or failures were discovered that would have precluded normal operation. The temperature (75°F) and dewpoint (62°F) about the time of the accident were plotted on a carburetor icing probability chart, which showed that the airplane was operating in an environment conducive for serious carburetor icing at a glide power setting. (See figure.) Figure. Carburetor Icing Probability Chart. Reference: FAA Special Airworthiness Information Bulletin CE-09-35 -
Analysis
The pilot reported that after engine start, taxi, and run-up, he remained on the ground about 10 minutes at idle power waiting for a rise in oil temperature and reduction in oil pressure since it was the first flight of the day, and the engine was cold. Shortly after departure while turning onto the crosswind leg of the traffic pattern, the engine lost power and the pilot executed a forced landing to a gravel road. During landing, the airplane impacted a drainage ditch, which resulted in substantial damage to both wings. A review of meteorological information revealed that the airplane was operating in an environment conducive to serious carburetor icing at a glide power setting. During a postaccident examination, no preimpact mechanical malfunctions or failures were discovered that would have precluded normal operation. With no anomalies noted from the postaccident examination and the weather conditions present at the time of the accident, it is likely that carburetor ice formed during the extended ground run at idle power while the pilot waited for the oil temperature to rise.
Probable cause
A total loss of engine power as a result of carburetor ice that formed while the engine was operating at a low power setting for an extended period of time before departure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-25-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N8843L
Operator
POLRIES LARRY J
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
25-5354
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-13T00:49:24Z guid: 192334 uri: 192334 title: WPR23LA210 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192304/pdf description:
Unique identifier
192304
NTSB case number
WPR23LA210
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T11:15:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-06T01:07:55.021Z
Event type
Accident
Location
Prescott, Arizona
Airport
PRESCOTT RGNL - ERNEST A LOVE FLD (PRC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during a discovery flight, he allowed the passenger to assume control of the airplane and guided her through various maneuvers. The passenger remained in control until reaching short final of the landing. The pilot noticed that the approach was slow and steep, prompting him to take control. He executed an early round-out maneuver and flare, but realized the airplane was too high and was responding poorly, leading him to initiate a go-around procedure. Right before he could increase the power, the left wing experienced an aerodynamic stall and dropped, resulting in contact with the runway. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in an aerodynamic stall. Contributing to the accident was his delayed decision to initiate a go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N249K
Operator
LEIGHNOR AIRCRAFT LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S12830
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-06T01:07:55Z guid: 192304 uri: 192304 title: WPR23LA214 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192309/pdf description:
Unique identifier
192309
NTSB case number
WPR23LA214
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T11:34:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-06T21:58:58.641Z
Event type
Accident
Location
Filer, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot initially reported that while he was taking off, the tail dropped and hit the ground. After a postaccident review of a security video that captured the accident, the pilot along with his flight instructor concluded that he input excessive left anti-torque pedal as he increased collective. A National Transportation Safety Board review of the same security video showed the helicopter as it rotated counterclockwise about its vertical axis. The fuselage pivoted about the right skid and the helicopter exceeded its critical roll angle, which resulted in dynamic rollover. The helicopter sustained substantial damage to the fuselage and tailboom. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operations.
Probable cause
The pilot’s improper anti-torque pedal inputs during takeoff, which resulted in a loss of helicopter control during takeoff and subsequent dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N205PA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1996
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-06T21:58:58Z guid: 192309 uri: 192309 title: WPR23LA211 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192305/pdf description:
Unique identifier
192305
NTSB case number
WPR23LA211
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T11:40:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-06T00:33:17.408Z
Event type
Accident
Location
Paul, Idaho
Airport
Rocky Ridge (n/a)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that during the takeoff roll, the airplane began to drift to the right. He applied left rudder correction; however, the airplane continued to drift right and exited the runway. The airplane continued over a small hill and became airborne. The pilot applied full power to maintain flight, and within a short distance, realized that the airplane was in an unusual attitude. He lowered the airplane’s nose, and the airplane contacted the ground. The left main landing gear and spreader separated from the airframe and the airplane came to rest upright, perpendicular to the runway. The left wing and aileron were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control on the takeoff roll, resulting in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ROCKWELL INTERNATIONAL
Model
S-2R
Amateur built
false
Engines
1 Turbo prop
Registration number
N4894X
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
2079R
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-06T00:33:17Z guid: 192305 uri: 192305 title: CEN23LA230 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192323/pdf description:
Unique identifier
192323
NTSB case number
CEN23LA230
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T14:00:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-06-07T23:41:41.671Z
Event type
Accident
Location
Rutherfordton, North Carolina
Airport
RUTHERFORD COUNTY/MARCHMAN FLD (FQD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported he was performing a 3-point landing with a right 90° crosswind. During the landing, the tailwheel began to "shimmy." The pilot applied forward control stick pressure to reduce weight on the tailwheel and attempt to alleviate the shimmy but did not have enough airspeed to lift the tail and correct the shimmy. The pilot reported that as airspeed decayed, he applied full “aft stick” and full left rudder, but the airplane continued to drift to the right. In an attempt to prevent a runway excursion, the pilot applied the wheel brakes and the airplane nosed over. The airplane sustained substantial damage to the rudder and damage to the propeller, spinner and cowling. The pilot reported that postaccident examination of the tailwheel locking mechanism revealed that it was worn and would not lock to the right. Loose tail wheel attachment hardware was also noted. The condition of the tailwheel should have been checked during the last annual inspection; however, it is possible that the locking mechanism could have worn further during the 7 months between the most recent inspection and the accident flight. At the time of the accident the airplane was landing on runway 01 with wind 060° at 8 knots.
Probable cause
The disengagement of the tailwheel locking mechanism during the landing roll which resulted in a loss of directional control during landing with a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CHAMPION
Model
7KCAB
Amateur built
false
Engines
1 Reciprocating
Registration number
N5068X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
151
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-07T23:41:41Z guid: 192323 uri: 192323 title: WPR23LA362 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193470/pdf description:
Unique identifier
193470
NTSB case number
WPR23LA362
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T14:05:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-12-05T01:48:27.119Z
Event type
Accident
Location
Minden, Nevada
Airport
MINDEN-TAHOE (MEV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the glider reported that while on downwind, the tow airplane maneuvered to avoid another aircraft, which resulted in a slack tow line. The tow line subsequently broke, and the glider pilot initiated a landing to a nearby runway from about 900 ft above ground level (agl). During the landing roll, the glider drifted right, and the right wing impacted a taxiway sign, which resulted in substantial damage to the wing spar. The pilot reported that there were no preaccident mechanical malfunctions or failures with the glider that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll, resulting in an impact with a taxiway sign.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
LET
Model
L-23 SUPER BLANIK
Amateur built
false
Registration number
N438BA
Operator
CIVIL AIR PATROL
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
029016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-05T01:48:27Z guid: 193470 uri: 193470 title: CEN23LA222 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192302/pdf description:
Unique identifier
192302
NTSB case number
CEN23LA222
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-03T19:00:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-06-15T01:43:18.77Z
Event type
Accident
Location
Garden Plain, Kansas
Airport
Yoder Airpark (SN61)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During the landing roll on a grass runway, the airplane decelerated quicker than the pilot expected, pulled to the right, and nosed over which resulted in a ground loop. The right lower wing and right elevator were substantially damaged during the ground loop. Postaccident examination of the airplane showed that the right main landing gear wheel inner tube and tire was likely flat prior to landing due to an undetected cut in the inner tube. The flat tire resulted in wheel pant fairing to contact the grass runway and the airplane became uncontrollable. Following the accident, the inner tube was inflated by the pilot and an audible leak was observed from the cut rubber area. The pilot reported that the tube was replaced during last the condition inspection, and it was unknown what caused the cut in the inner tube.
Probable cause
The pilot’s inability to maintain directional control during landing roll due to a flat tire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PITTS
Model
S-2S
Amateur built
false
Engines
1 Reciprocating
Registration number
N1PW
Operator
WELKIN AERO INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1004
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-15T01:43:18Z guid: 192302 uri: 192302 title: WPR23LA212 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192307/pdf description:
Unique identifier
192307
NTSB case number
WPR23LA212
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-04T10:05:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-07T00:21:17.739Z
Event type
Accident
Location
Colusa, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported this was the eighth aerial application flight of the day spraying rice fields. He had made all takeoff’s flying low under a power line about 3/4 mile from the departure end of the runway. He stated that due to the monotony of the flights combined with fatigue and a bi-plane wing configuration, he lost sight of the power line and struck it. The airplane impacted the ground and cartwheeled sustaining substantial damage to the wings, fuselage, vertical and horizontal stabilizer. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain clearance from a power line during a low-level aerial applicationflight. Contributing to the accident was the pilot’s fatigue.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN ACFT ENG COR-SCHWEIZER
Model
G-164B
Amateur built
false
Engines
1 Reciprocating
Registration number
N6750K
Operator
Valley Air
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
449-B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-07T00:21:17Z guid: 192307 uri: 192307 title: ANC23LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192329/pdf description:
Unique identifier
192329
NTSB case number
ANC23LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-04T11:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-08T01:54:07.282Z
Event type
Accident
Location
Anchorage, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, while conducting an off airport landing to a sand bar, the airplane landed beyond the intended landing point. During the landing roll on soft terrain, the pilot applied heavy braking and the airplane nosed over. The airplane sustained substantial damage to the right wing, right-wing lift strut and rudder. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's excessive braking during landing on a sand bar, which resulted in a noseover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18-150
Amateur built
false
Engines
1 Reciprocating
Registration number
N83330
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-7609080
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-08T01:54:07Z guid: 192329 uri: 192329 title: ERA23LA257 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192322/pdf description:
Unique identifier
192322
NTSB case number
ERA23LA257
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-04T15:50:00Z
Publication date
2023-07-07T04:00:00Z
Report type
Final
Last updated
2023-06-12T17:10:49.355Z
Event type
Accident
Location
Charlotte Amalie, Caribbean Sea
Airport
Cyril E King Airport (TIST)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The operator reported that while entering the traffic pattern for landing, the pilot saw a large bird and attempted to take evasive action, but the airplane and the bird collided. The bird entered the cabin through the right windscreen and struck two passengers. One passenger sustained serious injuries while the other passenger incurred minor injuries. The pilot declared an emergency and subsequently landed the airplane uneventfully. The operator reported that there were no preaccident mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
An in-flight collision with a bird while entering the traffic pattern.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
402
Amateur built
false
Engines
2 Reciprocating
Registration number
N7037E
Operator
HYANNIS AIR SERVICE INC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
402C0471
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-06-12T17:10:49Z guid: 192322 uri: 192322 title: ERA23LA269 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192379/pdf description:
Unique identifier
192379
NTSB case number
ERA23LA269
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-05T16:47:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-06-20T19:53:33.537Z
Event type
Accident
Location
Orlando, Florida
Airport
Orlando Executive Airport (ORL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a test flight following a maintenance event, the pilot of the helicopter took off and navigated to a landing zone near the airport. He conducted a normal landing and hover flight without incident for about 5 minutes. The pilot then took off again, climbed to about 600 ft mean sea level, and initiated a straight-in practice autorotation. About 50 ft above ground level (agl), he started the landing flare, while “simultaneously fully rolling on throttle all the way.” As the helicopter approached 15-20 ft agl, the helicopter was level, forward momentum slowed, and “it became clear the helicopter was struggling to maintain lift and we began settling.” Subsequently, he held the controls as still as possible and attempted to maintain level attitude, however, the helicopter landed hard in the grass. The tail boom sustained substantial damage. There pilot reported that there were no preimpact mechanical malfunctions or failures of the helicopter that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare during a practice autorotation, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N27UK
Operator
The Heli Team
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
1871
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-20T19:53:33Z guid: 192379 uri: 192379 title: CEN23LA229 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192321/pdf description:
Unique identifier
192321
NTSB case number
CEN23LA229
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-05T19:00:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-09T07:34:14.276Z
Event type
Accident
Location
Salem, Wisconsin
Airport
Private (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that she landed hard on the left main landing gear, which resulted in the landing gear collapse. The left wing contacted the ground, and the airplane spun 180°. A post- accident inspection revealed that there was substantial damage to the left wing. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare, which resulted in a hard landing and the left main landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N42220
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
14470
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-09T07:34:14Z guid: 192321 uri: 192321 title: DCA23FM034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192327/pdf description:
Unique identifier
192327
NTSB case number
DCA23FM034
Transportation mode
Marine
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-07T10:52:00Z
Publication date
2024-03-07T05:00:00Z
Report type
Final
Last updated
2024-03-01T05:00:00Z
Location
Tall Timbers, Maryland
Injuries
0 fatal, 0 serious, 1 minor
Probable cause
None. Close out memo
Has safety recommendations
false

