National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA15LA001
10/01/2014 0 EDT
Regis# NONE
Monongahela, PA
Apt: Rostraver FWQ
Acft Mk/Mdl AIR COMMAND 582
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Eng Mk/Mdl ROTAX 582
Fatal
Flt Conducted Under: FAR 091
Opr Name: DAVID P CHARLETTA
1
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: NON
Narrative
On October 1, 2014, at an unknown time, an unregistered Air Commander 582, was substantially damaged when it impacted terrain near Rostraver Airport
(FWQ), Monogahela, Pennsylvania. The private pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the
presumed local personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.
According to the Westmorland County, Pennsylvania Coroner's Summary Report, the accident pilot was last observed flying the single-seat gyroplane about
1350 on the day of the accident. When the pilot did not meet his family later that evening, they reported him missing. The wreckage was subsequently located
the following day about 0915, about 750 feet east of the runway 26 threshold at FWQ.
The wreckage was subsequently recovered from the site and a detailed examination of the airframe and engine was scheduled for a later date.
The pilot held a private pilot certificate with a rating for airplane single engine land and his most recent Federal Aviation Administration third-class medical
certificate was issued on August 12, 2014.
Printed: October 15, 2014
Page 1
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Air Data Research
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210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14CA286
06/06/2014 1850 EDT Regis# N6017R
Acft Mk/Mdl CESSNA AIRCRAFT CO 162
Acft SN 16200140
Eng Mk/Mdl CONT MOTOR O-200
Opr Name: GAU AIR LLC
Cross City, FL
Apt: Cross City CTY
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Opr dba:
Aircraft Fire: NONE
AW Cert: LTSP
Summary
The student pilot was conducting a solo cross country flight. While landing at the destination airport, he allowed the nose landing gear to contact the runway
first, which resulted in its subsequent collapse. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed substantial
damage to the engine firewall. The student pilot stated there were no mechanical malfunctions or anomalies of the airplane that would have precluded normal
operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's improper
landing flare, which resulted in a hard landing and the collapse of the nose landing gear.
Events
1. Landing-flare/touchdown - Abnormal runway contact
2. Landing-flare/touchdown - Landing gear collapse
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Not attained/maintained - C
Narrative
The student pilot was conducting a solo cross country flight. While landing at the destination airport, he allowed the nose landing gear to contact the runway
first, which resulted in its subsequent collapse. Postaccident examination of the airplane by a Federal Aviation Administration inspector revealed substantial
damage to the engine firewall. The student pilot stated there were no mechanical malfunctions or anomalies of the airplane that would have precluded normal
operation.
Printed: October 15, 2014
Page 2
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA470
08/31/2014 1400 CDT Regis# N821EV
Minneapolis, MN
Apt: Airlake LVN
Acft Mk/Mdl EVEKTOR-AEROTECHNIK AS
Acft SN 20070821
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 912 ULS
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: BAAR RONALD
Opr dba:
685
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: LTSP
Summary
The pilot maneuvered the airplane to land on runway 12 at the destination airport. Wind was from 190 degrees at 11 knots gusting to 18 knots. The estimated
crosswind component was between 10.5 to 17.5 knots. The pilot crabbed the airplane on a 1-2 mile straight-in approach for the runway. Prior to landing, the
pilot aligned the nose of the airplane with the runway centerline and reduced power. When the airplane touched down a gust of wind lifted the right wing and
lowered the left wing to the runway. As the pilot initiated a go-around the left wing contacted the ground and control of the airplane was lost. The pilot stated
that the airplane then stalled and impacted the ground. The pilot reported that his flight school did not fly if the crosswind component was 10 knots or higher
and as a result he did not have much experience flying in winds greater than 10 knots of crosswind.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of control while
landing with a crosswind. Contributing to the accident was the pilot lack of experience flying in similar weather conditions.
Events
1. Landing - Other weather encounter
2. Approach-VFR go-around - Abnormal runway contact
3. Approach-VFR go-around - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Ability to respond/compensate
3. Environmental issues-Conditions/weather/phenomena-Wind-Gusts-Ability to respond/compensate
4. Personnel issues-Experience/knowledge-Experience/qualifications-(general)-Pilot - F
Narrative
The pilot maneuvered the airplane to land on runway 12 at the destination airport. Wind was from 190 degrees at 11 knots gusting to 18 knots. The pilot
crabbed the airplane on a 1-2 mile straight-in approach for the runway. Prior to landing, the pilot aligned the nose of the airplane with the runway centerline and
reduced power. When the airplane touched down a gust of wind lifted the right wing and lowered the left wing to the runway. As the pilot initiated a go-around
the left wing contacted the ground and control of the airplane was lost. The pilot perceived that the airplane then stalled and impacted the ground. The pilot
reported that his flight school did not practice if the crosswind component was 10 knots or higher and as a result he did not have much experience flying winds
greater than 10 knots of crosswind.
Printed: October 15, 2014
Page 3
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR14CA364
09/03/2014 1215 PDT Regis# N245LS
Grass Valley, CA
Apt: Nevada County Air Park GOO
Acft Mk/Mdl FLIGHT DESIGN GMBH CTLS LSA-NO
Acft SN F-08-05-12
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 912 ULS 2
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: QUAN ERICK PAT
Opr dba:
499
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: LTSP
Summary
The pilot reported that on landing the airplane touched down hard and began to porpoise, striking the runway twice during the accident sequence. The pilot
reported a loss of nose wheel and rudder control responsiveness and was unable to maintain directional control when the airplane departed the runway to the
right, traveled down an embankment and subsequently rolled over, coming to rest inverted. The airplane sustained substantial damage to right wing, vertical
stabilizer and fuselage. The pilot reported no preimpact mechanical failures or malfunctions that would have precluded normal operation of the airplane.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate flare
which resulted in a loss of aircraft control during landing.