Vehicle 1

Vessel name
Rec Vessels
Vessel type
Yacht
Flag state
USA
Findings

Vehicle 2

Vessel name
Valmara
Vessel type
Yacht
Port of registry
Tall Timbers, Maryland
Flag state
USA
Findings
creator: NTSB last-modified: 2024-03-01T05:00:00Z guid: 192327 uri: 192327 title: WPR23LA222 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192345/pdf description:
Unique identifier
192345
NTSB case number
WPR23LA222
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-07T15:45:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-12T19:45:25.515Z
Event type
Accident
Location
Wishram, Washington
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, the intent for the flight was to conduct several aerial surveys of large fields. The flight departed with 37 gallons of fuel onboard intended for the 4-hour flight. A diversion was made due to scattered rain showers to wait for weather conditions to improve to the requirements for aerial photography. The engine lost total power about 9 miles from the intended destination. He realized he would be unable to land at his intended destination due to the airplane’s altitude and distance from it, so he performed an off airport forced landing in a field. The airplane touched down and rolled over inverted in a ravine sustaining substantial damage to the fuselage, vertical stabilizer, left wing and right aileron. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s improper fuel management, which resulted in fuel exhaustion and a total loss ofengine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N7155F
Operator
JR Imaging Logistics Inc.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
15063755
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-12T19:45:25Z guid: 192345 uri: 192345 title: WPR23LA221 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192343/pdf description:
Unique identifier
192343
NTSB case number
WPR23LA221
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-08T15:00:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-10T00:55:44.894Z
Event type
Accident
Location
Bend, Oregon
Airport
Bend Municipal (KBND)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while taxiing, after using a self-serve fuel station, the airplane’s left wing-tip fuel tank struck a post at the fuel station and a fire ignited. The pilot shut down the airplane’s engines and disembarked the airplane with his passenger. The left wing and fuselage were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from the fuel station, resulting in a ground collision and fire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
340A
Amateur built
false
Engines
2 Reciprocating
Registration number
N340SW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
340A0531
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-10T00:55:44Z guid: 192343 uri: 192343 title: CEN23LA236 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192356/pdf description:
Unique identifier
192356
NTSB case number
CEN23LA236
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-08T18:30:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-06-29T22:46:59.695Z
Event type
Accident
Location
Stevens Point, Wisconsin
Airport
Stevens Point Municipal Airport (STE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that during the approach to the destination airport, the winds were reported as 040o and 340o at 8 kts. The pilot chose to land on runway 30 because the airport windsock was pointed almost straight down the runway. The airplane touched down smoothly during landing, and he had the control yoke back and the ailerons rotated slightly into the wind in anticipation of a crosswind. The pilot stated the crosswind came suddenly and lifted the right wing. He added left aileron and “strong” left rudder, but it was too late to regain control. The airplane ground looped and struck the runway surface. The airplane sustained substantial damage that included left wing damage inboard of the left wing tip, left aileron, and left elevator. The pilot stated there was no mechanical malfunction/failure of the airplane that would have precluded normal operation. The pilot stated that the accident could have been prevented by reducing flaps from 40o after landing and applying additional aileron control input.
Probable cause
The pilot’s failure to maintain directional control during landing that resulted in a ground loop and impact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180G
Amateur built
false
Engines
1 Reciprocating
Registration number
N223WH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
18051355
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-29T22:46:59Z guid: 192356 uri: 192356 title: WPR23LA228 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192402/pdf description:
Unique identifier
192402
NTSB case number
WPR23LA228
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-09T08:50:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-20T21:52:53.046Z
Event type
Accident
Location
Bryce Canyon, Utah
Airport
BRYCE CANYON (BCE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while adjusting the aircraft's attitude for a 3-point tail-wheel landing, the aircraft bounced. Despite rudder and tail wheel inputs, the aircraft veered to the right side of the runway. The pilot elected to go around and applied full power. The airplane’s landing gear became entangled in nearby bushes and the airplane subsequently impacted terrain, which resulted in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain control of the airplane during the landing roll and subsequent impact with terrain during go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BENOIT LECLAIR
Model
RANS S-7S
Amateur built
true
Engines
1 Reciprocating
Registration number
N56QC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0215610
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-20T21:52:53Z guid: 192402 uri: 192402 title: CEN23LA235 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192344/pdf description:
Unique identifier
192344
NTSB case number
CEN23LA235
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-09T13:03:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-14T22:26:50.119Z
Event type
Accident
Location
Colorado Springs, Colorado
Airport
CITY OF COLORADO SPRINGS MUNI (COS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During landing, the tailwheel equipped airplane drifted left of the runway centerline. The pilot applied right rudder and began transitioning the tail down when the airplane began a ground loop to the right. The airplane exited the runway, which resulted in separation of the left main landing gear and substantial damage to the left wing and aileron. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot noted that there were thunderstorms in the vicinity of the airport at the time of the accident. He added that a better understanding of wind shear may have assisted in preventing the loss of control.
Probable cause
The pilot’s failure to maintain directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
T-6G
Amateur built
false
Engines
1 Reciprocating
Registration number
N16JV
Operator
Greatest Generation Naval Museum
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
49-3155
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-14T22:26:50Z guid: 192344 uri: 192344 title: WPR23LA227 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192400/pdf description:
Unique identifier
192400
NTSB case number
WPR23LA227
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-09T17:45:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-20T21:04:54.679Z
Event type
Accident
Location
Jerome, Idaho
Airport
JEROME COUNTY (JER)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The gyroplane pilot reported that, during the landing, the gyroplane began to veer left. He applied right rudder to counteract this, but the gyroplane rolled over to the right and came to rest on the runway, resulting in substantial damage to the rudder, horizontal stabilizer, and vertical stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or failures with the gyroplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
CAMILLE E PATCH
Model
CALIDUS
Amateur built
true
Engines
1 Reciprocating
Registration number
N800YA
Operator
AVIATE LLC DBA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
C00308
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-20T21:04:54Z guid: 192400 uri: 192400 title: CEN23LA253 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192424/pdf description:
Unique identifier
192424
NTSB case number
CEN23LA253
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-10T13:15:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-23T17:45:22.27Z
Event type
Accident
Location
Watkins, Colorado
Airport
Colorado Air and Spaceport (CFO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that shortly before touchdown he noticed the landing gear selector still in the up position. The pilot moved the selector to the down position, but the landing gear were unable to fully extend before touchdown. The bottom of the fuselage was substantially damage during the wheels-up landing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Additionally, the pilot reported he did not use a prelanding checklist to ensure that the landing was extended before touchdown.
Probable cause
The pilot’s failure to extend the landing gear before landing. Contributing to the accident was the pilot’s failure to utilize the prelanding checklist to ensure the landing gear was extended before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N6886P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-2022
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-23T17:45:22Z guid: 192424 uri: 192424 title: WPR23LA224 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192357/pdf description:
Unique identifier
192357
NTSB case number
WPR23LA224
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-10T16:00:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-15T06:04:09.337Z
Event type
Accident
Location
Agness, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that he decided to land on a gravel bar. Slightly before the gravel bar, he touched the main landing gear on the water prior to the gravel bar. He realized the airplane’s ground speed was too low and the airplane’s tail “started to come up”. He added full engine power and “up elevator,” but the airplane nosed over and came to rest inverted, in 1-2 feet of water. The rudder was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain sufficient airspeed and decision to touch down on the surface of the water, resulting in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180
Amateur built
false
Engines
1 Reciprocating
Registration number
N1778C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30478
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-15T06:04:09Z guid: 192357 uri: 192357 title: ERA23LA296 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192615/pdf description:
Unique identifier
192615
NTSB case number
ERA23LA296
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-10T17:00:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-10-17T17:37:08.93Z
Event type
Accident
Location
Lumberton, New Jersey
Airport
FLYING W (N14)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a simulated soft field take off from a paved runway the student pilot followed the procedure of holding control wheel back pressure while accelerating for takeoff. The airplane began to lift off the runway into ground effect with an excessive nose high attitude and began drifting to left of center line. Upon realizing the airplane was in an imminent stall due to the high angle attack and veering away from the runway centerline, the flight instructor took over control of the airplane, but the airplane had already drifted over the grassy area off the left side of the runway. During the subsequent runway excursion, the right side of the horizontal stabilator struck two of the runway edge lights and incurred substantial damage. Neither the flight instructor, nor the student pilot, heard the impact and continued their flight lesson. The damage was discovered after they completed the lesson. Following the accident, the flight instructor stated that he should have been more proactive in either taking control, or ensuring the student was relaxing the back pressure on the control wheel as they started gaining speed to help get the airplane in to ground effect for the simulated soft field departure.
Probable cause
The student pilot’s improper flight control inputs and the flight instructor’s delayed remedial action during takeoff, which resulted in a runway excursion and impact with the runway edge lights.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N8126X
Operator
Freeflight Aviation Llc.
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-8090154
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-17T17:37:08Z guid: 192615 uri: 192615 title: CEN23LA237 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192358/pdf description:
Unique identifier
192358
NTSB case number
CEN23LA237
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-11T15:06:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-13T00:27:37.026Z
Event type
Accident
Location
Pratt, Kansas
Airport
Pratt Regional (PTT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot and a camera operator were conducting aerial pipeline surveillance at the time of the accident. At the initial planned fuel stop, the self-service Jet A fuel pump did not operate properly, and the pilot was unable to obtain any assistance from the airport. With over “half a tank of fuel”, the pilot decided to depart and conduct some additional pipeline surveillance en route to an alternate fuel stop. However, Jet A fuel was not available at the alternate fuel stop. Efforts to find assistance also were not successful. The nearest airport with Jet A fuel was approximately 40 miles away, and about 15 gallons of fuel remained onboard the helicopter. The pilot elected to proceed 15 to 20 miles and land next to a road in an effort to reach cellphone coverage or find a passing vehicle to request assistance. After clearing a windmill farm the pilot began an approach for landing near a road about 6 miles from the intended destination airport. About 100 ft above ground level, “the engine flamed out due to lack of fuel.” The pilot entered an autorotation and subsequently impacted an agricultural field. The aft cabin and lower portion of the aft fuselage sustained substantial damage. The landing skids and aft portion of the tail boom were separated. Neither the pilot nor the operator reported any mechanical failures or malfunctions associated with the helicopter that would have precluded normal operation.
Probable cause
Fuel exhaustion due to the pilot’s inadequate preflight planning.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N85RB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
831
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-13T00:27:37Z guid: 192358 uri: 192358 title: WPR23LA230 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192404/pdf description:
Unique identifier
192404
NTSB case number
WPR23LA230
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-11T18:10:00Z
Publication date
2023-10-20T04:00:00Z
Report type
Final
Last updated
2023-06-21T06:15:00.819Z
Event type
Accident
Location
Mimbres, New Mexico
Airport
CASAS ADOBES AIRPARK (NM69)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
Prior to landing, the pilot made a low pass from north to south to check the windsock, which indicated a crosswind from the southwest; it was stable and not flapping and favored runway 16. During the landing flare, the airplane was struck by a gust of wind and the nose rose upward at a steep angle and then slammed back onto the ground. The nose wheel landing gear bent, and as the airplane slid down the runway the bent nose landing gear dug into the ground and the airplane flipped onto its back. The pilot reported that there was no evidence of any preexisting mechanical malfunction with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inflight loss of control while landing with wind gusts that resulted in a hard landing and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV6A
Amateur built
true
Engines
1 Reciprocating
Registration number
N60605
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25379
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T06:15:00Z guid: 192404 uri: 192404 title: CEN23LA238 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192359/pdf description:
Unique identifier
192359
NTSB case number
CEN23LA238
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-11T20:54:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-13T01:34:26.208Z
Event type
Accident
Location
Gassville, Arkansas
Airport
Roller Field (pvt)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he and the passenger departed his home airport and flew with another airplane to a private grass strip about 5 nm to the east. They both landed and were on the ground for about an hour. They noticed a storm building in the area and prepared to leave. The north-south runway sloped up to the north and featured tall trees on the north departure end. The pilot stated that he “opted to takeoff from the north to the south even though there was a building northwest wind.” Upon rotation, he heard the airplane’s stall warning horn, so he lowered the nose to gain airspeed, but the airplane was “very mushy, and was not gaining altitude.” The pilot struggled to maintain control as the wind pushed the airplane to the east. The airplane collided with a fence and telephone pole, then continued across a road and impacted several trees before coming to a stop. The airplane sustained substantial damage to both wings, the empennage, and the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. He added that the other airplane departed to the south without incident.
Probable cause
The pilot’s failure to maintain control of the airplane during takeoff with a quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M10
Amateur built
false
Engines
1 Reciprocating
Registration number
N9523V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
700013
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-13T01:34:26Z guid: 192359 uri: 192359 title: WPR23LA231 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192405/pdf description:
Unique identifier
192405
NTSB case number
WPR23LA231
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-12T10:30:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-20T20:49:58.464Z
Event type
Accident
Location
Chelan, Washington
Airport
LAKE CHELAN (S10)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was practicing touch and go maneuvers in the airport traffic pattern. During his second approach to land, the pilot improperly selected his touchdown point at the beginning of the runway instead of the runway threshold. When the pilot recognized he was not on the runway glide path by looking at the “visual approach slope indicator lights” (airport has a precision approach path indicator), he increased power to arrest his descent rate, but the right main landing gear collided with a road sign at the north end of the runway before the displaced threshold. The airplane impacted the ground, nosed over and came to rest inverted on the runway, and the airplane sustained substantial damage to the left wing. The pilot reported no preimpact mechanical malfunctions and anomalies that could have precluded normal operation.
Probable cause
The pilot’s improper selection of a touchdown point and delayed recognition, which resulted in an impact with an obstacle.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JOHNSON GARY L
Model
FISHER HORIZON 1
Amateur built
true
Engines
1 Reciprocating
Registration number
N88GJ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
HO 1186
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-20T20:49:58Z guid: 192405 uri: 192405 title: ERA23LA294 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192606/pdf description:
Unique identifier
192606
NTSB case number
ERA23LA294
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-13T11:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-08-02T19:57:01.837Z
Event type
Accident
Location
Wagener, South Carolina
Airport
SD Farms (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was taking off to the east from his personal, grass airstrip, which was 2,400 ft-long and 75 ft-wide. Surface wind at a nearby airport was from 120° at 8 knots with gusts to 12 knots. Just before rotation on the takeoff roll, he felt a large wind gust and decided to abort the takeoff. He was unable to stop the airplane in the remaining runway, it collided with a fence, the landing gear collapsed, and the airplane came to rest upright. The airplane’s wings and fuselage were substantially damaged during the accident. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s decision to take off from a short, grass runway in gusting wind conditions, resulting in a rejected takeoff and runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND
Model
DA50
Amateur built
false
Engines
1 Reciprocating
Registration number
OE-DSD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
50.C.A.A.017
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-02T19:57:01Z guid: 192606 uri: 192606 title: CEN23LA427 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193477/pdf description:
Unique identifier
193477
NTSB case number
CEN23LA427
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-13T22:35:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-12-05T20:18:57.379Z
Event type
Accident
Location
Indianola, Mississippi
Airport
INDIANOLA MUNI (IDL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
According to the airport manager, the non-certificated pilot attempted to land the light sport airplane at night. The airplane was not equipped with a two-way radio to activate the airport’s pilot-controlled runway lights. The pilot’s first landing attempt resulted in a go-around. After the go-around, the pilot called and asked a friend to shine headlights from a vehicle to illuminate the runway. On the second landing attempt, the airplane landed hard, bounced, and the pilot attempted a go-around. During the go-around the airplane impacted a beanfield. The airplane sustained substantial damage to both wings and the fuselage. The pilot did not return the National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident Report Form 6120.1.
Probable cause
The non-certificated pilot’s loss of control during the night landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
QUAD CITY
Model
CHALLENGER
Amateur built
true
Registration number
UNREG
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
UNK
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-05T20:18:57Z guid: 193477 uri: 193477 title: CEN23LA241 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192378/pdf description:
Unique identifier
192378
NTSB case number
CEN23LA241
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-15T09:45:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-21T20:55:58.48Z
Event type
Accident
Location
Holyoke, Colorado
Airport
HOLYOKE (HEQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The operator reported that, while landing during a solo instructional flight, the airplane touched down in a three-point attitude and veered left during the roll out.  The airplane ground looped to the left and exited the left side of the runway. During the ground loop, the right wing struck the ground. The airplane came to rest about 25 ft from the edge of the runway and sustained substantial damage to the right wing. The operator reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-401B
Amateur built
false
Engines
1 Reciprocating
Registration number
N6106U
Operator
Steggs Flying Service, Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
401B-0976
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T20:55:58Z guid: 192378 uri: 192378 title: CEN23LA240 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192373/pdf description:
Unique identifier
192373
NTSB case number
CEN23LA240
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-15T12:30:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-06-22T23:08:35.954Z
Event type
Accident
Location
Sibley, Iowa
Airport
Sibley (ISB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during an extended final approach, the “bottom fell out” and the airplane entered an aerodynamic stall. The pilot was unable to recover before the airplane touched down short of the runway. The left main landing gear collapsed during the hard landing, and the airplane sustained substantial damage to the fuselage and right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate airspeed on final approach resulting in the airplane inadvertently exceeding the critical angle of attack and entering an inadvertent aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TAYLORCRAFT
Model
BC-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N23679
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1413
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-22T23:08:35Z guid: 192373 uri: 192373 title: WPR23LA233 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192407/pdf description:
Unique identifier
192407
NTSB case number
WPR23LA233
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-16T16:02:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-20T21:04:57.659Z
Event type
Accident
Location
Elko, Nevada
Airport
Elko Regional Airport (EKO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that the winds at the airport were light and variable each of the three times he checked before takeoff. He performed a three-point takeoff, and as soon as he applied back pressure to the yoke, he observed a dust devil to the right and in front of the airplane. The airplane rolled aggressively left and he applied corrective control inputs as the airplane drifted to the left side of the runway. The main gear impacted vegetation, the airplane rolled, and came to rest inverted. The airplane sustained substantial damage to the wings and fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. A review of the Federal Aviation Administration Aviation (FAA) Weather Handbook (FAA-H-8083-28) and the FAA Aeronautical Information Manual found no detailed information listed about dust devils or the potential hazards of flying through dust devils.
Probable cause
The pilot’s loss of control after encountering a dust devil during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170B
Amateur built
false
Engines
1 Reciprocating
Registration number
N8223A
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
25075
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-20T21:04:57Z guid: 192407 uri: 192407 title: WPR23LA238 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192447/pdf description:
Unique identifier
192447
NTSB case number
WPR23LA238
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-16T20:13:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-26T20:44:24.642Z
Event type
Accident
Location
Mesa, Arizona
Airport
Falcon Field Airport (FFZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight school reported that the student pilot was conducting his second solo flight. In the landing flare the student pilot floated and began porpoising; hitting the nose wheel several times and striking the prop on the runway. The nosewheel collapsed sustaining substantial damage to the engine mount. There were no preaccident malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper flare, which resulted in a hard landing on the nose gear.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N28034
Operator
CAE Oxford Aviation Academy Phoenix
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2881357
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-06-26T20:44:24Z guid: 192447 uri: 192447 title: CEN23LA242 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192388/pdf description:
Unique identifier
192388
NTSB case number
CEN23LA242
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-17T12:30:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-26T16:46:01.585Z
Event type
Accident
Location
Odessa, Missouri
Airport
ROLLERT FARM (29MO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that during landing, the airplane touched down “slightly fast” and the airplane departed the end of the turf runway into an overrun area that had softer ground. When the airplane entered the overrun, it nosed over, which resulted in substantial damage to the fuselage and both wings. The pilot reported that there were no preaccident failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to attain the proper touchdown speed, which resulted in a runway excursion and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Tipton Kitfox
Model
Kitfox IV
Amateur built
true
Engines
1 Reciprocating
Registration number
N4287Y
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1661T1
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-26T16:46:01Z guid: 192388 uri: 192388 title: ERA23LA291 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192553/pdf description:
Unique identifier
192553
NTSB case number
ERA23LA291
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-17T13:45:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-24T15:33:55.594Z
Event type
Accident
Location
Dublin, Georgia
Airport
W H 'BUD' BARRON (DBN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that upon returning from a local flight, during the landing flare, he noticed the airplane was still sinking so he “began pulling back on the stick.” The airplane continued to sink, and the pilot added partial power, but the sink rate was not arrested, and the airplane impacted the ground, about 10 ft before the runway threshold. Upon impact with the ground, the nose landing gear collapsed, and the airplane slid about 1,000 ft down the runway. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector found substantial damage to the firewall. The pilot reported that he felt he used full elevator aft but did not think he was getting full authority and that an autopilot servo bracket may have interfered with the flight control. The safety pilot on board reported that the pilot performed a flight control check before the departure with no anomalies noted. Additionally, during a postaccident examination of the flight controls, the FAA inspector found the autopilot servo bracket was loose on the elevator control tube and a flight control check found the bracket did not restrict the aft movement of the elevator. The postaccident examination otherwise found no evidence of any preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare which resulted in a runway undershoot and a hard landing, which substantially damaged the airplane’s firewall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Volato
Model
400
Amateur built
false
Engines
1 Reciprocating
Registration number
PR-ZVL
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-24T15:33:55Z guid: 192553 uri: 192553 title: ANC23LA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192408/pdf description:
Unique identifier
192408
NTSB case number
ANC23LA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-17T17:25:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-21T00:32:28.224Z
Event type
Accident
Location
Anchorage, Alaska
Airport
Lake Hood Airport (LHD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that he was conducting tailwheel training in a tailwheel-equipped airplane. During takeoff with a left crosswind, the instructor prompted the pilot receiving training to focus on keeping left aileron control input to compensate for the crosswind during departure. During the takeoff roll the flight instructor realized the airplane had drifted to the right side of the runway. He took control of the airplane, banked the airplane left, and added left rudder, and the left wing struck a runway light, resulting in substantial damage to the wing and aileron. The flight instructor reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The instructor pilot’s failure to maintain directional control of the airplane during takeoff, which resulted in a wing impacting a runway light.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BUCK/CRAWFORD/CRAWFORD
Model
CHRISTAVIA MK-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N5075T
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
237
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T00:32:28Z guid: 192408 uri: 192408 title: ERA23LA271 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192401/pdf description:
Unique identifier
192401
NTSB case number
ERA23LA271
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-18T09:00:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-06-21T22:55:09.753Z
Event type
Accident
Location
Seymore, Tennessee
Airport
Seymour Air Park (TN20)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Analysis
The flight instructor stated that he was teaching the student pilot a soft-field takeoff technique on a 2,300-ft-long turf runway, with a passenger in the back seat. The flight instructor further stated that student pilot lifted off the airplane at 52 knots, but it settled back to the runway as the wind shifted from a headwind to a tailwind. The airplane then traveled about 100 ft beyond the departure end of the runway and struck bushes, coming to rest upright. The flight instructor added that there were no preimpact mechanical malfunctions with the airplane. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the left wing and fuselage. The inspector noted that the flaps were in the fully retracted position and asked the flight instructor why he did not perform the accident takeoff with 10° flap extension, per the owner’s manual. The flight instructor replied that was always how he performed soft-field takeoffs. The recorded wind speed about the time of the accident was 3 knots.
Probable cause
The flight instructor’s failure to properly configure the wing flaps for a soft-field takeoff on a short runway, which resulted in a runway overrun and collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N12395
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17261968
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T22:55:09Z guid: 192401 uri: 192401 title: CEN23LA245 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192398/pdf description:
Unique identifier
192398
NTSB case number
CEN23LA245
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-18T13:35:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-29T23:19:31.144Z
Event type
Accident
Location
Louise, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
According to the pilot, it was a windy day and also his first day performing aerial spray operations. While attempting to turn the helicopter from a west to east heading at about 10 feet off the ground, the pilot reported he lost directional control and the helicopter started to spin clockwise. His efforts to maintain control were not successful. He stated that the wind was beating him up, and most of his flight training did not include windy/gusty conditions. The helicopter impacted a rice field, which resulted in damage to the tail boom and rotor blades. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N932SH
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
3899
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-29T23:19:31Z guid: 192398 uri: 192398 title: CEN23LA244 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192396/pdf description:
Unique identifier
192396
NTSB case number
CEN23LA244
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-18T14:30:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-21T02:43:05.901Z
Event type
Accident
Location
Sturgis, South Dakota
Airport
STURGIS MUNI (49B)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported he departed in the airplane with about 660 lbs of fuel and about 3,500 lbs of liquid chemical for application to a pasture. After arriving at the pasture, the chemical dispersal system was malfunctioning, and the pilot decided to return to the airport. During the landing to the first quarter of the runway, the airplane was about 125 mph, with “half flap” applied, and the tailwheel was locked. As the tailwheel touched down on the dry concrete runway, the pilot initiated beta mode with the propeller, and the airplane “started veering to the right.” The pilot assessed that he “reversed the propeller too aggressively and too soon.” The airplane departed the runway to the right, the left main landing gear separated after impacting a ditch, and the airplane came to rest upright on a grass field. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the left wing. The operator reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. A postaccident examination of the chemical dispersal system found foreign object debris that was likely blocking the flow of the chemical. Title 14 Code of Federal Regulations Part 137 Agricultural Aircraft Operations does not contain full load landing training and recurrency requirements. The pilot reported the last time he performed a full load landing was about 2 years prior. The estimated density altitude for the airport was 6,101 ft.
Probable cause
The pilot’s improper timing to initiate beta mode with the propeller and his failure to maintain directional during the full load landing that resulted in a runway excursion. Contributing to the accident was the pilot’s lack of recent experience with performing a full load landing and the high-density altitude that likely affected aircraft performance during the landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-502
Amateur built
false
Engines
1 Turbo prop
Registration number
N290LA
Operator
ASCEND AG INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
502A-3137
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T02:43:05Z guid: 192396 uri: 192396 title: ANC23LA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192409/pdf description:
Unique identifier
192409
NTSB case number
ANC23LA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-19T12:00:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-21T01:19:54.139Z
Event type
Accident
Location
Talkeetna, Alaska
Airport
Talkeetna Airport (TKA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of a tailwheel equipped airplane reported that, during landing and upon touchdown, the airplane veered abruptly to the right with a lower-than-normal right wing. He applied left rudder and brake and the airplane veered to the left and exited the runway. The right main landing gear wheel dug into the gravel, the airplane spun and the right wingtip struck the ground. The right wing sustained substantial damage. The pilot discovered the right main landing gear tire was flat.
Probable cause
A loss of directional control, while landing, due to a flat main landing gear tire.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180
Amateur built
false
Engines
1 Reciprocating
Registration number
N9214C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
31313
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-21T01:19:54Z guid: 192409 uri: 192409 title: CEN23LA252 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192419/pdf description:
Unique identifier
192419
NTSB case number
CEN23LA252
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-20T13:55:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-06-22T23:05:13.111Z
Event type
Accident
Location
Norwich, New York
Airport
Lt Warren Eaton Airport (OIC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that during landing at the destination airport, his right foot slipped of the rudder pedal and became wedged between the pedal and the adjacent airplane structure. He partially freed his right foot and attempted to regain control when his left foot became wedged between the left pedal and the airplane structure. The pilot was unable to regain directional control and the airplane veered off the runway and impacted terrain. The airplane sustained substantial damage to the lower left wing. The pilot reported that he was not aware of any preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing rollout due to interference from the pilot’s foot/shoe with the airplane structure that resulted in a runway excursion and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Starduster
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N299KD
Operator
Southern Utah University
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
760
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-22T23:05:13Z guid: 192419 uri: 192419 title: CEN23LA251 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192418/pdf description:
Unique identifier
192418
NTSB case number
CEN23LA251
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-21T16:10:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-06-22T23:03:57.593Z
Event type
Accident
Location
Osceola, Iowa
Airport
OSCEOLA MUNI (I75)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the crosswind landing, the tailwheel equipped airplane touched down about 10 knots too fast, and the tailwheel started to shimmy. The flight instructor assisted the pilot with the controls as the airplane exited the runway into the adjacent grass area. However, the pilot was unable to regain control and the airplane ground looped. According to the flight instructor, the pilot had previously demonstrated proficiency in the airplane. The flight instructor reported that he did not intervene in a timely manner. The airplane sustained substantial damage to the left wing and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the tailwheel equipped airplane during a crosswind landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180
Amateur built
false
Engines
1 Reciprocating
Registration number
N3127C
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
30926
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-22T23:03:57Z guid: 192418 uri: 192418 title: WPR23LA235 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192422/pdf description:
Unique identifier
192422
NTSB case number
WPR23LA235
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-21T17:00:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-23T02:23:06.407Z
Event type
Accident
Location
Truckee, California
Airport
Truckee-Tahoe (TRK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that he had been approved by air traffic control (ATC), to enter the traffic pattern for runway 11. On final approach, ATC advised the pilot that the wind had changed, and suggested a straight in approach to land runway 02. The pilot accepted the suggestion and clearance to land runway 02. The airplane touched down on its main landing gear and as the tailwheel settled to the ground, the tail “was pushed around.” The airplane ground looped and came to a stop in the grass beside the runway. Once on the ground, the pilot noticed that multiple windsocks on the airport were displaying different wind directions and suspected the airplane had encountered a strong crosswind. The left wing sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control on landing roll out, during variable wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JOHN TOPLIFF
Model
PA18-200EXP
Amateur built
true
Engines
1 Reciprocating
Registration number
N356AW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
PA-18-200-1-JT
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-23T02:23:06Z guid: 192422 uri: 192422 title: WPR23LA237 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192444/pdf description:
Unique identifier
192444
NTSB case number
WPR23LA237
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-21T18:00:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-07-03T22:55:25.816Z
Event type
Accident
Location
Idaho Falls, Idaho
Airport
Idaho Falls Regional Airport (IDA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, the airplane was stable during approach when a wind gust caused the airplane to veer left when over the runway. The airplane subsequently flew over the grass area beside the runway and contacted a runway sign, which damaged the right strut and detached its wheel. The pilot aborted the landing, diverted to another airport with a longer runway, and successfully landed the airplane. The airplane sustained substantial damage to the fuselage structure. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control while landing with a gusting crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182F
Amateur built
false
Engines
1 Reciprocating
Registration number
N3531Y
Operator
CJ3 AVIATION LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18254431
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-03T22:55:25Z guid: 192444 uri: 192444 title: CEN23LA255 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192426/pdf description:
Unique identifier
192426
NTSB case number
CEN23LA255
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-22T13:15:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-06-29T22:41:47.487Z
Event type
Accident
Location
Westhope, North Dakota
Airport
Westhope Municipal Airport (D64)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot, who did not hold an airframe and powerplant (A&P) certificate, stated that after he installed the overhauled engine onto the agricultural airplane, he planned on flying the airplane during the accident flight to break the engine in prior to having it inspected and signed off by an A&P mechanic with inspection authorization. There was no record of a current annual inspection of the airplane prior to the flight. The pilot loaded the airplane with 20 gallons of water to test the spray system since he planned on flying for about an hour. During climb after takeoff, the pilot lost control, and the airplane descended and impacted terrain resulting in substantial damage to both wings and fuselage. The pilot stated there was no mechanical malfunction/failure of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control that resulted in an impact with terrain after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-25-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N7419Z
Operator
Pilot
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
25-3390
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-29T22:41:47Z guid: 192426 uri: 192426 title: CEN23LA263 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192455/pdf description:
Unique identifier
192455
NTSB case number
CEN23LA263
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-23T09:17:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-06-27T18:13:11.899Z
Event type
Accident
Location
Gunnison, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 4 serious, 0 minor
Analysis
The pilot reported that she had been checked out in the accident airplane that morning and this was only her second flight in the same type. She stated that she and three passengers were sightseeing in a canyon that began to narrow. As the flight progressed, she was unable to climb out of the canyon and stalled the airplane. During the stall recovery, the airplane impacted trees and terrain; a postcrash fire ensued and the airplane was destroyed. The pilot reported no mechanical malfunctions or anomalies that would have precluded normal operations.
Probable cause
The pilot’s improper decision to fly into an area of unsuitable terrain which the airplane was unable to exit, resulting in an aerodynamic stall and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182G
Amateur built
false
Engines
1 Reciprocating
Registration number
N3289S
Operator
DOUBLE LAZY H LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18255789
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-06-27T18:13:11Z guid: 192455 uri: 192455 title: CEN23LA260 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192452/pdf description:
Unique identifier
192452
NTSB case number
CEN23LA260
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-23T11:10:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-26T22:44:15.891Z
Event type
Accident
Location
Bolivar, Missouri
Airport
BOLIVAR MUNI (M17)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was performing a soft-field takeoff from a grass runway when the airplane encountered a wind gust shortly after rotation. The pilot reported that the wind gust pushed up the airplane’s nose and moved the airplane sideways. The left wing impacted the terrain, then the right wing and forward fuselage. The airplane sustained substantial damage to the left wing and forward fuselage. The pilot reported no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during a soft-field takeoff after encountering a wind gust.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SHARP GLENNIS
Model
ESCAPADE
Amateur built
false
Engines
1 Reciprocating
Registration number
N907ML
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
JAESC 0066
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-26T22:44:15Z guid: 192452 uri: 192452 title: WPR23LA259 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192574/pdf description:
Unique identifier
192574
NTSB case number
WPR23LA259
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-24T09:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-07-11T02:22:42.605Z
Event type
Accident
Location
Las Vegas, Nevada
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that he intended to land on a dry lakebed behind a model that was being photographed and create a ‘wall of dust’ using the airplane for a photograph. During the landing roll, the pilot stated he was moving too fast to stop before reaching the model and elected to execute a go-around. He then returned to the lakebed and landed, where he saw that the model had been seriously injured. According to the photographer, he and his model had been approached by the pilot, who offered his airplane as a backdrop for the photo shoot. After taking several photographs near the airplane, the pilot offered to overfly the model for additional photographs. The pilot flew over the model twice, and on the third flyover, the airplane was lower than the previous passes and the airplane’s left wing struck the model in the back of the head. Following the accident, the photographer obtained images from other photographers of the pilot performing similar maneuvers over other models at low altitude. Title 14 of the Combined Federal Regulations, § 91.119 Minimum safe altitudes: General, states: “Except when necessary for takeoff or landing, no person may operate an aircraft below the following altitudes: (c) An altitude of 500 feet above the surface, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure.” The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s unsafe inflight operation of the airplane and failure to maintain clearance from a person on the ground, which resulted in a serious injury.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N307F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
2379
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-07-11T02:22:42Z guid: 192574 uri: 192574 title: CEN23LA264 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192456/pdf description:
Unique identifier
192456
NTSB case number
CEN23LA264
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-24T12:30:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-06-27T18:15:20.639Z
Event type
Accident
Location
Scott City, Kansas
Airport
SCOTT CITY MUNI (TQK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Factual narrative
On June 24, 2023, about 1130 central daylight time, a Beech B19, N9721Q, sustained substantial damage when it was involved in an accident near Scott City, Kansas. The pilot was uninjured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he added 17.16 gallons of fuel which brought the total quantity to about 30 gallons. He then started the engine, let it idle about 600 rpm for a “few minutes,” and began to taxi to runway 35 at Scott City Municipal Airport (TQK). He waited for another airplane to perform a back-taxi and depart, then he back-taxied and completed an engine run-up before realizing he left something behind. He then taxied back to the FBO, collected his items, and taxied back to the runway for departure. The pilot stated that during the takeoff roll, he noticed that the engine rpm increased and did not note any anomalies. During the initial climb, he saw the engine RPM maintained about 2,200 rpm with full throttle. He stated that he was able to climb to about 500 ft agl and attempted a return to the airport. He said that when he was abeam the runway, he thought he was “losing altitude and power,” and made a shallow left turn towards the runway. Unable to maintain altitude during the turn, the pilot attempted a landing on a dirt road. During touchdown, the airplane bounced, exited the roadway, impacted a ditch, and slid into a cornfield, which resulted in substantial damage to the fuselage. A pilot witness reported seeing the accident airplane depart and noted that it did not appear to be climbing well when it started a turn to the northeast. He estimated the airplane was about 50 to 100 ft agl, when he lost sight of it while he was taxing.  After he turned his airplane around, he saw the accident airplane again when it was southwest of the runway. He stated that it appeared to be less than 100 ft agl and about 30° nose down at the time of impact. During a postaccident examination, continuity was established from the engine controls in the cockpit to their respective engine attach points. No preimpact mechanical malfunctions or anomalies were found that would have precluded normal operation. The reported weather conditions about 15 minutes before the accident included a temperature of 82°F and dewpoint of 59°F.  When plotted on a carburetor icing probability chart, the airplane was operating in an environment conducive for serious carburetor icing at a glide power setting. (See Figure 1) Figure 1: Carburetor Icing Probability Chart. Reference: Special Airworthiness Information Bulletin CE-09-35 -
Analysis
The pilot stated that after he started the engine, he let it idle about 600 rpm for a “few minutes,” and began to taxi to the runway for departure. He waited for another airplane to perform a back-taxi and depart, then he back-taxied and completed an engine run-up before realizing he left something behind. He then taxied back to the fixed base operator (FBO), collected his items, and again taxied to the runway for departure. He did not complete another engine run-up before takeoff. During the takeoff roll, he noticed the engine rpm increased and did not note any anomalies. During the initial climb, the engine rpm maintained about 2,200 rpm with full throttle set. He stated that he was able to climb about 500 ft above ground level (agl) and attempted a return to the airport. He said that when he was abeam the runway, he thought he was “losing altitude and power,” and made a shallow left turn towards the runway. Unable to maintain altitude during the turn, the pilot landed on a dirt road. During touchdown, the airplane bounced, exited the roadway, impacted a ditch, and slid into a cornfield, which resulted in substantial damage to the fuselage. During a postaccident examination, no preimpact mechanical malfunctions or failures were discovered that would have precluded normal operation. When the temperature and dewpoint at the time of the accident were plotted on a carburetor icing probability chart, it was revealed that the airplane was operating in an environment conducive for serious carburetor icing at a glide power setting. The pilot stated that he checked the carburetor heat before departure. After the carburetor heat check, it is likely that ice began to form in the carburetor’s venturi during the extended ground operation before departure, which, in turn, limited the engine rpm at 2,200.
Probable cause
A partial loss of engine power as a result of carburetor icing that formed while the engine was operating at a low power setting for an extended period before departure.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B19
Amateur built
false
Engines
1 Reciprocating
Registration number
N9721Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
MB-493
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-27T18:15:20Z guid: 192456 uri: 192456 title: ERA23LA303 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192663/pdf description:
Unique identifier
192663
NTSB case number
ERA23LA303
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-24T16:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-08-10T17:06:00.78Z
Event type
Accident
Location
Macon, Georgia
Airport
MACON DOWNTOWN (MAC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot receiving instruction, he had initiated the upwind-to-crosswind turn in the airport traffic pattern. With the left wing raised in the right turn, a bird came into the pilot’s view and struck the left wing before the pilot could initiate an evasive maneuver. The flight instructor assumed control of the airplane, completed the traffic pattern and the landing without injury to the occupants or damage beyond that resulting from the bird strike. Post-accident examination of the airplane revealed that the left wing was substantially damaged.
Probable cause
An inflight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA-28R-201
Amateur built
false
Engines
1 Reciprocating
Registration number
N285MG
Operator
Middle Georgia State University
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2844167
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T17:06:00Z guid: 192663 uri: 192663 title: CEN23LA331 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192731/pdf description:
Unique identifier
192731
NTSB case number
CEN23LA331
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-24T21:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-05T17:49:58.992Z
Event type
Accident
Location
Arnaudville, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The non-certificated pilot reported that he was flying low and slow over a field looking for a model airplane that he had lost the day before. He was returning to his private airstrip, flying low and slow over trees, when the airplane stalled. Before he could recover from the aerodynamic stall the landing gear contacted the trees, and the airplane fell to the ground. He reported that there were no preimpact mechanical problems with the airplane and that the accident was all pilot error. The airplane sustained substantial damage to both wings.
Probable cause
The pilot’s failure to maintain airspeed resulting in exceeding the airplane’s critical angle of attack and an aerodynamic stall. The low altitude at which the flight was conducted contributed to the outcome.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DAVID BROWN/U BALLDIN/T MORGAN
Model
ZENITH STOL CH701
Amateur built
true
Engines
1 Reciprocating
Registration number
N1836E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
7-5983
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-05T17:49:58Z guid: 192731 uri: 192731 title: ERA23LA279 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192492/pdf description:
Unique identifier
192492
NTSB case number
ERA23LA279
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-25T10:40:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-07-05T16:41:08.812Z
Event type
Accident
Location
Bonaire, Georgia
Airport
Warner Robbins Air Park (RAP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the experimental amateur-built airplane was flight testing a newly installed propeller. During ground static testing, the pilot found the propeller rpm to be acceptable. After liftoff, the engine rpm increased to a non-acceptable range. The pilot responded by reducing the throttle and retracting the flaps. He also described that the airplane’s flight controls felt like a “…mushy precursor to a stall.” The pilot then increased the engine power to full and lowered the nose of the airplane to increase airspeed. The airport was surrounded by housing developments, and the pilot turned left in an attempt to return to the airport, but the airplane would not maintain altitude. He then guided the airplane toward trees in order to avoid impacting the houses. During the accident sequence, the airplane sustained substantial damage to the wings, tailboom, and cabin structure. Following the accident, the pilot stated that he had, “inadequately adjusted” the propeller’s pitch before the accident flight, which resulted in the airplane’s inability to maintain thrust and lift.
Probable cause
The pilot’s failure to properly adjust the propeller’s pitch angle, which resulted in a loss of thrust and an inability to maintain altitude.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EDMISTEN ROBERT EUGENE SR
Model
RANS S-14 AIRAILE
Amateur built
true
Engines
1 Reciprocating
Registration number
N528RE
Operator
EDMISTEN ROBERT E SR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0803133
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-05T16:41:08Z guid: 192492 uri: 192492 title: WPR23LA240 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192449/pdf description:
Unique identifier
192449
NTSB case number
WPR23LA240
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-25T12:30:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-06-26T21:31:59.341Z
Event type
Accident
Location
Cedar Mountain, Utah
Airport
Cedar Mountain air strip (None)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the departure roll, the airplane became airborne at mid field. Shortly after, he felt a “settling sensation” and the airplane did not climb any further. The pilot checked the engine controls to ensure full power was available. Beyond the end of the runway, the airplane struck trees and came to rest between them. The airplane sustained substantial damage to both the wings and fuselage. The pilot reported that the temperature at the time of departure was 21° C, and that the airport elevation was 7550 ft msl. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s decision to depart with a high density altitude, which degraded the airplane’s climb performance and resulted in an impact with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N2358V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
14594
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-26T21:31:59Z guid: 192449 uri: 192449 title: ERA23LA278 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192484/pdf description:
Unique identifier
192484
NTSB case number
ERA23LA278
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-25T13:15:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-08-01T18:38:47.206Z
Event type
Accident
Location
Sanford, North Carolina
Airport
Raleigh Executive Jetport (TTA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot/builder of the tailwheel-equipped airplane reported that he had flown a few times around the airport traffic pattern and was preparing for a full stop landing. After touchdown, the airplane began to veer to the left. He applied right rudder; however, he ran out of rudder authority due to the crosswind conditions that prevailed. He applied right brake to prevent a runway excursion; however, the airplane nosed over and came to rest inverted. The airplane’s fuselage, right wing, and vertical stabilizer were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation and that the accident would have been prevented if he had more crosswind handling training.
Probable cause
The pilot’s failure to maintain directional control while landing in a crosswind, which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GOPALAN HARIHARAN
Model
4 Place
Amateur built
true
Engines
2 Reciprocating
Registration number
N108YZ
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
986
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-01T18:38:47Z guid: 192484 uri: 192484 title: CEN23LA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192459/pdf description:
Unique identifier
192459
NTSB case number
CEN23LA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-25T15:10:00Z
Publication date
2023-07-27T04:00:00Z
Report type
Final
Last updated
2023-06-27T01:08:28.579Z
Event type
Accident
Location
Livingston, Texas
Airport
Rcade Ranch (35XA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he performed a landing to a remote private grass airstrip surrounded by about 80 ft tall trees, on all sides. At about 40 mph during the rollout on the dry grass, a “strong wind gust lifted the right wing.” The pilot applied full right aileron and full right rudder, but they had “no effect,” nor was the right brake “effective.” The airplane departed the runway, impacted a hangar, and came to rest upright. The pilot and passenger were able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the right wing. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. The pilot further reported that he did not initiate a go-around due to the airstrip being “narrow” and both the tall trees and the hangar “being in the way.”
Probable cause
The pilot’s failure to maintain directional control during the rollout, which resulted in a runway excursion, and a collision with a building. Contributing to the accident were the obstacles at the airstrip that prevented the pilot from performing a go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Bearhawk Aircraft
Model
Model 5
Amateur built
true
Engines
1 Reciprocating
Registration number
N619MS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-27T01:08:28Z guid: 192459 uri: 192459 title: ERA23LA295 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192607/pdf description:
Unique identifier
192607
NTSB case number
ERA23LA295
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-25T20:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-12T20:09:37.124Z
Event type
Accident
Location
Sandersville, Georgia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that while conducting agricultural spraying operations, he flew back to the fuel truck for fuel. He radioed his spotter and asked if the area was clear, and the spotter told him it was. He was attempting to land on a trailer when the tail rotor came into contact with some tree limbs and several tail rotor blades separated from the helicopter. The helicopter immediately lost tail rotor authority and began to yaw. The pilot then tried to move the helicopter away from the trailer and land on the ground. The tail rotor and gearbox separated from the helicopter before the pilot landed the helicopter on the ground. The helicopter’s empennage was substantially damaged during the accident sequence. The pilot reported that there were no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance of trees during landing, which resulted in a tail rotor contact with tree limbs and a subsequent loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N919AC
Operator
VERTICAL VEGETATION MANAGEMENT LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
4020
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T20:09:37Z guid: 192607 uri: 192607 title: CEN23LA277 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192541/pdf description:
Unique identifier
192541
NTSB case number
CEN23LA277
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-26T12:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-07T23:14:49.429Z
Event type
Accident
Location
Elbert, Colorado
Airport
Kelly Air Park (CO15)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that, as the tail lifted during takeoff, the airplane veered left. He attempted to correct with full right rudder and full brakes. However, the airplane subsequently nosed over resulting in substantial damage to the fuselage, lift struts, rudder, and vertical stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or anomalies with the airplane that would have precluded normal operation. At about the time of the accident, wind was from 180° at 5 knots. The pilot decided to depart on runway 35 due to the prevailing airport traffic. He stated that departing with “more favorable wind conditions” may have prevented the accident.
Probable cause
The pilot's loss of directional control during takeoff and subsequent excessive use of brakes which resulted in a nose-over. Contributing to the accident was his decision to takeoff downwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C-50
Amateur built
false
Engines
1 Reciprocating
Registration number
N23161
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2943
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-07T23:14:49Z guid: 192541 uri: 192541 title: WPR23LA245 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192487/pdf description:
Unique identifier
192487
NTSB case number
WPR23LA245
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-26T17:46:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-06-30T03:26:17.296Z
Event type
Accident
Location
Williams, California
Airport
WILLIAMS (CN12)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The glider pilot reported that he partially extended the wing spoilers and completed a pre-landing checklist while on left base for his intended destination airport. Shortly after, the glider encountered “significant sinking air” and started a descent. He then maneuvered the glider directly towards the runway and stowed the wing spoilers to extend his glide for a precautionary landing. Subsequently, the glider impacting terrain short of the runway, which resulted in substantial damage to the nose of the glider. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s encounter with atmospheric conditions where the lift was not sufficient to maintain flight, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHLEICHER ALEXANDER GMBH & CO
Model
ASH 26 E
Amateur built
false
Engines
1 Reciprocating
Registration number
N26DX
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
26242
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-30T03:26:17Z guid: 192487 uri: 192487 title: WPR23LA242 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192463/pdf description:
Unique identifier
192463
NTSB case number
WPR23LA242
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-26T19:45:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-06-27T19:57:52.091Z
Event type
Accident
Location
Newdale, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that while his student was at the controls, he initiated a simulated engine failure, and the student executed the emergency procedures for a forced landing. The student chose a place to land and configured the airplane for landing, including full flaps. The instructor noticed that the airplane’s airspeed was “a little slow”, and he instructed the student to check the airspeed, then recover from the simulation. The student retracted the flaps instead of adding engine power, and the airplane stalled and sank. The instructor immediately attempted to take over the airplane’s controls from the student and verbally commanded “my controls”, but the student was “stuck on the controls and locked up.” The airplane continued to descend and touched down in a field and nosed over. Both wings, the fuselage, the vertical stabilizer, and the rudder sustained substantial damage. The instructor reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The premature retraction of the flaps by the student pilot, while just above the airplane’s stall speed. Contributing to the accident was the flight instructor’s inadequate supervision and failure to regain aircraft control from the student pilot.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N730SC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7225546
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-27T19:57:52Z guid: 192463 uri: 192463 title: ERA23LA289 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192536/pdf description:
Unique identifier
192536
NTSB case number
ERA23LA289
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-27T18:30:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-18T15:53:36.239Z
Event type
Accident
Location
Anderson, South Carolina
Airport
Anderson Regional Airport (AND)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Prior to the accident flight, the pilot reported experiencing vibrations in the helicopter. The pilot (who was also a mechanic) and another mechanic adjusted the main rotor dampers to address the issue. Following this adjustment, a 10-minute ground run was performed without any observed problems. The pilot then conducted a test flight during, which no issues were detected. Upon landing and while reducing the rotor rpm, the helicopter began to shake violently. The pilot attempted to perform the ground resonance recovery procedure and climbed the helicopter, but the vibration worsened, and he subsequently landed. After contacting the ground, the helicopter shook and spun uncontrollably before coming to a stop. The airframe and main rotor were substantially damaged during the accident sequence. Federal Aviation Administration inspectors examined the helicopter after the accident and found that the yellow main rotor blade’s damper had significantly higher torque than the red and blue blades, and that none of the dampers were torqued to the specification in the helicopter’s maintenance manual. The manual also described that incorrect torque adjustments of the dampers could result in “…conditions that may result in ground resonance and destruction of the helicopter. During a subsequent discussion with the assisting mechanic, he stated that he, “may have unintentionally over-torqued the blade [damper].” Based on this information, it is likely that the mechanics’ improper maintenance of the helicopter’s main rotor dampers resulted in the ground resonance event experienced at the conclusion of the post maintenance test flight test flight.
Probable cause
The mechanics’ improper torquing of the main rotor blade dampers, which resulted in a ground resonance event during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
269A
Amateur built
false
Engines
1 Reciprocating
Registration number
N90270
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
66-18283
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-18T15:53:36Z guid: 192536 uri: 192536 title: WPR23LA246 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192488/pdf description:
Unique identifier
192488
NTSB case number
WPR23LA246
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-28T13:50:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-06-30T02:50:05.101Z
Event type
Accident
Location
Big Creek Ranger Station, Idaho
Airport
Mile Hi (n/a)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that he conducted multiple passes over the landing area to assess the landing conditions and did not see that the grass surface was wet. Upon touchdown, he noticed the airplane did not decelerate as expected due to wet tires, and the brakes had little effect. The airplane veered off its intended path, heading toward steep downhill terrain. To prevent continuing uncontrollably downhill, the pilot attempted an intentional ground loop by applying full right rudder and power. Subsequently, the airplane tipped left and stopped before reaching the steeper terrain, resulting in substantial damage to the left aileron and left elevator. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to identify the wet landing surface and his subsequent inability to maintain directional control and stop during landing on the unimproved grass runway, which resulted in a runway excursion and unintentional ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BLACK SHEEP AVIATION LLC
Model
CCX-1865
Amateur built
true
Engines
1 Reciprocating
Registration number
N510US
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
CCX-1865-0007
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-06-30T02:50:05Z guid: 192488 uri: 192488 title: CEN23LA271 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192500/pdf description:
Unique identifier
192500
NTSB case number
CEN23LA271
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-29T23:09:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-07-10T20:17:22.087Z
Event type
Accident
Location
Siloam Springs, Arkansas
Airport
Smith Field (SLG)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while on final approach at night, he impacted power lines he did not see about 1.5 miles from the approach end of the runway. The airplane sustained substantial damage to the rudder, left wing, and left flap. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from power lines while on final approach to land.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N739GU
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17270639
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-10T20:17:22Z guid: 192500 uri: 192500 title: WPR23LA253 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192525/pdf description:
Unique identifier
192525
NTSB case number
WPR23LA253
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-06-30T15:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-10T21:41:23.989Z
Event type
Accident
Location
Novato, California
Airport
Gnoss Field Airport (DVO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the landing roll for a touch-and-go, he retracted the flaps and advanced the throttle to full. Subsequently, the airplane veered hard left and the pilot attempted to correct with opposite rudder control; however, the airplane exited the runway. The airplane impacted terrain and came to rest in a shallow creek , in which both wings were substantially damaged. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control of the airplane during the landing roll for a touch and go, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N372AH
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
172S10156
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-10T21:41:23Z guid: 192525 uri: 192525 title: ANC23LA048 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192637/pdf description:
Unique identifier
192637
NTSB case number
ANC23LA048
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-01T12:30:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-07-25T03:13:39.64Z
Event type
Accident
Location
Prospect Creek, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot performed a low pass over a highway. During climbout, the pilot maintained an excessive angle of attack and the airplane veered left and impacted trees. The airplane sustained substantial damage to the left elevator. The pilot reported there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack on climbout, which resulted in a loss of control and impact with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-4-210C
Amateur built
false
Engines
1 Reciprocating
Registration number
N40661
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2173C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-25T03:13:39Z guid: 192637 uri: 192637 title: WPR23LA273 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192641/pdf description:
Unique identifier
192641
NTSB case number
WPR23LA273
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-01T13:30:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-17T23:47:39.814Z
Event type
Accident
Location
Metaline Falls, Washington
Airport
Sullivan Lake State (O9S)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that during the landing rollout, after the tail came down, he felt and heard a “bang” as the airplane rolled over a concrete ring, embedded in the turf runway. The airplane continued down the runway and the right main landing gear tire dug into the ground, followed by the collapse of the right main landing gear. The fuselage sustained substantial damage. After exiting the airplane, the pilot noticed that the tailwheel steering link was broken. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing due to impact with a concrete ring embedded in the grass runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV8
Amateur built
true
Engines
1 Reciprocating
Registration number
N68TP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
83300
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-17T23:47:39Z guid: 192641 uri: 192641 title: ANC23LA049 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192638/pdf description:
Unique identifier
192638
NTSB case number
ANC23LA049
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-01T13:40:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-07-25T03:18:12.734Z
Event type
Accident
Location
Beluga, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot landed on a remote unimproved landing strip that was surrounded by overgrown vegetation. When the pilot attempted to takeoff, the left wing struck a stand of bushes, which pivoted the airplane to the left, and he was unable to maintain control of the airplane and subsequently impacted more bushes. The airplane sustained substantial damage to the wings. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's selection of an unsuitable takeoff site, resulting in a collision with brush-covered terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18
Amateur built
false
Engines
1 Reciprocating
Registration number
N15XX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-811
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-25T03:18:12Z guid: 192638 uri: 192638 title: ANC23LA046 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192552/pdf description:
Unique identifier
192552
NTSB case number
ANC23LA046
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-01T19:12:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-07-25T03:14:50.223Z
Event type
Accident
Location
Talkeetna, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While maneuvering a float-equipped airplane low-level over a river, the pilot turned the airplane downwind and it encountered a downdraft. The airplane subsequently lost altitude and the pilot added power to climb; however, the airplane’s float impacted a gravel bar adjacent to the river. The airplane came to rest in an area of gravel-covered terrain, sustaining substantial damage to the fuselage. The pilot reported there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s encounter with a downdraft while maneuvering low-level, which resulted in a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22
Amateur built
false
Engines
1 Reciprocating
Registration number
N3321B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-2136
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-25T03:14:50Z guid: 192552 uri: 192552 title: CEN23LA272 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192502/pdf description:
Unique identifier
192502
NTSB case number
CEN23LA272
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-01T21:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-17T23:48:44.431Z
Event type
Accident
Location
Chetek, Wisconsin
Airport
Chetek Municipal/Southworth Airport (Y23)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot stated that after he had performed a preflight inspection of the powered parachute and allowed the engine to warm up, he moved the powered parachute into position for takeoff. Prior to takeoff, he applied full engine power and watched the canopy rise and then reduced engine power and checked the canopy lines. He applied full engine power for takeoff, and the powered parachute lifted with no issues. However, when he looked down, the powered parachute was not climbing and headed toward trees. The pilot attempted to adjust the flight path to avoid the trees, but the powered parachute impacted a pole, the trees, and then descended into the ground. The powered parachute sustained substantial damage to the frame. The pilot stated there was no mechanical anomalies with the powered parachute that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during initial climb which resulted in an impact with a pole, trees, and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Powered parachute
Make
SIX CHUTER
Model
SR7 XL
Amateur built
false
Engines
1 Reciprocating
Registration number
N6365A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
SC1999CS
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-17T23:48:44Z guid: 192502 uri: 192502 title: ERA23LA282 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192511/pdf description:
Unique identifier
192511
NTSB case number
ERA23LA282
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-02T11:30:00Z
Publication date
2023-08-10T04:00:00Z
Report type
Final
Last updated
2023-07-12T15:33:31.734Z
Event type
Accident
Location
Kennesaw, Georgia
Airport
COBB COUNTY INTL-MCCOLLUM FLD (RYY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot reported that upon landing, the airplane began “veering toward the left side of the runway.” He attempted to correct with right rudder but was unsuccessful and subsequently attempted to abort the landing. During the maneuver the right main landing gear impacted a runway sign and the airplane touched back down in the grass next to the runway coming to a stop. During the accident sequence, the right horizontal stabilizer was substantially damaged. The owner reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s loss of directional control while landing, which resulted in a runway excursion and collision with an airport sign.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N734YD
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17269213
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T15:33:31Z guid: 192511 uri: 192511 title: CEN23LA274 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192504/pdf description:
Unique identifier
192504
NTSB case number
CEN23LA274
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-02T14:20:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-05T16:59:20.618Z
Event type
Accident
Location
Durango, Colorado
Airport
Animas Air Park (00C)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he forgot to lower the landing gear before landing, which resulted in substantial damage to the fuselage. He stated that he believed his noise cancelling headset contributed to not hearing the gear warning horn. He stated that there were no mechanical malfunctions or failures that would have precluded normal operation. Following the accident, when power was applied to the airplane, the gear warning horn sounded and when the landing gear handle was moved to the down position, all three gear extended.
Probable cause
The pilot’s failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-24-250
Amateur built
false
Engines
1 Reciprocating
Registration number
N7525P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
24-2727
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-05T16:59:20Z guid: 192504 uri: 192504 title: WPR23LA248 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192518/pdf description:
Unique identifier
192518
NTSB case number
WPR23LA248
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-03T09:30:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-05T20:42:47.595Z
Event type
Accident
Location
Moses Lake, Washington
Airport
Grant County (MWH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The instructor of the tailwheel-equipped airplane reported a left crosswind during the landing approach. The pilot receiving instruction executed a 3-point landing and the tailwheel bounced twice. The instructor told the student to “pin the tail” by applying full aft elevator. The airplane deviated right of runway centerline and the pilot corrected with left rudder. The airplane crossed the centerline to the left and did not respond to full right rudder and heavy right braking. The airplane ground looped to the left sustaining substantial damage to the right wing and right horizontal stabilizer and elevator. The pilot reported there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FOUND
Model
FBA2C
Amateur built
false
Engines
1 Reciprocating
Registration number
CFXRB
Operator
AngelOne Canada
Flight conducted under
Non-U.S., non-commercial
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
54
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-05T20:42:47Z guid: 192518 uri: 192518 title: WPR23LA250 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192521/pdf description:
Unique identifier
192521
NTSB case number
WPR23LA250
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-03T12:09:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-05T20:34:04.326Z
Event type
Accident
Location
McCall, Idaho
Airport
McCall Municipal Airport (KMYL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that, during landing, he positioned his feet on the heel brake pedals and applied wheel brakes. When the airplane’s tail rose, the pilot’s heels remained on the brake pedals and the airplane nosed over and came to rest inverted. The wing struts and rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s application of wheel brakes during landing roll out, resulting in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18
Amateur built
false
Engines
1 Reciprocating
Registration number
N36KG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-4586
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-05T20:34:04Z guid: 192521 uri: 192521 title: ERA23LA292 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192554/pdf description:
Unique identifier
192554
NTSB case number
ERA23LA292
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-03T14:50:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-11T23:37:34.905Z
Event type
Accident
Location
Suffolk, Virginia
Airport
SUFFOLK EXEC (SFQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was returning from her fifth skydive run of the day. During the landing, “the flare seemed insufficient” and the nose landing gear collapsed during touchdown. The airplane continued off the side of the runway and came to rest in the grass. During the accident sequence, the airplane sustained substantial damage to the engine mounts. The operator reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate landing flare, which resulted in a nose landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
208B
Amateur built
false
Engines
1 Turbo prop
Registration number
N716MM
Operator
ARNE AVIATION LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Skydiving
Commercial sightseeing flight
false
Serial number
208B0746
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T23:37:34Z guid: 192554 uri: 192554 title: CEN23LA288 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192570/pdf description:
Unique identifier
192570
NTSB case number
CEN23LA288
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-03T19:40:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-07-11T19:08:07.491Z
Event type
Accident
Location
Oregon, Illinois
Airport
Private Airstrip (NA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that his approach to a grass airstrip was too fast, which resulted in the airplane bouncing after landing. Subsequently, the airplane veered off the runway into a cornfield, and contacted trees. The airplane sustained substantial damage to both wings. The pilot reported there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control after a bounced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
AIRBORNE
Model
XT 582
Amateur built
false
Engines
1 Reciprocating
Registration number
N5613B
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
XT582-0001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T19:08:07Z guid: 192570 uri: 192570 title: ANC23LA047 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192578/pdf description:
Unique identifier
192578
NTSB case number
ANC23LA047
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-04T17:00:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-07-10T23:33:40.312Z
Event type
Accident
Location
Kusatan, Alaska
Airport
McArthur River Gravel Bar (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll out on a remote, gravel/sand bar, the main landing gear wheels encountered an area of uneven sand and the airplane bounced and pitched into the air. She attempted to correct to no avail. Subsequently, when the airplane touched down from the bounce, the wheels dug into the sand, and the airplane nosed over, resulting in substantial damage to the wing struts. The pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The pilot's selection of unsuitable terrain for landing, which resulted in a bounced landing and an encounter with soft terrain, and a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-5-210C
Amateur built
false
Engines
1 Reciprocating
Registration number
N51592
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6023C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-10T23:33:40Z guid: 192578 uri: 192578 title: WPR23LA254 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192532/pdf description:
Unique identifier
192532
NTSB case number
WPR23LA254
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-04T17:02:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-06T03:25:10.418Z
Event type
Accident
Location
Belgrade, Montana
Airport
BOZEMAN YELLOWSTONE INTL (KBZN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot of the tailwheel equipped airplane reported that during landing, the airplane’s tail swung to the right and the airplane veered to the left. The airplane struck a runway edge cone, then exited the turf runway and nosed over. The left wing, both wing struts, the vertical stabilizer, and the rudder were substantially damaged. The pilot said there was a 6-10 kt left quartering tailwind when he exited the airplane. He reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing with a quartering tailwind, which resulted in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
MX7-180C
Amateur built
false
Engines
1 Reciprocating
Registration number
N3171H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22045C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-06T03:25:10Z guid: 192532 uri: 192532 title: ERA23LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192520/pdf description:
Unique identifier
192520
NTSB case number
ERA23LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-04T20:30:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-06T22:49:24.462Z
Event type
Accident
Location
Myrtle Beach, South Carolina
Airport
MYRTLE BEACH INTL (MYR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 3 minor
Analysis
The pilot was taxiing the helicopter about 3 ft above the ground in preparation to takeoff when his door popped open. The pilot said he instinctively removed his left hand from the collective to shut the door; however, before he could even reach the door, the collective lowered and there was reduction in power. The helicopter then rolled over on to its right side, which resulted in substantial damage to the fuselage and main rotor system. The pilot reported there were no preimpact mechanical malfunctions that contributed to the accident.
Probable cause
The pilot’s failure to maintain control of the helicopter during a hover taxi, which resulted in a rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N7507X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
true
Serial number
1218
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-06T22:49:24Z guid: 192520 uri: 192520 title: CEN23LA275 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192530/pdf description:
Unique identifier
192530
NTSB case number
CEN23LA275
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-05T13:10:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-18T23:38:52.368Z
Event type
Accident
Location
Grand Prairie, Texas
Airport
Grand Prairie Municipal (GPM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot executed a wheel landing but before the tail wheel settled onto the runway, the airplane drifted to the right after encountering an unexpected wind shift. His efforts to maintain control were not successful. The airplane subsequently exited the runway and traversed across the grass towards a retention pond. In an attempt to stop the airplane before the pond, the pilot applied heavy braking, and the airplane nosed over and came to rest inverted. The vertical stabilizer, rudder, left wing and lift strut sustained substantial damage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. He added that transitioning the tail wheel down onto the runway sooner instead of expediting his exit from the runway, he may have been able to maintain directional control during the wind shift.
Probable cause
The pilot’s failure to maintain directional control during landing. Contributing to the accident was the unexpected sudden wind shift.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180A
Amateur built
false
Engines
1 Reciprocating
Registration number
N889SL
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
50226
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-18T23:38:52Z guid: 192530 uri: 192530 title: ERA23LA290 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192544/pdf description:
Unique identifier
192544
NTSB case number
ERA23LA290
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-05T13:15:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-06T22:52:51.527Z
Event type
Accident
Location
Clearwater, Florida
Airport
CLEARWATER AIR PARK (CLW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was attempting to take off when the engine lost total power about 100-200 ft above the runway. He attempted to re-start the engine by switching the fuel selector from the right main tank to the left main tank, but the engine did not re-start. The pilot made a forced landing to a grassy area beyond the runway. The airplane traveled down an embankment, struck a pole and a metal gate, which resulted in substantial damage to the left wing and several engine mounts. Postaccident examination of the airplane revealed the right main fuel tank was intact and fuel was observed in the tank. When the fuel was drained from the tank’s quick drain valve, as well as the fuel strainer located on the lower fuselage, a large amount of water was drained prior to any fuel being drained. Water was also drained from the carburetor bowl and the drain plug was corroded. The pilot said that he performed a preflight inspection “per the checklists” and had drained fuel from both the left and right main fuel tanks prior to the flight; however, he did not drain the fuselage fuel strainer as part of the preflight inspection, which is required per the checklist. According to the airplane’s pilot operating handbook (POH), “This strainer should be drained regularly to avoid the accumulation of water or sediment.” Though the pilot said he drained the right main fuel tank prior to flight, he did not drain the fuselage fuel strainer as required per the checklist. As such, the loss of engine power on takeoff was most likely due to water contamination in the available fuel supply.
Probable cause
The pilot’s improper preflight inspection which resulted in a loss of engine power due to fuel contamination (water).
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N8579W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-10091
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-06T22:52:51Z guid: 192544 uri: 192544 title: CEN23LA280 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192546/pdf description:
Unique identifier
192546
NTSB case number
CEN23LA280
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-05T15:50:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-17T22:11:47.68Z
Event type
Accident
Location
Amity, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that during an aerial application flight, the helicopter impacted wires that he failed to see, which resulted in substantial damage to the fuselage and rotor blades. He stated that a road that paralleled the field dipped down, which made the wires appear below the horizon. The pilot stated that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to see and avoid wires while conducting a low-level aerial application flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON
Model
206L-1
Amateur built
false
Engines
1 Turbo shaft
Registration number
N828WP
Operator
CEDAR RIDGE AVIATION LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
45294
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-17T22:11:47Z guid: 192546 uri: 192546 title: CEN23LA292 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192579/pdf description:
Unique identifier
192579
NTSB case number
CEN23LA292
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-05T16:45:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-07-18T23:41:09.834Z
Event type
Accident
Location
Burlington, Vermont
Airport
Burlington International Airport (KBVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the flight instructor, the student pilot was a little high on the final approach for the short field landing, which resulted in a steeper approach. Before touch down, the student decreased the pitch attitude, and there was little to no flare. The airplane landed flat, bounced, then hit the nosewheel first as they touched down and bounced a second time. During the second bounce, both pilots heard a noise, the student felt a vibration in the rudder pedals, and initiated a go-around. The flight instructor assumed control of the airplane during climb out and confirmed there were no anomalies with the rudder system before transferring the controls back to the student. During the next landing, the flight instructor stated that the student flared a little high and the airplane ballooned before touchdown. During the landing roll, the airplane veered to the right and neither pilot was able to maintain directional control. The nose landing gear collapsed as both pilots applied the brakes. The airplane impacted a taxiway light and came to rest on the runway. The airplane sustained substantial damage to the firewall and lower fuselage at the nose landing gear support structure. Based on the pilot’s statements it is likely the nose landing gear was compromised during the first landing attempt. The flight instructor reported that there were no anomalies with the airplane before the first landing. He added that the accident could have been prevented if they had performed a go-around if a stabilized approach was not established.
Probable cause
The student pilot’s improper landing flare, which resulted in a hard, bounced landing and the flight instructor’s delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172R
Amateur built
false
Engines
1 Reciprocating
Registration number
N64AF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17280069
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-18T23:41:09Z guid: 192579 uri: 192579 title: CEN23LA279 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192545/pdf description:
Unique identifier
192545
NTSB case number
CEN23LA279
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-05T17:41:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-07-07T01:06:30.085Z
Event type
Accident
Location
Chapman, Kansas
Airport
Smokey Valley Ag (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot intended to spray a corn field and had discussed the location of power lines with his ground crew. As he approached the field, he observed power lines on 3 sides of the field in addition to a large set of power lines feeding into an adjacent substation. The pilot completed a 360° survey to identify the hazards including power lines, guy wires, and trees. During the survey, the middle of the field appeared to be clear. The pilot initiated an initial application pass and the helicopter struck a green wire, about 1/4" in diameter. The pilot’s efforts to maintain control of the helicopter were not successful, and it subsequently impacted the corn field. The helicopter came to rest on its left side with substantial damage to the fuselage, tail boom, main rotor blades, and flight controls. The pilot stated that there were no failures or malfunctions related to the helicopter before the impact with the power line. He also noted that the power line was green in color which was “practically invisible” with the background of the corn field.
Probable cause
The pilot’s failure to maintain clearance from the power line during an agricultural application pass.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N67FA
Operator
SF LEASING LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
5168
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-07T01:06:30Z guid: 192545 uri: 192545 title: CEN23LA281 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192547/pdf description:
Unique identifier
192547
NTSB case number
CEN23LA281
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-06T09:24:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-07-11T21:32:56.906Z
Event type
Accident
Location
Jeffersonville, Indiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that, before the flight, he and his student inserted a calibrated wooden stick into the fuel tank to check the fuel quantity of the airplane and believed that it indicated just below ¾ tank, or about 16 gallons of fuel remaining. They completed the preflight inspection and proceeded with the flight to another airport for takeoff and landing practice. While at the other airport, they performed six circuits of the traffic pattern before proceeding back toward the departure airport. As they approached the airport, the flight instructor heard the engine speed decrease and initially thought his student had retarded the throttle, but she had not. The engine recovered briefly and then sputtered again. The flight instructor said he checked the mixture, master switch, ignition, and fuel pump settings, and the engine continued to have spurts of power. He surmised that they were experiencing a fuel issue and noted that the fuel gauge read empty. He notified air traffic control, and was cleared to land, but had insufficient altitude and executed a forced landing to a corn field. The airplane received substantial damage to the fuselage including separation of the empennage. Postaccident examination of the airplane revealed no usable fuel remained in the fuel tank. The flight instructor reported that he believed the time of day, weather conditions and lighting combined with an expectation bias, contributed to misreading of the fuel stick, which likely read below ½ tank before the flight. He also noted that he prepared a safety presentation about the event to present to flying club members and other aviation meetings. Based on the available information, the engine power loss was due to exhaustion of the airplane’s fuel supply.
Probable cause
The pilot’s improper fuel management, which resulted in fuel exhaustion and a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA20-C1
Amateur built
false
Engines
1 Reciprocating
Registration number
N988CT
Operator
FLIGHT CLUB 502 INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
C0088
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T21:32:56Z guid: 192547 uri: 192547 title: CEN23LA290 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192573/pdf description:
Unique identifier
192573
NTSB case number
CEN23LA290
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-07T09:30:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-07-14T01:11:06.535Z
Event type
Accident
Location
Caswell Beach, North Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After a successful landing in the open sea, the pilot reported that the water was rougher than it appeared from the air and while making a subsequent take off attempt, the right float caught a swell and the airplane spun to the right resulting in substantial damage to both wings. The airplane came to rest inverted in the water. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to properly evaluate the sea state during an open sea landing and subsequent takeoff attempt resulting in an inadvertent impact with the water.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GOOD JAMES
Model
AIR CAM
Amateur built
true
Engines
2 Reciprocating
Registration number
N38HP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
111042
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-14T01:11:06Z guid: 192573 uri: 192573 title: WPR23LA268 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192586/pdf description:
Unique identifier
192586
NTSB case number
WPR23LA268
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-07T09:30:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-07-12T00:22:12.95Z
Event type
Accident
Location
Deer Park, Washington
Airport
DEER PARK (DEW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, during landing roll with a 90° left crosswind at 6 kts, the airplane had a slight drift to the left after touchdown. He attempted corrective inputs by using a combination of right rudder and right brake, but the airplane continued drifting to the left and departed the runway. Subsequently, the landing gear collapsed, and the airplane collided with the dirt surface, resulting in substantial damage to the right wing. The pilot initially reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation and that a gust of wind pushed the tail of the airplane’s tail to the right. The pilot later stated he suspected the right brake had locked during landing, which he said would have reduced the braking effectiveness on the right side. Pictures of skid marks on the runway associated with the right tire show a lighter and narrower skid mark initially parallel to the runway heading, that increased in width and darkness as it turned to the left to where the airplane exited the runway. The right main tire was flat spotted and worn through about ½ the thickness of the sidewall. The airplane was not examined or secured after the accident due to the pilot’s initial assessment that there were no abnormalities or malfunctions with the airplane, and that the airplane had been affected by wind. The evidence is consistent with the pilot’s testimony that he applied right rudder and brake to counter the left turn during landing rollout with a left crosswind.
Probable cause
The pilot’s failure to maintain directional control during landing with a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VICKERS-ARMSTRONG LTD
Model
SPITFIRE IX
Amateur built
false
Engines
1 Reciprocating
Registration number
N633VS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
CBAF IX.571
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T00:22:12Z guid: 192586 uri: 192586 title: WPR23LA260 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192576/pdf description:
Unique identifier
192576
NTSB case number
WPR23LA260
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-07T18:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-07-12T04:51:48.395Z
Event type
Accident
Location
Fremont Island, Utah
Airport
Freemont Island Lower (89D)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the flight instructor, during the landing roll the pilot undergoing instruction applied asymmetrical braking and locked the left brake. This led to a ground loop. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot undergoing instruction’s excessive application of asymmetrical braking during landing, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
170B
Amateur built
false
Engines
1 Reciprocating
Registration number
N1664D
Operator
SCUD AIR SOLUTIONS LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
20306
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T04:51:48Z guid: 192576 uri: 192576 title: CEN23LA294 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192601/pdf description:
Unique identifier
192601
NTSB case number
CEN23LA294
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-07T21:30:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-08-10T19:36:35.652Z
Event type
Accident
Location
Lee's Summit, Missouri
Airport
LEE'S SUMMIT MUNI (LXT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After completion of a local flight, the pilot landed and exited the runway. Shortly after exiting the runway the airplane’s engine stopped running. The pilot attempted to restart the engine, which was unsuccessful, and he noticed smoke. The pilot and passenger exited the airplane and a fire ensued that damaged the forward fuselage and firewall. Postaccident examination of the airplane indicated that the fire was concentrated in an area near the left carburetor. Examination of the carburetor did not reveal any anomalies; however, the extent of the fire damage precluded determination of the source of the fire.
Probable cause
An engine fire after landing for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPISTREL LSA S R L
Model
ALPHA TRAINER
Amateur built
false
Engines
1 Reciprocating
Registration number
N201ZM
Operator
SUMMIT FLIGHT ACADEMY LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
913 AT 912 LSA
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T19:36:35Z guid: 192601 uri: 192601 title: WPR23LA261 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192577/pdf description:
Unique identifier
192577
NTSB case number
WPR23LA261
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T02:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-11T00:59:59.778Z
Event type
Accident
Location
La Grande, Oregon
Airport
LA GRANDE/UNION COUNTY (LGD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while overflying a grass airstrip to land, the left wing struck a tree after crossing the departure end of the runway at treetop level. The pilot maneuvered to a local airport for an emergency landing. During landing, shortly after the airplane crossed the runway threshold, a ground observer notified the pilot that the left landing gear was not extended. The pilot then placed the landing gear selector lever in UP position, but the right gear did not retract Subsequently, the airplane ground looped shortly after touchdown and collapsed the right landing gear. Post accident examination revealed that the left wing had substantial damage from impact with a tree. The pilot added that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain clearance from trees during an airstrip overfly, which resulted in impact damage to the left wing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
NORTH AMERICAN
Model
AT-6G
Amateur built
false
Engines
1 Reciprocating
Registration number
N92761
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
182-413
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T00:59:59Z guid: 192577 uri: 192577 title: CEN23LA287 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192569/pdf description:
Unique identifier
192569
NTSB case number
CEN23LA287
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T10:10:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-07-11T01:00:35.544Z
Event type
Accident
Location
Big Prairie, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and pilot receiving instruction were completing water landings in the amphibious airplane. They had already completed several landings on the same pond without incident. During the accident landing, upon touchdown the airplane impacted a submerged log, which punctured a large hole in the hull. The pilots egressed without further incident and the airplane sank. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s collision with a submerged log during a water landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AEROFAB
Model
LA-4
Amateur built
false
Engines
1 Reciprocating
Registration number
N993PT
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
341
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T01:00:35Z guid: 192569 uri: 192569 title: CEN23LA289 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192572/pdf description:
Unique identifier
192572
NTSB case number
CEN23LA289
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T11:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-18T01:41:17.457Z
Event type
Accident
Location
Frankston, Texas
Airport
Aero Estates Airport (T25)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During landing, the airplane drifted right of the runway centerline. The pilot was unable to maintain directional control, and the airplane exited the runway and impacted a tree and a parked golfcart. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation. The pilot noted that he had limited function of his left leg and was unable to apply sufficient left rudder input to maintain directional control.
Probable cause
The pilot’s failure to maintain directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20A
Amateur built
false
Engines
1 Reciprocating
Registration number
N8335E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1513
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-18T01:41:17Z guid: 192572 uri: 192572 title: WPR23LA262 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192580/pdf description:
Unique identifier
192580
NTSB case number
WPR23LA262
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T13:30:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-07-11T03:48:46.06Z
Event type
Accident
Location
Shelter Cove, California
Airport
SHELTER COVE (0Q5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot reported that he departed with 74 gallons of fuel onboard for the flight of about 84 nm. After an uneventful flight the pilot selected the runway that was favored by prevailing winds. He then extended the landing gear and reduced power while the airplane was on the downwind leg of the airport traffic pattern over the ocean. The pilot encountered a partial loss of engine power as he turned to the base leg and the airplane began to descend from 800 ft above ground level. He performed emergency procedures for a loss of power from memory, but the engine continued to run at low power. Unable to maintain altitude, the airplane impacted the ocean and sank. The pilot and passenger, who were both seriously injured, egressed the airplane and swam to shore. Subsequent efforts to locate and recover the airplane were unsuccessful.
Probable cause
A partial loss of engine power for reasons that could not be determined because the airplane was not located and recovered.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
P35
Amateur built
false
Engines
1 Reciprocating
Registration number
N9520Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-7016
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T03:48:46Z guid: 192580 uri: 192580 title: WPR23LA265 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192583/pdf description:
Unique identifier
192583
NTSB case number
WPR23LA265
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T14:52:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-11T03:46:00.607Z
Event type
Accident
Location
Emmett, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The flight instructor reported that he was demonstrating a turning autorotation to his student. The instructor entered the glide, turned, and kept the engine and rotor RPM gauges in the green arc, while maintaining an airspeed of about 55 knots. He increased the throttle setting and raised the collective lever as the helicopter descended through 200 ft AGL, however, the rotor RPMs fell below the green arc. The instructor made the decision to continue the autorotation with ground contact and applied aft cyclic to reduce the decent rate. The helicopter landed hard and nosed over onto its right side, resulting in substantial damage to the tailboom and tail rotor assembly. The instructor reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The instructor’s failure to maintain airspeed during a simulated turning autorotation, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N74778
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
3968
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T03:46:00Z guid: 192583 uri: 192583 title: WPR23LA266 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192584/pdf description:
Unique identifier
192584
NTSB case number
WPR23LA266
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T15:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-12T17:33:10.597Z
Event type
Accident
Location
Judith Gap, Montana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he “failed to recon” the field he had just landed on. During his departure attempt, high density altitude and soft ground led to a longer than expected takeoff roll. While maneuvering to avoid a bank on the opposite side of a road the airplane struck a power pole resulting in substantial damage to the right wing. The pilot reported no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's decision to take off on a soft field that exceeded the performance capabilities of the airplane, which resulted in an impact with a pole and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N4135M
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-3034
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T17:33:10Z guid: 192584 uri: 192584 title: WPR23LA267 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192585/pdf description:
Unique identifier
192585
NTSB case number
WPR23LA267
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T15:33:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-11T08:27:58.649Z
Event type
Accident
Location
Coquille Bay, Oregon
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the airplane reported that, after completing a preflight inspection of the airplane he departed for a local flight. While enroute, at about 1500 above ground level (agl), the right tank ran out of fuel and the “engine cut out.” As he was switching tanks, the airplane impacted terrain and nosed over. The airplane sustained substantial damage to both wings and forward fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper fuel management, which resulted in fuel starvation, a total loss of engine power, and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-22-160
Amateur built
false
Engines
1 Reciprocating
Registration number
N9507D
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-6422
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-11T08:27:58Z guid: 192585 uri: 192585 title: CEN23LA293 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192589/pdf description:
Unique identifier
192589
NTSB case number
CEN23LA293
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T20:30:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-12T19:56:45.89Z
Event type
Accident
Location
Canandaigua, New York
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
Following an uneventful flight, the pilot descended the balloon at a steep angle into a field lined with trees. The pilot had briefed the passengers on the proper brace position before the flight and then again just before the landing. The basket touched down firmly, slid about 15 ft, and stopped upright. The passenger reported that the hard landing pushed her knee into the gas tank that she was standing next to. The passenger stated that after the first hard landing the balloon bounced again and then tipped over. Following the landing the passenger experienced pain in her leg. It was later determined the passenger had a broken left tibia. The pilot stated that there were no mechanical malfunctions with the balloon that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain the proper descent rate during the balloon’s approach to landing, which resulted in a hard landing, the passenger’s leg hitting the gas tank, and serious injury.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
AEROSTAR INTERNATIONAL INC
Model
RX 8
Amateur built
false
Registration number
N9184D
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
true
Serial number
RX8-3196
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-12T19:56:45Z guid: 192589 uri: 192589 title: CEN23LA298 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192610/pdf description:
Unique identifier
192610
NTSB case number
CEN23LA298
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-08T21:00:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-07-12T20:42:47.057Z
Event type
Accident
Location
Lino Lakes, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was flying his amphibious airplane over a neighborhood and decided to do a touch and go on a lake; however, he failed to retract the landing gear and the airplane flipped over when it contacted the water. The airplane came to rest inverted in the lake and sustained substantial damage to both wings. The pilot did not report to the responding law enforcement officer that there were any mechanical malfunctions with the airplane that would have precluded normal operation. The pilot was contacted on multiple occasions, but he did not submit the required National Transportation Safety Board Pilot/Operator Aircraft Accident/Incident Report Form 6120.1.
Probable cause
The pilot’s failure to retract the landing gear on the amphibious airplane before landing on water.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Mariner
Model
Unknown
Amateur built
false
Engines
1 Unknown
Registration number
UNREG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
Unknown
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-12T20:42:47Z guid: 192610 uri: 192610 title: CEN23LA301 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192618/pdf description:
Unique identifier
192618
NTSB case number
CEN23LA301
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-10T11:35:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-13T04:57:22.237Z
Event type
Accident
Location
Titusville, Florida
Airport
Space Coast Regional Airport (TIX)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
After completion of a local solo flight, the student pilot was conducting the engine cooling shutdown procedure on the dry ramp when the helicopter suddenly became airborne, climbed about 30ft, and entered a nose down attitude impacting the ground. The helicopter came to rest upright, and the pilot was able to egress from the helicopter without further incident. The helicopter sustained substantial damage to the main rotor system, the tail boom, and the tail rotor system. The student pilot reported that he had engaged both the cyclic and collective friction prior to completing other post flight activities. Postaccident examination of the helicopter showed the collective friction to not be fully engaged. The friction was found at an approximate 90-degree angle to the collective lever, which corresponds to the friction not being fully engaged. The helicopter pilot’s flight manual states that the collective friction is to be on for the engine cooling shutdown procedure. No preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal flight operation were reported.
Probable cause
The student pilot’s failure to maintain helicopter control while on the ground when his attention was diverted for post flight activities.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
SCHWEIZER
Model
269C-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N21409
Operator
US AVIATION TRAINING SOLUTIONS
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
0365
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-13T04:57:22Z guid: 192618 uri: 192618 title: WPR23LA274 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192651/pdf description:
Unique identifier
192651
NTSB case number
WPR23LA274
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-10T15:25:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-19T01:18:20.43Z
Event type
Accident
Location
Long Beach, California
Airport
Long Beach Airport (Daugherty Field) (LGB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The flight instructor reported that he was on the ramp, observing his student pilot practice landings while flying solo. During the student pilot’s first landing, he observed the left wing and main gear lift, and the student pilot overcorrected to the left and exited the runway into grass. The student pilot elected to execute a go-around, but impacted the rooftop of a hangar. The airplane sustained substantial damage to the wings and fuselage. The instructor reported there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during landing and the subsequent go-around, which resulted in impact with a hangar.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N3307E
Operator
Pacific Air Flight School, LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17271499
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-19T01:18:20Z guid: 192651 uri: 192651 title: ERA23LA305 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192690/pdf description:
Unique identifier
192690
NTSB case number
ERA23LA305
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-11T14:39:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-24T22:15:53.911Z
Event type
Accident
Location
Gray, Georgia
Airport
N/A (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that about 12 miles from the airport of departure, while returning after a local flight, he observed a large bird on his right side. He attempted to avoid the bird but was unsuccessful and the bird impacted the leading edge of the right wing. The pilot returned to the airport of departure and landed safely. Postaccident examination of the airplane revealed that the right wing was substantially damaged. The operator reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
An in-flight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28
Amateur built
false
Engines
1 Reciprocating
Registration number
N271MG
Operator
Middle Georgia State University
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2881453
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-24T22:15:53Z guid: 192690 uri: 192690 title: CEN23LA302 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192621/pdf description:
Unique identifier
192621
NTSB case number
CEN23LA302
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-12T07:48:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-07-17T23:53:50.312Z
Event type
Accident
Location
Custer, South Dakota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the sightseeing flight stated that after departure, the balloon’s speed increased, and its direction of travel became different from preflight wind observations. During the flight, the pilot established radio contact with the pilot of another company balloon, and they decided to land at a park. The other company balloon, which was ahead of the accident balloon, landed in the park without incident. When the accident pilot attempted a similar landing, the balloon encountered wind shear, and he continued the flight and flew about 1.5 miles. The pilot found a long field sheltered by trees and terrain, in which to attempt a landing. The pilot briefed the passengers to hold on tight and to crouch down in the balloon’s basket for the landing. At 100 ft above ground level (agl), the balloon encountered wind shear and slowed to about 5 kts. At 50 ft agl, the approach was “normal,” but the balloon’s speed increased “very rapidly.” The pilot stated that he was committed to the landing due to the amount of heat he had vented from the balloon, which would not allow for a climb. The balloon touched down “fairly smoothly,” but its speed increased. The pilot pulled the rapid deflation line, but the balloon lifted off, so he reseated the deflation system to reduce a descent rate that ensued from about 20 ft agl. The pilot then pulled the rapid deflation line again when the balloon was about to touch down. During touchdown, the balloon tipped over onto its side and came to a stop after traveling about 120 ft. The balloon did not sustain damage. A passenger received serious injuries. The pilot stated there was no mechanical malfunction/failure of the balloon.
Probable cause
The pilot’s weather encounter that resulted in a high speed landing, the balloon tipping over, and serious injury to a passenger.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
ARBC INC DBA LINDSTRAND
Model
260A
Amateur built
false
Registration number
N605KD
Operator
Flying Circus Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
true
Serial number
5770
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-17T23:53:50Z guid: 192621 uri: 192621 title: CEN23LA300 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192617/pdf description:
Unique identifier
192617
NTSB case number
CEN23LA300
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-12T09:45:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-13T05:05:08.356Z
Event type
Accident
Location
Hertford, North Carolina
Airport
Abe Godfrey PRIVATE (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, during the landing roll, the airplane drifted to the right and exited the runway. Upon exiting the runway, the right wing contacted soybean plants, the airplane ground looped and the left wing impacted the ground, which resulted in substantial damage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in a runway excursion and subsequent impact with vegetation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Acrosport
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N827JA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
827
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-13T05:05:08Z guid: 192617 uri: 192617 title: DCA23LA378 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192698/pdf description:
Unique identifier
192698
NTSB case number
DCA23LA378
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-12T16:10:00Z
Publication date
2023-10-19T04:00:00Z
Report type
Final
Last updated
2023-07-27T01:10:23.696Z
Event type
Accident
Location
Inverness, Florida
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 2 serious, 4 minor
Analysis
Allegiant Airlines flight 227 (AAY227), which originated from Asheville Regional Airport (AVL), Asheville, North Carolina, encountered convective-induced turbulence while descending to 13,000 ft during the approach into St. Petersburg-Clearwater International Airport (PIE), Clearwater, Florida. The captain was a check pilot, and the first officer was the pilot flying. AAY227 established communication with air traffic control (ATC) and reported that the airplane was descending to cross the CAPOH intersection at flight level (FL) 270. The controller notified the flight crew of an area of moderate to heavy precipitation at the airplane’s 12:00 position which was 45 miles away and advised the crew to anticipate deviations to the right of the airplane’s course. The controller instructed AAY227 to descend and maintain FL 190, deviate to the right of course upon leaving FL 260, and proceed directly to the OLENE intersection when able. AAY227 was descending from FL 230 when the controller instructed the crew to cross OLENE at 13,000 ft and 250 knots. The flight crewmembers reported that when they started the descent the airplane was in clear air and the ride was relatively smooth. The crewmembers also indicated that the initial crossing restriction for OLENE was given late by ATC and that the airplane was about 4,500 ft high on the descent profile, so they deployed the speed brakes and turned off the autopilot to meet the altitude and speed restrictions. The flight crew stated that no pilot reports (PIREPS) were conveyed during the flight and airborne weather radar did not show any significant precipitation returns. The cabin crewmembers stated that, although the seatbelt sign was on, they had not received the chimes that indicate final descent preparation should begin because the airplane had not yet descended through 10,000 ft. As AAY227 approached its level-off altitude, the flight crewmembers observed a small cumulus buildup at an altitude of about 13,000 ft that was unavoidable. According to the first officer, the clouds were not dark and looked no different than the clouds that the airplane had previously flown through. As the airplane entered the clouds, it encountered some minor expected jolts, and just before exiting, a severe jolt of turbulence occurred that lasted about 1.5 seconds. After the turbulence encounter, the captain immediately called the cabin crew and was informed of multiple injuries. The captain declared an emergency and asked for priority handling direct to PIE. The airplane subsequently made an uneventful landing. There were four flight attendants (FA) working the flight and they stated that just after the initial descent announcements, the lead FA (FA 1) was in the forward galley, FA 4 was in the aft galley, and FA 2 and FA 3 were walking through the cabin conducting seatbelt compliance checks. As the FAs were completing their checks, the airplane encountered turbulence, and all four flight attendants contacted the ceiling and then the cabin floor. After landing, FA 2 and 4 were provided medical assistance for serious injuries. Four passengers received minor injuries. FA 1 and FA 3 were not injured. A postaccident review of the radar and satellite imagery indicated that several low-level gust fronts had merged near the accident site, resulting in convective buildup where the airplane had been operating. The National Weather Service issued a convective SIGMET (Significant Meteorological Information) for the area about 15 minutes prior to the encounter, of thunderstorms moving eastward at 10 knots, with implied potential for severe turbulence in and near convective cells. The Tampa WSR-88D detected a developing cell in the immediate vicinity of the turbulence event with echoes between 15 – 45 dBZ, however, cockpit weather radar does not typically pick up echoes less than 20 dBZ. Therefore, it is unlikely the flight crew were aware that they were entering into a larger area of convection that included higher intensity echoes located east of their flight path and encountered moderate or greater convectively induced turbulence (CIT) within the clouds.
Probable cause
An inadvertent encounter with convectively induced turbulence during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIRBUS
Model
A320-214
Amateur built
false
Engines
2 Turbo fan
Registration number
N249NV
Operator
Allegiant Air, LLC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
7766
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-27T01:10:23Z guid: 192698 uri: 192698 title: CEN23LA307 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192631/pdf description:
Unique identifier
192631
NTSB case number
CEN23LA307
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-12T17:55:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-07-19T17:35:57.545Z
Event type
Accident
Location
Greenwood, Indiana
Airport
Indy South Greenwood Airport (HFY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While performing a soft-field takeoff, the student pilot lost directional control of the airplane during the takeoff roll. He attempted to correct with the application of rudder and brake inputs but was unsuccessful, and the airplane came to rest upright in a ditch adjacent to the runway. The airplane sustained substantial damage to the right wing. The student pilot reported no preaccident mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N701DE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17268367
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-19T17:35:57Z guid: 192631 uri: 192631 title: ANC23LA055 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192672/pdf description:
Unique identifier
192672
NTSB case number
ANC23LA055
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-13T16:00:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-08-10T01:35:45.665Z
Event type
Accident
Location
Palmer, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The instructor pilot reported that he was conducting training in a tailwheel equipped airplane, and during takeoff the student pilot inadvertently applied the brakes and the airplane nosed over, resulting in substantial damage to the rudder. The instructor pilot reported that there were no preaccident mechanical malfunctions or anomalies that would have precluded normal operation.
Probable cause
The student pilot’s inadvertent application of the brakes, which resulted in the airplane nosing over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-18
Amateur built
false
Engines
1 Reciprocating
Registration number
N37WP
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
18-756
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T01:35:45Z guid: 192672 uri: 192672 title: ANC23LA050 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192639/pdf description:
Unique identifier
192639
NTSB case number
ANC23LA050
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-13T16:30:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-07-25T03:19:36.884Z
Event type
Accident
Location
Matanuska Glacier, Alaska
Airport
Scandinavian Peaks Hut Airstrip (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported he encountered downdrafts during landing on a remote gravel airstrip near a glacial base camp known for downdrafts and mountain rotors. He elected to depart the airstrip into rising terrain due to more favorable winds. During initial climb out the pilot reported the airplane encountered more downdrafts than expected. Unable to outclimb rising terrain, the pilot performed a forced landing in an area of rough, rock-covered terrain, and during landing the airplane sustained substantial damage to the wings and fuselage. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s encounter with downdrafts resulting in decreased performance insufficient to outclimb rising terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1B
Amateur built
false
Engines
1 Reciprocating
Registration number
N460JC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2343
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-25T03:19:36Z guid: 192639 uri: 192639 title: CEN23LA308 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192632/pdf description:
Unique identifier
192632
NTSB case number
CEN23LA308
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-13T17:15:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-07-20T01:28:49.392Z
Event type
Accident
Location
Atchison, Kansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during an aerial application pass in a helicopter, he failed to observe a second lower powerline near a previously observed high-tension powerline. The pilot attempted to maneuver under the lower powerline but was unsuccessful, and the helicopter impacted the lower powerline and subsequently the terrain. The helicopter sustained substantial damage to the main rotor system, the tail boom, and the tail rotor system. The pilot reported there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to adequately survey a field for obstructions prior to a low-level aerial application pass, which resulted in an impact with a powerline.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
369D
Amateur built
false
Engines
1 Turbo shaft
Registration number
N533DR
Operator
Heinen Bros Ag
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
490533D
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-20T01:28:49Z guid: 192632 uri: 192632 title: CEN23LA325 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192716/pdf description:
Unique identifier
192716
NTSB case number
CEN23LA325
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-14T07:50:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-07-27T21:26:31.588Z
Event type
Accident
Location
Erie, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 2 minor
Analysis
The pilot reported that while conducting a sightseeing flight, the surface wind increased earlier than forecast. He decided to terminate the flight and make a high wind landing. He briefed his passengers that they were going to land quicky and drag to a stop. He reminded them to stay in the basket and hold on. The balloon skipped twice after contacting the ground and then dragged to a stop. One of the passengers was ejected and her hair was caught under the basket. She sustained minor injuries. Two other passengers remained in the basket but sustained serious injurious. The pilot sustained minor injuries and the remaining three passengers were not injured. The pilot reported there were no mechanical malfunctions or failures with the balloon that would have precluded normal operation. Prior to the flight, the pilot obtained a weather brief, and the weather forecast reported a front to pass around 0800. A terminal aerodrome forecast (TAF) for Rocky Mountain Metro Airport (BJC) about 7 miles southwest of Erie, Colorado, forecast wind to be out of the northwest at 7 knots at 0300 and then shift to wind out of the northeast at 12 knots around 0800. When the pilot launched the balloon in Erie at 0638, the wind was calm. About half an hour after launch, reported surface wind in Erie was out of the northeast at 5 knots gusting 15 knots.
Probable cause
A hard landing due to the high wind conditions which resulted in two passengers sustaining serious injuries.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
ULTRAMAGIC SA
Model
N-210
Amateur built
false
Engines
1 None
Registration number
N1958S
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Air race/show
Commercial sightseeing flight
false
Serial number
210/149
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-27T21:26:31Z guid: 192716 uri: 192716 title: CEN23LA305 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192627/pdf description:
Unique identifier
192627
NTSB case number
CEN23LA305
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-14T08:18:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-18T17:06:10.052Z
Event type
Accident
Location
Lafayette, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 3 minor
Analysis
While conducting a sightseeing flight for a balloon festival, the pilot noted wind about 17 miles per hour (mph). He was unable to locate calmer winds at different altitudes. The pilot decided to terminate the flight and make a high wind landing. During the high wind landing, the basket touched down hard and began to drag. One passenger was ejected from the basket which resulted in the balloon becoming airborne. The pilot was releasing air through the top vent and the balloon settled again to the ground and dragged to a stop. The passenger ejected and another that remained in the basket were seriously injured. The pilot and two passengers had minor injuries. There were no mechanical malfunctions with the balloon. Prior to the flight, the pilot obtained a weather brief, and the weather forecast reported a front to pass around 0800. After considering the weather, the pilot decided to launch on a low, short flight between 30 to 45 minutes. The pilot reported that he launched at 0643 and a couple minutes later, he noticed the winds aloft were stronger than expected and attempted to find a suitable landing area. On the pilot’s weather forecast, obtained several hours prior to the flight, the velocity and direction (VAD) winds showed wind at 5,900 ft mean sea level (msl) at 19 kts, which increased to 26 kts at 6,200 ft msl. At 0655, the closest aviation weather reporting facility reported a calm wind. At 0715, the same facility reported wind at 5 knots gusting to 15 knots.
Probable cause
Failure of the pilot to ensure the passengers were properly braced for the high wind landing. Contributing to the accident was the increase in prevailing winds prior to the forecast.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
ADAMS BALLOON
Model
AB
Amateur built
false
Registration number
N895FA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
279
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-18T17:06:10Z guid: 192627 uri: 192627 title: ERA23LA301 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192656/pdf description:
Unique identifier
192656
NTSB case number
ERA23LA301
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-14T13:08:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-02T22:07:37.68Z
Event type
Accident
Location
Lumberton, New Jersey
Airport
FLYING W (N14)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing approach he was distracted and forgot to extend the airplane’s landing gear. The airplane subsequently touched down on the runway and the fuselage and wings were substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-31-310
Amateur built
false
Engines
2 Reciprocating
Registration number
N400S
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
31-7712083
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-02T22:07:37Z guid: 192656 uri: 192656 title: CEN23LA311 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192646/pdf description:
Unique identifier
192646
NTSB case number
CEN23LA311
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-14T17:30:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-07-25T23:42:32Z
Event type
Accident
Location
Benson, Minnesota
Airport
Benson Municipal Airport (KBBB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that on the afternoon of the aerial application flight, the visibility was degrading due to smoke from nearby wildfires. Upon arrival at the target field, he circled twice to study the powerlines and obstacles, where he observed two distantly spaced power poles, and mistakenly thought they were termination points of a powerline. During the low-level aerial application pass, the airplane subsequently impacted a powerline as he flew between the power poles. The pilot returned to the airport and landed without incident. The airplane sustained substantial damage to the right aileron. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to adequately survey a field for obstructions prior to a low-level aerial application pass, which resulted in an impact with a powerline. Contributing to the accident was the degraded visibility due to the smoke in the area.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-802
Amateur built
false
Engines
1 Turbo prop
Registration number
N22FK
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
802-0965
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-25T23:42:32Z guid: 192646 uri: 192646 title: ERA23LA368 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193055/pdf description:
Unique identifier
193055
NTSB case number
ERA23LA368
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-14T21:50:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-09-13T23:05:01.639Z
Event type
Accident
Location
Culpeper, Virginia
Airport
CULPEPER RGNL (CJR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and student pilot completed several night landings without anomaly. Then, during the next takeoff, the student pilot applied engine power and the airplane accelerated down the runway. Just after reaching 50 knots, they noticed two deer standing in the center of the runway and called to abort the takeoff. They reduced the engine power and applied the brakes, but they were unable to stop before striking one of the deer with the left wing, which resulted in substantial damaged to the wing. The flight instructor reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s impact with a deer while performing a takeoff at night.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N1809H
Operator
Piston2Jet LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-7790314
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-13T23:05:01Z guid: 193055 uri: 193055 title: CEN23LA309 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192634/pdf description:
Unique identifier
192634
NTSB case number
CEN23LA309
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-16T18:36:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-07-18T01:07:39.604Z
Event type
Accident
Location
Princeton, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot attempted to depart from a rough grass field. The student pilot reported that the airplane did not climb as expected and during a turn, the airplane struck a pipe protecting a gas meter. He landed the airplane to avoid trees in his flight path. During the precautionary landing, the airplane sustained substantial damage to the fuselage and both wings. During an interview with the Federal Aviation Administration inspector assigned to the accident the student pilot did not allude to any mechanical issues with the airplane. The student pilot stated further that he did not have enough room for the takeoff. It was estimated that the field length was about 700 feet.
Probable cause
The student pilot’s decision to attempt a takeoff from an unimproved field which resulted in an impact with an obstacle.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C-65
Amateur built
false
Engines
1 Reciprocating
Registration number
N41317
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
8008
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-18T01:07:39Z guid: 192634 uri: 192634 title: WPR23LA277 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192666/pdf description:
Unique identifier
192666
NTSB case number
WPR23LA277
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-17T08:20:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-07-26T02:27:34.312Z
Event type
Accident
Location
Casper, Wyoming
Airport
Casper/Natrona County Airport (KCPR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported being cleared to land by air traffic control and reported being cautioned of wake turbulence by an airplane that landed ahead in sequence. The pilot aimed to touchdown at a point beyond the presence of the wake turbulence. The airplane encountered light turbulence prior to landing and contacted the runway misaligned with the runway centerline. The pilot applied opposite input correction which produced a roll force resulting in the right wing contacting the ground, substantially damaging the airplane. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing after encountering wake turbulence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Weight-shift
Make
EVOLUTION AIRCRAFT INC
Model
REVOLT
Amateur built
false
Registration number
N277GH
Operator
KC CONSTRUCTION
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001022
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-26T02:27:34Z guid: 192666 uri: 192666 title: ERA23LA302 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192662/pdf description:
Unique identifier
192662
NTSB case number
ERA23LA302
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-17T11:25:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-20T15:34:42.21Z
Event type
Accident
Location
Lebanon, New Hampshire
Airport
Lebanon Municipal Airport (LEB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, during the preflight inspection he noted the battery switch was in the ON position from two days prior and the battery was depleted. He had line personnel from the fixed based operator help jump start the airplane, which started easily, and he spent 20 minutes on the ramp setting up the avionics and preparing for the flight. He checked the voltage and “assumed the battery was accepting charge from the alternator” and elected to depart on the flight. About 10 miles into the flight, he noticed that the panel lighting was dimming, and the avionics turned off. The pilot returned to the departure airport and while enroute, he noticed the alternator circuit breaker was popped. He reset the circuit breaker and power was restored to the avionics. While circling over the airport, he was cleared to land, and attempted to lower the landing gear, however the alternator circuit breaker popped again, and the avionics powered down. The pilot performed an emergency hydraulic dump to lower the landing gear, however, the nose securing bar, which was used to lock the nose gear in the down position when manually extending the landing gear, was located out of reach in the back of the cabin. The pilot asked the tower controller if the nose landing gear was down, and the response indicated that it “appeared to be down.” The pilot landed the airplane, however when the nose landing gear touched down it collapsed, and the airplane slid about 500 ft, resulting in substantial damage to the fuselage. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to store the nose landing gear securing bar within reach in the cabin, which resulted in a nose gear collapse following a manual landing gear extension.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
POLLOCK MICHAEL D
Model
VELOCITY 173RG
Amateur built
false
Engines
1 Reciprocating
Registration number
N173DT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-20T15:34:42Z guid: 192662 uri: 192662 title: WPR23LA276 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192660/pdf description:
Unique identifier
192660
NTSB case number
WPR23LA276
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-18T14:50:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-20T00:40:25.102Z
Event type
Accident
Location
Chelan, Washington
Airport
Lake Chelan Airport (S10)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that, during the landing roll the airplane veered left, he attempted to correct with opposite right rudder. The airplane then ground looped, the right wing struck the surface, and the airplane nosed over coming to rest inverted. The airplane sustained substantial damage to the empennage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's loss of directional control during the landing roll, which resulted in a ground loop and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N300SS
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15062792
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-20T00:40:25Z guid: 192660 uri: 192660 title: CEN23LA368 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192895/pdf description:
Unique identifier
192895
NTSB case number
CEN23LA368
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-18T16:05:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-08-18T02:10:26.141Z
Event type
Accident
Location
Eagle River, Wisconsin
Airport
EAGLE RIVER UNION (EGV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot reported that during the landing at the destination airport, the airplane floated down the runway, landed long, and did not slow as expected. He continued to apply the brakes as the airplane neared the end of the runway, then felt a gust of wind from the left. The pilot was unable to maintain control and the airplane veered off the right side of the runway. The airplane nosed over in the grass and came to rest inverted which resulted in substantial damage to the right wing and empennage. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation and that to prevent the accident he could have landed closer to the threshold of the runway. The responding FAA inspector examined the airplane and found that the throttle was not all the way to idle.
Probable cause
The pilot’s failure to maintain proper airspeed on approach, which resulted in an extended touchdown, loss of control, and runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7921W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-1958
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-18T02:10:26Z guid: 192895 uri: 192895 title: WPR23LA281 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192684/pdf description:
Unique identifier
192684
NTSB case number
WPR23LA281
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-19T09:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-25T20:15:05.655Z
Event type
Accident
Location
Hamilton, Montana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the powered parachute reported that, after raising the wing and during takeoff, the powered parachute experienced an unexpected right turn. He checked to see if any steering lines were tangled but could not confirm that they were. He attempted to increase the right turn to avoid impacting a tree but was unable to clear it, and the powered parachute came to rest in the treeThis is not supported in the 6120 in the docket. You’ll need to add a record of conversation if you want to keep it. . A stabilizer tube and a center of gravity tube sustained substantial damage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the powered parachute that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff and subsequent impact with a tree.
Has safety recommendations
false

Vehicle 1

Aircraft category
Ultralight
Make
SIX CHUTER INC
Model
SR7
Amateur built
false
Engines
1 Reciprocating
Registration number
N942WA
Second pilot present
false
Flight conducted under
Part 103: Ultralight
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
97-1739-2SR7
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-07-25T20:15:05Z guid: 192684 uri: 192684 title: WPR23LA282 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192686/pdf description:
Unique identifier
192686
NTSB case number
WPR23LA282
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-20T10:40:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-24T19:29:19.553Z
Event type
Accident
Location
Elko, Nevada
Airport
Elko Regional Airport (KEKO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that the density altitude conditions were increasing but were within takeoff performance limits. During taxi to his planned departure runway, he was informed that the runway was closed, so he chose to depart from a different runway about 4,400 ft shorter than originally planned for. During takeoff the airplane did not have the performance necessary to attain rotation speed before the end of the runway, but the pilot did not abort the takeoff. He rotated the airplane 5-10 knots too slow and was unable to clear a fence off the departure end of the runway. The airplane sustained substantial damage to the wings and fuselage. The pilot reported there were no preaccident mechanical malfunctions or failures that would preclude normal operation.
Probable cause
The pilot’s failure to ensure adequate airplane performance before taking off from a significantly shorter runway than originally planned for.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-140
Amateur built
false
Engines
1 Reciprocating
Registration number
N4149J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-22474
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-24T19:29:19Z guid: 192686 uri: 192686 title: CEN23LA323 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192707/pdf description:
Unique identifier
192707
NTSB case number
CEN23LA323
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-20T19:45:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-07-31T05:43:01.568Z
Event type
Accident
Location
Oshkosh, Wisconsin
Airport
Wittman Regional Airport (KOSH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, he was landing on runway 27 at or beyond the green dot. The pilot reduced engine power after he reached the green dot. The airplane impacted the runway hard and both main landing gear collapsed. The airplane sustained substantial damage to the fuselage. The pilot stated that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
RV-10
Amateur built
true
Engines
1 Reciprocating
Registration number
N917CM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
41171
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-31T05:43:01Z guid: 192707 uri: 192707 title: WPR23LA280 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192683/pdf description:
Unique identifier
192683
NTSB case number
WPR23LA280
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-21T09:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-07-24T20:15:34.688Z
Event type
Accident
Location
Kalispell, Montana
Airport
Glacier Park International Airport (GPI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, during the landing roll with a right crosswind, he felt the right-wing lift, causing the airplane to veer to the left. He attempted to correct with right rudder; however, the airplane ground looped and came to rest in a nosed down position. The airplane sustained substantial damage to the right aileron. The pilot reported no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control of the airplane during landing with a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12S
Amateur built
false
Engines
1 Reciprocating
Registration number
N48MR
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
12-2583
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-24T20:15:34Z guid: 192683 uri: 192683 title: ERA23LA312 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192709/pdf description:
Unique identifier
192709
NTSB case number
ERA23LA312
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-21T11:40:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-07-28T04:48:18.813Z
Event type
Accident
Location
Roanoke, Virginia
Airport
ROANOKE-BLACKSBURG RGNL/WOODRUM FLD (ROA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and student pilot were practicing crosswind landings in the traffic pattern. On the first landing attempt, the student pilot crabbed into the wind and as the airplane was over the runway, he applied left aileron in order to straighten the airplane over centerline and the flight instructor called to perform a go around maneuver. While in the traffic pattern, the flight instructor explained that using the rudder was normal practice to straighten out the airplane instead of the aileron and to try again on the second landing. During the second landing attempt, the student applied left rudder to straighten out over runway centerline. Before the airplane touched down, he added more left rudder. Again, the flight instructor called to perform a go around maneuver, however, the wheels touched down and the airplane bounced to the left. The student pilot applied full engine power and the airplane veered to the left. The flight instructor took over the flight controls and attempted to correct the turn by applying right rudder, however the airplane continued to drift to the left. The airplane continued off the side of the runway and impacted the ground, resulting in the nose landing gear collapsing and the empennage partially separating from the airplane. The airplane slid and came to rest on a taxiway. The airplane incurred substantial damage to the empennage. After the accident, the flight instructor remarked that the student pilot might have had his foot on the left rudder, which may have been why the instructor's right rudder input was not sufficient. Furthermore, a Federal Aviation Administration inspector asked the student pilot if he released the left rudder when the flight instructor took control of the airplane and he noted that he was unsure, since the accident sequence happened so quickly. The flight instructor reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during the landing, and the flight instructor’s inadequate remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40
Amateur built
false
Engines
1 Reciprocating
Registration number
N524DS
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
40.260
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-28T04:48:18Z guid: 192709 uri: 192709 title: CEN23LA321 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192703/pdf description:
Unique identifier
192703
NTSB case number
CEN23LA321
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-21T12:30:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-10T22:00:58.814Z
Event type
Accident
Location
Plains, Kansas
Airport
Private Airstrip (00)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Prior to flight, the pilot noted that rain had made the turf airstrip too wet to conduct aerial application flights. The middle of the airstrip had standing water, but the edges of the runway had fewer areas of water. The pilot took off at a reduced weight, without an aerial load, to fly to another location. During the takeoff, the airplane contacted the water on the runway, and the pilot lost control. The airplane subsequently veered off the runway resulting in the wing’s spray booms getting entangled in high weeds. The airplane spun and came to rest. Substantial damage was sustained to the left wing and empennage.
Probable cause
The pilot’s failure to maintain control during takeoff from a water-contaminated runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-602
Amateur built
false
Engines
1 Turbo prop
Registration number
N602AA
Operator
DICKSON SHANNON
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
602-1194
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T22:00:58Z guid: 192703 uri: 192703 title: ERA23LA311 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192708/pdf description:
Unique identifier
192708
NTSB case number
ERA23LA311
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-22T08:37:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-08-18T16:02:07.03Z
Event type
Accident
Location
WINTER HAVEN, Florida
Airport
WINTER HAVEN RGNL (GIF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was on a solo cross-country flight. The pilot arrived at the destination airport, and after an uneventful landing, he planned to practice takeoffs and landings in the airport traffic pattern. While on short final approach during the next landing attempt, the pilot contemplated going around as the airplane was not aligned with the runway. He instead continued to approach and attempted to correct the misalignment. While crossing the runway threshold, the airplane was “a little high” and still not aligned along the runway centerline. The pilot reduced the engine power and continued his attempt to align the airplane with the runway using the rudder. The pilot then decided to go around just as the landing gear contacted the runway, adding engine power and pulling back the control yoke. The airplane then veered to the left and departed the runway surface as the pilot reduced the engine power back to idle to stop the go-around attempt. It subsequently collided with a taxiway sign and was substantially damaged. The pilot reported that there were not preimpact mechanical malfunctions or the failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing, which resulted in a runway excursion and collision with a taxiway sign.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7528W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-1449
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-18T16:02:07Z guid: 192708 uri: 192708 title: WPR23LA284 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192717/pdf description:
Unique identifier
192717
NTSB case number
WPR23LA284
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-22T11:00:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-07-26T21:56:09.923Z
Event type
Accident
Location
Red Lodge, Montana
Airport
RED LODGE (RED)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while landing a tailwheel airplane, a gust of wind pushed the tail to the right. The pilot attempted to correct with rudder and differential braking; however, the airplane ground looped to the left and veered off the left side of the runway impacting a fence and substantially damaging the left wings. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing with wind gusts, which resulted in a ground loop and collision with a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
A75N1
Amateur built
false
Engines
1 Reciprocating
Registration number
N53132
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-2923
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-26T21:56:09Z guid: 192717 uri: 192717 title: ERA23LA304 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192681/pdf description:
Unique identifier
192681
NTSB case number
ERA23LA304
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-23T14:05:00Z
Publication date
2023-09-08T04:00:00Z
Report type
Final
Last updated
2023-08-24T17:29:42.712Z
Event type
Accident
Location
Stow, Massachusetts
Airport
Minute Man Air Field (6B6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 3 serious, 0 minor
Analysis
The pilot reported that the airplane approached fast and bounced twice on the 3,110-ft-long runway. After the second bounce, he attempted to abort the landing, but trees at the end of the runway were already too close to clear. He turned right to avoid the trees, but then turned left to avoid a house, and collided with the trees. The airplane was substantially damaged during the accident and all three occupants of the airplane were seriously injured. Postaccident examination of the wreckage by a Federal Aviation Administration inspector did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation, nor did the pilot report any.
Probable cause
The pilot’s delayed decision to abort the landing, which resulted in a collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182
Amateur built
false
Engines
1 Reciprocating
Registration number
N7ET
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18256796
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-24T17:29:42Z guid: 192681 uri: 192681 title: ERA23LA315 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192734/pdf description:
Unique identifier
192734
NTSB case number
ERA23LA315
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-23T22:24:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-10-17T17:28:07.449Z
Event type
Accident
Location
Guilford, Connecticut
Airport
Fairground (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot had been operating the hot air balloon for several hours and was providing tethered flights to passengers at a fairground during a night event. The pilot described that at the conclusion of a several minute flight, he would land and exchange passengers. To maintain the weight of the balloon during the passenger exchange, one passenger would disembark and then would be replaced by a boarding passenger. There were also several (volunteer) ground crewmembers who would keep their weight on the balloon’s basket and help control the flow of passengers in and out of the basket. Shortly before the accident, the pilot was assisting a passenger with boarding when two passengers unexpectedly disembarked. The balloon suddenly started to rise, and the pilot yelled, “clear, watch the ropes,” which was the signal to the ground crewmembers to take their hands off the basket and to make sure that none of the exiting passengers got caught in the tether ropes. As the balloon rose, the pilot felt a shake, and when he looked over the side of the basket, he saw one of the ground crewmembers lying on the ground. One of the passengers described that when she stepped off the balloon, it began rising. She saw a ground crewmember hanging on the outside of the basket as it climbed. When the balloon reached about 15 to 20 feet above the ground, the ground crewmember let go. The ground crewmember was seriously injured during the fall.
Probable cause
The pilot’s inadequate supervision of the boarding process and the ground crewmember’s failure to immediately let go of the balloon after it began an inadvertent climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
HEAD BALLOONS INC
Model
AX8-88
Amateur built
false
Registration number
N4522E
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
183
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-10-17T17:28:07Z guid: 192734 uri: 192734 title: DCA23LA383 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192743/pdf description:
Unique identifier
192743
NTSB case number
DCA23LA383
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-24T16:30:00Z
Publication date
2023-10-16T04:00:00Z
Report type
Final
Last updated
2023-07-31T15:32:37.18Z
Event type
Accident
Location
East Palestine, Ohio
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
Southwest Airlines flight 1118 encountered moderate turbulence while descending through 12,000 ft for landing at Pittsburg International Airport (PIT) Pittsburg, Pennsylvania, and a flight attendant fractured her wrist. The flight crew reported that while descending on the JESEY4 RNAV arrival into PIT they observed low cumulus clouds with tops at about 14,000 ft. The captain notified the flight attendants to take their seats due to the possibility of turbulence. As they descended through the cloud layer at about 12,000 ft the flight encountered an area of moderate turbulence for about 20-30 seconds. After receiving the notification from the captain to take their seats. The “B” and “C” position flight attendants (FAs) moved to their respective jumpseats and were attempting to fasten their safety harnesses when the turbulence event occurred. The “B” position FA was thrown into the air and impacted the jump seat. The “C” position FA was thrown into the air and impacted the aft lavatory fracturing her wrist. She described the turbulence as “like nothing I have ever felt almost like something hit the back of the airplane.” The flight crew stated that they were not notified of the injury until after the plane had landed and they were walking to their accommodations. At the time of the turbulence encounter there were no active significant meteorological information (SIGMETs), convective SIGMETs, airman’s meteorological information (AIRMETs), center weather advisories (CWAs), or pilot reports (PIREPs) of any significant turbulence other than occasional light turbulence/chop over the area. Eddy dissipation rate (EDR) is a universal measure of turbulence rate. Recorded data from the airplane revealed that about 1929 Coordinated Universal Time (UTC), or 1529 local, at an altitude of about 9,970 ft the EDR indicated 0.40 which equates to moderate turbulence. According to the flight crew, neither the clouds nor the turbulence were depicted on their Weather Services International (WSI) Pilotbrief weather application or displayed on their airplane weather radar.
Probable cause
An inadvertent encounter with convectively induced turbulence (CIT) during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737
Amateur built
false
Engines
2 Turbo fan
Registration number
N279WN
Operator
SOUTHWEST AIRLINES CO
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
32532
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-31T15:32:37Z guid: 192743 uri: 192743 title: ANC23LA057 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192719/pdf description:
Unique identifier
192719
NTSB case number
ANC23LA057
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-25T17:30:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-07-27T21:43:59.353Z
Event type
Accident
Location
Point Baker, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during takeoff in a float-equipped airplane, with left quartering tailwind, a gust of wind resulted in a loss of directional control. He aborted the takeoff but was unable to regain control and the left wing impacted a pole which rotated the airplane to the left and the right wing struck a boat. The airplane sustained substantial damage to both wings. The pilot reported that there were no pre-accident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff with a quartering tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
DHC-2 MK. I(L20A)
Amateur built
false
Engines
1 Reciprocating
Registration number
N6782L
Operator
SEAWIND AVIATION INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
820
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-27T21:43:59Z guid: 192719 uri: 192719 title: CEN23LA326 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192720/pdf description:
Unique identifier
192720
NTSB case number
CEN23LA326
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-26T12:00:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-08-10T22:24:04.662Z
Event type
Accident
Location
Charles City, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the aerial application flight stated that when the flight returned to the load truck, it still had aerial application product aboard, which he was unaware of. He requested and received an additional 60 gallons of product that was loaded onto the helicopter for the accident flight. After loading the helicopter with the additional product, it now was about 172 lbs over the helicopter’s gross weight. When the helicopter departed from the load truck on the accident flight, the helicopter experienced a decay in rotor rpm and settled into an adjacent corn field about 75 ft from the truck. The helicopter sustained substantial damage to the main and tail rotor blades and tail boom. The pilot stated that he was not properly prepared to jettison the load in the event of an emergency and his power cross checks were not adequate. The pilot stated that there was no mechanical malfunction/failure of the helicopter. An excessive load would have reduced the climb performance capability of the helicopter and resulted in settling.
Probable cause
The pilot’s improper preflight of the helicopter to ensure that it was within the loading and performance limitations that resulted in settling and impact with terrain during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N4174L
Operator
Back Nine Aerial LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
12495
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T22:24:04Z guid: 192720 uri: 192720 title: ERA23LA314 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192723/pdf description:
Unique identifier
192723
NTSB case number
ERA23LA314
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-26T15:00:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-08-01T17:53:49.814Z
Event type
Accident
Location
Chattanooga, Tennessee
Airport
LOVELL FLD (CHA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot and the flight instructor were climbing out after departing from the airport when the cabin door suddenly opened. The flight instructor tried to close the door but could not get it closed properly. The pilot subsequently returned to the airport to land. During the landing approach, the pilot was distracted, flew too low, and the airplane contacted several approach lights short of the runway threshold. The airplane sustained substantial damage to the wings and empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain the proper glidepath during final approach, which resulted in a collision with the approach lights short of the runway. Contributing was the pilot’s distraction due to the cabin door opening.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20R
Amateur built
false
Engines
1 Reciprocating
Registration number
N62GH
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
29-0190
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-01T17:53:49Z guid: 192723 uri: 192723 title: CEN23LA328 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192722/pdf description:
Unique identifier
192722
NTSB case number
CEN23LA328
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-26T15:45:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-27T18:41:15.961Z
Event type
Accident
Location
Hanlontown, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while spraying at low altitude with power lines on the edges of the field, the airplane struck a cable, which resulted in substantial damage to the tail rotor blades and tail rotor drive shaft. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation and that he should have examined the field more thoroughly prior to conducting spray operations.
Probable cause
The pilot’s failure to maintain clearance from a cable during spray operations.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N467HA
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
0984
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-27T18:41:15Z guid: 192722 uri: 192722 title: ERA23LA316 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192735/pdf description:
Unique identifier
192735
NTSB case number
ERA23LA316
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-27T13:11:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-08-08T06:17:03.934Z
Event type
Accident
Location
MAIDEN, North Carolina
Airport
Laneys Airport (N92)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The flight instructor and student departed on an instructional flight and flew to a nearby grass airstrip for pattern work. Although the flight instructor had flown into the airstrip before, he did not check the runway length before the flight departed and thought it was longer than the actual published 2,400-ft length. After arriving at the destination airstrip the, student entered left downwind for runway 13, resulting in a right quartering tailwind of about 5 knots. The flight instructor told the student to perform a short field landing. The student turned early onto the base leg of the airport traffic pattern, then turned onto final approach, resulting in the airplane being high and fast. After informing the student that the airplane was high and fast the student pitched the airplane down, which increased the airspeed, but he did not reduce power. The airplane continued to be high and fast, and somewhere before the midpoint of the runway the flight instructor told the student to go around. He repeated the instruction after the student hesitated. The student leveled off, added full power, removed carburetor heat, but left the flaps extended at 30° while he pitched for Vx airspeed. While climbing slightly, and with insufficient runway remaining to land, the flight instructor took the controls from the student and at that time realized the flaps were still at 30°. The airplane subsequently collided with trees beyond the end of the runway before descending to the ground resulting in substantial damage to the fuselage, wings, and empennage. The flight instructor reported there was no preimpact mechanical failures or malfunctions of the airplane that would have precluded normal operation. He also reported that the accident could have been prevented by executing a go-around much earlier.
Probable cause
The flight instructor’s inadequate supervision of the landing approach and go-around, and his delayed remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N6194Q
Operator
Flight Level Aviation LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15285189
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-08T06:17:03Z guid: 192735 uri: 192735 title: CEN23LA330 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192730/pdf description:
Unique identifier
192730
NTSB case number
CEN23LA330
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-27T13:30:00Z
Publication date
2023-09-21T04:00:00Z
Report type
Final
Last updated
2023-07-28T02:38:04.262Z
Event type
Accident
Location
Cortland, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot and the passenger were conducting a personal cross-country flight. While on approach to the airport, which was a planned fuel stop, the airplane sustained a total loss of engine power. The pilot performed a forced landing to a corn field and the airplane came to rest nose-down. The two occupants were extracted from the airplane by first responders. The airplane sustained substantial damage to both wings and the fuselage. The pilot reported to first responders that the airplane “ran out of fuel.” The pilot did not report any preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation.
Probable cause
The pilot’s improper fuel planning, that resulted in a total loss of engine power due to fuel exhaustion, and a subsequent forced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
177
Amateur built
false
Engines
1 Reciprocating
Registration number
N30632
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17701371
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-28T02:38:04Z guid: 192730 uri: 192730 title: WPR23LA291 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192757/pdf description:
Unique identifier
192757
NTSB case number
WPR23LA291
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-27T18:15:00Z
Publication date
2023-11-02T04:00:00Z
Report type
Final
Last updated
2023-08-09T01:08:31.455Z
Event type
Accident
Location
Friday Habor, Washington
Airport
Friday Harbor Airport (FHR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, the airplane bounced during touchdown on a 3-point landing. The pilot elected to not correct with power or to execute a go-around. During the second touchdown, he was unable to arrest the airplane veering to the right and ground looped. The airplane exited the runway and the left gear collapsed. The left wing sustained substantial damage. The pilot reported there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during landing, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N185GG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18502787
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-09T01:08:31Z guid: 192757 uri: 192757 title: DCA23LA382 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192742/pdf description:
Unique identifier
192742
NTSB case number
DCA23LA382
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-28T09:16:00Z
Publication date
2023-11-15T05:00:00Z
Report type
Final
Last updated
2023-07-31T14:56:03.713Z
Event type
Accident
Location
Myrtle Beach, Atlantic Ocean
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
United Airlines flight 2122 encountered severe turbulence while in cruise flight at flight level (FL) 330 enroute to Punta Cana Airport (PUJ), Dominican Republic, and a flight attendant (FA) sustained serious injuries. The flight crew reported that after reaching a cruise altitude of FL330 and before entering oceanic airspace they downloaded the latest Weather Services International (WSI) radar image, lightning data, and SkyPath ride reports. The airborne radar was in use which depicted some very small, scattered cells well below their altitude. Shortly thereafter, the captain visually acquired a cloud buildup immediately ahead and below their altitude. With no visual indication of the cloud on the weather radar they made a right turn to avoid any potential turbulence. While in the right turn, the airplane entered visual meteorological conditions and the captain visually acquired another cloud buildup directly ahead. To avoid the buildup the captain continued the right turn to no avail. The airplane entered the clouds and immediately encountered severe turbulence for about 5 seconds. A public address (PA) announcement was immediately made “be seated immediately, be seated immediately”. Following the turbulence encountered the flight crew was notified that two aft FAs had been injured. Just before the turbulence event, the number 2L and 2R FAs had moved the beverage cart to the aft galley, so the 2R FA could use the lavatory. After entering the lavatory, she was thrown into the air and landed on her left ankle and knee. The 2L FA stated that as soon as the 2R FA entered the lavatory, they encountered severe turbulence. She and the beverage cart were tossed into the air, and she impacted the floor of the airplane on her left side. She stated that the impact was like “slamming down from a 5th floor building”. Upon being notified of the injuries, the flight crew declared an emergency and diverted to Myrtle Beach, South Carolina, for medical assistance. The two injured FAs were transported to local hospitals where one was diagnosed with serious injuries. At the time of the turbulence encounter there were no active significant meteorological information (SIGMETs), convective SIGMETs, airman’s meteorological information (AIRMETs), or pilot reports (PIREPs) of any significant turbulence.
Probable cause
An encounter with convectively induced turbulence (CIT) while in cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-924ER
Amateur built
false
Engines
2 Turbo fan
Registration number
N77431
Operator
UNITED AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
International
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
32833
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-07-31T14:56:03Z guid: 192742 uri: 192742 title: CEN23LA335 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192748/pdf description:
Unique identifier
192748
NTSB case number
CEN23LA335
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-28T12:02:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-07-31T17:52:41.88Z
Event type
Accident
Location
Tyler, Minnesota
Airport
Tyler Municipal Airport (63Y)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot attempted the takeoff with the flaps in the half or first notch position. Unable to rotate during the takeoff roll, the pilot selected the full flap position, and the agricultural airplane lifted off the 2,500-ft long turf airstrip about 150 feet before the end of the runway. The airplane was unable to climb out of ground effect and contacted corn stalks that were located past the end of the runway. The airplane descended into the vegetation and came to rest nose down and upright. The airplane sustained substantial damage to both wings. According to the airplane owner’s handbook, a takeoff distance of about 1,370 feet was required to clear a 50-foot obstacle with the sprayer configuration. The handbook recommended that the wing flaps be retracted at all times during takeoff.
Probable cause
The pilot’s improper flap position during takeoff, which resulted in degraded climb performance and a collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-25-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N7094Z
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
25-5052
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-07-31T17:52:41Z guid: 192748 uri: 192748 title: CEN23LA343 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192780/pdf description:
Unique identifier
192780
NTSB case number
CEN23LA343
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-28T12:30:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-08-03T00:17:34.436Z
Event type
Accident
Location
Charleston, West Virginia
Airport
Mallory (WV12)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll the airplane veered left, and he was unable to correct before the airplane impacted a tree, which resulted in substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain direction control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CUB CRAFTERS
Model
CCX-1865
Amateur built
true
Engines
1 Reciprocating
Registration number
N28ZV
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CCX-1865-0008
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-03T00:17:34Z guid: 192780 uri: 192780 title: WPR23LA309 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192832/pdf description:
Unique identifier
192832
NTSB case number
WPR23LA309
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-28T17:30:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-08-11T04:10:38.209Z
Event type
Accident
Location
Dune City, Oregon
Airport
Cape Blanco (5S6)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was enroute to acquire additional fuel but ran out of fuel and experienced a total loss of engine power before reaching the destination. The airplane collided with trees during the forced landing, substantially damaging both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper fuel management, which resulted in fuel exhaustion, a total loss of engine power, and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N66165
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15075887
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-11T04:10:38Z guid: 192832 uri: 192832 title: CEN23LA336 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192749/pdf description:
Unique identifier
192749
NTSB case number
CEN23LA336
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-29T08:30:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-09T19:56:34.732Z
Event type
Accident
Location
Alta, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was completing an aerial application flight over a cultivated field. During the fourth pass, the airplane encountered a dust devil (also called a whirlwind), lost lift and impacted powerlines. Upon impact with the powerlines the rudder separated from the airplane and the airplane began a left turn. Unable to arrest the turn, the pilot reduced power and made a forced landing to the field that he was spraying. Upon touch down the left main landing gear separated from the fuselage and the airplane slid to a stop. The airplane sustained substantial damage to the left wing, vertical stabilizer and rudder. The operator reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. A review of the Federal Aviation Administration Aviation (FAA) Weather Handbook (FAA-H-8083-28) and the FAA Aeronautical Information Manual found no detailed information listed about dust devils or the potential hazards of flying through dust devils.
Probable cause
The airplane’s encounter with a dust devil, which resulted in a loss of lift, and subsequent collision with powerlines.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-402B
Amateur built
false
Engines
1 Turbo prop
Registration number
N402PR
Operator
BARTS FLYING SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
402B-1282
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-09T19:56:34Z guid: 192749 uri: 192749 title: WPR23LA292 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192759/pdf description:
Unique identifier
192759
NTSB case number
WPR23LA292
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-29T12:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-02T00:13:45.124Z
Event type
Accident
Location
Buhl, Idaho
Airport
BUHL MUNI (U03)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, during the landing, he encountered a gusting tail wind. While attempting to control the speed to prevent stall, the airplane veered to the left of the runway. The pilot applied right rudder in an attempt to correct this, resulting in a ground loop. The airplane sustained substantial damage to the left wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain airplane control during landing with a gusting tail wind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JOHN ESPE
Model
CRUISER
Amateur built
true
Engines
1 Reciprocating
Registration number
N314E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
12001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-02T00:13:45Z guid: 192759 uri: 192759 title: CEN23LA338 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192753/pdf description:
Unique identifier
192753
NTSB case number
CEN23LA338
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-29T19:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-08-15T17:58:15.921Z
Event type
Accident
Location
Ozark, Arkansas
Airport
Etna Airport (2AR1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot stated that on his second flight in the airplane, he completed some basic maneuvers without incident and returned to the airport. Shortly after, he and a passenger boarded for a local flight. The pilot completed an engine run up with no anomalies noted, and then departed from the grass runway. About 70 ft above ground level he felt a vibration and was unable to maintain altitude. The engine RPM and oil pressure decreased as the airspeed slowed. The airplane collided with trees and then impacted the ground. The pilot and passenger egressed without incident, then the airplane burst into flames. The passenger recorded a video of the entire accident flight. The video revealed that during the initial climb, the engine RPM and sound appeared to gradually decrease. The airplane did not continue to climb, and the engine RPM continued to decrease. The airplane collided with a tree and then impacted the ground. A postaccident photo from the pilot showed the airplane was mostly consumed by the fire. The pilot provided a summary of his postaccident engine examination, which revealed that the oil supply line to the propeller speed reduction unit was completely clogged with an unknown gray material. Also, the gear reduction drive was seized, lacked oil, and the bearings were covered in a dry, rusty powder. It is likely that the loss of engine power was due to oil starvation of the propeller speed reduction unit.
Probable cause
Oil starvation of the propeller speed reduction unit which resulted in a total loss of engine power.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
RANS
Model
S-6ES
Amateur built
true
Engines
1 Reciprocating
Registration number
N123TG
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0291162
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2023-08-15T17:58:15Z guid: 192753 uri: 192753 title: WPR23LA293 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192760/pdf description:
Unique identifier
192760
NTSB case number
WPR23LA293
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-30T00:19:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-08-01T03:56:19.04Z
Event type
Accident
Location
Port Angeles, Washington
Airport
Sequim Valley Airport (W28)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported being unable to land at the destination airport at night due to the runway lights not being operational. The pilot then diverted to two other nearby airports but was unable to identify either airport. During the process of trying to locate a runway the pilot did not adequately monitor the fuel onboard and all the fuel was consumed from the selected fuel tank, which resulted in a total loss of engine power. The pilot switched fuel tanks, but the engine did not restart. The pilot has no memory beyond that phase of the event. The airplane collided with trees and terrain, sustaining substantial damage to both wings and the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate fuel monitoring, which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N8675W
Operator
BRFLYERS LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-10205
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-01T03:56:19Z guid: 192760 uri: 192760 title: CEN23LA342 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192774/pdf description:
Unique identifier
192774
NTSB case number
CEN23LA342
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-30T09:18:00Z
Publication date
2023-08-31T04:00:00Z
Report type
Final
Last updated
2023-08-02T19:45:54.861Z
Event type
Accident
Location
Denison, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Analysis
The pilot reported to his wife that while conducting an aerial application flight, he became distracted in the cockpit and failed to see and avoid wires that were spanning the field. The helicopter subsequently impacted the wires and then terrain, which resulted in substantial damage to the fuselage. The pilot was hospitalized but succumbed to his injuries 18 days after the accident.
Probable cause
The pilot’s inflight distraction, which resulted in his failure to see and avoid wires.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL
Model
206B
Amateur built
false
Engines
1 Turbo shaft
Registration number
N231RL
Operator
NOR WES INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
1324
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-02T19:45:54Z guid: 192774 uri: 192774 title: WPR23LA290 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192756/pdf description:
Unique identifier
192756
NTSB case number
WPR23LA290
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-30T16:45:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-01T01:52:08.774Z
Event type
Accident
Location
Coolin, Idaho
Airport
Cavanaugh Bay (66S)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 1 minor
Analysis
The pilot reported that during the takeoff roll, he “saw rotate speed” and then pitched for best climb speed. He had no further memory of the event. A witness reported that they saw the airplane lift off from the runway and remain in ground effect until it crossed the departure end of the runway. As it crossed the departure end of the runway, it was in a left bank and then struck a tree. The airplane impacted a public beach and came to rest upright, in shallow water. The wings and fuselage sustained substantial damage. At 1535, the temperature was 30°C, the dewpoint was 4°C, and the altimeter setting was 29.98. The calculated density altitude was 4,790 ft. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from trees after takeoff, during high density altitude weather conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
23
Amateur built
false
Engines
1 Reciprocating
Registration number
N2362Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-76
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-01T01:52:08Z guid: 192756 uri: 192756 title: CEN23LA339 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192755/pdf description:
Unique identifier
192755
NTSB case number
CEN23LA339
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-31T11:18:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-01T23:13:19.989Z
Event type
Accident
Location
Sherman, Texas
Airport
Sherman Municipal Airport (KSWI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the landing roll, a gust of wind lifted the right wing of the airplane. The pilot was unable to maintain directional control and the airplane departed the left side of the runway and nosed over in a grassy area adjacent to the runway. The airplane sustained substantial damage to the engine mount, firewall, left wing, vertical stabilizer, and rudder. An examination of the airplane revealed that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll, which resulted in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150F
Amateur built
false
Engines
1 Reciprocating
Registration number
N6837F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15063437
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-01T23:13:19Z guid: 192755 uri: 192755 title: CEN23LA341 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192767/pdf description:
Unique identifier
192767
NTSB case number
CEN23LA341
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-07-31T15:00:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-08-02T20:51:26.281Z
Event type
Accident
Location
Arthur, Illinois
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that he had confirmed that there were no powerlines to avoid before entering a field to perform spray operations. While spraying next to a tree line and approaching a road, the pilot could not recall whether there were powerlines or not. The pilot reported that while making a precautionary maneuver to avoid any potential powerlines, he had forgotten about the tree line. The helicopter struck a tree branch, and subsequently impacted terrain, which resulted in substantial damage to the fuselage, empennage, and main rotor blades. The pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from trees during a low-level aerial application flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER COMPANY
Model
R44 II
Amateur built
false
Engines
1 Reciprocating
Registration number
N644ME
Operator
RAS AVIATION LLC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
13439
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-02T20:51:26Z guid: 192767 uri: 192767 title: ANC23LA058 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192778/pdf description:
Unique identifier
192778
NTSB case number
ANC23LA058
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-01T16:15:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-08-09T22:13:49.008Z
Event type
Accident
Location
Wasilla, Alaska
Airport
High Ridge Association Airport (97AK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot stated that he planned to take the passenger on a local sightseeing flight. During takeoff from the 1,600 ft. long gravel-covered runway, the airplane performed as expected until reaching about 50 ft above ground level (agl), at which point the climb performance degraded significantly. He observed no change in engine performance or weather conditions. As the airplane neared the end of the runway, he realized that he would not be able to pass over the trees that bordered the airport and attempted to maintain direction control avoiding a heading to the larger trees. The airplane collided with the trees sustaining substantial damage to the wings and fuselage. The pilot reported that there were no preimpact mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance during takeoff, which resulted in impact with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CORT J NEUMAN
Model
APEX
Amateur built
true
Engines
1 Reciprocating
Registration number
N907AX
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-09T22:13:49Z guid: 192778 uri: 192778 title: WPR23LA298 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192775/pdf description:
Unique identifier
192775
NTSB case number
WPR23LA298
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-01T17:37:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-04T03:32:06.592Z
Event type
Accident
Location
Long Beach, California
Airport
LONG BEACH (DAUGHERTY FLD) (LGB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot in a Cessna 152 reported that, after completing the engine start procedure checklist, he set the parking brake and both he and the instructor placed their feet on the brake pedals. As both pilots looked down to plug in their headsets the airplane rolled forward and struck the right wing of a Cessna 172 that was taxiing in front of them. As a result of the collision, the Cessna 172’s right wing was substantially damaged. The flight crews of both airplanes reported that there were no preaccident mechanical failures or malfunctions with their airplanes that would have precluded normal operation.
Probable cause
The flight instructor’s inattention during ground operations, which resulted in unintentional movement of the airplane and ground collision with another airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N46393
Operator
ACES HIGH AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15283042
Damage level
Minor
Events
Findings

Vehicle 2

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N65537
Operator
ACES HIGH AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S9726
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-04T03:32:06Z guid: 192775 uri: 192775 title: CEN23LA381 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192937/pdf description:
Unique identifier
192937
NTSB case number
CEN23LA381
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-01T19:22:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-30T04:16:08.221Z
Event type
Accident
Location
Scottsburg, Indiana
Airport
Honaker Field Airport (3R8)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The student pilot attempted a personal flight in an airplane that did not have an airworthiness certificate. Additionally, he did not have any required student pilot solo endorsements for solo flight. A witness to the accident flight stated that the student pilot performed a successful airplane runup before takeoff. During the takeoff, the airplane lifted off when it was about halfway down the runway and climbed to about tree top level. A few seconds later, the right wing dropped, and the airplane descended into terrain in a nose-down attitude. The engine continued to operate after the impact until the witness turned the magnetos and fuel selector valve off. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane confirmed flight control continuity.
Probable cause
The student pilot’s failure to maintain airplane control after takeoff that resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GEORGE STONE
Model
KIT FOX MODEL 3
Amateur built
false
Engines
1 Reciprocating
Registration number
N815US
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
815
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-30T04:16:08Z guid: 192937 uri: 192937 title: CEN23LA354 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192793/pdf description:
Unique identifier
192793
NTSB case number
CEN23LA354
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-02T07:15:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-08-09T03:00:07.932Z
Event type
Accident
Location
Clewiston, Florida
Airport
Clewiston (2IS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and student pilot were practicing short field landings when the student pilot landed hard on the nose landing gear. The flight instructor took control of the airplane and performed a touch-and-go. The flight instructor held the nose landing gear off the ground on the full stop landing; however, the nose landing gear collapsed, and the airplane veered off the runway and into the grass. Post flight examination revealed buckling and wrinkling of the lower fuselage. The examination of the airplane found no mechanical malfunctions or failures that would have precluded normal operations. The flight instructor reported that the student pilot was low on the approach, but the flight instructor did not intervene because the student pilot was going to take his private pilot checkride later that day and could perform short field landings. Neither the flight instructor nor the student pilot returned the National Transportation Safety Board 6120.1 Pilot/Operator Aircraft Accident/Incident Report.
Probable cause
The student pilot’s improper landing flare, which resulted in a hard landing on the nose landing gear. Contributing to the accident was the flight instructor’s inadequate supervision of the student pilot.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N1403R
Operator
Wayman Aviation Academy
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S9877
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-09T03:00:07Z guid: 192793 uri: 192793 title: CEN23LA346 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192785/pdf description:
Unique identifier
192785
NTSB case number
CEN23LA346
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-02T07:20:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-08-07T21:02:47.534Z
Event type
Accident
Location
Halstad, Minnesota
Airport
Aslesen (8MN2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after loading about 100 gallons of jet fuel and about 420 gallons of aerial spray product, he began a takeoff roll on the 2,506 ft asphalt runway. The pilot attempted to rotate the airplane with about 300 ft of runway remaining. Unable to climb out of ground effect, the pilot attempted to jettison the aerial spray product during and after takeoff. The airplane was airborne for about 200 yards before it settled into the soybean field. The airplane sustained substantial damage to the wings, empennage, and fuselage. During an interview, the pilot stated that he took off with a tailwind with one notch of flaps and remembers over torquing the engine. He reported that he likely rotated too soon, was slow, and never got out of ground effect. The pilot reported, and a postaccident examination corroborated that, there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s attempt to rotate the airplane without sufficient airspeed which resulted in a lack of climb performance and impact with terrain. Contributing to the accident was the pilot’s decision to attempt the takeoff with a tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-502
Amateur built
false
Engines
1 Turbo prop
Registration number
N45453
Operator
Airborne Custom Spraying
Flight conducted under
Part 137: Agricultural
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
502-0122
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-07T21:02:47Z guid: 192785 uri: 192785 title: CEN23LA345 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192784/pdf description:
Unique identifier
192784
NTSB case number
CEN23LA345
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-02T16:59:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-08-19T02:04:23.489Z
Event type
Accident
Location
Rosenberg, Texas
Airport
Lane Airpark (T54)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot stated that in preparation for his solo cross-country flight, he reviewed his flight planning with his flight instructor. He said he flew to the destination airport, where he performed one approach and landing, followed by flight maneuvers north of the airport, and then landed. The pilot shut the airplane down to use the restroom. Prior to departure from the destination airport, he did not visually check the airplane fuel level through the fuel filler ports. During the return flight, he visually observed the fuel quantity, and it was “dropping rapidly,” and he decided to land at an alternate airport. During the approach to the alternate airport, the engine “sputtered” and quit. He landed the airplane with a tailwind and “slammed on the brakes” to try to slow the airplane down as soon as possible. The airplane overran the runway and impacted a fence and construction equipment that resulted in substantial damage to both wings. Postaccident examination of the airplane revealed no useable fuel in the airplane fuel tanks.
Probable cause
The student pilot’s improper fuel management that resulted in fuel exhaustion, a total loss of engine power, and a subsequent forced landing and landing overrun at an alternate airport.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N38483
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-7790556
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-19T02:04:23Z guid: 192784 uri: 192784 title: CEN23LA348 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192801/pdf description:
Unique identifier
192801
NTSB case number
CEN23LA348
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-03T11:52:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-08-05T02:05:26.515Z
Event type
Accident
Location
Philadelphia, Pennsylvania
Airport
NORTHEAST PHILADELPHIA (PNE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot receiving instruction reported that while on final approach, the airspeed became slow so he lowered the airplane nose to increase the airspeed. The airplane landed firmly at the runway threshold and bounced. During the recovery from the bounce, the flight instructor commanded a go-around maneuver. During the go-around, the airplane’s nose rose high, and the airplane yawed and rolled to the left. The airplane impacted the ground alongside the runway and nosed over. Post accident examination revealed that the vertical stabilizer, rudder, empennage, and left wing sustained substantial damage. There were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot receiving instruction’s failure to maintain control during a go-around. Contributing to the accident was the flight instructor’s inadequate supervision of the flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N860TW
Operator
TAILWINDS LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S9220
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-05T02:05:26Z guid: 192801 uri: 192801 title: CEN23LA347 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192789/pdf description:
Unique identifier
192789
NTSB case number
CEN23LA347
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-03T12:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-04T05:52:55.731Z
Event type
Accident
Location
Jamestown, North Dakota
Airport
Central Ag Spraying (PRI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was to ferry the airplane that the pilot had never flown. During takeoff roll on the narrow (10 ft wide) runway, the pilot advanced the throttle slowly, which resulted in the airplane’s slow acceleration. As the end of the runway approached, the pilot selected full throttle and the airplane lifted off the ground at a slow airspeed. As the airplane climbed out of ground effect, the pilot did not increase airspeed adequately due, in part, to his concern of power lines off the end of the runway. The airplane subsequently entered an aerodynamic stall and impacted terrain, which substantially damaged the right wing. The pilot reported no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot likely did not maintain proper airspeed during initial climb, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. The pilot attributed his lack of familiarity with the airplane and the narrow runway as factors to the accident.
Probable cause
The pilot’s failure to maintain proper airspeed after liftoff, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AIR TRACTOR INC
Model
AT-401
Amateur built
false
Engines
1 Turbo prop
Registration number
N6015W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
401-0947
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-04T05:52:55Z guid: 192789 uri: 192789 title: ERA23LA326 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192811/pdf description:
Unique identifier
192811
NTSB case number
ERA23LA326
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-05T13:33:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-08-24T23:00:05.705Z
Event type
Accident
Location
Elberon, Virginia
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The purpose of the rotorcraft external load flight was to spray water from the helicopter and wash some outside insulators that were suspended from power line structure arms. During the wash, the crew heard a bang, and the helicopter descended into trees. A Federal Aviation Administration inspector examined the wreckage after the accident and observed substantial damage to the fuselage and rotor blades. The inspector also observed damage to the power line structure arm that was consistent with main rotor blade contact. The inspector did not find evidence of any preimpact mechanical malfunctions or failures of the helicopter, nor did the operator report any. Based on this information, it is likely that the helicopter’s main rotor struck the power line structure while the pilot was maneuvering in close proximity to it.
Probable cause
The pilot’s failure to maintain clearance from a power line structure arm, which resulted in main rotor blade contact.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HUGHES
Model
369
Amateur built
false
Engines
1 Turbo shaft
Registration number
N353AH
Operator
HAVERFIELD INTERNATIONAL INC
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
811079D
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-24T23:00:05Z guid: 192811 uri: 192811 title: WPR23LA318 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192906/pdf description:
Unique identifier
192906
NTSB case number
WPR23LA318
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-05T17:41:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-08-22T00:20:21.323Z
Event type
Accident
Location
Indian Creek, Idaho
Airport
INDIAN CREEK USFS (S81)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the airplane reported that, while enroute, the engine was running rough and the airplane subsequently lost power. His attempts to restore power were unsuccessful. Due to high airspeed and low altitude the pilot elected to land gear up on a dirt airstrip which resulted in substantial damage to the underside of the airplane. Postaccident examination revealed 18 gallons of fuel in the right fuel tank and the left fuel tank was void of fuel; neither fuel tank was breached. The operator of the airplane reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's improper fuel management, which resulted in fuel starvation, and gear up landing on a dirt airstrip.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T210M
Amateur built
false
Engines
1 Reciprocating
Registration number
N7067Z
Operator
GEM AIR, LCC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
21062572
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-22T00:20:21Z guid: 192906 uri: 192906 title: CEN23LA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192831/pdf description:
Unique identifier
192831
NTSB case number
CEN23LA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-06T23:15:00Z
Publication date
2023-09-28T04:00:00Z
Report type
Final
Last updated
2023-08-09T20:24:36.294Z
Event type
Accident
Location
Waco, Texas
Airport
WACO RGNL (ACT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot reported he was anxious on the flight controls in preparation for night landing. During the approach, he felt the airplane was higher above the runway than his actual altitude, and he descended the airplane in a nose low attitude which caused a hard landing on the nose wheel. The student pilot then pulled back on the control yoke, and subsequently the airplane porpoised and settled on to the runway surface. The airplane sustained substantial damage to the forward fuselage. The student pilot reported that the airplane had no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The solo student pilot’s improper descent path which resulted in a hard landing on the nose wheel and subsequent bounced landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N6319G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S10781
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-09T20:24:36Z guid: 192831 uri: 192831 title: CEN23LA356 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192833/pdf description:
Unique identifier
192833
NTSB case number
CEN23LA356
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-08T10:30:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-08-15T16:57:12.332Z
Event type
Accident
Location
Roanoke, Texas
Airport
NORTHWEST RGNL (52F)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, while executing a three-point landing in a tailwheel-equipped airplane, the airplane touched down and a wind gust pushed the nose of the airplane to the left. The pilot attempted to keep the wings level and remain on the runway. He then applied the brakes and “shoved” the flight control stick forward. The airplane hit the runway on its nose and came to rest upright which resulted in substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, the pilot was landing the airplane on runway 17 with wind from 090° at 9 knots.
Probable cause
The pilot's failure to maintain directional control during the landing roll with crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
VANS
Model
JV-Special / RV8
Amateur built
true
Engines
1 Reciprocating
Registration number
N7776J
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-15T16:57:12Z guid: 192833 uri: 192833 title: CEN23LA357 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192834/pdf description:
Unique identifier
192834
NTSB case number
CEN23LA357
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-08T14:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-10T22:35:43.461Z
Event type
Accident
Location
Hartington, Nebraska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while he maneuvered to apply agricultural product to a field, he did not perceive a higher slope of crops before making an application pass. The airplane’s landing gear became entangled in the crops and the pilot could not power the airplane free. The airplane impacted terrain and came to rest upright. Substantial damage was sustained to the airplane’s left wing and empennage. The pilot reported no mechanical malfunctions contributed to the accident.
Probable cause
The pilot’s misperception of the surrounding elevation resulting in a collision with crops and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA25
Amateur built
false
Engines
1 Reciprocating
Registration number
N8847L
Operator
BECKER FLYING SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
25-5358
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-10T22:35:43Z guid: 192834 uri: 192834 title: ERA23LA339 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192888/pdf description:
Unique identifier
192888
NTSB case number
ERA23LA339
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-09T10:15:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-09-28T18:42:43.143Z
Event type
Accident
Location
Princeton, New Jersey
Airport
PRINCETON (39N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was practicing solo takeoffs and landings in the airport traffic pattern. He successfully completed two takeoffs and landings. He then decided to attempt a soft-field technique takeoff. As the airplane began to lift off the ground, the pilot reported that an unexpected gust of wind from the northwest caught him off guard, and he lost control of the airplane. The airplane subsequently collided with trees, resulting in substantial damage to both wings. The pilot reported that there were no pre-impact mechanical malfunctions or failures that would have prevented normal operation of the airplane.
Probable cause
The pilot’s inadequate compensation for the prevailing wind conditions during takeoff, which resulted in a loss of control and subsequent collision with trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172R
Amateur built
false
Engines
1 Reciprocating
Registration number
N172FW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17280080
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-28T18:42:43Z guid: 192888 uri: 192888 title: CEN23LA358 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192839/pdf description:
Unique identifier
192839
NTSB case number
CEN23LA358
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-09T11:00:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-08-17T19:33:04.853Z
Event type
Accident
Location
Sevierville, Tennessee
Airport
Gatlinburg-Pigeon Forge Airport (GKT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and his student were practicing hovering autorotations over an asphalt taxiway. The flight instructor reported that during the third autorotation, he either did not completely roll the throttle into the spring-loaded override, or he inadvertently allowed the throttle to open while arresting the descent. The helicopter climbed to about 25 ft above ground level and then it entered an uncontrolled right spin. The flight instructor immediately communicated to the student pilot that he had taken over the flight controls but was unsure if the student pilot had fully relinquished the flight controls. The flight instructor maneuvered the helicopter over a grass field and initiated a hovering autorotation. The helicopter landed hard and spread the skids, which resulted in substantial damage to the fuselage. The flight instructor shutdown the helicopter and he and his student were able to egress without further incident. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The flight instructor’s improper flight control inputs during the practice hovering autorotation that resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N798MG
Operator
Sevier County Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2704
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-17T19:33:04Z guid: 192839 uri: 192839 title: WPR23LA312 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192866/pdf description:
Unique identifier
192866
NTSB case number
WPR23LA312
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-09T17:15:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-08-24T21:37:35.552Z
Event type
Accident
Location
Dixon, California
Airport
NA (NA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that while conducting a pleasure flight he elected to land on an unimproved dirt airstrip. During the landing roll, the right main landing gear struck an unidentified object/hole which pulled the airplane to the right off the landing surface and toward a fence line. The pilot applied excessive braking, and the airplane nosed over and came to rest inverted. The airplane sustained substantial damage to the left-wing strut and the top of the vertical stabilizer and rudder. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control after striking an unidentified object during landing on an unimproved runway, and his subsequent use of excessive braking that resulted in a nose-over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7GCBC
Amateur built
false
Engines
1 Reciprocating
Registration number
N50443
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1128-79
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-24T21:37:35Z guid: 192866 uri: 192866 title: ERA23LA329 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192837/pdf description:
Unique identifier
192837
NTSB case number
ERA23LA329
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-09T20:30:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-08-15T18:08:53.757Z
Event type
Accident
Location
Holy Hill, South Carolina
Airport
HOLLY HILL (5J5)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that the accident flight was his first flight in this make and model airplane, and he planned to complete a few high-speed taxi runs before deciding to takeoff. During the first high-speed taxi attempt, the pilot lifted the nose wheel up, and after riding on the rear wheels he increased engine power to “slightly lift off”; however, the airplane quickly climbed to 30 or 40 feet above ground level within a few seconds. Subsequently, the pilot reduced power to land, but the airplane immediately entered an aerodynamic stall and rolled to the left. The airplane continued to descend and impacted a hangar which resulted in substantial damage to the fuselage and wings. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation. He further added that he was unfamiliar with the airplane.
Probable cause
The pilot’s exceedance of the critical angle of attack during the initial climb, which resulted in an aerodynamic stall at low altitude and a collision with a hangar. Contributing to the accident was the pilot’s lack of experience in the accident make and model airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
EIPPER FORMANCE INC
Model
MXII
Amateur built
true
Engines
1 Reciprocating
Registration number
N1624Z
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1764
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-15T18:08:53Z guid: 192837 uri: 192837 title: CEN23LA362 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192870/pdf description:
Unique identifier
192870
NTSB case number
CEN23LA362
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-10T10:15:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-19T02:06:53.227Z
Event type
Accident
Location
Harvard, Illinois
Airport
Adkins Airport (8IL0)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that prior to departure, he preflighted the airplane and found no anomalies. There no issues with his takeoff from the grass airstrip but once airborne, he felt uncomfortable to continue the flight due to hazy weather conditions. He then returned to the airstrip and landed without incident. He attempted a second takeoff with a left quartering crosswind, during which the airplane moved aggressively to the left. He applied additional right rudder control input, but the left turn increased, and the airplane impacted a cornfield about 1,000 ft down the runway. The airplane sustained substantial damage to the left- and right-wing spars and the fuselage. The pilot stated the accident could have been prevented by reducing the throttle setting or turning off the magnetos in a timely manner. Postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during takeoff that resulted in a runway excursion and an impact with the cornfield.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-38-112
Amateur built
false
Engines
1 Reciprocating
Registration number
N2351A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
38-78A0649
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-19T02:06:53Z guid: 192870 uri: 192870 title: ANC23LA062 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192882/pdf description:
Unique identifier
192882
NTSB case number
ANC23LA062
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-10T13:10:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-08-28T17:00:51.938Z
Event type
Accident
Location
Chaka Creek, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot and passenger were performing a high pass over a remote airstrip to ensure the surface was suitable for landing. About ½ down the 850 ft airstrip, the pilot initiated a go-around with the throttle, mixture, and propeller controls in the full forward position and then realized the engine was not producing full power. With rising terrain ahead and the airspeed near the stall speed, the pilot elected to attempt a forced landing on the remaining airstrip. During the forced landing, the right main landing gear impacted brush, and the airplane spun about 120° and came to rest upright. Postaccident examination of the airplane revealed substantial damage to the left horizontal stabilizer and right wing. The pilot stated that the engine likely experienced carburetor icing during the approach and attempted go-around. The pilot reported no preimpact mechanical failures with the airplane that would have precluded normal operation. Based on the pilot’s report of the temperature and dew point at the time of the accident, the airplane was operating in conditions conducive to the formation of serious icing (at cruise power). The pilot reported he did not apply the carburetor heat when the engine began to lose power due to the low altitude and airspeed during the attempted go-around maneuver. It is likely the engine sustained a partial loss of engine power due to the formation of carburetor ice.
Probable cause
A partial loss of engine power as a result of carburetor ice. Contributing to the outcome was the pilot’s failure to effectively use carburetor heat in conditions conducive to the formation of carburetor ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180J
Amateur built
false
Engines
1 Reciprocating
Registration number
N42610
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18052366
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-28T17:00:51Z guid: 192882 uri: 192882 title: WPR23LA315 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192871/pdf description:
Unique identifier
192871
NTSB case number
WPR23LA315
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-10T15:05:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-08-15T01:09:24.772Z
Event type
Accident
Location
Marysville, California
Airport
Yuba County (MYV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that during an instructional flight, he was conducting a high-speed taxi exercise on the runway with a student pilot, to work on rudder control. He instructed the student to remain at or below 50 mph and that they would begin slowing the airplane about 1,000 ft from the departure end of the runway. About halfway down the length of the runway, the instructor noticed that the airspeed seemed high, and he informed the student that they “needed to slow down a little”; however, the airplane continued to accelerate. When the instructor told the student to begin their deceleration, the airplane did not decelerate as expected. As the airplane overran the runway, the instructor took the flight controls and elected to take off. The airplane was flown to the originating airport, where substantial damage to the horizontal stabilizer and elevator was discovered during postflight inspection, which resulted from impact with a runway end light during the runway excursion. The instructor reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The flight instructor’s failure to monitor the airplane’s speed during a high-speed taxi, resulting in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N20268
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17261144
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-15T01:09:24Z guid: 192871 uri: 192871 title: CEN23LA366 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192892/pdf description:
Unique identifier
192892
NTSB case number
CEN23LA366
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-11T10:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-18T02:35:43.755Z
Event type
Accident
Location
Derby, Kansas
Airport
Cook Airfield (K50)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll, the airplane drifted left so he applied right rudder, but the rudder pedals were “jammed” by the passenger in the left seat. The pilot was unable to maintain directional control. The airplane departed the left side of the runway and continued through a culvert, which resulted in substantial damage to the fuselage. The pilot reported no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control during takeoff roll due the passenger’s interference with the rudder pedals, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N6205E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
46305
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-18T02:35:43Z guid: 192892 uri: 192892 title: CEN23LA365 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192885/pdf description:
Unique identifier
192885
NTSB case number
CEN23LA365
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-11T11:30:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-08-17T23:49:14.23Z
Event type
Accident
Location
Chillicothe, Missouri
Airport
Chillicothe Municipal Airport (CHT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of a tailwheel equipped airplane reported that during the landing roll the tailwheel shimmied, and the airplane veered right of the runway centerline. He was able to maintain directional control and taxied to the loading area to prepare the airplane for the next agricultural application flight. He reported that this was the fourth landing of the day and there were no anomalies with the previous landings. While taxiing the airplane to the runway for takeoff the pilot had to use left rudder and brake to keep the airplane going straight on the taxiway. During the takeoff roll the tailwheel began to shimmy again and the airplane veered to the right. The pilot reduced the engine power and applied brakes to abort the takeoff but was unable to maintain directional control of the airplane. The airplane exited the runway and ground looped in a grassy area adjacent to the runway. Substantial damage was noted to the tailwheel’s empennage supporting structure and the tailwheel exhibited deformation to the right. Examination of the airplane revealed the tailwheel assembly was partially separated from the empennage supporting structure and all observed fractures were consistent with overload separation. It is likely that the tailwheel was damaged during a previous landing and that damage resulted in the shimmy during the previous landing and the pilot’s difficulty in maintaining control during the taxi and takeoff. An examination of the of the tailwheel assembly, tailwheel control, and rudder revealed no mechanical anomalies that would have precluded normal operations before the damage occurred. Given the difficulties taxiing for takeoff, the pilot should not have continued with the takeoff with a known anomaly.
Probable cause
The pilot’s decision to operate the airplane with a known tailwheel anomaly, which resulted in a loss of directional control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188B
Amateur built
false
Engines
1 Reciprocating
Registration number
N9237R
Operator
Justin Goad
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
18802176T
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-17T23:49:14Z guid: 192885 uri: 192885 title: PLD23LR003 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192854/pdf description:
Unique identifier
192854
NTSB case number
PLD23LR003
Transportation mode
Pipeline
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-12T11:22:00Z
Publication date
2024-01-02T05:00:00Z
Report type
Final
Event type
Accident
Location
Pittsburgh, Pennsylvania
Injuries
6 fatal, 2 serious, 0 minor
Pipeline operator
Peoples Gas
Pipeline type
Distribution
Regulator type
PA
Probable cause
Probable cause not determined, non-jurisdictional failure
Has safety recommendations
false

Vehicle 1

Findings
creator: NTSB last-modified: 2024-01-02T05:00:00Z guid: 192854 uri: 192854 title: ERA23LA336 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192862/pdf description:
Unique identifier
192862
NTSB case number
ERA23LA336
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-13T18:35:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-08-29T23:20:39.046Z
Event type
Accident
Location
North Myrtle Beach, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that he visually confirmed there were 52 gallons of fuel onboard and that both fuel caps were secure to their respective fuel port during his preflight inspection of the airplane. The pilot then departed on the approximate 1 hour and 15-minute flight. While en route, the “low fuel light” flickered on and off. The pilot noted the fuel gauge was reading half full, and he continued with the flight. When the airplane was about 8 minutes from the destination airport, and after descending to traffic pattern altitude, the engine stopped producing power. The pilot was unable to restart the engine and made a forced landing to a highway. The airplane impacted a jersey barrier during the landing, which resulted in substantial damage to the airframe. Federal Aviation Administration inspectors examined the airplane accident site and observed that the left wing fuel cap was missing and blue fuel stains were evident on the wing aft of the fuel cap that extended to the trailing edge of the flap. Recovery personnel also reported that both fuel tanks were empty when the wings were removed for transport. The missing fuel cap was not located. Based on this information, it is likely that the pilot did not properly secure the left fuel cap during the preflight inspection, and that during the flight it separated from the airplane. The remaining fuel was siphoned from the fuel tanks through the open fuel port, resulting in fuel exhaustion, and the total loss of engine power.
Probable cause
The pilot’s failure to properly secure the left wing fuel cap, which resulted in a loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182P
Amateur built
false
Engines
1 Reciprocating
Registration number
N22RE
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18263425
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-29T23:20:39Z guid: 192862 uri: 192862 title: ANC23LA063 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192889/pdf description:
Unique identifier
192889
NTSB case number
ANC23LA063
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-14T11:20:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-08-28T17:02:34.419Z
Event type
Accident
Location
Skwentna, Alaska
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While landing on a river and coming off the float step, the airplane’s float contacted an undetected submerged gravel bar in shallow water. The airplane pivoted, nosed over, and came to rest inverted. The airplane sustained substantial damage to the vertical stabilizer and rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The airplane’s float contacted an undetected submerged gravel bar during landing which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
U206G
Amateur built
false
Engines
1 Reciprocating
Registration number
N4891Z
Operator
Rust's Flying Service
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
U20606044
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-28T17:02:34Z guid: 192889 uri: 192889 title: CEN23LA363 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192876/pdf description:
Unique identifier
192876
NTSB case number
CEN23LA363
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-15T09:05:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-16T19:36:46.265Z
Event type
Accident
Location
Lansing, Michigan
Airport
Captial Regional International (LAN)
Weather conditions
Instrument Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that after a normal start and taxi, the airplane was cleared for takeoff. During the takeoff roll, the airplane drifted right and the pilot corrected with the left rudder. When the airplane reached 100 knots, he rotated the airplane, and about 30 feet in altitude, the airplane experienced a roll to the right. The pilot tried to correct the roll with left rudder but was unable to provide sufficient left rudder. At this point, the airplane had drifted to the right of the runway and over the adjacent parallel taxiway. He was able to regain partial control by reducing engine power and banking the airplane to the left. The pilot attempted to land on the taxiway but was unable to judge his height above ground due to the low visibility, and subsequently impacted terrain to the right of the taxiway. Both wings and the fuselage sustained substantial damage. Prior to exiting the airplane, the pilot noted that the rudder trim was set to the full nose-right position. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Prior to the accident, maintenance was completed that consisted of an “Event II & Routine” inspection. The inspection procedure required the rudder trim system to be lubricated, a trim tab free play inspection, and an operational check prior to returning the airplane to service. Review of the maintenance procedures revealed there was no guidance on returning the rudder trim control system back to a neutral position at completion of the inspection.
Probable cause
The pilot’s failure to properly set the rudder trim position which resulted in a loss of directional control during takeoff. Contributing was the pilot’s inadequate checklist procedures prior to takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C-99
Amateur built
false
Engines
2 Turbo prop
Registration number
N261SW
Operator
Ameriflight, LLC
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Cargo
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
U-202
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-16T19:36:46Z guid: 192876 uri: 192876 title: WPR23LA319 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192919/pdf description:
Unique identifier
192919
NTSB case number
WPR23LA319
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-15T11:00:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-30T20:57:05.495Z
Event type
Accident
Location
Moab, Utah
Airport
Canyonlands Regional Airport (CNY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll, the airplane veered right, exited the runway, and ground looped. Subsequently, the left wing sustained substantial damage. The pilot reported no mechanical anomalies or failures that would have precluded normal operations.
Probable cause
The pilot’s loss of directional control during landing, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180J
Amateur built
false
Engines
1 Reciprocating
Registration number
N9977N
Operator
Mesha Holding LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18052632
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-30T20:57:05Z guid: 192919 uri: 192919 title: CEN23LA379 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192928/pdf description:
Unique identifier
192928
NTSB case number
CEN23LA379
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-16T10:34:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-12T23:07:58.082Z
Event type
Accident
Location
Houston, Texas
Airport
DAVID WAYNE HOOKS MEML (DWH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the pilot receiving instruction reported that the airplane struck a bird during initial climb after takeoff. They were able to continue and land uneventfully. The airplane sustained substantial damage to the right wing.
Probable cause
An in-flight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
S35
Amateur built
false
Engines
1 Reciprocating
Registration number
N5874J
Operator
MY FLIGHT LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
D-7866
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-12T23:07:58Z guid: 192928 uri: 192928 title: CEN23LA376 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192921/pdf description:
Unique identifier
192921
NTSB case number
CEN23LA376
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-18T18:45:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-08-22T20:51:13.107Z
Event type
Accident
Location
Hovland, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
1 fatal, 0 serious, 0 minor
Analysis
The non-certificated pilot departed in the powered parachute on a local flight. When the pilot did not return for landing, search and rescue efforts were initiated that located the deceased pilot in a lake in about 44 ft of water. The aircraft was not located. Flight track information for the flight was not available. The pilot never held a medical certificate, and no pilot or maintenance logbooks were made available to the investigation. An autopsy of the pilot was performed, and the cause of death was hypothermia and drowning. Toxicology testing was negative for screened drugs and alcohol.
Probable cause
The collision with the lake by a noncertificated pilot for reasons that could not be determined.
Has safety recommendations
false

Vehicle 1

Aircraft category
Powered parachute
Make
SIXCHUTER
Model
SPIRIT XL
Amateur built
false
Engines
1 Reciprocating
Registration number
N538DR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2879
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-08-22T20:51:13Z guid: 192921 uri: 192921 title: WPR23LA322 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192924/pdf description:
Unique identifier
192924
NTSB case number
WPR23LA322
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-18T19:10:00Z
Publication date
2023-11-30T05:00:00Z
Report type
Final
Last updated
2023-08-23T20:57:09.207Z
Event type
Accident
Location
Lone Pine, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The pilot reported that, while conducting a low pass over an off-airport landing strip at an altitude of 100 ft above the ground, the airplane encountered a downdraft. The pilot felt the airplane was unable to climb out of the valley without stalling, so he maintained airspeed, but the airplane descended and impacted the ground. The airplane subsequently rebounded and came to a rest in an upright position, which resulted in substantial damage to both wings, fuselage, and empennage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's inability to maintain altitude after encountering a downdraft, which resulted in collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN AMERICAN AVN. CORP.
Model
AA-5B
Amateur built
false
Engines
1 Reciprocating
Registration number
N4537Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA5B1292
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-23T20:57:09Z guid: 192924 uri: 192924 title: DCA23LA421 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192927/pdf description:
Unique identifier
192927
NTSB case number
DCA23LA421
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-18T19:11:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2023-09-18T23:04:31.851Z
Event type
Accident
Location
Over the, Atlantic Ocean
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 8 minor
Analysis
United Airlines flight 918 encountered clear air turbulence during cruise flight, while en route to the London Heathrow International Airport (LHR), London, United Kingdom resulting in one flight attendant (FA) sustaining a serious injury. The flight originated at Dulles International Airport (IAD), Dulles, Virginia. The flight crew reported that their preflight weather briefing revealed no significant areas of weather or turbulence over their planned route to LHR. During their preflight checks an open status message “PASS ADDRESS SYSTEM” displayed on their engine indication and crew alerting system (EICAS) display and maintenance was called. A technician responded who reinitialized the entire passenger address (PA) system and cleared the status message. The flight crew reported that prior to the JOBOC intersection, there was minimal light turbulence, and the seatbelt sign had been on and off sporadically as required. They also indicated that no turbulence was identified in their immediate vicinity from their inflight weather resources. About 80 nm east of JOBOC, the flight encountered very light turbulence and the first officer (FO), who was the pilot flying, made the PA announcement: “Flight Attendants take your seats.” In a postaccident statement, the captain reported that while in the forward lavatory, the flight encountered very light turbulence and he heard through the lavatory wall, the FO make the PA announcement: “Flight Attendants take your seats.” However, because he did not hear the PA announcement over the lavatory speaker he didn’t know if the rest of the crew or passengers heard this announcement.  The in-flight service manager (ISM), who was in the cockpit at the time also heard the FO make the announcement “Flight Attendants take your jumpseats.” As the captain attempted to take his seat (left seat) the flight encountered a moderate turbulence spike that made his knees buckle and threw him back down into the 1st observer’s seat. He indicated that he was able to flash the seatbelt sign on and off three times rapidly. The flight crew then executed all the steps of the TURBULENCE IMMEDIATE ACTION GUIDE. The turbulence ended as abruptly as it had begun. The captain then made a PA announcement “Flight attendants check in.” The ISM advised the captain that all the flight attendants had been knocked to the floor and one was seriously injured. The flight crew contacted dispatch and advised of the clear air turbulence encounter. The dispatcher had no reports of turbulence from any other United flights in the area. According to the cabin crew, they did not hear the PA announcement “Flight Attendants take your seats” and therefore they were completing their normal duties when, without warning, the airplane encountered turbulence. One FA, who was delivering meals at the time of the turbulence encounter, was thrown down, impacted the floor, and was injured. According to the ISM, shortly after the encounter, the captain came on the PA and said “Flight Attendants, Check In.” The cabin crew heard that announcement and the ISM reported to the flight crew that one FA was on the floor and was unable to get up. Upon being notified of the injured FA, the flight crew declared a medical emergency and requested paramedics meet the aircraft at the gate in LHR. The injured FA was moved to an unoccupied passenger seat, given ice, and was assisted by an onboard medical doctor for the rest of the flight. After landing the FA was transported to a local hospital where she was diagnosed with a fractured left fibula. A postaccident functional check of the passenger address system revealed no malfunctions or anomalies with the system.
Probable cause
An inadvertent encounter with clear air turbulence during cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
777-222
Amateur built
false
Engines
2 Turbo fan
Registration number
N209UA
Operator
UNITED AIRLINES INC
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
30215
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-09-18T23:04:31Z guid: 192927 uri: 192927 title: CEN23LA374 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192917/pdf description:
Unique identifier
192917
NTSB case number
CEN23LA374
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-19T11:00:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-08-22T19:30:45.265Z
Event type
Accident
Location
Bay Port, Michigan
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was beginning his fourth agricultural application flight of the day and that the air temperature and wind speed had increased from previous flights that morning. He began the takeoff roll to the north on the soft, wet runway and noted that toward the end of the runway, the airplane entered “ground effect” and had difficulty climbing. He attempted a slight right turn to avoid trees on the northwest end of the runway and the airplane descended into a soybean field and impacted a drainage ditch. The airplane nosed over and tumbled multiple times which resulted in substantial damage to both wings, fuselage, and empennage. The pilot reported that there were no mechanical malfunctions with the airplane that would have precluded normal operation. The nearest recorded weather observation reported the wind from 240° at 6 knots, which resulted in a left quartering tailwind for the takeoff.
Probable cause
The pilot’s decision to takeoff from a soft wet runway with a quartering tailwind which resulted in a lack of climb performance and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A188B
Amateur built
false
Engines
1 Reciprocating
Registration number
N8075G
Operator
VAUGHNS FLYING SERVICE INC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
18801226T
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-22T19:30:45Z guid: 192917 uri: 192917 title: WPR23LA320 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192920/pdf description:
Unique identifier
192920
NTSB case number
WPR23LA320
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-19T15:20:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-08-31T21:58:17.156Z
Event type
Accident
Location
Santa Rosa, California
Airport
Santa Rosa (STS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported the airplane recently had an engine upgrade and he was flying it to break in the engine. He had performed fuel calculations based on its previously consumption rate and did not realize the new engine was consuming more fuel than planned. During final approach the airplane experienced a total loss of power due to fuel exhaustion. The pilot performed a forced landing on an open field with high vegetation, substantially damaging the right wing and right horizontal stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate fuel management which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172H
Amateur built
false
Engines
1 Reciprocating
Registration number
N3282L
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
false
Serial number
17256182
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-08-31T21:58:17Z guid: 192920 uri: 192920 title: CEN23LA386 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192960/pdf description:
Unique identifier
192960
NTSB case number
CEN23LA386
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-20T08:05:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-08-31T00:26:54.608Z
Event type
Accident
Location
Granbury, Texas
Airport
PECAN PLANTATION (0TX1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
According to two witnesses, the pilot of the gyroplane started his takeoff roll with the rotor in a horizontal position. Both witnesses stated that the gyroplane’s take off roll was longer than usual. When the pilot pitched the rotor up, the gyroplane pitched up, climbed about 30 to 40 ft above the ground, rolled to the left, and subsequently impacted the runway. The left main landing gear separated from the gyroplane after impacting the runway, and the gyroplane departed the runway to the left. The gyroplane came to rest about 1,400 ft from its departure point. The pilot was seriously injured. During the runway excursion, the gyroplane’s rotor impacted the ground resulting in substantial damage to the rotor, horizontal stabilizer, vertical stabilizer, and rudder. The pilot stated via telephone that there were no mechanical malfunctions or failures that would have precluded normal operation. The pilot did not provide an NTSB Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report. According to FAA-H-8083-21 Rotorcraft Flying Handbook, “The normal takeoff for most amateur-built gyroplanes is accomplished by prerotating to sufficient rotor r.p.m. to prevent blade flapping and tilting the rotor back with cyclic control. Using a speed of 20 to 30 m.p.h., allow the rotor to accelerate and begin producing lift. As lift increases, move the cyclic forward to decrease the pitch angle on the rotor disc.” It is likely the pilot did not position the rotor at the appropriate pitch angle to allow the main rotor to reach sufficient takeoff rpm before attempting to takeoff.
Probable cause
The pilot’s improper takeoff procedure which resulted in a loss of control during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
Silverlight
Model
AR-1
Amateur built
true
Engines
1 Reciprocating
Registration number
N57AR
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
0057
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-31T00:26:54Z guid: 192960 uri: 192960 title: CEN23LA373 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192913/pdf description:
Unique identifier
192913
NTSB case number
CEN23LA373
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-20T19:29:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-25T17:42:21.374Z
Event type
Accident
Location
New Haven, Indiana
Airport
Haven Center (26IN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while landing at a private grass airstrip, the airplane landed hard and bounced. The right wing struck corn stalks that bordered the airstrip. The airplane continued into the cornfield, nosed over, and came to rest inverted. During the runway excursion and subsequent nose over, the left wing impacted the ground and sustained substantial damage. The pilot reported that the airplane had no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control while landing, which resulted in a runway excursion, impact with corn stalks, and subsequent nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150D
Amateur built
false
Engines
1 Reciprocating
Registration number
N4150U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15060150
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-25T17:42:21Z guid: 192913 uri: 192913 title: ERA23LA345 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192912/pdf description:
Unique identifier
192912
NTSB case number
ERA23LA345
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-20T19:30:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-08-23T22:33:10.657Z
Event type
Accident
Location
Warrenton, Virginia
Airport
FLYING CIRCUS AERODROME (3VA3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the pilot, after takeoff in the vintage tailwheel-equipped biplane, he was notified via radio that the right main landing gear was partially separated from the airframe. The pilot, returned to the airport and during landing, he continued to fly the airplane down the runway with the right main landing gear in the air until the airplane decelerated and settled onto the turf runway. Once the airplane slowed, it “ground loop[ed]” and came to rest on the nose, which resulted in substantial damage to the left wing. Postaccident examination revealed that the inner strut had separated from the outer strut but remained partially attached.
Probable cause
A ground loop during landing resulting from a partial separation of the right main landing gear strut during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
WACO
Model
UPF-7
Amateur built
false
Engines
1 Reciprocating
Registration number
N39721
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
5854
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-23T22:33:10Z guid: 192912 uri: 192912 title: ERA23LA343 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192904/pdf description:
Unique identifier
192904
NTSB case number
ERA23LA343
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-21T10:55:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-09-20T20:28:24.642Z
Event type
Accident
Location
Millbrook, New York
Airport
SKY ACRES (44N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was landing the vintage, tailwheel-equipped airplane. As he touched down on the paved runway that had slight downhill, the pilot described that he “tapped” the brakes, and the right brake “grabbed a little harder than the left.” The pilot attempted to correct with rudder but the airplane ground looped after the right main landing gear separated from the fuselage. The airplane came to rest in the grass area next to the runway. During the accident sequence, the left wing and fuselage were substantially damaged. A Federal Aviation Administration inspector examined the airplane after the accident did not observe any abnormalities of the airplane’s brakes. Based on the lack of any anomalous findings during the postaccident examination of the brakes, it is likely that the pilot lost directional control of the tailwheel-equipped during landing, which resulted in a ground loop.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-17
Amateur built
false
Engines
1 Reciprocating
Registration number
N4814H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17-112
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-20T20:28:24Z guid: 192904 uri: 192904 title: CEN23LA375 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192918/pdf description:
Unique identifier
192918
NTSB case number
CEN23LA375
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-21T14:56:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-08-29T19:39:47.135Z
Event type
Accident
Location
Rice, Minnesota
Airport
Oleen AG Air (NA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he performed a straight in landing to a private airstrip. He anticipated a crosswind from the east, so he made the approach with additional airspeed to have more controllability in the crosswind. He stated that he landed about two thirds of the way down the 2,574 ft runway, reduced power, and reduced the propeller pitch to low. The tailwheel settled to the ground at a location on the runway where there was a break in the adjacent tree line. The pilot reported that the crosswind intensified at this point, and the airplane yawed to the left. The left main landing gear exited the paved portion of the runway. The pilot attempted to correct with rudder and brakes; however, the airplane continued off the runway and into a plowed field. The airplane nosed over and came to rest inverted in the field. The vertical stabilizer was substantially damaged. The pilot reported that there were no mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, wind at an airport 12 nm northwest of the accident site was 090°at 8 knots. The pilot was landing to the south.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with a left crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
SCHWEIZER AIRCRAFT CORP
Model
G-164B
Amateur built
false
Engines
1 Turbo prop
Registration number
N943QC
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
711B
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-29T19:39:47Z guid: 192918 uri: 192918 title: CEN23LA378 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192926/pdf description:
Unique identifier
192926
NTSB case number
CEN23LA378
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-22T18:10:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-09-12T23:52:06.103Z
Event type
Accident
Location
Cleburne, Texas
Airport
Cleburne Regional Airport (CPT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
While landing to runway 15 in gusty wind conditions, the pilot lost control of the tailwheel equipped airplane, it nosed over, and came to rest inverted. The airplane sustained substantial damage to the right wing and lift strut. The pilot reported there were no preaccident mechanical malfunctions or failures which would have precluded normal operation. The wind at the time of the accident was 100° at 13 knots with gusts to 20 knots. The calculated crosswind component was between 10 and 15 knots.
Probable cause
The pilot’s failure to maintain directional control while landing in gusty crosswind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J4
Amateur built
false
Engines
1 Reciprocating
Registration number
N6581H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4-831
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-12T23:52:06Z guid: 192926 uri: 192926 title: CEN23LA380 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192930/pdf description:
Unique identifier
192930
NTSB case number
CEN23LA380
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-23T14:18:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-24T16:16:20.152Z
Event type
Accident
Location
Klein, Texas
Airport
DAVID WAYNE HOOKS MEML (DWH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing roll, as the nose landing gear contacted the runway, he felt a vibration from the front of the airplane, then it veered hard left. During the veer, the airplane began to skid so he applied right rudder but was unable to maintain directional control. The airplane departed the runway surface, the nose landing gear collapsed, and the right wing impacted terrain, which resulted in substantial damage to the right wing. At the time of the accident, the pilot was landing the airplane with 20° left crosswind at 7 knots gusting to 16 knots. Postaccident examination of the airplane showed that there were no preaccident mechanical malfunctions of failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the crosswind landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
182T
Amateur built
false
Engines
1 Reciprocating
Registration number
N908VA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18281555
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-24T16:16:20Z guid: 192930 uri: 192930 title: CEN23LA382 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192944/pdf description:
Unique identifier
192944
NTSB case number
CEN23LA382
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-23T15:40:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-08-30T04:18:08.455Z
Event type
Accident
Location
Bonham, Texas
Airport
Jones Field Airport (F00)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor stated that during a simulated one engine inoperative approach and landing, the pilot receiving instruction chose to leave the landing gear retracted until the landing was assured. The pilot receiving instruction turned the airplane onto a short base leg before final, increased the mixture and propeller control settings, and increased the airplane bank angle so as not to overshoot the final approach course. The flight instructor saw that the airplane airspeed was decreasing and told the pilot receiving instruction that they were low. The pilot receiving instruction increased airplane pitch, which resulted in a decrease in airspeed, a loss of altitude, and a rolling motion. The flight instructor leveled the wings and reduced pitch to regain airplane control and lift. When the airplane was over the runway threshold, the flight instructor did not remember that the landing gear was still retracted and he did not complete the final landing checklist, which resulted in a landing with the landing gear retracted. The airplane sustained substantial damage to the underside fuselage longerons. There was no mechanical malfunction/failure of the airplane or system that would have precluded normal operations.
Probable cause
The failure of the pilot receiving instruction and flight instructor to follow the landing checklist and extend the landing gear before landing
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA-44-180
Amateur built
false
Engines
2 Reciprocating
Registration number
N7122E
Operator
American Flyers
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
4496447
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-30T04:18:08Z guid: 192944 uri: 192944 title: ERA23LA348 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192935/pdf description:
Unique identifier
192935
NTSB case number
ERA23LA348
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-23T16:30:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-11-02T05:25:37.084Z
Event type
Accident
Location
Pink Hill, North Carolina
Airport
Howard Field (NONE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The private pilot and mechanic were performing at flight following the completion of an annual inspection. After takeoff the pilot flew in the airport traffic pattern, departed the area, then elected to return. While on final approach to land, when the airplane was about 30 ft from the runway threshold, the pilot stated that the airplane was struck by a downdraft. He reported briefly hearing the stall warning horn but did not recall if he applied power adding, “I guess I froze.” The airplane struck the ground short of the runway in a bean field, collided with a ditch, then nosed over coming to rest inverted on the runway. The vertical stabilizer was substantially damaged. The pilot reported there was no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate compensation for prevailing wind conditions during the landing approach, which resulted in the airplane contacting the ground short of the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N8474J
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15066374
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-02T05:25:37Z guid: 192935 uri: 192935 title: WPR23LA337 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193018/pdf description:
Unique identifier
193018
NTSB case number
WPR23LA337
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-25T10:15:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-09-07T01:16:30.312Z
Event type
Accident
Location
Los Lunas, New Mexico
Airport
Mid Valley Airpark (E98)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that during the takeoff roll, his seat slid aft on the seat rails, and he could not reach the rudder pedals. He reduced engine power and stretched to reach the brakes, however, he no longer had forward visibility. The airplane drifted to the right, and then to the left of the runway. The pilot braked hard, and the airplane nosed over. He later realized that the seat position peg had not been fully seated in the seat rail detent, and that the rear seat rail cotter pin was not installed. Both wings, the vertical stabilizer, and the rudder were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to secure the seat’s position in the seat rail, which resulted in a loss of directional control and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
195B
Amateur built
false
Engines
1 Reciprocating
Registration number
N2192C
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
16177
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-07T01:16:30Z guid: 193018 uri: 193018 title: WPR23LA325 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192951/pdf description:
Unique identifier
192951
NTSB case number
WPR23LA325
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-25T14:00:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-28T22:30:49.625Z
Event type
Accident
Location
Carson City, Nevada
Airport
Carson City (KCXP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that during landing, the airplane encountered a gust of wind and ballooned above the runway. Just before touchdown, the airplane encountered a second gust of wind and the pilot added engine power to abort the landing. Subsequently, the airplane drifted to the left and touched down on the parallel taxiway, skidded across the taxiway, and then impacted a ditch. The airplane’s engine mount and fuselage were substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during an aborted landing in gusting wind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N4432R
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17263177
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-28T22:30:49Z guid: 192951 uri: 192951 title: ERA23LA350 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192947/pdf description:
Unique identifier
192947
NTSB case number
ERA23LA350
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-26T11:45:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-08-28T15:18:57.612Z
Event type
Accident
Location
Immokalee, Florida
Airport
IMMOKALEE RGNL (IMM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 2 minor
Analysis
The flight instructor stated that the accident flight was an introductory flight for a new student pilot. He stated that during an introductory flight, it was normal for a student pilot to take the cyclic control and get familiar with the “feel” of the helicopter. During the accident pilot, the student pilot hovered the helicopter at 10 ft above ground level for about 10 minutes with no anomalies, then suddenly, the student pilot pushed the cyclic forward and to the right “very fast.” The flight instructor could not regain control before the main rotor contacted the ground. The helicopter rolled to the right and came to rest on tits right side, sustaining substantial damage to the main rotor mast, tail rotor, and fuselage. The flight instructor stated there were no preimpact mechanical malfunctions or failures of the helicopter that would have precluded normal operation.
Probable cause
The flight instructor’s inadequate supervision of the student pilot during hover flight, which resulted in main rotor blade contact with the ground after the student pilot applied a sudden control input.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N4147Q
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
1844
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-28T15:18:57Z guid: 192947 uri: 192947 title: CEN23LA384 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192952/pdf description:
Unique identifier
192952
NTSB case number
CEN23LA384
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-26T13:42:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-09-05T16:43:08.091Z
Event type
Accident
Location
West Lafayette, Indiana
Airport
PURDUE UNIVERSITY (LAF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that during the initial climb, about 600 ft above ground level, his student observed a bird under the nose of the airplane. The flight instructor took control of the airplane and maneuvered the airplane in an attempt to avoid the bird. The bird went over the top of the airplane and struck the vertical stabilizer, which resulted in substantial damage. The flight instructor landed the airplane without further incident.
Probable cause
An in-flight collision with a bird during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-44-180
Amateur built
false
Engines
2 Reciprocating
Registration number
N767PA
Operator
PURDUE AVIATION LLC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
4496114
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-05T16:43:08Z guid: 192952 uri: 192952 title: CEN23LA385 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192954/pdf description:
Unique identifier
192954
NTSB case number
CEN23LA385
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-27T12:15:00Z
Publication date
2023-10-26T04:00:00Z
Report type
Final
Last updated
2023-08-29T17:20:34.508Z
Event type
Accident
Location
Hibbing, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The helicopter was operating at a remote, unimproved landing zone (LZ) with a ground crew consisting of firefighters. They were conducting aerial firefighting training with an external load consisting of a 50 ft longline and a water bucket. The LZ consisted of about 2.5 ft tall prairie grass, with the tail of the helicopter going up slope. During the landing to the LZ, the tail rotor impacted a backpack on the ground. The helicopter landed upright and the pilot shutdown the helicopter. The pilot performed a self-assessment of the damage sustained to the tail rotor blades and then flew the helicopter back to the airtanker base with the ground crew onboard. The helicopter sustained substantial damage to both tail rotor blades and the tail rotor hub. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. The pilot was in radio contact with the ground crew during the training. However, during the landing, there was no communication between the ground crew and the pilot either via radio or hand signal. The orange-colored backpack was owned and was used by the ground crew. According to the operator, the pilot and the ground crew had worked together previously conducting aerial firefighting operations and the pilot had landed to the LZ several times in the past.
Probable cause
The ground crew’s failure to secure the backpack at the landing zone (LZ), that resulted in the tail rotor impacting the backpack during the landing. Contributing to the accident was the pilot’s inadequate selection of an area at the LZ, the lack of awareness of the backpack at the LZ, and the absence of communication between the pilot and the ground crew during the landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
206
Amateur built
false
Engines
1 Turbo shaft
Registration number
N19BH
Operator
Brainerd Helicopter Service, Inc.
Second pilot present
false
Flight conducted under
Part 133: Rotorcraft ext. load
Flight operation type
Firefighting
Commercial sightseeing flight
false
Serial number
52370
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-29T17:20:34Z guid: 192954 uri: 192954 title: WPR23LA327 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192956/pdf description:
Unique identifier
192956
NTSB case number
WPR23LA327
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-27T13:30:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-08-30T05:04:18.902Z
Event type
Accident
Location
Santa Fe, New Mexico
Airport
Sante Fe Regional (SAF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported being high and fast on final approach. When he reduced power to land the airplane descended rapidly and landed hard. The left landing gear collapsed and the airplane exited the runway, resulting in substantial damage to the left wing. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper landing flare following an unstable approach, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
310Q
Amateur built
false
Engines
2 Reciprocating
Registration number
N117TC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
310Q0786
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-30T05:04:18Z guid: 192956 uri: 192956 title: CEN23LA383 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192949/pdf description:
Unique identifier
192949
NTSB case number
CEN23LA383
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-27T18:00:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-08-28T21:13:54.09Z
Event type
Accident
Location
Mosby, Missouri
Airport
Midwest National Air Center Airport (GPH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during a hover taxi, he inadvertently allowed the engine rpm to decrease. He increased the throttle, but the helicopter landed hard on its skids in the grass and the tail rotor impacted the ground. The ground strike resulted in substantial damage to the tail rotor blades and tailboom assembly. The pilot reported that there were no preaccident mechanical failures or malfunctions with the helicopter that would have precluded normal operation. The pilot noted that a better scan of the engine instruments could have prevented the accident.
Probable cause
The pilot’s failure to maintain adequate rotor rpm which resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
HILLER
Model
UH-12A
Amateur built
false
Engines
1 Reciprocating
Registration number
N8178H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
178
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-28T21:13:54Z guid: 192949 uri: 192949 title: WPR23LA326 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192955/pdf description:
Unique identifier
192955
NTSB case number
WPR23LA326
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-28T10:15:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-29T20:29:06.747Z
Event type
Accident
Location
Leavenworth, Washington
Airport
LAKE WENATCHEE STATE (27W)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that, while taxiing for takeoff on a gravel bar, he encountered a slope. To prevent potential loss of control, he applied brake pressure to both wheels, causing the airplane to nose over, resulting in substantial damage to the rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain airplane control during taxi, which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
HENRY STEVEN J
Model
JA 30 SUPERSTOL
Amateur built
true
Engines
1 Reciprocating
Registration number
N869BB
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
JA366-04-14
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-29T20:29:06Z guid: 192955 uri: 192955 title: ERA23LA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192964/pdf description:
Unique identifier
192964
NTSB case number
ERA23LA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-28T13:00:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-09-29T23:37:26.558Z
Event type
Accident
Location
Hopkinsville, Kentucky
Airport
Hopkinsville-Christian County (HVC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that, before departing in his tailwheel-equipped airplane, a U.S. Army CH-47 heavy-lift helicopter departed and proceeded upwind. When the helicopter was established on the downwind leg of the traffic pattern, the pilot initiated his takeoff. At 40 ft above ground level in the initial climb, the airplane “hit the helicopter’s rotor wash” which rolled the airplane “about 135 degrees to its right.” The pilot was able to level the wings before the airplane touched down in low brush to the right of the runway and came to rest near the airport boundary fence. The airplane sustained substantial damage to the main landing gear support structure and the pilot deplaned uninjured. The pilot reported there were no mechanical malfunctions or anomalies with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadvertent encounter with helicopter wake turbulence during initial climb, which resulted in a loss of airplane control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7ECA
Amateur built
false
Engines
1 Reciprocating
Registration number
N8679V
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1093-75
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-29T23:37:26Z guid: 192964 uri: 192964 title: WPR23LA330 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192962/pdf description:
Unique identifier
192962
NTSB case number
WPR23LA330
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-29T10:05:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-08-30T18:40:53.168Z
Event type
Accident
Location
Reno, Nevada
Airport
Reno/Stead (KRTS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The operator of the uncrewed aircraft system (UAS) reported that, he and an external emergency safety pilot were conducting an engineering test flight to fine tune the autopilot’s tail rotor yaw limits. While hovering at 50 ft agl, the operator incorrectly input a full left tail rotor command, causing the UAS to begin a rapid counterclockwise rotation. The auto pilot was unable to maintain a level attitude or stabilize the UAS during the rotation, and descended uncontrollably. The safety pilot attempted to stabilize the UAS manually, using the emergency RC controller, to no avail. The UAS impacted the surface, resulting in substantial damage to the tailboom. The operator of the UAS reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The operator’s incorrect input into the ground station controller, resulting in a loss of control during flight and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Unmanned
Make
YAMAHA
Model
Fazer SAR
Amateur built
false
Engines
1 Reciprocating
Registration number
N53GR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
L36-2-000113
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-08-30T18:40:53Z guid: 192962 uri: 192962 title: CEN23LA387 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192967/pdf description:
Unique identifier
192967
NTSB case number
CEN23LA387
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-30T08:15:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-09-14T01:35:54.729Z
Event type
Accident
Location
Henderson, Kentucky
Airport
Henderson City (EHR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that shortly after takeoff, he encountered a flock of geese. One of the geese struck the right wing tip, which resulted in substantial damage to the right wing. The pilot declared an emergency with approach control and landed the airplane without further incident. The pilot reported that there were no mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
An in-flight collision with a bird shortly after takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
200
Amateur built
false
Engines
2 Turbo prop
Registration number
N313CT
Operator
BEL-Air. LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
BB-461
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-14T01:35:54Z guid: 192967 uri: 192967 title: CEN23LA428 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193537/pdf description:
Unique identifier
193537
NTSB case number
CEN23LA428
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-30T18:30:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-01-17T21:38:15.395Z
Event type
Accident
Location
Maurice, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was moving the airplane from a nearby airport to his residence and was landing on a road. He said that during the landing he used too much brake, lost directional control, and the airplane went off the left side of the road. The right wing struck a pole and the airplane sustained substantial damage to the right wing. The pilot stated that the airplane did not have a current annual inspection and when asked specifically if there were any mechanical problems with the airplane, he said there were none.
Probable cause
The pilot’s failure to maintain directional control during the landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
17-31A
Amateur built
false
Engines
1 Reciprocating
Registration number
N14723
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
74-32-144
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-17T21:38:15Z guid: 193537 uri: 193537 title: CEN23LA389 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192972/pdf description:
Unique identifier
192972
NTSB case number
CEN23LA389
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-31T08:05:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-09-01T22:58:27.599Z
Event type
Accident
Location
Liberty Hill, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During an instructional flight, the instructor reported that they were practicing simulated engine failures and power recovery autorotations. During the fourth practice autorotation, the pilot receiving instruction attempted to terminate the maneuver with power to a 5 ft above ground level hover. The pilot did not move the twistgrip throttle from idle power back to full open and began raising the collective. The helicopter “fell through” and experienced a hard landing onto a field. The helicopter bounced, touched down hard again and spun about 150° resulting in substantial damage to the tail boom and empennage. The instructor reported that there were no mechanical malfunctions or failures that contributed to the accident.
Probable cause
The pilot’s improper recovery from a practice autorotation resulting in a hard landing. Contributing to the accident was the instructor’s inadequate supervision of the pilot receiving instruction.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MCDONNELL DOUGLAS HELI CO
Model
530FF
Amateur built
false
Engines
1 Turbo shaft
Registration number
N530JR
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
0711FF
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-01T22:58:27Z guid: 192972 uri: 192972 title: WPR23LA331 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192980/pdf description:
Unique identifier
192980
NTSB case number
WPR23LA331
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-31T11:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-09-06T04:15:49.407Z
Event type
Accident
Location
Ennis, Montana
Airport
Ennis Big Sky Airport (KEKS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing approach he forgot to extend the airplane’s landing gear. The airplane subsequently touched down on the runway and the fuselage was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
N35
Amateur built
false
Engines
1 Reciprocating
Registration number
N92NJ
Operator
REGISTRATION PENDING
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
D-6604
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-06T04:15:49Z guid: 192980 uri: 192980 title: CEN23LA392 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192979/pdf description:
Unique identifier
192979
NTSB case number
CEN23LA392
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-31T16:13:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-09-12T23:14:31.963Z
Event type
Accident
Location
Midlothian, Texas
Airport
MID-WAY RGNL (JWY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was familiarizing himself with the airplane in preparation for a multi-day cross-country flight. He also said that there was a potential that he would provide flight instruction to a student during the upcoming flights, so he wanted to perform three takeoffs and landings in the airplane to meet the recent flight experience requirements of Title 14 Code of Federal Regulations Part 61.57. He said that as he approached the airport, the reported weather indicated the wind was aligned with the runway. During the approach, he noted that the windsock showed a left crosswind, and he adjusted the approach using crosswind control correction for the left crosswind. During the rollout, the wind shifted, and the right wing rose. The pilot attempted to correct but when the wing came back down the airplane veered off the left side of the runway and the right main landing gear collapsed. He said that after the event the windsock showed a right crosswind and he believed that there was some windshear that resulted in the right wing raising during the event. The airplane received substantial damage to the right wing. The pilot reported that there were no mechanical issues with the airplane. The recorded weather at the airport where the accident occurred was from 020° at 3 knots, about the time of the accident.
Probable cause
The pilot’s failure to maintain directional control during landing which resulted in the right main landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
7ECA
Amateur built
false
Registration number
N11648
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
838-72
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-12T23:14:31Z guid: 192979 uri: 192979 title: WPR23LA333 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193010/pdf description:
Unique identifier
193010
NTSB case number
WPR23LA333
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-08-31T19:15:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-09-06T01:44:38.29Z
Event type
Accident
Location
Three Rocks, California
Airport
none - private farm strip (N/A)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that the airplane’s hopper had been loaded with 300 gallons of water. During the takeoff roll, the airplane did not accelerate as expected so he initiated the emergency dump procedure to jettison the water. The airplane became airborne and the pilot maintained a high angle of attack to climb over trees near the end of the runway. The airplane subsequently experienced an aerodynamic stall, descended into an adjacent field, and impacted terrain. The left wing, right aileron, and elevator sustained substantial damage. The pilot said he suspected the airplane performance was affected by density altitude and he reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The airplane’s exceedance of the critical angle of attack, resulting in an aerodynamic stall and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AYRES CORPORATION
Model
S2R-T34
Amateur built
false
Engines
1 Turbo prop
Registration number
N61373
Second pilot present
false
Flight conducted under
Part 137: Agricultural
Flight operation type
Aerial application
Commercial sightseeing flight
false
Serial number
T34-216
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-06T01:44:38Z guid: 193010 uri: 193010 title: WPR23LA332 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193008/pdf description:
Unique identifier
193008
NTSB case number
WPR23LA332
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-01T13:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-09-07T03:19:19.993Z
Event type
Accident
Location
Coolidge, Arizona
Airport
Coolidge Municipal Airport (P08)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during a simulated instrument approach he forgot to extend the airplane’s landing gear. The airplane subsequently touched down on the runway and the fuselage and wings were substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200T
Amateur built
false
Engines
2 Reciprocating
Registration number
N440DM
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
34-7670040
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-07T03:19:19Z guid: 193008 uri: 193008 title: CEN23LA393 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192994/pdf description:
Unique identifier
192994
NTSB case number
CEN23LA393
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-01T13:50:00Z
Publication date
2023-10-05T04:00:00Z
Report type
Final
Last updated
2023-09-06T22:37:37.586Z
Event type
Accident
Location
Plover, Wisconsin
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while en route to his planned fuel stop destination, the engine experienced a slight hesitation. The pilot then changed course to the nearest airport and turned on the auxiliary fuel pump. The engine roughness stopped for about 15 seconds, then occurred again, and the engine subsequently lost total power. Unable to maintain altitude and reach the nearest airport, the pilot conducted a forced landing to a roadway. During the forced landing, the airplane’s left wing tip struck a roadway sign, and the right float impacted a moving vehicle that was on the roadway. The airplane sustained substantial damage to the left wing rear spar. Postaccident examination of the airplane revealed the left fuel tank contained no usable fuel, and the right tank contained about 14 gallons of fuel. The fuel selector was found in the left fuel tank position. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadequate fuel management which resulted in a total loss of engine power due to fuel starvation.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
R172K
Amateur built
false
Engines
1 Reciprocating
Registration number
N172SP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
R172-2842
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-06T22:37:37Z guid: 192994 uri: 192994 title: CEN23LA394 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192995/pdf description:
Unique identifier
192995
NTSB case number
CEN23LA394
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-02T05:54:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-09-05T18:57:24.123Z
Event type
Accident
Location
Englewood, Colorado
Airport
CENTENNIAL (APA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The flight instructor and his student were conducting an instructional flight in the airport traffic pattern when the airplane collided with multiple geese during initial climb. Due to the collision, the engine experienced a loss of engine power, so the flight instructor continued straight ahead. He conducted a forced landing on a golf course and the airplane nosed over. The airplane sustained substantial damage to the fuselage, empennage, and both wings.
Probable cause
An in-flight collision with multiple geese during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N20818
Operator
ATP USA
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S12579
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-05T18:57:24Z guid: 192995 uri: 192995 title: ERA23LA391 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193306/pdf description:
Unique identifier
193306
NTSB case number
ERA23LA391
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-03T09:30:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-18T21:10:09.203Z
Event type
Accident
Location
Anderson, South Carolina
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot of the balloon reported that before the flight, the reported wind direction called for a favorable path with many available landing areas; however, during the flight the wind shifted and the balloon traveled over congested living areas and neighborhoods. As he was looking for a place to land the wind was light and variable. He attempted an approach to a cul-de-sac; however, spectators were parked there, preventing a landing. He aborted the approach and tried another to a corner field. That approach was also aborted due to powerlines in the vicinity. He attempted another approach to a “small area” and the balloon’s envelope caught tree limbs during the descent. After becoming briefly suspended in the tree branches about 5 to 8 feet above the ground, the branches broke and balloon basket dropped to the ground. The passenger sustained a minor injury, the pilot was not injured. Postaccident examination of the balloon revealed substantial damage to several fabric panels and two suspension cables. The pilot reported that there were no preaccident mechanical malfunctions or failures with the balloon that would have precluded normal operation.
Probable cause
The pilot’s failure to avoid trees during the descent for landing, resulting in substantial damage to the balloon.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
BALLOON WORKS
Model
FIREFLY 7
Amateur built
false
Registration number
N192HH
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
F7-781
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-18T21:10:09Z guid: 193306 uri: 193306 title: ERA23LA389 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193284/pdf description:
Unique identifier
193284
NTSB case number
ERA23LA389
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-03T12:50:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-10-25T19:10:06.921Z
Event type
Accident
Location
Baltimore, Maryland
Airport
MARTIN STATE (MTN)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was attempting to land when the airplane bounced after touchdown and turned into the wind like a weathervane. The pilot aborted the landing, but as the airplane began to climb, it struck a taxiway light. The pilot thought he struck the left landing gear and contacted the control tower who confirmed that all three-landing gear appeared down and locked. The pilot was able to return to the airport and land without incident. Postaccident examination of the airplane revealed the left horizontal stabilizer was substantially damaged. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane during the aborted landing, which resulted in a collision with a taxiway light.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BELLANCA
Model
17-30A
Amateur built
false
Engines
1 Reciprocating
Registration number
N74TR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
74-30713
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-25T19:10:06Z guid: 193284 uri: 193284 title: CEN23LA400 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193016/pdf description:
Unique identifier
193016
NTSB case number
CEN23LA400
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-03T16:45:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-09-14T19:29:42.667Z
Event type
Accident
Location
Eden Prairie, Minnesota
Airport
Flying Cloud (KFCM)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while landing, he took out the crosswind correction too soon, and the airplane veered to the left. The right wing dipped and struck the runway. The airplane became momentarily airborne again and when it settled back to the runway, the propeller struck the ground. The airplane exited the runway and came to rest in the grass. The right wing was substantially damaged. The pilot landed on runway 28R with wind 230°at 8 kts. The pilot reported that there were no mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during a landing with a left crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N5254D
Operator
Inflight Pilot Training
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17272473
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-14T19:29:42Z guid: 193016 uri: 193016 title: WPR23LA335 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193012/pdf description:
Unique identifier
193012
NTSB case number
WPR23LA335
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-04T10:30:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-09-07T19:15:03.65Z
Event type
Accident
Location
Marble Canyon, Arizona
Airport
MARBLE CANYON (L41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while departing, the airplane climbed to an altitude of 20 feet above the ground. The airspeed began decreasing, and the airplane started descending. The pilot pitched down as the stall warning sounded. The airplane impacted the terrain, collapsing the nose wheel and substantially damaging the left wing. The pilot stated the airplane had encountered windshear and that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of airplane control after an encounter with windshear during takeoff which resulted in collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150M
Amateur built
false
Engines
1 Reciprocating
Registration number
N9328U
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15078277
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-07T19:15:03Z guid: 193012 uri: 193012 title: ERA23LA364 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193025/pdf description:
Unique identifier
193025
NTSB case number
ERA23LA364
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-06T23:00:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-03T00:22:08.069Z
Event type
Accident
Location
Norwood, Massachusetts
Airport
Norwood Memorial Airport (OWD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot and passenger proceeded on the cross-country nigh flight and on arrival near the destination airport the pilot stated that he was instructed by air traffic control to descend through class B airspace on a straight-in approach to the runway, which required him to descend at a rate of about 1,000 ft-per-minute. While flying the straight-in approach he indicated that he was, “a little behind on the aircraft as we descended.” With the lights and the runway in sight he descended too quickly on final approach and impacted airport approach lighting then the ground short of the runway, resulting in substantial damage to the right wing. The pilot stated that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to fly an appropriate glide path during the landing approach, which resulted in a collision with approach lights and the ground short of the intended runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA24
Amateur built
false
Engines
1 Reciprocating
Registration number
N400RW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
26-63
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-03T00:22:08Z guid: 193025 uri: 193025 title: DCA23LA445 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193031/pdf description:
Unique identifier
193031
NTSB case number
DCA23LA445
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-07T02:32:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-09-11T20:44:38.047Z
Event type
Accident
Location
Hebron, Kentucky
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
United Airlines flight 1759 encountered moderate turbulence while descending through 11,000 ft for landing at Cincinnati/Northern Kentucky International Airport (CVG) Hebron, Kentucky, and a flight attendant (FA) fractured her pelvis. The flight crew reported that while descending on the SARGO-3 arrival into CVG they observed a single cloud with no apparent vertical development at about 11,000 ft. With no indication of an adverse ride from air traffic control (ATC), their onboard weather applications or their weather radar, the pilots elected to continue. Upon entering the cloud, the flight encountered about 2 seconds of moderate turbulence. Following the turbulence encounter the flight crew received a call from the cabin advising them that a FA had been injured. The aft FA assigned to jumpseat 2L reported that she was completing her duties in the aft galley and was seated in her jumpseat but had not fastened her safety harness, when suddenly and without warning, they encountered severe turbulence. She was thrown into the air, struck the ceiling and impacted the floor on her side fracturing her pelvis. Upon being notified of the injury, the flight crew declared a medical emergency and requested paramedics meet the aircraft at the gate. The injured FA was transported to the hospital where she was diagnosed with a fractured pelvis. At the time of the turbulence encounter there were no active significant meteorological information (SIGMETs), convective SIGMETs, airman’s meteorological information (AIRMETs), or pilot reports (PIREPs) of any significant turbulence.
Probable cause
An inadvertent encounter with convectively induced turbulence (CIT) during descent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737-9
Amateur built
false
Engines
2 Turbo fan
Registration number
N37531
Operator
UNITED AIRLINES INC
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
66119
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-09-11T20:44:38Z guid: 193031 uri: 193031 title: WPR23LA355 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193151/pdf description:
Unique identifier
193151
NTSB case number
WPR23LA355
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-07T10:47:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-10-02T21:02:40.629Z
Event type
Accident
Location
Woodland, California
Airport
WATTS-WOODLAND (O41)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel equipped airplane reported that shortly after touchdown, during the landing roll, the airplane veered left, exited the runway, and ground looped. Subsequently, the right wing impacted the ground and sustained substantial damage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AMERICAN CHAMPION AIRCRAFT
Model
7GCBC
Amateur built
false
Engines
1 Reciprocating
Registration number
N234RA
Operator
TOM EATON CONSULTING LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
13512003
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-02T21:02:40Z guid: 193151 uri: 193151 title: CEN23LA404 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193027/pdf description:
Unique identifier
193027
NTSB case number
CEN23LA404
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-07T12:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-13T00:29:32.134Z
Event type
Accident
Location
Arcola, Texas
Airport
Houston Southwest (AXH)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During an evaluation flight with a company pilot, the instructor pilot reported that he failed to re-apply engine power prior to the completion of a practice autorotation with a power recovery. During the maneuver, the instructor’s attention was diverted from reapplying engine power by an airplane holding short of the runway near their planned touchdown point. The helicopter subsequently landed hard on the runway, which resulted in substantial damage to the tail boom. The instructor reported that there were no preaccident mechanical malfunctions of failures with the helicopter that would have precluded normal operation.
Probable cause
The instructor’s failure to re-apply engine power during a power recovery after a practice autorotation which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
MCDONNELL DOUGLAS HELICOPTER
Model
369E
Amateur built
false
Engines
1 Turbo shaft
Registration number
N8372F
Operator
CITY OF HOUSTON POLICE DEPARTMENT
Second pilot present
true
Flight conducted under
Public aircraft
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
0488E
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-13T00:29:32Z guid: 193027 uri: 193027 title: CEN23LA408 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193044/pdf description:
Unique identifier
193044
NTSB case number
CEN23LA408
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-07T15:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-12T23:16:38.644Z
Event type
Accident
Location
Berryville, Arkansas
Airport
CARROLL COUNTY (4M1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he performed a landing using 30° flap setting for practice and the airplane bounced. He decided to perform a go-around because he wanted to perform a better landing. He applied full engine power and the airplane pitched up and entered a left bank that the pilot was not able to correct. The airplane continued in the left bank until striking trees on the left side of the runway. The airplane received substantial damage to the fuselage, right wing and empennage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain aircraft control during the attempted go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FLIGHT DESIGN GMBH
Model
CTSW
Amateur built
false
Engines
1 Reciprocating
Registration number
N603CT
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
5645005
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-12T23:16:38Z guid: 193044 uri: 193044 title: CEN23LA406 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193042/pdf description:
Unique identifier
193042
NTSB case number
CEN23LA406
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-08T18:41:00Z
Publication date
2023-10-17T04:00:00Z
Report type
Final
Last updated
2023-09-15T00:29:45.133Z
Event type
Accident
Location
Elk Grove Village, Illinois
Airport
CHICAGO O'HARE INTL (ORD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot reported that he had completed a charter flight and departed to pick up new passengers at an airport about 200 nautical miles away. While on approach to the destination airport, the previous passengers notified the pilot that they were ready to be picked up, so the pilot did not land and turned the airplane back toward the departure airport. The pilot climbed to 10,000 ft and noticed the airplane’s fuel burn was high, so he climbed to 16,000 ft. The pilot reported that “everything was routine until about a 3-mile final” to the runway, when the controller asked the pilot to slow to a final approach speed. An airplane was still on the runway, so the controller told the pilot to go around. The pilot told controllers twice that he had minimum fuel available. The pilot continued on a visual approach for the same runway when the right engine lost power followed by the left engine. He feathered both propellers and made a forced landing to a wooded area. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot later stated that he was “trying to do too much with too little” fuel and the accident was a result of poor fuel management. Although the controller directed the pilot to go around, the pilot should have recognized the criticality of the minimum fuel situation and landed the airplane.
Probable cause
The pilot’s improper fuel planning, that resulted in a total loss of engine power due to fuel exhaustion, and a subsequent forced landing. Also causal was the pilot’s decision to go around with minimum fuel.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B200
Amateur built
false
Engines
2 Turbo prop
Registration number
N220KW
Operator
Onyx Flight, Inc
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
BB-1120
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-15T00:29:45Z guid: 193042 uri: 193042 title: CEN23LA415 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193115/pdf description:
Unique identifier
193115
NTSB case number
CEN23LA415
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-10T19:50:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-10-03T01:06:15.476Z
Event type
Accident
Location
Moberly, Missouri
Airport
Omar N Bradley Airport (MBY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor stated that prior to beginning the instructional flight, he visually confirmed there was fuel in each fuel tank. He did not use a fuel dip stick when he checked the fuel level and approximated the fuel level as 17 gallons. He said the flight would have required 8 gallons of fuel. About 10 miles from the destination airport, with the fuel selector positioned to the right main fuel tank, the engine began to run rough. He then selected the right auxiliary fuel tank, and the engine began to run smoothly again. About 4 miles from the destination airport and during the approach for landing, the engine began to run rough again. He then selected the left auxiliary fuel tank, but engine power was not restored. With the engine at idle power, he tried to restore engine power by cycling through the remaining fuel tanks but was unsuccessful. He then performed a forced landing to a field, during which the engine ceased to operate. The airplane sustained substantial damage to the fuselage. Postaccident examination of the airplane revealed no leaks with the fuel system and no useable fuel was found in the left and right main fuel tanks. The flight instructor stated that after the accident, he checked the left auxiliary/tip tank and there was 7 gallon of fuel present. The examination revealed no failures or malfunctions with the airframe and engine that would have precluded normal airplane operation.
Probable cause
The flight instructor’s inadequate fuel management that resulted in fuel starvation and a total loss of engine power during an approach for landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-32-300
Amateur built
false
Engines
1 Reciprocating
Registration number
N4219T
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
32-7240037
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-03T01:06:15Z guid: 193115 uri: 193115 title: ERA23LA374 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193083/pdf description:
Unique identifier
193083
NTSB case number
ERA23LA374
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-14T15:05:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-19T00:21:36.331Z
Event type
Accident
Location
Cortland, New York
Airport
CORTLAND COUNTY-CHASE FLD (N03)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The multi-segment cross-country flight was the pilot’s first time flying the tailwheel-equipped airplane. Arriving at the destination airport, the pilot noted quartering gusts when he cleared a tree line to land on the asphalt runway. Following touchdown, the airplane pulled to the right and he applied left brake to correct; however, the airplane nosed over. The airplane sustained substantial damage to the wings, empennage, and fuselage. Postaccident examination of the brakes revealed no evidence of any preaccident mechanical failures or malfunctions that would have precluded normal operation. The recorded wind at the nearest weather reporting facility, about 13 miles southwest of the accident airport, was a quartering right crosswind at 12 knots, gusting to 19 knots at the time of the accident.
Probable cause
The pilot's failure to maintain directional control while landing in a gusting crosswind, which resulted in a noseover. Contributing was the pilot’s lack of familiarity with the airplane.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
305
Amateur built
false
Engines
1 Reciprocating
Registration number
N5269G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21471
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-19T00:21:36Z guid: 193083 uri: 193083 title: ERA23LA371 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193065/pdf description:
Unique identifier
193065
NTSB case number
ERA23LA371
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-14T16:10:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-11-13T04:38:10.06Z
Event type
Accident
Location
Cross Keys, New Jersey
Airport
CROSS KEYS (17N)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the banner tow airplane performed a normal takeoff and stayed in the airport traffic pattern for the banner pickup. The pilot described that after successfully capturing the pickup rope, he climbed with the engine at full power, the flaps retracted, and at a speed of about 45 to 50 mph. The airplane drifted left before the banner left the ground, and the pilot attempted to correct the flight path to the right. The airplane and banner subsequently climbed above the nearby trees, after which the pilot released the banner. The airplane then abruptly pitched up, the right wing “dropped,” and the airplane entered a 180-degree spin to the right that continued to ground impact. The pilot was seriously injured and the airplane was substantially damaged during the impact with trees and terrain. The operator reported, and a post accident examination by a Federal Aviation Administration inspector confirmed, that there were no preimpact mechanical malfunctions or failures of the airplane and its flight controls that would have precluded normal operation. The operator also reported that it was their company’s standard procedure to climb the airplane at a speed of 55 mph with the flaps extended 10 degrees in order to achieve best climb out. Additionally, when releasing a banner, the prescribed procedure included pushing forward on the control yoke to prevent an abrupt pitch up. Based on this information, it is likely that the pilot climbed at too low an airspeed during the banner pickup, resulting in a loss of control, his decision to release the banner, and the uncorrected pitch up of the airplane that ultimately resulted in the aerodynamic stall/spin.
Probable cause
The pilot’s failure to maintain adequate airspeed during the banner pickup, which resulted in a low altitude aerodynamic stall/spin.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150G
Amateur built
false
Engines
1 Reciprocating
Registration number
N2880S
Operator
HIGH EXPOSURE INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Banner tow
Commercial sightseeing flight
false
Serial number
15066780
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-13T04:38:10Z guid: 193065 uri: 193065 title: ERA23LA375 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193093/pdf description:
Unique identifier
193093
NTSB case number
ERA23LA375
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-18T09:15:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-19T22:06:35.35Z
Event type
Accident
Location
Winston-Salem, North Carolina
Airport
SMITH REYNOLDS (INT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot reported that during the second solo landing of the day she experienced a slight balloon, and once the airplane settled on the runway it was in a “partial crab to the right.” Upon touching down, she over corrected to the left and the airplane departed the runway surface into the grass. While in the grass the airplane struck a runway sign, which resulted in substantial damage to the left wing and the left horizontal stabilizer. The solo student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s loss of directional control upon landing which resulted in substantial damage to the left wing and left horizontal stabilizer.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N1451U
Operator
PIEDMONT FLIGHT INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17267118
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-19T22:06:35Z guid: 193093 uri: 193093 title: ERA23LA381 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193158/pdf description:
Unique identifier
193158
NTSB case number
ERA23LA381
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-19T13:15:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-28T23:24:48.549Z
Event type
Accident
Location
Erwinna, Pennsylvania
Airport
VANSANT (9N1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was attempting to take off in a right crosswind and had the right aileron fully deflected during the takeoff roll. As the tail-wheel equipped airplane became airborne, a wind gust pushed the airplane to the left side of the runway toward a tree line. The pilot attempted to turn the airplane back into the wind, but the lower left wing contacted a tree limb. The airplane descended into trees resulting in substantial damage to the rudder and both lower wings. The pilot reported there were no mechanical failures or malfunctions of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the airplane while taking off in a crosswind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
B75
Amateur built
false
Engines
1 Reciprocating
Registration number
N46Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
75-1377
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-28T23:24:48Z guid: 193158 uri: 193158 title: CEN23LA416 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193121/pdf description:
Unique identifier
193121
NTSB case number
CEN23LA416
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-21T09:55:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-09-27T20:48:39.26Z
Event type
Accident
Location
Montrose, Colorado
Airport
MONTROSE RGNL (MTJ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that, during the third stop-and-go landing, the airplane touched down and veered to the left. The pilot attempted to correct with opposite rudder; however, the pilot encountered an unexpected wind gust, and the airplane weather vaned to the right. The airplane ground looped to the right, partially collapsing the left main landing gear, and came to rest upright. The airplane sustained substantial damage to the forward fuselage structure. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. At the time of the accident, the pilot was landing on runway 17 with wind from 200° at 12 knots and gusting to 21 knots.
Probable cause
The pilot’s failure to maintain directional control during the landing roll with a gusting quartering headwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150L
Amateur built
false
Engines
1 Reciprocating
Registration number
N5460Q
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15073360
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-27T20:48:39Z guid: 193121 uri: 193121 title: WPR23LA353 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193142/pdf description:
Unique identifier
193142
NTSB case number
WPR23LA353
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-21T14:00:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-09-27T20:41:30.154Z
Event type
Accident
Location
Monument Valley, Utah
Airport
Monument Valley AIrport (UT25)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that he made an uneventful flight to the destination airport and configured the tailwheel-equipped airplane for landing. During the approach he noted that there was no unusual gust or crosswind, and he touched down on the main wheels just after the runway’s identification numbers. On the landing roll, the pilot reduced the power to idle, and the tailwheel settled on the runway. The airplane encountered a sudden wind gust, raising the right wing. Despite the pilot’s attempts to maintain directional control, the airplane ground-looped to the right and departed the runway surface. The airplane continued into a ditch and the left gear collapsed, resulting in the left wing contacting the ground. The pilot reported that there were no pre impact mechanical failures or malfunctions with the airframe or engine.
Probable cause
The pilot’s failure to maintain directional control after encountering a wind gust on the landing roll, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180K
Amateur built
false
Engines
1 Reciprocating
Registration number
N63130
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18052831
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-27T20:41:30Z guid: 193142 uri: 193142 title: ERA23LA377 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193120/pdf description:
Unique identifier
193120
NTSB case number
ERA23LA377
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-21T18:50:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-10-13T21:23:11.912Z
Event type
Accident
Location
Bucyrus, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The balloon pilot reported that after a local sightseeing flight, she maneuvered and descended toward the landing zone that was an open field that had power lines nearby. After clearing the power lines, the pilot further descended and just prior to impact she “added a small amount of heat,” however, the basket bounced twice and tipped over onto its side. The pilot then completely deflated the balloon to prevent the basket from getting dragged on the ground. During the bounced landing and basket tip over, one of the passengers fell to the bottom of the basket, which resulted in a serious injury to her right leg. The pilot reported that there were no preimpact mechanical malfunctions or failures with the balloon that would have precluded normal operation.
Probable cause
The balloon pilot’s bounced landing, which resulted in the basket tipping over and a serious injury to a passenger.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
AVIAN BALLOON
Model
SKYHAWK
Amateur built
false
Engines
1 Unknown
Registration number
N2067Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
207
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-10-13T21:23:11Z guid: 193120 uri: 193120 title: CEN23LA421 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193143/pdf description:
Unique identifier
193143
NTSB case number
CEN23LA421
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-22T07:30:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-09-26T23:57:09.564Z
Event type
Accident
Location
Midland, Texas
Airport
Midland Airpark (MDD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot reported, that during the landing flare, the airplane floated down the runway. He attempted to settle the airplane softly onto the runway, but the airplane bounced twice and came to rest in the dirt on the side of the runway. A post-accident examination revealed that the nose landing gear folded forward, which resulted in substantial damage to the tunnel structure. The student pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operations.
Probable cause
The student pilot’s improper landing flare, which resulted in a hard, bounced landing, and the nose landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N391SP
Operator
FLORIS FLIGHT SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
172S8286
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-26T23:57:09Z guid: 193143 uri: 193143 title: WPR23LA356 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193152/pdf description:
Unique identifier
193152
NTSB case number
WPR23LA356
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-22T16:00:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-09-27T23:13:45.095Z
Event type
Accident
Location
Eatonville, Washington
Airport
Swanson Airport (2W3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while taking off in a tailwheel-equipped airplane, he experienced a wind gust that lifted the left wing upwards and caused the right wing to contact the runway. Subsequently, he lost directional control of the airplane, resulting in a ground loop and impact with a berm. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain directional control during the takeoff roll, in gusty wind conditions, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N7955H
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-858
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-27T23:13:45Z guid: 193152 uri: 193152 title: CEN23LA422 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193147/pdf description:
Unique identifier
193147
NTSB case number
CEN23LA422
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-26T14:09:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-28T20:04:37.803Z
Event type
Accident
Location
Welsh, Louisiana
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was making a simulated landing approach to determine clearance requirements for a runway he was planning to put on his property. He said that during the approach, there was a slight tailwind, and he flew about 6 to 7 ft. above the ground during the approach. There was a fence that crossed the approach path. The pilot surmised that as he approached the fence and added power the airplane settled and the tail skid caught the top wire of the electric fence, which altered the airplane’s trajectory. The airplane struck a building on the property and then the ground. The airplane sustained substantial damage to the left wing and fuselage. The pilot reported that the airplane had no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain sufficient altitude from obstacles during the simulated landing approach which led to a collision with a fence and a building.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
QUICKSILVER
Model
SPORT II
Amateur built
true
Engines
1 Reciprocating
Registration number
N728NN
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
548
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-28T20:04:37Z guid: 193147 uri: 193147 title: ERA23LA379 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193148/pdf description:
Unique identifier
193148
NTSB case number
ERA23LA379
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-26T15:51:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-09-28T14:59:46.439Z
Event type
Accident
Location
Sanford, Florida
Airport
ORLANDO SANFORD INTL (SFB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot performed a preflight inspection before he initiated the startup and taxi without any anomalies noted. During the initial climb after takeoff, about 100 ft above ground level over the runway, an engine compartment access cover opened. The pilot called the air traffic control tower and was cleared to land on a parallel runway. The pilot continued in the traffic pattern, but slowed the airplane in hopes that the access cover would not detach. The pilot became focused on the open cover and let the airspeed decrease, which resulted in a buffet, the left wing dropping, and the airplane “[falling] out of the sky.” The airplane subsequently impacted a taxiway and came to rest on the parallel runway, resulting in substantial damage to the fuselage and left wing. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation. He also stated that he, “…focused way too much on the open engine cover and way too little on flying the airplane… The result was classic stall/spin scenario too close to the ground.”
Probable cause
The pilot’s failure to maintain airplane control after an engine access cover opened during the initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DORR DAN W
Model
SEQUOIA F.8L FALCO
Amateur built
true
Engines
1 Reciprocating
Registration number
N708WC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
1046
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-28T14:59:46Z guid: 193148 uri: 193148 title: WPR23LA357 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193154/pdf description:
Unique identifier
193154
NTSB case number
WPR23LA357
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-27T11:15:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-09-28T23:35:34.551Z
Event type
Accident
Location
Redding, California
Airport
REDDING MUNI (RDD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot of the airplane reported that shortly after rotation, the airplane began to drift to the left of runway centerline. He tried/attempted to correct back to runway centerline, but the airplane continued to drift left. The airplane descended and landed hard. It bounced back into the air and impacted the windsock. The airplane came to rest upright inside the windsocks segmented circle. The airplane sustained substantial damage to the right wing, aft fuselage, right horizontal stabilizer, and right elevator. The student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s loss of airplane control during takeoff, which resulted in a bounced landing and impact with the airport’s windsock.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172R
Amateur built
false
Engines
1 Reciprocating
Registration number
N17274
Operator
IASCO FLIGHT TRAINING INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17280353
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-28T23:35:34Z guid: 193154 uri: 193154 title: WPR23LA358 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193157/pdf description:
Unique identifier
193157
NTSB case number
WPR23LA358
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-27T14:10:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-10-12T22:13:27.267Z
Event type
Accident
Location
Salt Lake City, Utah
Airport
SALT LAKE CITY INTL (SLC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The solo student pilot reported that during a landing attempt he experienced a right crosswind and used rudder and aileron control inputs to remain on the runway centerline. During the roundout the airplane bounced and began to veer left of the runway centerline. He applied brakes and attempted to return the airplane to the center of the runway, but the airplane departed the left runway edge and impacted a taxiway sign. The airplane sustained substantial damage to the left wing. The student pilot reported no preimpact mechanical malfunctions or anomalies that could have precluded normal operation.
Probable cause
The student pilot’s failure to maintain directional control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N190BM
Operator
Elevate Aviation
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
9381
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-12T22:13:27Z guid: 193157 uri: 193157 title: WPR23LA359 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193159/pdf description:
Unique identifier
193159
NTSB case number
WPR23LA359
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-27T15:30:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-09-29T02:32:36.594Z
Event type
Accident
Location
San Diego, California
Airport
GILLESPIE FLD (SEE)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that upon arrival at the destination airport the reported wind conditions were variable wind at 10 knots gusting to 12 knots. The pilot reported that he performed a 3-point landing; on touch down, he was not able to maintain center line due to gusty southern crosswinds and the airplane ground looped. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing in gusty wind conditions that resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108-1
Amateur built
false
Engines
1 Reciprocating
Registration number
N9128K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
108-2128
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-09-29T02:32:36Z guid: 193159 uri: 193159 title: CEN23LA426 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193178/pdf description:
Unique identifier
193178
NTSB case number
CEN23LA426
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-28T06:31:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-10-03T00:54:35.493Z
Event type
Accident
Location
Boerne, Texas
Airport
Boerne Stage Airfield (5C1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that during the landing roll his feet become entangled in the rudder pedals and he inadvertently applied brake pressure. The airplane veered left and the pilot unsuccessfully attempted to regain directional control with opposite rudder and increased engine power. Airport surveillance cameras recorded the airplane depart the runway surface, bounce, and impact a hangar, which resulted in substantial damage to both wings and the fuselage. The pilot did not return the National Transportation Safety Board 6120.1/2 form.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
LUSCOMBE
Model
8A
Amateur built
false
Engines
1 Reciprocating
Registration number
N71804
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3231
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-03T00:54:35Z guid: 193178 uri: 193178 title: ERA23LA387 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193172/pdf description:
Unique identifier
193172
NTSB case number
ERA23LA387
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-29T08:10:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-10-02T21:09:25.878Z
Event type
Accident
Location
Liberty, South Carolina
Airport
PICKENS COUNTY (LQK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
After completing a successful landing, the pilot of the tailwheel-equipped airplane applied engine power to begin the takeoff. During the takeoff roll, the airplane began to veer right. The pilot applied left rudder to correct; however, the airplane veered left and exited the left side of the runway. The airplane impacted the precision approach path indicators light system resulting in substantial damage to the left wing and left horizontal stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the takeoff roll which resulted in a runway excursion and substantial damage to the left wing and left horizontal stabilizer.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
JOHN W MOLL
Model
Vans RV-7
Amateur built
true
Engines
1 Reciprocating
Registration number
N557JM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
70912
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-02T21:09:25Z guid: 193172 uri: 193172 title: ERA23LA386 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193170/pdf description:
Unique identifier
193170
NTSB case number
ERA23LA386
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-30T12:00:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-10-02T20:21:33.805Z
Event type
Accident
Location
Greensboro, Georgia
Airport
Greene County Regional airport (CPP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Shortly after landing, while taxing to the ramp to park, the solo student pilot was going to turn the airplane 180° to orient it with the parking spot. During the turn, the airplane’s left wing impacted a light pole resulting in substantial damage to wing spar. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain clearance from a light pole during taxi.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N9522L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17276570
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-02T20:21:33Z guid: 193170 uri: 193170 title: ERA23LA385 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193169/pdf description:
Unique identifier
193169
NTSB case number
ERA23LA385
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-09-30T16:05:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-11-03T01:19:29.383Z
Event type
Accident
Location
Port Clinton, Ohio
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
After takeoff the airline transport pilot and pilot-rated passenger of the amphibious airplane performed landings at an airport and on a river, performed airwork, then proceeded west, where when near a river, both looked for wires and poles but neither saw any. The pilot landed uneventfully on the river and while on the step he initiated takeoff. Although the pilot was looking and did not see any wires or poles associated with wires that spanned the river, the pilot-rated passenger spotted unmarked powerlines spanning the river immediately before impact with them during the initial climb and called them out to the pilot. The airplane collided with the wire(s), and the airplane pitched down and impacted the river resulting in substantial damage to the right wing, right wing lift strut, and aft empennage. The pilot stated there were no preimpact failures or malfunctions of the airplane that would have precluded normal operation of the airplane.
Probable cause
The pilot’s failure to detect and avoid unmarked powerline(s) while attempting to take off from a river.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
T206
Amateur built
false
Engines
1 Reciprocating
Registration number
N34PL
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
T20608403
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-03T01:19:29Z guid: 193169 uri: 193169 title: CEN24LA001 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193173/pdf description:
Unique identifier
193173
NTSB case number
CEN24LA001
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-01T14:30:00Z
Publication date
2023-11-09T05:00:00Z
Report type
Final
Last updated
2023-10-02T21:52:22.113Z
Event type
Accident
Location
Waupaca, Wisconsin
Airport
WAUPACA MUNI (PCZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
The pilot reported that during the landing, the airplane bounced twice, and he initiated a go-around. During the go-around, the airplane departed the runway to the left, and impacted a grass hill near the runway. The airplane came to rest upright and sustained substantial damage to the fuselage and both wings. The pilot informed local authorities there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the go-around, that resulted in a runway excursion and an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
23
Amateur built
false
Engines
1 Reciprocating
Registration number
N1963F
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-541
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-02T21:52:22Z guid: 193173 uri: 193173 title: ERA24LA002 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193186/pdf description:
Unique identifier
193186
NTSB case number
ERA24LA002
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-02T19:15:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-10-04T20:37:50.015Z
Event type
Accident
Location
Gallipolis, Ohio
Airport
GALLIA-MEIGS RGNL (GAS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot approached the runway for landing and described that the main landing gear first touched down first. The nose landing gear then contacted the runway and immediately collapsed. The student pilot applied the brakes and the airplane departed the left side of the runway onto the grass. The airplane struck a lighting system and came to rest about 35 ft from the runway, which resulted in substantial damage to the right wing. The student pilot reported “there were no visible signs of mechanical failure” on the nose landing gear prior to the accident flight, and a Federal Aviation Administration inspector who examined the nose landing gear after the accident did not observe any mechanical discrepancies.
Probable cause
A collapse of the nose landing gear during landing, which resulted in a runway excursion and collision with an approach lighting system.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N7461W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-1367
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-04T20:37:50Z guid: 193186 uri: 193186 title: ERA24LA013 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193275/pdf description:
Unique identifier
193275
NTSB case number
ERA24LA013
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-05T08:00:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-10-21T00:32:55.533Z
Event type
Accident
Location
Chesterfield, Virginia
Airport
RICHMOND EXEC-CHESTERFIELD COUNTY (FCI)
Weather conditions
Unknown
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a maintenance event, a mechanic was asked to evaluate damage to the airplane’s right wing. Further inspection of the right wing and its internal components revealed that the rear wing spar was cracked, and several wing skin rivets had sheared. The right wing strut and right main landing gear strut were also bent. The flight club that operated the airplane reported that 22 pilots had flown the airplane in the recent past and no pilot admitted to any significant event during landing. The substantial damage to the right wing was likely the result of a hard landing; however, due to the several flights flown with the damage, the investigation was not able to determine a specific flight during which the hard landing may have occurred.
Probable cause
A hard landing that resulted in substantial damage to the airplane’s right wing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
COSTRUZIONI AERONAUTICHE TECNA
Model
P2010
Amateur built
false
Engines
1 Reciprocating
Registration number
N143TU
Operator
WING NUTS FLYING CLUB LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Unknown
Commercial sightseeing flight
false
Serial number
043/US
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-21T00:32:55Z guid: 193275 uri: 193275 title: CEN24LA025 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193309/pdf description:
Unique identifier
193309
NTSB case number
CEN24LA025
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-06T16:30:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-10-27T18:04:00.054Z
Event type
Accident
Location
Riesel, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and student pilot were conducting a local instructional flight and saw several large birds in front of the airplane. They attempted to avoid the birds but were unable, and one bird collided with the left wing. The flight instructor assumed control of the airplane, which was difficult to control, and returned to the airport for an uneventful landing. The airplane sustained substantial damage to the left wing.
Probable cause
An in-flight collision with a bird.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172R
Amateur built
false
Engines
1 Reciprocating
Registration number
N2444H
Operator
Texas State Technical College
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17280874
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-27T18:04:00Z guid: 193309 uri: 193309 title: ERA24LA005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193224/pdf description:
Unique identifier
193224
NTSB case number
ERA24LA005
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-07T20:30:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2023-12-19T01:51:33.856Z
Event type
Accident
Location
Harrisonburg, Virginia
Airport
SHENANDOAH VALLEY RGNL (SHD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was returning to his home airport, and prior to landing, he received an automated weather briefing noting a 90-degree crosswind that was from 320 degrees at 12 knots, with gusts. The runway in use was runway 05, and a preceding aircraft reported a direct crosswind. The initial approach and landing were uneventful. When the airplane touched down and all three wheels were on the ground, an unexpected gust of wind lifted the left wing and started pushing the airplane towards the right. The airplane exited the runway into the grass. The wind then lifted the tail of the airplane and it nosed over onto the vertical stabilizer. The fuselage and empennage of the airplane were substantially damaged. The pilot reported that there were no mechanical malfunctions or failures with the airplane, that would have precluded normal operation.
Probable cause
The pilot’s inadequate compensation for the prevailing wind conditions, which resulted in a loss of control and subsequent runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT AIRCRAFT INC
Model
A-1C-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N13BF
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3021
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-19T01:51:33Z guid: 193224 uri: 193224 title: WPR24LA011 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193228/pdf description:
Unique identifier
193228
NTSB case number
WPR24LA011
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-08T08:15:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-10-17T02:18:08.917Z
Event type
Accident
Location
Albuquerque, New Mexico
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot of the balloon reported that during a landing, with wind about 8 knots, she used her smart vent system to land. The balloon landed hard, which resulted in one passenger breaking her ankle. The pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to control the balloon’s descent rate during a landing in windy conditions, which resulted in a passenger sustaining a broken ankle.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
CAMERON BALLOONS US
Model
A-105
Amateur built
false
Engines
1 None
Registration number
N105BM
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6538
Damage level
None
Events
Findings
creator: NTSB last-modified: 2023-10-17T02:18:08Z guid: 193228 uri: 193228 title: ERA24LA004 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193209/pdf description:
Unique identifier
193209
NTSB case number
ERA24LA004
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-08T16:45:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-10-18T22:05:38.017Z
Event type
Accident
Location
Georgetown, Kentucky
Airport
Georgetown-Scott County (27K)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane reported that he was returning to his home airport after a local flight and the reported wind was from 300° at 9 knots with gusts to 13 knots. He performed a low approach to runway 3 with a direct crosswind. He remained in the traffic pattern for another approach to runway 3. After an uneventful touchdown and initial rollout, with the throttle at idle, the airplane began to veer to the left. He countered with right rudder and was able to maintain his track throughout most of the landing roll. Near the end of the rollout, while still on the paved surface, the airplane veered left more abruptly, and the right wingtip touched the runway. The airplane then departed the runway to the left and nosed over into the grass. The pilot egressed the airplane without injury. An examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the upper wing, rudder, and vertical stabilizer. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane during the landing roll in gusting a gusting crosswind, resulting in a runway excursion and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MICHAEL J WRIGHT
Model
SA300
Amateur built
true
Engines
1 Reciprocating
Registration number
N27MW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M001W
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-10-18T22:05:38Z guid: 193209 uri: 193209 title: CEN24LA007 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193218/pdf description:
Unique identifier
193218
NTSB case number
CEN24LA007
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-09T11:14:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-10-10T23:42:41.455Z
Event type
Accident
Location
Peyton, Colorado
Airport
Meadow Lake Airport (FLY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that preceding the accident he had performed four uneventful touch and go landings for practice. During the fifth and final landing to a full stop, the airplane veered left of runway centerline. The pilot attempted to correct by applying rudder and brakes and reported that he “went too far” with braking application. The airplane nosed over, which resulted in substantial damage to the vertical stabilizer and rudder. A postaccident examination of the airplane revealed no mechanical anomalies with the flight controls or brakes. The Fairchild 24 is a vintage aircraft. The previous owner was given field approval for installation of a Cleveland wheel and brake kit #199-64, commonly used for higher weight Cessna 310 airplanes. The Cleveland brakes provided more braking power than the originally installed brakes, which likely contributed to the pilot’s excessive braking.
Probable cause
The pilot’s excessive brake application during landing rollout led to the airplane nosing over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
FAIRCHILD
Model
24 G
Amateur built
false
Engines
1 Reciprocating
Registration number
N19173
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
2958
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-10T23:42:41Z guid: 193218 uri: 193218 title: WPR24LA008 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193214/pdf description:
Unique identifier
193214
NTSB case number
WPR24LA008
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-09T11:55:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-10-11T00:00:17.961Z
Event type
Accident
Location
Caldwell, Idaho
Airport
Caldwell Executive (KEUL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the helicopter reported that he and his flight instructor were performing a full touchdown autorotation onto the taxiway. Shortly after the helicopter touched down, during its ground slide, it veered to the left and exited the taxiway. The helicopter then pivoted on its left skid toe, rolled over its right skid, and came to rest on its right side. The horizontal stabilizer was substantially damaged. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, resulting in a roll over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N838SH
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
3811
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-11T00:00:17Z guid: 193214 uri: 193214 title: WPR24LA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193256/pdf description:
Unique identifier
193256
NTSB case number
WPR24LA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-12T10:00:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-10-18T03:25:55.458Z
Event type
Accident
Location
Mesa, Arizona
Airport
PHOENIX-MESA GATEWAY (IWA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor of the tailwheel-equipped airplane reported that, while demonstrating a wheel landing during an instructional flight with a student in the rear seat, the nose swerved to the right upon lowering the tailwheel. The pilot corrected with left rudder input, but the airplane ground looped to the right, resulting in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s failure to maintain directional control during the landing roll, which resulted in a ground loop.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
A75N1(PT17)
Amateur built
false
Engines
1 Reciprocating
Registration number
N4777V
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
75-5733
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-18T03:25:55Z guid: 193256 uri: 193256 title: DCA24FM005 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193274/pdf description:
Unique identifier
193274
NTSB case number
DCA24FM005
Transportation mode
Marine
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-12T21:35:00Z
Publication date
2024-03-06T05:00:00Z
Report type
Final
Last updated
2024-02-29T05:00:00Z
Location
Fort Lauderdale, Florida
Injuries
null fatal, null serious, null minor
Probable cause
Close-out memo issued in lieu of probable cause.
Has safety recommendations
false

Vehicle 1

Vessel name
Self Made
Vessel type
Yacht
Port of registry
Fort Lauderdale
Flag state
USA
Findings
creator: NTSB last-modified: 2024-02-29T05:00:00Z guid: 193274 uri: 193274 title: CEN24LA016 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193265/pdf description:
Unique identifier
193265
NTSB case number
CEN24LA016
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-13T09:00:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-10-31T17:17:53.002Z
Event type
Accident
Location
Denton, Texas
Airport
Denton Enterprise Airport (KDTO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was landing on runway 18R on a solo flight and the airplane drifted to the left while between 100-200 ft above the runway. The student pilot initiated a go around. During the go around attempt, the main landing gear touched the ground; one wheel touched the runway surface, and the other wheel touched the grass adjacent to the runway. The right wing impacted the ground. The airplane departed the runway and came to rest upright. The airplane sustained substantial damage to the right wing. The student pilot reported there were no preaccident mechanical malfunctions or failures that would have precluded normal operation. The student pilot further reported that the surface wind had shifted to a tailwind during the flight and that the wind at the time of the accident, as observed at the windsock, was from 330°.
Probable cause
The student pilot’s failure to maintain directional control while landing with a tailwind.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N6605J
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
28-5066
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-31T17:17:53Z guid: 193265 uri: 193265 title: WPR24LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193293/pdf description:
Unique identifier
193293
NTSB case number
WPR24LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-14T08:10:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-03T00:53:50.999Z
Event type
Accident
Location
Albuquerque, New Mexico
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 0 minor
Analysis
The pilot stated that the flight was a balloon sightseeing flight that was departing from a large balloon festival. He received a weather briefing as part of the festival and there was no forecasted adverse conditions. Prior to departure, he briefed all 12 passengers on the proper landing position (knees slightly bent with both hands holding onto the rope). After a normal accent, the pilot flew for about 40 minutes and prepared to land. During the descent, he noted that the surface winds were faster than earlier in the flight. As they descended to about 75 ft above ground level (agl), the balloon encountered windshear and turbulent air. In response, the balloon descended faster than the pilot anticipated, and he was unable to arrest the descent. The balloon contacted a chain-link fence and touched down in a field. As a result of the landing, a passenger suffered a bone fracture (in the ankle area). The balloon did not sustain damage. The pilot stated that there were no pre-impact mechanical malfunctions or failures that would have precluded normal operation. The High-Resolution Rapid Refresh (HRRR) sounding over the landing site indicated a stable atmosphere with no thermals and a defined low-level temperature inversion to about 2,000 ft agl with light and variable winds to the surface.  No strong winds were indicated below 10,000 ft mean seal level (msl).
Probable cause
The pilot’s inability to maintain control of the balloon during landing due to unforecasted windshear and turbulent air.
Has safety recommendations
false

Vehicle 1

Aircraft category
Balloon
Make
CAMERON BALLOONS U S
Model
A-315
Amateur built
false
Registration number
N315RR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Business
Commercial sightseeing flight
true
Serial number
6979
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-03T00:53:50Z guid: 193293 uri: 193293 title: ERA24LA009 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193248/pdf description:
Unique identifier
193248
NTSB case number
ERA24LA009
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-14T11:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-10-18T18:34:45.774Z
Event type
Accident
Location
Myakka City, Florida
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot stated that he had erected barbed wire fences on both sides of his private airstrip to keep cows off the runway. During takeoff, he veered left and struck the fence. The airplane nosed over, resulting in substantial damage to the wings and empennage. The pilot reported that there were no preimpact mechanical malfunctions of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate clearance from a fence during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MONOCOUPE
Model
90AL-115
Amateur built
false
Engines
1 Reciprocating
Registration number
N87621
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
869
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-18T18:34:45Z guid: 193248 uri: 193248 title: CEN24LA015 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193262/pdf description:
Unique identifier
193262
NTSB case number
CEN24LA015
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-17T14:30:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-10-18T23:25:41.11Z
Event type
Accident
Location
Greeley, Colorado
Airport
GREELEY-WELD COUNTY (GXY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot and pilot-rated-passenger intended to complete a personal cross-country flight with variable wind about 6 knots at the departure airport. The pilot noted the windsock nearest the airplane indicated a tailwind, but the other windsocks farther down the runway indicated a headwind or crosswind. During takeoff, the airplane became airborne faster than expected and climbed well, so the pilot made an early right turn over airport hangars. The airplane’s upper wing slats fluttered which indicated to the pilot that the airspeed was low, then they “came out hard,” which indicated the airplane was near a stall. The pilot ensured the throttle was full forward and decreased pitch attitude to maintain airspeed but felt like the airplane “was being forced down.” Unable to maintain altitude, and with no suitable forced landing area, he maneuvered the airplane to collide with the side of a hangar and the ground, then it nosed over. The airplane sustained substantial damage to the wings, fuselage, and empennage. The pilot reported that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation. Airport surveillance video showed the airplane at low altitude and appeared to climb until it overflew airport hangars. The airplane maintained a climb pitch attitude as it descended into the hangars.
Probable cause
The pilot’s decision to turn out early during the initial climb and failure to maintain adequate airspeed/angle-of-attack, which resulted in an aerodynamic stall and impact with airport hangars. Contributing to the accident was the variable wind conditions above the hangars and the pilot’s lack of awareness of those conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DEHAVILLAND
Model
TIGER MOTH DH 82A
Amateur built
false
Engines
1 Reciprocating
Registration number
N41DH
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
84734
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-18T23:25:41Z guid: 193262 uri: 193262 title: CEN24LA017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193266/pdf description:
Unique identifier
193266
NTSB case number
CEN24LA017
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-17T14:50:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-11-02T01:45:45.628Z
Event type
Accident
Location
Mitchell, Indiana
Airport
Virgil I Grissom Municipal Airport (BFR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The air medical flight departed from a hospital and was enroute to the operator’s base of operation. About 30 minutes after departure, while in cruise flight, at an airspeed of about 109 kts and an altitude of about 1,058 ft above ground level, the helicopter encountered a bird strike with a black vulture (Coragyps atratus). A heavy vibration ensued, and the pilot performed an off-airport landing to a field. The helicopter sustained substantial damage, which was a bent pitch change link for the main rotor system, from the bird strike. There was no mechanical malfunction/failure of the helicopter that would have precluded normal operations.
Probable cause
The inflight collision with a bird while in cruise flight.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
BELL HELICOPTER TEXTRON CANADA
Model
206L-4
Amateur built
false
Engines
1 Turbo shaft
Registration number
N490AE
Operator
Air Evac MS Inc
Second pilot present
false
Flight conducted under
Part 135: Air taxi & commuter
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
52336
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-02T01:45:45Z guid: 193266 uri: 193266 title: DCA24LA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193541/pdf description:
Unique identifier
193541
NTSB case number
DCA24LA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-18T23:55:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2023-12-19T17:54:31.33Z
Event type
Incident
Location
Chicago, Illinois
Airport
CHICAGO O'HARE INTL (ORD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
United Airlines (UAL) flight 3885, a Boeing 787, impacted a hangar with its right-wing tip while taxiing to parking at Chicago O’Hare International Airport (KORD), Chicago, Illinois. The flight was a maintenance ferry flight conducted under Title 14 Code of Federal Regulations Part 91 from Newark Liberty International Airport (KEWR), Newark, New Jersey. According to the flight crew, after landing on runway 10C at ORD they were cleared to taxi to a UAL maintenance facility via taxiways P to Z. After receiving an air traffic control (ATC) clearance, they crossed runway 10L, continued via taxiway Z crossing both runways 9R and 9C before making a right turn onto taxiway D. Ground control cleared them to enter the ramp at taxiway YY1 and to contact UAL’s Maintenance Ramp frequency. UAL maintenance subsequently instructed them to make a left on YY, which was incorrect, and proceed to the north side of the ramp, where a truck with marshallers would be waiting to guide them to parking. After completing the left turn on YY, the flight crew realized they were about to enter an American Eagle ramp area instead of their intended destination of the UAL ramp area. Unfamiliar with the area they stopped the airplane and queried UAL maintenance as to where they should park. UAL maintenance asked the flight crew to proceed onto the American Eagle ramp and make a 180° turn. The captain noted no wingspan restrictions on the airport charts and no obstacles other than hangars in the area. He stated that there were no taxiway lights; however, there was adequate overhead lighting on the ramp. The captain then asked the first officer (FO) if they were clear to the right, to which the FO responded “yes”. Shortly thereafter, while proceeding onto the ramp and on the associated taxiway line they heard a loud bang and the airplane veered to the right. The FO looked out his window and stated, “we hit the hangar”. UAL Maintenance Ramp Area Figure 1 - Google Earth image with taxi route in red. The inset photo of accident site was provided by United Airlines. Green arrow indicates the location of United Airlines maintenance ramp area. The right-wing tip of the airplane struck a hanger resulting in minor damage to the wing. The damage to the hanger was estimated at about $236,000. A B787 has a wingspan of 197 feet 3 inches. The distance from the taxiway centerline to the hangar was about 98 ft accommodating a wingspan of about 196 ft. Had the marshallers met the airplane at American Eagle ramp and provided obstruction clearance guidance and/or the flight crew requested additional ground handling support before attempting to turn around in an unfamiliar area it is likely that the collision would not have occurred.
Probable cause
The flight crew’s misperception of the distance required to safely pass the hangar and failure to request additional ground handling support while taxiing, which resulted in a collision with a hangar. Contributing to the accident was United Airlines Maintenance Ramp personnel’s ambiguous taxi instructions and lack of obstruction clearance guidance.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
787
Amateur built
false
Engines
2 Turbo fan
Registration number
N30913
Operator
UNITED AIRLINES INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
35879
Damage level
Minor
Events
Findings
creator: NTSB last-modified: 2023-12-19T17:54:31Z guid: 193541 uri: 193541 title: WPR24LA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193298/pdf description:
Unique identifier
193298
NTSB case number
WPR24LA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-19T20:42:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-10-25T17:07:45.93Z
Event type
Accident
Location
The Dalles, Oregon
Airport
COLUMBIA GORGE RGNL/THE DALLES MUNI (DLS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that the airplane encountered “extreme” turbulence while on the approach to an intermediate stopover airport during a night cross-country flight. The pilot extended the downwind leg of the traffic pattern to stabilize the airplane, and during the base leg turn, the airplane struck a wire and subsequently impacted terrain. The airplane sustained substantial damage to both wings and fuselage. The airport is located at an elevation of 246 ft mean sea level (msl) in a major river gorge. The northern ridge line above the airport is about 2,900 ft msl, and the southern ridge line is about 1,300 ft msl. The accident location is located about 2 miles south of the airport at an estimated evaluation of about 650 ft msl. High tension powerlines are positioned south of the airport along the southern ridge. According to the United States Navy Observatory, the official sunset was at 17:12 Pacific daylight time (PDT), the official end of civil twilight was at 17:42 PDT and the official moon set was at 20:02 PDT. The night cross-county training flight was part of the pilot’s training curriculum for her commercial, airplane single engine land certificate. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s encounter with severe turbulence at night which resulted in an extended downwind and collision with wires during the base turn.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
152
Amateur built
false
Engines
1 Reciprocating
Registration number
N6308Q
Operator
HILLSBORO AERO ACADEMY LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
15285227
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-25T17:07:45Z guid: 193298 uri: 193298 title: ERA24LA020 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193302/pdf description:
Unique identifier
193302
NTSB case number
ERA24LA020
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-20T15:53:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-10-27T21:34:01.263Z
Event type
Accident
Location
Jackson, Tennessee
Airport
MC KELLAR-SIPES RGNL (MKL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that following a cross-country flight, on the first approach to land he performed a go-around due to gusting wind and an unstable approach. During the second approach to the same runway, the pilot reported that the approach was stable, however, near the runway threshold the airplane began sinking and impacted the runway with all three wheels at once. Subsequently, the airplane immediately veered to the left off the runway despite the pilot’s attempt to apply wheel brakes and maintain directional control. During the runway excursion, the nose landing gear collapsed which resulted in substantial damage to the engine mount and fuselage. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll in gusting wind conditions, which resulted in a runway excursion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-180
Amateur built
false
Engines
1 Reciprocating
Registration number
N9101J
Operator
OLD SCHOOL AIRCRAFT LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-3143
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-27T21:34:01Z guid: 193302 uri: 193302 title: ERA24LA017 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193287/pdf description:
Unique identifier
193287
NTSB case number
ERA24LA017
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-20T16:00:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-10-24T15:06:47.887Z
Event type
Accident
Location
Tellico Plains, Tennessee
Airport
PVT (PVT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane was attempting to land on his 1,200-ft-long private airstrip. When he flew by the windsock to check wind direction and speed, he noticed a significant crosswind was prevailing. After turning onto final approach, and after passing the point at which a go-around could be performed due to trees and terrain off the end of the runway, he noticed the wind had changed direction and was now a strong tailwind. He continued the approach and landed more than halfway down the runway, then aggressively applied the brakes to attempt to stop. The airplane subsequently nosed over and sustained substantial damage to the rudder and wings. The pilot reported that there were no preimpact mechanical malfunctions of the airplane that would have precluded normal operation.
Probable cause
The pilot's overapplication of brakes after landing long on a constrained runway and with a tailwind, which resulted in a nose-over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AVIAT
Model
A1
Amateur built
false
Engines
1 Reciprocating
Registration number
N958TW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3403
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-24T15:06:47Z guid: 193287 uri: 193287 title: ERA24LA021 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193303/pdf description:
Unique identifier
193303
NTSB case number
ERA24LA021
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-21T13:00:00Z
Publication date
2023-11-16T05:00:00Z
Report type
Final
Last updated
2023-10-30T16:35:03.795Z
Event type
Accident
Location
Orangeburg, South Carolina
Airport
ORANGEBURG MUNI (OGB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the student pilot were practicing crosswind takeoffs and landings. After completing two successful landings, the student pilot was taxiing back to the runway when the airplane drifted to the right and the right wing impacted a fuel truck parked next to the taxiway. The impact resulted in substantial damage to the right wing. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The student pilot’s failure to maintain adequate clearance from a fuel truck while taxiing. Also contributing was the flight instructor’s inadequate monitoring of the student pilot.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N7607T
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
47207
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-30T16:35:03Z guid: 193303 uri: 193303 title: CEN24LA022 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193294/pdf description:
Unique identifier
193294
NTSB case number
CEN24LA022
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-21T19:35:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2023-10-30T21:22:17.875Z
Event type
Accident
Location
Iola, Kansas
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he had 48 gallons of fuel on board and assumed that he would be able to fly for about 5 hours. After about 4 hours and 20 minutes of flying, the pilot began his descent for landing at his destination, turned the fuel pump on, and checked the fuel gauges. The gauges read about 3 or 4 gallons of fuel remaining in each fuel tank. Shortly thereafter, the engine quit. The pilot switched fuel tanks and the engine started again momentarily and then quit again. He landed the airplane on a gravel road about 1.5 miles northeast of the airport. After touchdown, the right wing struck a tree and separated from the fuselage resulting in substantial damage. The pilot reported that he believes the airplane ran out fuel, which resulted in the loss of engine power.
Probable cause
The pilot’s inadequate fuel planning, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-181
Amateur built
false
Engines
1 Reciprocating
Registration number
N5324F
Operator
Toby Baker
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
28-7790088
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-30T21:22:17Z guid: 193294 uri: 193294 title: CEN24LA023 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193305/pdf description:
Unique identifier
193305
NTSB case number
CEN24LA023
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-22T19:00:00Z
Publication date
2023-12-07T05:00:00Z
Report type
Final
Last updated
2023-10-26T17:16:22.807Z
Event type
Accident
Location
Mount Pleasant, Michigan
Airport
Mount Pleasant Municipal (MOP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while landing, a deer ran in front of the airplane from the left side. The pilot was unable to avoid the collision, and the deer struck the left wing, which resulted in substantial damage to the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The airplane’s collision with a deer on the runway during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-201T
Amateur built
false
Engines
1 Reciprocating
Registration number
N8088E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-7921045
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-26T17:16:22Z guid: 193305 uri: 193305 title: CEN24LA026 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193319/pdf description:
Unique identifier
193319
NTSB case number
CEN24LA026
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-24T16:15:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-10-30T22:15:32.862Z
Event type
Accident
Location
Savoy, Illinois
Airport
Willard Airport (CMI)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During a multi-engine instructional flight, the flight instructor simulated an engine failure at the final approach fix. The pilot receiving instruction focused on maintaining control of the airplane and neither the pilot nor the flight instructor verified that the landing gear was extended. During the landing, they realized that the landing gear was still retracted. The airplane sustained substantial damage to the lower fuselage. A postaccident examination of the landing gear system by a mechanic revealed no mechanical anomalies that would have precluded normal operation. The instructor stated that there was nothing mechanically wrong with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to extend the landing gear before landing and the flight instructor’s inadequate supervision to ensure that the landing gear was extended.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-44-180
Amateur built
false
Engines
2 Reciprocating
Registration number
N5331N
Operator
University of Illinois
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
4496106
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-30T22:15:32Z guid: 193319 uri: 193319 title: ERA24LA019 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193301/pdf description:
Unique identifier
193301
NTSB case number
ERA24LA019
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-25T09:57:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-10-26T14:54:10.24Z
Event type
Accident
Location
Atlanta, Georgia
Airport
Newnan Coweta County Airport (CCO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the student pilot were landing the tailwheel-equipped airplane at the destination airport. The flight instructor described that the student’s wheel landing was at the proper speed and aligned with the runway, but with a slight left drift. The student applied right rudder along with (inadvertent) right brake pressure. The flight instructor announced “I have the aircraft” but felt significant resistance on the flight controls. He repeated the call as the airplane approached the right side of the runway. As the airplane progressed toward the grass off the side of the runway, the flight instructor again verbalized that he was trying to take control of the airplane as the student pilot applied both brakes. The airplane then abruptly stopped and nosed over. The airplane’s vertical stabilizer was substantially damaged during the accident. The flight instructor reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s inadequate remedial action and the student pilot’s failure to relinquish the flight controls as directed by the flight instructor, resulting in a loss of control and nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N7981E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17781
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-26T14:54:10Z guid: 193301 uri: 193301 title: WPR24LA025 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193324/pdf description:
Unique identifier
193324
NTSB case number
WPR24LA025
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-26T15:02:00Z
Publication date
2023-12-21T05:00:00Z
Report type
Final
Last updated
2023-10-31T00:17:14.255Z
Event type
Accident
Location
Reno, Nevada
Airport
Reno/Stead (RTS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 1 serious, 1 minor
Analysis
The check pilot of the multi engine airplane reported that he was conducting a familiarization flight with a pilot that his company was in the process of hiring (pilot applicant.) On final approach, at approximately 100 ft above ground level, the pilot applicant made a pitch adjustment and the airplane’s nose pitched down excessively. Both pilots pulled back on the yokes to arrest the descent, but the airplane impacted terrain short of the runway, which resulted in substantial damage to the right wing and fuselage. The check pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot applicant’s excessive nose down pitch, and the check pilot’s delayed remedial action, which resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GULFSTREAM AEROSPACE
Model
Commander 690C
Amateur built
false
Engines
2 Turbo prop
Registration number
N840KB
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
11640
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-10-31T00:17:14Z guid: 193324 uri: 193324 title: ERA24LA028 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193332/pdf description:
Unique identifier
193332
NTSB case number
ERA24LA028
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-28T09:46:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-07T00:13:44.346Z
Event type
Accident
Location
Ronkonkoma, New York
Airport
Long Island Mac Arthur Airport (ISP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor was teaching the student pilot to hover the helicopter about 5 ft above a grass area. The student pilot was having difficulty with over-controlling the helicopter and had been applying abrupt control inputs. The flight instructor was demonstrating the behavior of the helicopter with the application of collective control when the student pilot raised the collective control too hard, which resulted in the helicopter tilting right. The flight instructor attempted to correct, but the student pilot was holding the controls tightly and the helicopter’s right skid contacted the ground, resulting in a dynamic rollover. The flight instructor reported that there were no preimpact mechanical malfunctions or failures of the helicopter that would have precluded normal operation.
Probable cause
The student pilot’s abrupt control input and the flight instructor’s inadequate remedial action, which resulted in a dynamic rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R22 BETA
Amateur built
false
Engines
1 Reciprocating
Registration number
N964SH
Operator
Flying Helicopters Made Easy
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
3941
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-07T00:13:44Z guid: 193332 uri: 193332 title: ERA24LA027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193331/pdf description:
Unique identifier
193331
NTSB case number
ERA24LA027
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-28T11:50:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-01T00:10:32.539Z
Event type
Accident
Location
Asheville, Alabama
Airport
DUGGER'S FLD (AL60)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was attempting to land on a constrained turf runway. A witness described that the airplane approached the runway too fast, landed long, and bounced several times. The pilot subsequently aborted the landing with limited runway remaining. The witness described that the airplane “staggered into the air” at a high pitch angle with the wings rocking left and right. The pilot described that the airplane’s nose “dropped” before it impacted the ground. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation. Based on this information, it is likely that the pilot exceeded the airplane’s critical angle of attack during the aborted landing and subsequent initial climb, which resulted in an aerodynamic stall and impact with terrain.
Probable cause
The pilot’s failure to maintain control of the airplane during initial climb after an aborted landing, which resulted in an aerodynamic stall and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MUSTANG
Model
II
Amateur built
true
Engines
1 Reciprocating
Registration number
N71CB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
CB-1
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-01T00:10:32Z guid: 193331 uri: 193331 title: ERA24LA029 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193339/pdf description:
Unique identifier
193339
NTSB case number
ERA24LA029
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-28T16:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-14T21:41:51.826Z
Event type
Accident
Location
Elmira, New York
Airport
HARRIS HILL (4NY8)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
At the conclusion of the glider flight, the pilot entered the left airport traffic pattern for landing, but the wind conditions had changed, so he maneuvered to the right traffic pattern. While on approach, the glider was too high, so he extended the dive brakes and attempted to slip the glider, but he was unable to lose enough altitude for a safe landing on the runway, and elected to land on an adjacent field. During touchdown, the nose of the glider dug into the soft terrain, resulting in substantial damage to the airframe. The pilot stated there were no preimpact mechanical issues that precluded normal operation or performance and that he was “just too high” and unable to safely land on the runway.
Probable cause
The pilot’s failure to attain a proper glidepath for a landing on the intended runway, which resulted in an off-airport landing and impact with soft terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Glider
Make
SCHWEIZER
Model
SGS 2-33A
Amateur built
false
Registration number
N17903
Operator
HARRIS HILL SOARING CORP
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
283
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-14T21:41:51Z guid: 193339 uri: 193339 title: ERA24LA025 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193329/pdf description:
Unique identifier
193329
NTSB case number
ERA24LA025
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-28T17:25:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-07T02:11:04.991Z
Event type
Accident
Location
Williamston, North Carolina
Airport
MARTIN COUNTY (MCZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 2 serious, 0 minor
Analysis
Just prior to touch down, the pilot saw a deer to his left. As the airplane settled, he corrected to the right to avoid the deer but over-corrected and could not straighten the airplane’s path. He added full power to attempt a go-around maneuver; however, the airplane exited the right side of the runway and collided with a drainage culvert. The airplane sustained substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
Loss of directional control to avoid a deer during landing, which resulted in a runway excursion and collision with a culvert.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
305
Amateur built
false
Engines
1 Reciprocating
Registration number
N19YM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22827
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-07T02:11:04Z guid: 193329 uri: 193329 title: ERA24LA046 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193415/pdf description:
Unique identifier
193415
NTSB case number
ERA24LA046
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-29T11:56:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-01T18:21:45.932Z
Event type
Accident
Location
Highgate, Vermont
Airport
FRANKLIN COUNTY STATE (FSO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the landing rollout on a 3,001-ft-long, asphalt runway, he intended to retract the flaps, but instead he retracted the landing gear. The result was that all three of the landing gear assemblies retracted into their respective wheel wells during the landing roll. The lower fuselage stringers were substantially damaged. The pilot added that there were no preimpact mechanical malfunctions with the airplane. The airplane was equipped with a squat switch on the left main landing gear that was designed to prevent the landing gear from inadvertently retracting; however, the switch required that sufficient weight be on the landing gear in order to work effectively. The pilot stated, and a video of the landing confirmed, that the airplane was still moving at relatively high speed when he selected the landing gear handle to the retracted position. The pilot reported that the squat switch was tested at the last annual inspection and that it operated normally during the inspection. Based on this information, it is likely that the airplane’s wings were still generating lift when the landing gear handle was selected to the retracted position and the gear struts was not compressed enough to activate the squat switch.
Probable cause
The pilot’s inadvertent retraction of the landing gear during landing rollout, which resulted in a landing gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-39
Amateur built
false
Engines
2 Reciprocating
Registration number
N289WW
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
39-84
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-01T18:21:45Z guid: 193415 uri: 193415 title: ERA24LA031 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193347/pdf description:
Unique identifier
193347
NTSB case number
ERA24LA031
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-29T13:15:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-11-07T00:17:04.567Z
Event type
Accident
Location
Ocklawaha, Florida
Airport
WOODS AND LAKES AIRPARK (FA38)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that he was attempting a second landing, after going around due to “heavy turbulence” on his first approach. He reported that he experienced a tailwind and the airplane floated before landing “longer than usual.” He applied the brakes but was unable to stop on the runway resulting in a runway overrun. After departing the runway, the airplane impacted a fence resulting in substantial damage to the left wing and engine mount. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to attain a proper touchdown point which resulted in a runway overrun and subsequent impact with a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-28-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N9159W
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-10778
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-07T00:17:04Z guid: 193347 uri: 193347 title: CEN24LA030 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193338/pdf description:
Unique identifier
193338
NTSB case number
CEN24LA030
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-10-30T18:30:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-11-03T18:53:19.749Z
Event type
Accident
Location
Lamar, Colorado
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that about 4 hours and 15 minutes after departure, the engine lost all power. The pilot was successful in restoring engine power by switching fuel tanks and turning on the auxiliary fuel pump. However, the engine lost all power again about 5 miles from the destination runway. The pilot conducted a forced landing to a field, during which the airplane struck a fence resulting in substantial damage to both wings. Postaccident examination of the airplane revealed that the fuel tanks contained no usable fuel. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot's inadequate fuel planning and improper in-flight decision making, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20K
Amateur built
false
Engines
1 Reciprocating
Registration number
N1167J
Flight conducted under
Part 91: General aviation
Flight operation type
Ferry
Commercial sightseeing flight
false
Serial number
25-0690
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-03T18:53:19Z guid: 193338 uri: 193338 title: CEN24LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193365/pdf description:
Unique identifier
193365
NTSB case number
CEN24LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-03T11:32:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-14T02:27:11.614Z
Event type
Accident
Location
Houston, Texas
Airport
Conroe/North Houston Regional Airport (CXO)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the personal flight stated that during a two mile final for landing at the destination airport, he encountered a group of four large birds. He pitched the airplane down to avoid striking one of the birds, but he did not have time to avoid them. The airplane struck one of the birds at an airspeed of 105 kts and at an altitude of 880 ft mean sea level. The bird, identified as a black vulture, remained draped around the vertical stabilizer, and there was some loss of stability about the vertical axis. The pilot still had positive control of the airplane, and he declared an emergency landing without further incident. The airplane sustained substantial damage to the vertical stabilizer.
Probable cause
The bird strike to the airplane’s vertical stabilizer during an approach for landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRASSMAN TIMOTHY B
Model
RV-14A
Amateur built
true
Engines
1 Reciprocating
Registration number
N5875G
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
140691
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-14T02:27:11Z guid: 193365 uri: 193365 title: WPR24LA027 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193355/pdf description:
Unique identifier
193355
NTSB case number
WPR24LA027
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-04T14:00:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-11-16T05:10:53.69Z
Event type
Accident
Location
Ririe, Idaho
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the tailwheel-equipped airplane intended to spend the day practicing takeoffs and landings at multiple remote backcountry sites with a group of three other similar airplanes. He practiced at the original departure airport before the other group arrived and reported that those flights were nominal. The group then departed for the first intended destination, which was a flat landing site surrounded by tall grass and brush. Those landings were uneventful, so the group decided to proceed to another close landing spot. This landing area appeared wider and flatter than the previous, however the grass was taller and thicker, such that the ground was obscured. The first airplane landed uneventfully, and the accident pilot decided that rather than landing he would perform a touch-and-go, with the wheels touching the grass so he could assess the conditions. As the pilot began to flare the airplane, he decided that it was safe to proceed with a full-stop landing. As the wheels touched the ground, it became apparent that the surface was much rougher than he anticipated, and the airplane bounced after the main wheels touched two large rocks 200 ft into the ground roll. The pilot retracted the flaperons and as the airplane decelerated the nose began to drop, even though he was holding the control stick full aft. The pilot stated that he was likely inadvertently applying brake pressure as he pushed against the rudder pedals to pull back further on the control stick, and that this may have exacerbated the pitch down motion. The airplane then nosed over. The airplane came to rest inverted and sustained substantial damage to both wing struts and multiple wing ribs.
Probable cause
The pilot’s inadvertent excessive use of brakes which resulted in a nose-over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
KITFOX
Model
S5
Amateur built
true
Engines
1 Reciprocating
Registration number
N88VJ
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-16T05:10:53Z guid: 193355 uri: 193355 title: ERA24LA035 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193382/pdf description:
Unique identifier
193382
NTSB case number
ERA24LA035
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-04T14:20:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-15T00:29:05.806Z
Event type
Accident
Location
Tompkinsville, Kentucky
Airport
TOMPKINSVILLE/MONROE COUNTY (TZV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot was practicing an emergency descent and landing when he deployed full wing flaps and descended to the touchdown point. About 10 to 15 ft above ground level, the airplane encountered a rapid sink rate that he failed to arrest. The airplane touched down hard, and the fuselage was substantially damaged. The pilot stated that, upon reflection, if he had added the power and extended the airplane’s glide path, he might have been in a better position for landing; however, he allowed the airplane to get “too slow.” The pilot reported no mechanical anomalies with the airplane that would have precluded normal operation.
Probable cause
The pilot's failure to maintain adequate airspeed during the approach, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA18
Amateur built
false
Engines
1 Reciprocating
Registration number
N4056Z
Operator
G & L AIRBORNE INC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18-8064
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-15T00:29:05Z guid: 193382 uri: 193382 title: CEN24LA032 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193348/pdf description:
Unique identifier
193348
NTSB case number
CEN24LA032
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-05T16:00:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-11-14T00:00:20.144Z
Event type
Accident
Location
Kokomo, Indiana
Airport
Glenndale Airport (8I3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that the B-29 replica airplane’s nose landing gear encountered a depression on the runway during the landing roll. The airplane yawed to the left, departed the runway surface, and struck a golf cart with a spectator, that was parked on the edge of the runway. The spectator sustained minor injuries. The airplane sustained substantial damage to both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
Tom Hodgson
Model
29
Amateur built
true
Engines
4 Reciprocating
Registration number
N29XB
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
001
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-14T00:00:20Z guid: 193348 uri: 193348 title: ERA24LA039 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193392/pdf description:
Unique identifier
193392
NTSB case number
ERA24LA039
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-07T18:00:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-21T20:39:11.693Z
Event type
Accident
Location
London, Kentucky
Airport
LONDON/CORBIN/MAGEE (LOZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot purchased the airplane the day prior to the accident. During the landing at the destination airport, the airplane bounced, and the pilot intended to abort the landing; however, he accidentally advanced the elevator trim lever, rather than the throttle lever (which were similarly positioned and shaped). The airplane subsequently touched down a second time nose-low, resulting in damage to the main landing gear and propeller. Several fuselage tubes were also substantially damaged during the landing. The pilot stated that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s inadvertent application of nose down pitch trim during the attempted aborted landing, which resulted in abnormal contact with the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GAULDEN WILLIAM D
Model
VANS RV-4
Amateur built
true
Engines
1 Reciprocating
Registration number
N2606A
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
3270
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-21T20:39:11Z guid: 193392 uri: 193392 title: CEN24LA034 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193362/pdf description:
Unique identifier
193362
NTSB case number
CEN24LA034
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-08T09:30:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-09T03:38:24.295Z
Event type
Accident
Location
Fort Worth, Texas
Airport
HICKS AIRFIELD (T67)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that after landing at the airport, he was taxing the airplane on the dry asphalt. During the taxi, he observed a motorcycle on the taxiway coming toward the airplane. While focusing on the motorcycle, the right wing impacted several garbage cans, the airplane turned to the right, and impacted a hangar door. The airplane came to rest upright, and the pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the right wing. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. This was the pilot’s first visit to the airport, and he reported he did not visually observe the garbage cans during the taxi, as they were in an area that was shadowed from a hangar. According to the Federal Aviation Administration Chart Supplement for the airport, the remarks section states, “uncontrolled vehicle tfc inv of hangars and on twys.”
Probable cause
The distraction of the pilot during the taxi, resulting in a ground collision.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GRUMMAN AMERICAN AVN. CORP.
Model
AA-5
Amateur built
false
Engines
1 Reciprocating
Registration number
N9568U
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
AA5A-0068
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-09T03:38:24Z guid: 193362 uri: 193362 title: WPR24LA031 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193376/pdf description:
Unique identifier
193376
NTSB case number
WPR24LA031
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-10T14:00:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-14T21:08:38.357Z
Event type
Accident
Location
Pendleton, Oregon
Airport
EASTERN OREGON RGNL AT PENDLETON (PDT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The operator of the unmanned aircraft system (UAS) reported that during a test flight, the UAS descended, delivered a package to the practice location, and began a vertical climb to return to the landing zone. During the vertical climb, the UAS registered a low voltage health alert and initiated an “urgent land maneuver.” During the maneuver, the UAS battery depleted to a point where it lost propulsive power, and impacted terrain, resulting in substantial damage to all 4 wings, and spar damage to the number 2, 3, and 4 wings. Postaccident review of the circumstances surrounding the flight by the operator revealed that an insufficiently charged battery had been installed on the UAS. The operator reported that there were no preaccident mechanical failures or malfunctions with the UAS that would have precluded normal operation.
Probable cause
The operator’s use of an insufficiently charged battery that resulted in a total loss of engine power and subsequent impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Unmanned
Make
AMAZON.COM SERVICES LLC
Model
MK27-2
Amateur built
false
Registration number
N692PA
Operator
AMAZON.COM SERVICES LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Flight test
Commercial sightseeing flight
false
Serial number
17868SN000777
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-14T21:08:38Z guid: 193376 uri: 193376 title: ERA24LA037 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193388/pdf description:
Unique identifier
193388
NTSB case number
ERA24LA037
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-13T08:48:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-11-20T23:49:08.92Z
Event type
Accident
Location
Frederick, Maryland
Airport
Frederick Municipal Airport (FDK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot said that he extended the airplane’s landing gear in preparation to land but did not confirm if the gear was down and locked. As such, he was not aware that the landing gear did not extend due to a failure of the system’s hydraulic filter. The pilot landed gear up, resulting in substantial damage to the fuselage. The pilot said that when the airplane was recovered from the runway, recovery personnel were able to lift the airplane and extend the landing gear using the emergency gear hand pump.
Probable cause
A failure of a hydraulic filter, which preluded normal extension of the landing gear. Also causal was the pilot’s failure to confirm that he landing gear was extended before landing, which resulted in a gear up landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
210
Amateur built
false
Engines
1 Reciprocating
Registration number
N9515X
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
21057815
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-20T23:49:08Z guid: 193388 uri: 193388 title: WPR24LA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193448/pdf description:
Unique identifier
193448
NTSB case number
WPR24LA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-16T18:38:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-11-29T23:43:26.042Z
Event type
Accident
Location
Yuma, Arizona
Airport
YUMA MCAS/YUMA INTL (NYL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the gyroplane reported that, during a touch-and-go landing to the runway, he encountered a gusting wind, causing the gyroplane to veer left to the grass. Subsequently, the gyroplane collided with the runway hold short sign, resulting in substantial damage to the fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the gyroplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during landing, which resulted in a runway excursion and collision with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Gyroplane
Make
THEODORE C KALMAN
Model
ELA ECLIPSE 10
Amateur built
true
Engines
1 Reciprocating
Registration number
N82TK
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
04175271014
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-29T23:43:26Z guid: 193448 uri: 193448 title: CEN24LA040 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193404/pdf description:
Unique identifier
193404
NTSB case number
CEN24LA040
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-17T14:04:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-11-20T19:34:24.298Z
Event type
Accident
Location
Mountain View, Arkansas
Airport
Mountain View Airport (7M2)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The purpose of the flight was for a potential buyer (not a certificated pilot) to receive a familiarization flight from a sport pilot before the purchase of the airplane. The sport pilot demonstrated two to three touch and go landings. He stated that each touch and go had various crosswinds and wind gusts. After the demonstrated touch and go landings, the potential buyer asked if he could try an approach and landing, took the flight controls, and flew a standard traffic pattern. He noted that the windsock was straight out and perpendicular to the runway on short final before landing. Upon touchdown, the right wing rose suddenly, and the left wing struck the runway. The airplane veered to the left and the potential buyer applied the brakes. The sport pilot took the flight controls and attempted a go-around, during which the airplane exited the runway to the left, struck a runway light and spun around. The airplane sustained substantial damage to the left wing. There were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. At the time of the accident the potential buyer was landing the airplane on runway 27 with wind variable at 4 knots.
Probable cause
The sport pilot’s poor decision to allow a noncertificated pilot to land the airplane which resulted in a loss of control during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
ICP SRL
Model
SAVANNAH S
Amateur built
false
Engines
1 Reciprocating
Registration number
N425LM
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
22-11-54-0920
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-20T19:34:24Z guid: 193404 uri: 193404 title: CEN24LA047 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193427/pdf description:
Unique identifier
193427
NTSB case number
CEN24LA047
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-18T11:50:00Z
Publication date
2023-12-13T05:00:00Z
Report type
Final
Last updated
2023-11-28T03:21:39.716Z
Event type
Accident
Location
Barataria, Louisiana
Airport
Intracoastal waterway (null)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that she had setup for landing on an intracoastal waterway and picked a landing area based on the locations of three nearby boats. During final approach, she had the three boats in sight, one of which was on the far right side of waterway and traveling in the same direction. She determined that the boats would not be a factor and continued to land. The airplane touched down on the choppy water and she added power to keep the airplane on the step. Immediately after touchdown the airplane veered left, then nosed over and sustained substantial damage to the right wing. The pilot egressed the airplane without further incident. She noticed that the recreational boat that was originally on the right side of the waterway was now on the left side and the boat driver stated that the airplane hit the boat. Since the pilot was seated in the left seat, her view to the lower right area of the airplane would have been restricted by the airframe. The pilot added that three other airplanes had just landed on the waterway and there was one more in position to land behind her.
Probable cause
A recreational boat crossed in front of the airplane’s path during landing on the water which resulted in the airplane colliding with the boat.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
A185F
Amateur built
false
Engines
1 Reciprocating
Registration number
N61919
Operator
Southern Seaplane, Inc.
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
18504274
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-28T03:21:39Z guid: 193427 uri: 193427 title: ERA24LA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193410/pdf description:
Unique identifier
193410
NTSB case number
ERA24LA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-19T12:26:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2023-11-22T21:04:49.344Z
Event type
Accident
Location
Saluda, South Carolina
Airport
Saluda County Airport (6J4)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot and the flight instructor planned a flight itinerary that included multiple stops with the aim of the pilot receiving 7 hours of training in the airplane. Prior to the accident, the flight instructor learned that the pilot had not performed go-arounds or touch-and-go landings in the airplane make and model. Upon flying the airplane into the accident airport, the favorable weather conditions and lack of air traffic led them to decide to conduct the training in the traffic pattern there. The first landing was made by the pilot to a full stop with taxi back. The second landing, which was a touch-and-go, was performed by the flight instructor. The third, followed by the fourth and final landing was performed by the pilot. During the fourth landing, with the wing flaps fully extended, the pilot lost directional control of the airplane and attempted to abort the landing as the airplane veered to the left (a right crosswind prevailed at that time). The pilot tried to correct back toward to the runway centerline, but the airplane went off the left side of the runway. The airplane then touched down in the grass, traveled down an embankment, nosed over, and came to rest inverted. The airframe was substantially damaged during the accident sequence. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control of the airplane during an aborted landing in crosswind conditions. Contributing to the accident was the flight instructor’s inadequate remedial action.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERO COMMANDER
Model
112
Amateur built
false
Engines
1 Reciprocating
Registration number
N1143J
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
143
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-22T21:04:49Z guid: 193410 uri: 193410 title: ERA24LA048 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193426/pdf description:
Unique identifier
193426
NTSB case number
ERA24LA048
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-20T11:17:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-11-27T20:59:48.802Z
Event type
Accident
Location
Blairstown, New Jersey
Airport
BLAIRSTOWN (1N7)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the student pilot were practicing a simulated loss of engine power landing procedure. When the airplane was over the runway, it began to “excessively” float and the instructor told the student to go-around. The student added full power and pulled back on the control yoke to initiate the go-around. The instructor said the airplane almost immediately banked toward the left of the runway. He immediately took over the controls and attempted to recover from the situation; however, he said that he was unable to overpower the student’s excessive input and the airplane impacted the ground resulting in substantial damage to the right wing. The instructor reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The student pilot’s improper control inputs and the flight instructor’s delayed remedial action, which resulted in a loss of control during an attempted go-around.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N739MK
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17270649
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-27T20:59:48Z guid: 193426 uri: 193426 title: CEN24LA044 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193417/pdf description:
Unique identifier
193417
NTSB case number
CEN24LA044
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-22T13:15:00Z
Publication date
2024-01-04T05:00:00Z
Report type
Final
Last updated
2023-11-27T19:39:22.75Z
Event type
Accident
Location
DeWitt, Arkansas
Airport
Dewitt Municipal (5M1)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
The pilot reported that upon landing a crosswind “pushed” the airplane off the runway. The airplane encountered a ditch, crossed a taxiway, and impacted a fence. The airplane sustained damage to the fuselage, both wings, and the left-wing strut. The pilot reported that there were no preaccident failures or malfunctions with the airplane which would have precluded normal operation.
Probable cause
The pilot’s loss of airplane directional control while landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
AERONCA
Model
7AC
Amateur built
false
Engines
1 Reciprocating
Registration number
N84692
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
7AC-3401
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-27T19:39:22Z guid: 193417 uri: 193417 title: ERA24LA047 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193420/pdf description:
Unique identifier
193420
NTSB case number
ERA24LA047
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-22T18:20:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-11-24T19:15:55.144Z
Event type
Accident
Location
Meridianville, Alabama
Airport
HUNTSVILLE EXEC TOM SHARP JR FLD (MDQ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The pilot reported that, while turning from the left base to the final approach leg of the airport traffic pattern, the airplane’s stall warning horn sounded. The pilot pitched the airplane’s nose down and increased engine power. The airplane then “violent[ly]” pitched up and to the left. He continued his attempt to regain control, but the airplane then pitched up and to the right, and eventually impacted terrain about 200 ft short of the runway threshold. The pilot and passenger incurred minor injuries, and the airplane sustained substantial damage to the empennage, both wings, and engine mount. The pilot reported that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The pilot’s exceedance of the airplane’s critical angle of attack while on final approach to land, which resulted in an aerodynamic stall, a loss of airplane control, and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MOONEY
Model
M20F
Amateur built
false
Engines
1 Reciprocating
Registration number
N9339M
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
670253
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-24T19:15:55Z guid: 193420 uri: 193420 title: ERA24LA049 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193428/pdf description:
Unique identifier
193428
NTSB case number
ERA24LA049
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-26T09:35:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-01T18:17:44.479Z
Event type
Accident
Location
Valdosta, Georgia
Airport
VALDOSTA RGNL (VLD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot stated that during the landing flare he realized that he forgot to extend the landing gear and determined it was too late to go around. The underside of the airplane’s fuselage settled onto the runway and skidded down the asphalt, resulting in substantial damage to the structure of the fuselage. The pilot reported there were no mechanical malfunctions that would have prevented normal operation of the airplane. The airplane was equipped with a landing gear position warning horn that was designed to sound when the throttle lever was pulled back for landing. The pilot reported that he did not specifically remember hearing the warning horn during the landing flare; however, he stated he might have mistaken the landing gear warning horn for the stall warning horn as he was expecting to hear the stall warning during the landing flare. The pilot reported that when he went back to the airplane after the accident and powered up the airplane’s electrical system, the landing gear warning horn operated normally.
Probable cause
The pilot’s failure to extend the landing gear before landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N94EM
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Positioning
Commercial sightseeing flight
false
Serial number
E-2011
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-01T18:17:44Z guid: 193428 uri: 193428 title: CEN24LA054 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193463/pdf description:
Unique identifier
193463
NTSB case number
CEN24LA054
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-26T17:40:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2023-12-04T20:39:38.139Z
Event type
Accident
Location
Council Bluffs, Iowa
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while descending through a cloud layer, a crewmember saw a flock of birds and alerted the pilot. The pilot reported that he disconnected the autopilot and attempted to avoid the birds. The birds impacted the airplane which resulted in substantial damage to the left horizontal stabilizer. The crew made an uneventful landing following the bird strike
Probable cause
An in-flight collision with a bird during decent.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
560XL
Amateur built
false
Engines
2 Turbo fan
Registration number
N475CW
Operator
Ultra Air, LLC
Second pilot present
true
Flight conducted under
Part 135: Air taxi & commuter
Flight operation type
Unknown
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
560-5080
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-04T20:39:38Z guid: 193463 uri: 193463 title: WPR24LA058 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193539/pdf description:
Unique identifier
193539
NTSB case number
WPR24LA058
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-27T11:20:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2023-12-29T04:23:48.26Z
Event type
Accident
Location
Las Cruces, New Mexico
Airport
LAS CRUCES INTL (LRU)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
At the time of the accident, the student pilot was on a solo cross-country flight to obtain a private, single engine airplane add-on to his certificate. He reported that during a landing attempt he noted that the approach was stable at a constant airspeed and power setting. The pilot said that at an unknown point in the approach, he experienced a downdraft as he felt “a little push down” and observed a rapid change in his rate of descent. The pilot could not recall at what altitude he encountered the downdraft. The airplane landed hard and sustained substantial damage to the fuselage. The weather station at the airport reported that the wind was calm at the time of the accident. The pilot reported no preimpact mechanical malfunctions or anomalies that could have precluded normal operation.
Probable cause
An encounter with a downdraft during an approach to land, which resulted in a hard landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172P
Amateur built
false
Engines
1 Reciprocating
Registration number
N5495K
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17274160
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-29T04:23:48Z guid: 193539 uri: 193539 title: WPR24LA043 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193447/pdf description:
Unique identifier
193447
NTSB case number
WPR24LA043
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-28T17:40:00Z
Publication date
2024-01-10T05:00:00Z
Report type
Final
Last updated
2023-11-30T03:31:00.559Z
Event type
Accident
Location
Modesto, California
Airport
MODESTO CITY-COUNTY-HARRY SHAM FLD (MOD)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that while landing in a tailwind, he lost directional control on the tail wheeled airplane, and it veered to the left. Subsequently, the main gear exited the runway surface and resulted in the airplane nosing over. The airplane sustained substantial damage to the vertical stabilizer and left-wing strut. The pilot reported that there were no preaccident mechanical failures or malfunctions that would have precluded normal operation.
Probable cause
The failure of the pilot to maintain directional control of the airplane during landing, which resulted in a nose over.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
180J
Amateur built
false
Engines
1 Reciprocating
Registration number
N9991N
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
18052646
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-11-30T03:31:00Z guid: 193447 uri: 193447 title: ERA24LA061 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193508/pdf description:
Unique identifier
193508
NTSB case number
ERA24LA061
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-29T17:19:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-26T19:24:48.266Z
Event type
Accident
Location
Manassas, Virginia
Airport
Manassas Regional Airport (HEF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during initial climb, around 700 ft above ground level, a bird impacted the leading edge of the left wing, resulting in substantial damage to the wing. After impacting the bird, the pilot informed air traffic control that he would need to return to the airport, performed a normal traffic pattern, and landed without further incident.
Probable cause
An in-flight collision with a bird during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
DIAMOND AIRCRAFT IND INC
Model
DA 40
Amateur built
false
Engines
1 Reciprocating
Registration number
N999VC
Operator
Piston2Jet
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
40.506
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-26T19:24:48Z guid: 193508 uri: 193508 title: CEN24LA051 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193455/pdf description:
Unique identifier
193455
NTSB case number
CEN24LA051
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-29T18:15:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-12-15T21:22:48.752Z
Event type
Accident
Location
Glencoe, Minnesota
Airport
GLENCOE MUNI (GYL)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During the landing roll on an airport at dusk, 3 or 4 deer ran out across the runway traveling right to left. The airplane collided with two of the deer and the engine lost power as one of the propellers struck a deer. Substantial damage was sustained to the engine mount, firewall, and right forward fuselage. The flight instructor reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. The Federal Aviation Administration (FAA) Airport Directory information for the airport listed a warning for deer on and in the vicinity of the airport. A review of the NTSB accident database and FAA wildlife strike database did not locate other incidents of wildlife strikes at this airport. The flight instructor further reported that the accident could have been prevented if deer fencing was installed at the airport.
Probable cause
The collision with deer during the landing rollout.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N92505
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2890211
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-15T21:22:48Z guid: 193455 uri: 193455 title: ERA24LA052 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193457/pdf description:
Unique identifier
193457
NTSB case number
ERA24LA052
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-11-30T12:30:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-07T20:38:31.73Z
Event type
Accident
Location
Martinsville, Virginia
Airport
BLUE RIDGE (MTV)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The private pilot was flying with a flight instructor and was working towards his tailwheel endorsement. During a wheel landing attempt with a direct crosswind from the left, the airplane swerved, and the pilot attempted to make a correction by applying right rudder. Subsequently, the airplane ground looped before the flight instructor could take control of the airplane, and the left wing and left elevator struck the runway surface. Following the ground loop, the pilot continued the taxi to the ramp without further incident. The fuselage, left wing, and left elevator sustained substantial damage. The pilot and flight instructor reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during a wheel landing in crosswind conditions and the flight instructor’s delayed remedial action, which resulted in a ground loop on the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
STINSON
Model
108-2
Amateur built
false
Engines
1 Reciprocating
Registration number
N9564K
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
108-2564
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-07T20:38:31Z guid: 193457 uri: 193457 title: ERA24LA057 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193481/pdf description:
Unique identifier
193481
NTSB case number
ERA24LA057
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-05T16:00:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2024-02-08T05:55:46.407Z
Event type
Accident
Location
Social Circle, Georgia
Airport
Sleepy Hollow (18GA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
According to the flight instructor, he was simulating an engine failure with the student pilot. He selected a field to approach and proceeded to reduce the engine rpm to simulate the engine failure. They continued the maneuver until they were approximately 100 feet above the ground, at which point he instructed the student pilot to add full power and climb out. The student pilot complied, but right at that moment, the flight instructor felt a heavy gust of wind. He described it as a downdraft, and despite the engine producing full power, it would not climb. The flight instructor took control of the airplane and attempted to recover it from the descent. The airplane continued to descended until it collided with a fence and touched down in the field. During the landing roll, the airplane impacted a tree, resulting in substantial damage to the horizontal stabilizer. The pilots reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation. An engine test run was facilitated, and no anomalies were noted during the test.
Probable cause
An encounter with a downdraft while maneuvering at low altitude, which resulted in a collision with a fence.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
TEXTRON AVIATION INC
Model
172S
Amateur built
false
Engines
1 Reciprocating
Registration number
N53AA
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
172S11737
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-02-08T05:55:46Z guid: 193481 uri: 193481 title: CEN24LA055 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193486/pdf description:
Unique identifier
193486
NTSB case number
CEN24LA055
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-06T15:26:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-12-12T02:39:58.797Z
Event type
Accident
Location
Alamosa, Colorado
Airport
San Luis Valley Regional Airport/Bergman Field (ALS)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the personal flight stated that he was the flying pilot and was seated in the right pilot seat with a passenger rated pilot seated in the left pilot seat. The pilot stated during landing that perhaps the airplane bounced. The airplane was right of the runway centerline and not pointed down the runway. The pilot stated that he corrected to the left and the airplane skidded off the runway and into a dirt area. The airplane’s left main landing gear collapsed, and the airplane sustained substantial damage that included damage to the left wing. Automatic Dependent Surveillance-Broadcast data showed that the airplane crossed the runway approach end with a ground speed of approximately 113 kts during calm wind conditions. The airplane’s ground speed was approximately 70 kts about 4,000 ft down the runway when it began to veer off the runway. The Piper Aircraft PA-30 Owner’s Handbook states that the final approach speed for the airplane is 100 mph (86.9 kts). The bounce during landing was consistent with an excessive touchdown speed after a final approach flown at a speed higher than that specified for the airplane. The pilot stated that was no mechanical malfunction/failure of the airplane that would have precluded normal airplane operation.
Probable cause
The pilot’s failure to maintain directional control during landing with an excessive touchdown speed that resulted in a loss of control and impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-30
Amateur built
false
Engines
2 Reciprocating
Registration number
N7790Y
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
30-146
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-12T02:39:58Z guid: 193486 uri: 193486 title: ERA24LA060 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193506/pdf description:
Unique identifier
193506
NTSB case number
ERA24LA060
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-08T17:11:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-11T21:21:00.015Z
Event type
Accident
Location
Mount Vernon, Alabama
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he and a passenger had departed for a local sight-seeing flight and while flying low over a river the left wing impacted the water. The impact “pulled the plane into the river,” which resulted in substantial damage to the forward fuselage, wings, and tail structure. The pilot reported that there were no pre-accident mechanic malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s decision to operate the airplane at a low altitude over a river, and his failure to maintain clearance from the river while maneuvering.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150
Amateur built
false
Engines
1 Reciprocating
Registration number
N5952T
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15060652
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-11T21:21:00Z guid: 193506 uri: 193506 title: CEN24LA059 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193510/pdf description:
Unique identifier
193510
NTSB case number
CEN24LA059
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-10T12:13:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-12-12T03:07:25.711Z
Event type
Accident
Location
Lubbock, Texas
Airport
LUBBOCK PRESTON SMITH INTL (LBB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during the approach the airplane was flying “3-5 mph faster than normal” to account for the gusting wind condition. Just prior to the nosewheel touching down, the pilot felt a “strong gust that pulled the nose of the aircraft into the wind.” As the nosewheel touched down, the pilot applied right rudder, and the airplane departed the runway. The airplane impacted a runway sign, the nose gear collapsed, and the airplane came to rest upright with a nose down attitude. The two occupants were able to egress from the airplane without further incident. The airplane sustained substantial damage to the engine mount. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain directional control during the landing that resulted in a runway excursion, an impact with a runway sign, and a nose gear collapse.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA28
Amateur built
false
Engines
1 Reciprocating
Registration number
N8538N
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
28-11337
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-12T03:07:25Z guid: 193510 uri: 193510 title: CEN24LA058 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193503/pdf description:
Unique identifier
193503
NTSB case number
CEN24LA058
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-10T17:11:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-12-11T21:21:41.621Z
Event type
Accident
Location
Ann Arbor, Michigan
Airport
ANN ARBOR MUNI (ARB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he was flying the RNAV (GPS) approach to runway 24 and experienced turbulence about 1,500 ft mean sea level (msl), which was about 700 ft above ground level (agl). He continued the approach with an airspeed between 95 and 100 kts. He stated that about 50 ft agl and short of the runway, the airplane encountered wind shear that violently forced the airplane to the ground. The airplane impacted the ground in a wings level attitude and continued onto the runway. The left main landing gear separated, the airplane veered off the left side of the runway, then came to rest in the grass facing 180° from the direction of travel. Postaccident photos of the airplane revealed substantial damage to the right wing. The pilot reported no preimpact mechanical malfunctions or failures that would have precluded normal operation. The pilot stated to the responding fire department that there was a 30 kt crosswind on final approach. The recorded wind data around the time of the accident showed the wind was from 250° to 260° and 7 to 11 kts.
Probable cause
The airplane’s encounter with unexpected wind shear during final approach, which resulted in a hard landing short of the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA46-500TP
Amateur built
false
Engines
1 Turbo prop
Registration number
N90ZZ
Operator
CAHOOTS AIR LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
4697223
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-11T21:21:41Z guid: 193503 uri: 193503 title: ERA24LA063 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193511/pdf description:
Unique identifier
193511
NTSB case number
ERA24LA063
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-10T22:50:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-13T23:31:44.251Z
Event type
Accident
Location
Lajas, Puerto Rico
Airport
LAJAS AIRPARK (PR25)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during takeoff from the private airstrip, the right wing of the airplane impacted bushes alongside of the narrow turf runway. As a result of the impact, the airplane to yawed to the right. The pilot attempted to pull back on the yoke, but lost control and the airplane impacted the ground and nosed over. The pilot reported that there were no pre-accident mechanic malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain adequate clearance from bushes alongside the runway, which resulted in a loss of directional control during the takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
150L
Amateur built
false
Engines
1 Reciprocating
Registration number
N1707Q
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
15073007
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-13T23:31:44Z guid: 193511 uri: 193511 title: ERA24LA065 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193523/pdf description:
Unique identifier
193523
NTSB case number
ERA24LA065
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-11T12:15:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-26T19:40:46.416Z
Event type
Accident
Location
Newport News, Virginia
Airport
Newport News Williamsburg Intl (PHF)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor and the pilot-rated student were in the flying in the airport traffic pattern practicing landings. During the initial climb following a touch-and-go landing, with the student at the controls, a large bird flew directly in front of the airplane. The student attempted to avoid it; however, the bird struck the leading edge of the left wing. The flight instructor took over the controls and landed the airplane uneventfully. An inspector with the Federal Aviation Administration examined the airplane and found that the wing had been substantially damaged as a result of the birdstrike.
Probable cause
An inflight collision with a bird during initial climb.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172
Amateur built
false
Engines
1 Reciprocating
Registration number
N733QJ
Operator
RICK AVIATION INC
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
17268463
Damage level
Unknown
Events
Findings
creator: NTSB last-modified: 2023-12-26T19:40:46Z guid: 193523 uri: 193523 title: ERA24LA064 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193518/pdf description:
Unique identifier
193518
NTSB case number
ERA24LA064
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-12T16:44:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2023-12-26T19:18:10.567Z
Event type
Accident
Location
Sidney, Ohio
Airport
SIDNEY MUNI (SCA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The right seat pilot reported that after performing a preflight inspection, he anticipated the airplane would need to be refueled and subsequently left the fuel caps unlocked. After a discussion with the left seat pilot (who was acting as the pilot-in-command), they decided they would not need to refuel before the flight. Both pilots performed another walk around inspection and neither pilot noticed that the fuel caps remained unlocked. Shortly after takeoff, the right seat pilot noticed that both fuel caps were not secure, and that fuel was escaping from both main fuel tanks. He elected to make return to the departure airport and land on the opposite direction runway. The pilots were both manipulating the controls when they landed the airplane “hard” on the main landing gear. The airplane then bounced and veered to the right of the runway, impacting a terminal sign and taxi light. The hard landing and subsequent runway excursion resulted in substantial damage to the wings and fuselage. The pilots reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilots’ improper landing flare, which resulted in a hard landing, runway excursion, and subsequent impact with a terminal sign and taxi light.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
A36
Amateur built
false
Engines
1 Reciprocating
Registration number
N6643H
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
E-1667
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-26T19:18:10Z guid: 193518 uri: 193518 title: ERA24LA085 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193632/pdf description:
Unique identifier
193632
NTSB case number
ERA24LA085
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-15T21:33:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-01-09T20:34:46.879Z
Event type
Accident
Location
Griffin, Georgia
Airport
BROOK BRIDGE AERODROME (8GA9)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that his intended destination airport was Cedar Ridge Airport (GA62), Griffin, GA, but due to misidentification of the airport while airborne, he landed at Brook Bridge Aerodrome (8GA9), Vaughn, GA. He reported that he did not realize he was approaching the wrong airport until he was “too low and too slow.” The airplane touched down on a shared taxiway/driveway before impacting a utility pole with the left wing. Subsequently, the airplane spun and impacted trees resulting in substantial damage to the left wing, nose structure, and right wing. The pilot reported that there were no pre-accident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s misidentification of a taxiway as the intended runway, which resulted in a collision with a utility pole and trees.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
58
Amateur built
false
Engines
2 Reciprocating
Registration number
N303RA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
TH-506
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-09T20:34:46Z guid: 193632 uri: 193632 title: ERA24LA083 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193602/pdf description:
Unique identifier
193602
NTSB case number
ERA24LA083
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-16T11:37:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2024-01-11T20:55:18.053Z
Event type
Accident
Location
Tuscumbia, Alabama
Weather conditions
Unknown
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot was practicing hovering without the supervision of a flight instructor. The pilot reported that the winds were gusty and he estimated the surface winds to be about 10 to 15 mph. The pilot stated he started to drift and attempted to make a turn; during the turn, the pilot realized he was too close to some objects, and he began to panic. The pilot lowered the collective and the back right skid contacted the ground, after which he pulled up on the collective and lost control of the helicopter. Subsequently, the helicopter rolled over into a ditch; the pilot evacuated and a post-accident fire ensued, resulting in substantial damage to the helicopter. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Probable cause
The pilot’s failure to maintain control of the helicopter, which resulted in the right skid contacting the ground and a subsequent rollover.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
RABE RICHARD
Model
EXEC 162F
Amateur built
true
Engines
1 Reciprocating
Registration number
N60932
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
6429
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-11T20:55:18Z guid: 193602 uri: 193602 title: CEN24LA071 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193565/pdf description:
Unique identifier
193565
NTSB case number
CEN24LA071
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-17T11:46:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2024-01-03T22:37:49.784Z
Event type
Accident
Location
Stephenville, Texas
Airport
Stephenville Clark Regional Airport (SEP)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The student pilot stated that when he entered the destination airport traffic pattern for landing, there were strong wind gusts that were not on the automated weather observing system report. He said the airplane’s descent during the approach was stable, so he decided to continue the approach for landing. He said that shortly after the airplane’s nose wheel landing gear touched down on the runway, the airplane caught a strong wind gust that resulted in a weathervane effect and a sharp change in its direction to the right. He then applied left rudder control input, but the airplane veered to the right and off the runway where it impacted terrain. The airplane sustained substantial damage to the fuselage. The pilot stated there was no preaccident failures or malfunctions the airplane that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain directional control during landing that resulted in an impact with terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172N
Amateur built
false
Engines
1 Reciprocating
Registration number
N4501E
Operator
Optima Aviation LLC DBA N4501E
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
17271614
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-03T22:37:49Z guid: 193565 uri: 193565 title: CEN24LA068 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193540/pdf description:
Unique identifier
193540
NTSB case number
CEN24LA068
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-18T15:20:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2024-01-02T21:27:05.593Z
Event type
Accident
Location
Forney, Texas
Weather conditions
Visual Meteorological Conditions
Injuries
null fatal, null serious, null minor
Analysis
The pilot reported that while returning from a 5-hour aerial survey flight, she noticed about a quarter tank of fuel indicated on each fuel gauge and continued the flight toward the destination airport. While on the approach, the pilot noticed that both engines sputtered and both fuel gauges indicated empty. The pilot conducted a forced landing to a highway median, and the airplane impacted guardrails. Both wings, the empennage, and fuselage sustained substantial damage. Postaccident examination of the airplane revealed that the fuel tanks contained no usable fuel.
Probable cause
The pilot's inadequate fuel planning and improper in-flight decision-making, which resulted in a total loss of engine power due to fuel exhaustion.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-23-250
Amateur built
false
Engines
2 Reciprocating
Registration number
N66RC
Operator
PACIFIC FLEET AVIATION LLC
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
27-8054046
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-02T21:27:05Z guid: 193540 uri: 193540 title: ERA24LA068 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193542/pdf description:
Unique identifier
193542
NTSB case number
ERA24LA068
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-18T18:35:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2023-12-21T17:52:03Z
Event type
Accident
Location
Pahokee, Florida
Airport
PALM BEACH COUNTY GLADES (PHK)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 2 minor
Analysis
The accident occurred during a transition training instructional flight, and the pilot receiving instruction had not previously logged any flight experience in the accident airplane make and model. The pilot receiving instruction reported that on final approach they entered a side slip to align with the runway. The airplane was stable approaching the threshold but once past the threshold the airplane started to drift to the right of the centerline. The pilot called for a go-around and controls were passed to the flight instructor. The flight instructor stated that 20-30 feet above the runway the tail began to swing from left to right and he took control of the airplane. The airplane floated over the runway for a few seconds while he used the rudder to compensate for the unexpected gust of wind. The flight instructor stated that the airplane became difficult to control before one wing contacted the runway. The tail structure separated from the fuselage and the fuselage, engine mount, and both wings were substantially damaged. The flight instructor stated that there were no preimpact mechanical malfunctions or failures of the airplane that would have precluded normal operation.
Probable cause
The flight instructor’s failure to maintain control of the airplane after encountering a wind gust during landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CIRRUS DESIGN CORP
Model
SR20
Amateur built
false
Engines
1 Reciprocating
Registration number
N875SB
Operator
SkyBlue Aviation
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
2720
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-21T17:52:03Z guid: 193542 uri: 193542 title: CEN24LA072 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193566/pdf description:
Unique identifier
193566
NTSB case number
CEN24LA072
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-19T10:05:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2023-12-29T08:28:04.777Z
Event type
Accident
Location
Red Lake, Minnesota
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that they overflew the frozen lake and passed on the original landing area due to ice cracks and heaves. He flew to another area of the lake and located a suitable landing spot. He completed a low pass to survey the landing area and confirm its suitability. During the landing roll, he was unable to stop the airplane in the surveyed area; the airplane continued into a crack in the ice and became partially submerged. The airplane sustained substantial damage to the firewall and lower fuselage. The pilot reported that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation.
Probable cause
The pilot’s inadequate landing surface evaluation and failure to stop the airplane on the frozen lake, which resulted the airplane continuing into a crack in the ice.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
172M
Amateur built
false
Engines
1 Reciprocating
Registration number
N46056
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
17264174
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-29T08:28:04Z guid: 193566 uri: 193566 title: DCA24LA051 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193561/pdf description:
Unique identifier
193561
NTSB case number
DCA24LA051
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-19T18:30:00Z
Publication date
2024-03-12T04:00:00Z
Report type
Final
Last updated
2024-01-10T00:21:12.767Z
Event type
Accident
Location
St. Louis, Missouri
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
Southwest Airlines flight 2217 struck a bird while climbing though 6,000 ft. after departure from the St. Louis Lambert International Airport (STL), St. Louis, Missouri. According to the flight crew, during the climb they saw a “quick flash” pass diagonally from right to left across the nose of the airplane, followed by a “thud” sound. Which they surmised was a bird that had impacted the nose or belly area of the airplane. After confirming that the flight controls, engines, and pressurization system were operating normally, they decided to continue to their destination. They advised the company of a possible bird strike via an aircraft communicating and reporting system (ACARS) message to coordinate with maintenance for an inspection and damage assessment upon landing. The flight continued normally with no change in the performance or operation of the airplane and landed without further incident. After landing the crew performed a post-flight walk around to search for any evidence of a bird strike, when they discovered impact damage to the leading edge of the left horizontal stabilizer (see figure 1). Maintenance personnel subsequently discovered a crack, about 12 inches long, in the left horizonal stabilizer lower spar chord. Although the bird impact caused substantial damage to the left horizontal stabilizer, the flight crew was able to control the airplane and the captain reported that “the flight controls and everything felt normal”. Figure 1 – Photo of the left horizontal stabilizer leading edge showing the location of the bird impact. (Source: Southwest Airlines) A review of pilot reports near the time and location of the event revealed that no prior information about bird activity had been reported.
Probable cause
A bird strike during climbout.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BOEING
Model
737
Amateur built
false
Engines
2 Turbo fan
Registration number
N8514F
Operator
SOUTHWEST AIRLINES CO
Second pilot present
true
Flight conducted under
Part 121: Air carrier
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
true
Commercial sightseeing flight
false
Serial number
36975
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-10T00:21:12Z guid: 193561 uri: 193561 title: CEN24LA074 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193571/pdf description:
Unique identifier
193571
NTSB case number
CEN24LA074
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-26T12:15:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2023-12-27T21:01:23.761Z
Event type
Accident
Location
Ponca City, Oklahoma
Airport
Ponca City Regional (PNC)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he completed the before landing checklist while on the downwind leg of the airport traffic pattern. The approach and landing were completed at a reduced flap setting due to the gusty wind. After the airplane touched down, the pilot “felt a pull to the left,” and he thought that there might have been an issue with the nose wheel steering. The airplane ultimately departed the left side of the runway, and the left main landing gear collapsed. The left wing was damaged during the accident sequence. A postaccident examination conducted by a Federal Aviation Administration inspector did not reveal any anomalies with respect to the nose wheel assembly or the steering linkage. Rudder control continuity was confirmed. Surface weather observations indicated that a 50° - 70° right crosswind with gusts to 30 knots prevailed about the time of the accident.
Probable cause
The pilot’s loss of directional control during landing in gusty crosswind conditions.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200T
Amateur built
false
Engines
2 Reciprocating
Registration number
N510P
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
34-7970268
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2023-12-27T21:01:23Z guid: 193571 uri: 193571 title: WPR24LA062 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193584/pdf description:
Unique identifier
193584
NTSB case number
WPR24LA062
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-28T10:57:00Z
Publication date
2024-02-01T05:00:00Z
Report type
Final
Last updated
2024-01-02T21:00:26.778Z
Event type
Accident
Location
Lake Havasu, California
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 1 minor
Analysis
On a previous flight, the pilot of the amphibious light sport airplane had pulled the landing gear circuit breakers to mitigate the risk of accidentally raising the landing gear while on the ground. Prior to the accident flight, which departed from a hard-surface runway, he serviced the airplane with fuel and performed a preflight check. He intended to perform water landings on an adjacent lake, and after takeoff he selected the gear-up switch but had forgotten to reset the circuit breakers. Shortly after takeoff he felt a light airframe vibration and decided to expedite the landing. While circling the landing spot, and slowing the airplane for the approach, the gear misconfigured warning sounded. However, the pilot silenced the warning because his attention was diverted by the landing due to the vibration, so the gear remained extended as the airplane touched the water. The airplane then nosed over and sustained substantial damage. The “before engine start” checklist in the pilot’s operating handbook states that the circuit breakers should be in. There is no reference in the handbook to pulling the circuit breakers to prevent accidental activation.
Probable cause
The pilot’s failure to confirm the landing gear was configured for a water landing during the approach. Contributing to the accident was the pilot’s deviation from the airplanes operating procedures by previously pulling the landing gear circuit breakers, which resulted in the landing gear not retracting when commanded during takeoff.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PROGRESSIVE AERODYNE INC
Model
SEAREY LSA
Amateur built
false
Engines
1 Reciprocating
Registration number
N312PR
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
1127
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-02T21:00:26Z guid: 193584 uri: 193584 title: CEN24LA081 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193605/pdf description:
Unique identifier
193605
NTSB case number
CEN24LA081
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-29T15:27:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-01-09T03:19:26.67Z
Event type
Accident
Location
Beaumont, Texas
Airport
JACK BROOKS RGNL (BPT)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
During the landing attempt with a direct left crosswind in the tailwheel-equipped airplane, the pilot reported he heard a pop, and the airplane veered to the right. The pilot attempted to make a correction to the left to maintain airplane control. The pilot felt the empennage lift and the propeller struck the runway. The right main landing gear collapsed, the right wing struck the runway, and the airplane pivoted around the left main landing gear coming to rest on the runway. The airplane sustained substantial damage to the right wing and wing struts. According to a mechanic, postaccident examination revealed fractures to the landing gear structure that were consistent with an abnormal sideload and subsequent ground loop. No other mechanical failures or malfunctions were reported with the airplane that would have precluded normal operation. At the time of the accident, the pilot was landing the airplane on runway 34 with wind from 250° at 12 knots and gusting to 16 knots.
Probable cause
The pilot’s failure to maintain directional control during landing in crosswind conditions, which resulted in a ground loop on the runway.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
MAULE
Model
M-6-235
Amateur built
false
Engines
1 Reciprocating
Registration number
N71MS
Operator
TAF AERIAL SERVICES LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Aerial observation
Commercial sightseeing flight
false
Serial number
7452C
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-09T03:19:26Z guid: 193605 uri: 193605 title: ERA24LA079 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193587/pdf description:
Unique identifier
193587
NTSB case number
ERA24LA079
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-30T15:04:00Z
Publication date
2024-01-25T05:00:00Z
Report type
Final
Last updated
2024-01-08T22:32:22.929Z
Event type
Accident
Location
Daytona Beach, Florida
Airport
DAYTONA BEACH INTERNATIONAL (DAB)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot of the helicopter reported that while flying at an indicated altitude around 200 to 300 ft, while on approach to land at an off-airport landing zone, he saw a black “drone” [unmanned aerial system (UAS)] in front of his windscreen. He attempted to avoid the UAS but was unable and the UAS impacted the main rotor resulting in substantial damage to a main rotor blade. The pilot reported that there were no preaccident mechanical malfunctions or failures with the helicopter that would have precluded normal operation. The UAS operator reported that he was conducting operations over a construction site. The area was inside of the class C airspace of a nearby airport and the UAS operator was using a Federal Aviation Administration Certificate of wavier or authorization (COA) that had been previously obtained by the construction company who hired him. The UAS operator reported that he was flying at an altitude of 180 ft, and that before the flight he had not realized that this altitude was above the maximum altitude of 150 ft imposed by the COA. The COA also required the UAS operator to notify the air traffic control tower at the nearby airport at least 15 minutes prior to the proposed start time of any operations. The UAS operator stated, and a review of contact records by the air traffic control tower confirmed, that no call was received from the UAS operator notifying them of the operation. Additionally, the drone operations manager for the construction company who contracted the UAS operator reported that the operator was supposed to check in with the on-site supervisor before conducting operations and stated that this did not happen on the day of the accident.
Probable cause
The UAS operator’s failure to operate within the limitations of the COA that he was using to operate inside class C airspace, which resulted in a collision between the UAS and the helicopter.
Has safety recommendations
false

Vehicle 1

Aircraft category
Helicopter
Make
ROBINSON HELICOPTER
Model
R44
Amateur built
false
Engines
1 Reciprocating
Registration number
N828AK
Operator
Tunica Helicopters LLC
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Other work use
Commercial sightseeing flight
true
Serial number
1689
Damage level
Substantial
Events
Findings

Vehicle 2

Aircraft category
Unmanned
Make
DJI
Model
MAVIC 2
Amateur built
false
Registration number
FA3XNWMRAN
Second pilot present
false
Flight conducted under
Part 107: Small UAS
Flight operation type
Other work use
Commercial sightseeing flight
false
Serial number
163DF81001N020
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2024-01-08T22:32:22Z guid: 193587 uri: 193587 title: ERA24LA084 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193603/pdf description:
Unique identifier
193603
NTSB case number
ERA24LA084
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2023-12-31T15:13:00Z
Publication date
2024-03-21T04:00:00Z
Report type
Final
Last updated
2024-01-11T18:04:43.025Z
Event type
Accident
Location
Midland, Virginia
Airport
WARRENTON/FAUQUIER (HWY)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he aborted a bounced, 3-point landing at a nearby airport and then decided to return to his home airport. During the subsequent landing attempt at his home airport, the nose landing gear collapsed, resulting in substantial damage to the fuselage. An examination of the airplane revealed that the nose wheel and nose wheel attach bracket had broken free from the rest of the nose landing gear, and these items were recovered from the aborted landing airport. Following the accident, the pilot reported that he believed that a no-flap landing may prevented the bounced landing. In an interview with the pilot after the accident flight, the pilot also reported that he performed a preflight inspection of the nose landing gear and that he found no mechanical failures or anomalies, and that the nose gear operated normally during taxi and takeoff for the accident flight. Based on this information, it is likely that the pilot’s improper recovery from the bounced landing resulted in damage that ultimately led to the failure of the nose landing gear during the subsequent landing.
Probable cause
The pilot’s improper recovery from a bounced landing, which resulted in damage to, and the separation of the nose wheel and fork bracket assembly, and subsequent collapse of the nose landing gear assembly.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
GOLDEN AVIO S R L
Model
F30 Brio
Amateur built
false
Engines
1 Reciprocating
Registration number
N37GA
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
004CE
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-11T18:04:43Z guid: 193603 uri: 193603 title: CEN24LA075 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193582/pdf description:
Unique identifier
193582
NTSB case number
CEN24LA075
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-01-01T15:40:00Z
Publication date
2024-02-08T05:00:00Z
Report type
Final
Last updated
2024-01-17T01:17:08.112Z
Event type
Accident
Location
Mansfield, Louisiana
Airport
C E 'RUSTY' WILLIAMS (3F3)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that she conducted a normal, full flap landing to the runway. After touchdown, the airplane’s nose landing gear collapsed, and a postimpact fire ensued after the airplane skidded to a stop. The airplane was destroyed by the postimpact fire which precluded a postaccident examination of the nose landing gear system. An airport surveillance video appeared to show the airplane bounce and porpoise several times before the airplane came to rest. Due to the poor quality of the surveillance video and lack of available evidence, the reason for the nose landing gear collapse and postimpact fire during landing sequence could not be determined.
Probable cause
The nose landing gear collapse and postimpact fire due to undetermined reasons.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
C23
Amateur built
false
Engines
1 Reciprocating
Registration number
N9729L
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-1356
Damage level
Destroyed
Events
Findings
creator: NTSB last-modified: 2024-01-17T01:17:08Z guid: 193582 uri: 193582 title: CEN24LA086 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193629/pdf description:
Unique identifier
193629
NTSB case number
CEN24LA086
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-01-07T06:10:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2024-01-11T02:43:00.087Z
Event type
Accident
Location
Fort Worth, Texas
Airport
PEROT FLD/FORT WORTH ALLIANCE (AFW)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The flight instructor reported that he and the private pilot receiving instruction had just completed their seventh landing of the morning. The private pilot reduced the throttle on downwind and the landing gear warning horn sounded so he increased the throttle and continued in the traffic pattern. The flight instructor prompted him to extend the flaps and the student stated that he would extend the landing gear. They “confirmed 3 green,” which would indicate that the landing gear was down and locked. During the landing flare, “no gear warning horn was alarming,” but as they got closer to the ground the instructor observed sparks out of the left window. The airplane slid on the runway, came to rest upright, and sustained substantial damage to the lower fuselage longerons. The Federal Aviation Administration (FAA) inspector completed an extensive examination and functional testing of the landing gear system. With the airplane on jacks, he cycled the landing gear at least six times and determined the landing gear, warning annunciations and aural alerts operated per the procedures in the airplane’s maintenance manual and there were no anomalies found.
Probable cause
The pilot’s failure to extend the landing gear and the flight instructor’s lack of recognition and inadequate remedial action, which resulted in a gear up landing.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER AIRCRAFT INC
Model
PA-44-180
Amateur built
false
Engines
2 Reciprocating
Registration number
N816AT
Operator
ATP Flight School
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
4496535
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-11T02:43:00Z guid: 193629 uri: 193629 title: ERA24LA089 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193664/pdf description:
Unique identifier
193664
NTSB case number
ERA24LA089
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-01-09T13:15:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-01-19T22:29:45.014Z
Event type
Accident
Location
Groton, Connecticut
Airport
GROTON-NEW LONDON (GON)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
On the downwind leg of the traffic pattern the pilot receiving instruction and the flight instructor were having a conversation about when to extend the landing gear, as the pilot receiving instruction was new to this airplane. During this discussion the pilots were contacted by air traffic control (ATC) and a conversation took place about a possible change of runway. After the exchange with ATC the pilots did not return to their conversation about when to extend the landing gear. After being cleared to land, the pilot receiving instruction performed a normal approach to landing. The pilots reported that they realized they had forgotten to extend the landing gear when they heard the airplane contact the runway. The airplane skidded down the asphalt, resulting in substantial damage to the external longerons of the fuselage. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The airplane was equipped with a landing gear position warning horn that was designed to sound when either of the throttles were pulled back for landing. Neither pilot specifically remembered hearing the warning horn during the accident landing. After the airplane was recovered, the landing gear warning horn was tested and was found to operate normally.
Probable cause
The pilot receiving instruction’s failure to extend the landing gear prior to landing. Also contributing, was the flight instructor’s failure to monitor the airplane’s configuration while on approach to land.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-34-200
Amateur built
false
Engines
2 Reciprocating
Registration number
N33300
Operator
UPGRADE INCORPORATED
Second pilot present
true
Flight conducted under
Part 91: General aviation
Flight operation type
Instructional
Commercial sightseeing flight
false
Serial number
34-7450205
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-19T22:29:45Z guid: 193664 uri: 193664 title: CEN24LA087 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193640/pdf description:
Unique identifier
193640
NTSB case number
CEN24LA087
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-01-09T16:35:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2024-01-12T00:45:51.961Z
Event type
Accident
Location
Park Rapids, Minnesota
Airport
SKY MANOR AERO ESTATES (MN86)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that he completed a full preflight inspection of the airplane with no issues noted, including inspecting all the flight control surfaces. During the run-up, the pilot checked all the flight controls and he noted they “all checked perfect.” The pilot was operating at a remote airport that was surrounded by pine trees, about 90 ft tall, on all sides. The takeoff roll from the snow-covered runway was “normal” and about 150 ft agl, the airplane “started turning/pulling left” in a descending turn. The pilot attempted to correct the turn and descent to no avail. The pilot decided to continue to use engine power until the airplane impacted trees. The airplane impacted several trees and came to rest nose down. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage, both wings, and the engine mount. The pilot reported there were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. A postaccident examination of the airframe established flight control continuity.
Probable cause
The pilot’s failure to maintain directional control and terrain clearance during initial climb, that resulted in an impact with trees and terrain.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
J3C
Amateur built
false
Engines
1 Reciprocating
Registration number
N1401V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
10771
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-12T00:45:51Z guid: 193640 uri: 193640 title: CEN24LA090 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193667/pdf description:
Unique identifier
193667
NTSB case number
CEN24LA090
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-01-10T18:15:00Z
Publication date
2024-02-20T05:00:00Z
Report type
Final
Last updated
2024-01-18T01:15:31.423Z
Event type
Accident
Location
Lampasas, Texas
Airport
LAMPASAS (LZZ)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported, that while conducting a full stop landing, he was concerned with a military helicopter about ¾ of the way down the right side of the runway. Due to the helicopter’s position, he reduced the engine power to idle and touched down about 10 mph faster than usual. During the rollout, the pilot overcorrected to the left, the airplane tilted to the right, and the right wing contacted the ground. The right main landing gear collapsed, and the right wing sustained substantial damage. The pilot reported that there was a possibility of rotor wash from the military helicopter. There was no evidence of any preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operations.
Probable cause
The pilot’s failure to maintain directional control during the landing roll.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
PIPER
Model
PA-12
Amateur built
false
Engines
1 Reciprocating
Registration number
N7670H
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
12-549
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-01-18T01:15:31Z guid: 193667 uri: 193667 title: CEN24LA105 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193742/pdf description:
Unique identifier
193742
NTSB case number
CEN24LA105
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-02-02T14:00:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-02-05T20:26:33.267Z
Event type
Accident
Location
Blytheville, Arkansas
Airport
BLYTHEVILLE MUNI (HKA)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot reported that during landing the airplane bounced multiple times. During each successive bounce, the airplane gained more altitude to the point that the pilot was scared. He added full power to go around, the airplane turned left, and he was unable to maintain control. The airplane impacted a ditch off the side of the runway and sustained substantial damage to the fuselage. The pilot reported that there were no preimpact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Probable cause
The pilot’s improper descent path which resulted in a bounced landing and loss of control.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
BEECH
Model
B23
Amateur built
false
Engines
1 Reciprocating
Registration number
N6148N
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Commercial sightseeing flight
false
Serial number
M-1225
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-02-05T20:26:33Z guid: 193742 uri: 193742 title: CEN24LA106 link: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193743/pdf description:
Unique identifier
193743
NTSB case number
CEN24LA106
Transportation mode
Aviation
Investigation agency
NTSB
Completion status
Completed
Occurrence date
2024-02-02T16:00:00Z
Publication date
2024-02-29T05:00:00Z
Report type
Final
Last updated
2024-02-05T20:05:56.313Z
Event type
Accident
Location
Hayward, Wisconsin
Airport
Sawyer County (HYR)
Weather conditions
Visual Meteorological Conditions
Injuries
0 fatal, 0 serious, 0 minor
Analysis
The pilot and passenger were returning from a local flight. During landing rollout, the tail rose off the runway, and the airplane nosed over. It came to rest upside down on the runway centerline with no injuries to the occupants. The airframe sustained damage to the fuselage, both wings, the vertical stabilizer, and the rudder. The pilot stated there were no issues with the airplane and thought that applying less rudder and brake pressure might have prevented the accident.
Probable cause
The pilot’s loss of control during landing rollout.
Has safety recommendations
false

Vehicle 1

Aircraft category
Airplane
Make
CESSNA
Model
140
Amateur built
false
Engines
1 Reciprocating
Registration number
N1887V
Second pilot present
false
Flight conducted under
Part 91: General aviation
Flight operation type
Personal
Flight service type
Passenger
Flight terminal type
Domestic
Scheduled flight
false
Commercial sightseeing flight
false
Serial number
14067
Damage level
Substantial
Events
Findings
creator: NTSB last-modified: 2024-02-05T20:05:56Z guid: 193743 uri: 193743