Events
1. Landing-flare/touchdown - Abnormal runway contact
2. Landing-landing roll - Loss of control on ground
3. Landing-landing roll - Runway excursion
4. Landing-landing roll - Roll over
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Not attained/maintained - C
Narrative
The pilot reported that on landing the airplane touched down hard and began to porpoise, striking the runway twice during the accident sequence. The pilot
reported a loss of nose wheel and rudder control responsiveness and was unable to maintain directional control when the airplane departed the runway to the
right, traveled down an embankment and subsequently rolled over, coming to rest inverted. The airplane sustained substantial damage to right wing, vertical
stabilizer and fuselage. The pilot reported no preimpact mechanical failures or malfunctions that would have precluded normal operation of the airplane.
Printed: October 15, 2014
Page 4
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Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR15CA011
10/12/2014 1630
Acft Mk/Mdl FOXAIR LLC KITFOX LIGHT SPORT-N
Regis# N725KA
Nampa, ID
Acft SN KA11242203
Acft Dmg:
Fatal
Opr Name: DEXTER WOODWARD
Printed: October 15, 2014
Page 5
0
Rpt Status: Prelim
Ser Inj
Opr dba:
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
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210-695-2204 - [email protected] - www.airsafety.com
0
Prob Caus: Pending
Flt Conducted Under: FAR 091
Aircraft Fire:
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA291
06/05/2014 1115 CDT Regis# N752J
Acft Mk/Mdl JABIRU USA SPORT AIRCRAFT LLC
Acft SN 804
Eng Mk/Mdl JABIRU 3300A
Acft TT
Opr Name: READ WILLIAM CHARLES
Opr dba:
216
Middleton, WI
Apt: Middleton Muni - Morey Field C29
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: LTSP
Narrative
The pilot stated he was taking off from a turf runway and he did not maintain directional control of the airplane on the soft runway surface. The airplane struck a
runway edge marker, substantially damaging the airplane at the gear strut attachment point. The pilot reported there were no anomalies with the airplane prior
to impact.
Printed: October 15, 2014
Page 6
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Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN12LA636
09/16/2012 1852 CDT Regis# N3533D
Acft Mk/Mdl JDT MINI-MAX LLC 1500R
Acft SN 852
Eng Mk/Mdl ROTAX 447UL
Acft TT
Opr Name: DAVID D. KING
Opr dba:
253
Cameron, MO
Apt: Cameron Memorial Airport EZZ
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
1
Ser Inj
0
Aircraft Fire: NONE
Summary
A witness to the accident reported that he was outside his residence when he heard the accident airplane departing to the south. He initially heard the sound of
the airplane's engine before he saw the airplane climbing away from the runway at an estimated 45-degree, nose-up pitch attitude. The witness did not perceive
any engine anomalies as the airplane climbed to about 350 feet above the ground, where it suddenly rolled right and entered a near-vertical descent into terrain.
The postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The
witness's description of the airplane's flightpath was consistent with an aerodynamic stall and spin during initial climb.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
adequate airspeed during initial climb, which resulted in an aerodynamic stall and spin at a low altitude.
Events
1. Initial climb - Loss of control in flight
2. Initial climb - Aerodynamic stall/spin
3. Uncontrolled descent - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
Narrative
HISTORY OF FLIGHT
On September 16, 2012, about 1852 central daylight time, an experimental JDT Mini-Max LLC model 1500R light sport airplane, N3533D, was substantially
damaged when it collided with terrain shortly after takeoff from the Cameron Memorial Airport (EZZ), Cameron, Missouri. The sport pilot, who was the sole
occupant, was fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 without a
flight plan. Day visual meteorological conditions prevailed for the personal flight. The local area flight was originating at the time of the accident.
A witness to the accident reported that he was outside his residence when he heard the accident airplane departing to the south. He initially heard the sound of
the engine before he spotted the airplane climbing away from runway 17 at an estimated 45-degree nose up pitch attitude. The witness reported that he did not
perceive any engine anomalies as the airplane climbed to about 350 feet above the ground, where it suddenly rolled to the right and entered a near vertical
descent into terrain.
PERSONNEL INFORMATION
According to Federal Aviation Administration (FAA) records, the accident pilot, age 52, held a sport pilot certificate, issued on October 9, 2010, with airplane
single engine land rating. The pilot had never applied for an aviation medical certificate; however, the operation of a light-sport aircraft only required a valid
driver's license. A search of FAA records showed no accident, incident, enforcement, or disciplinary actions.
The pilot's most recent logbook entry was dated August 12, 2012, at which time he had accumulated 72.8 hours total flight time, of which 38.5 hours were as
pilot-in-command. The pilot's first recorded flight in the accident airplane was completed on June 11, 2011. He had accumulated 30 hours in the accident
airplane as of the last logbook entry. He had flown 27.5 hours during the past year, 16 hours during the prior 6 months, and 10 hours during previous 90 days.
There was no record that the pilot had flown during the 30 day period before the accident flight. All of the flight time accumulated during the previous year had
been completed in the accident airplane.
AIRCRAFT INFORMATION
The experimental light sport airplane was a 2002 JDT Mini-Max LLC model 1500R, serial number (s/n) 852. A two-stroke, two-cylinder, air cooled,
Printed: October 15, 2014
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Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
40-horsepower, Rotax model 447UL engine, s/n 5504279, powered the airplane. The engine was equipped with a three-blade Ivoprop propeller. The single-seat,
tail-wheel equipped airplane was constructed of wood and fabric and had a maximum takeoff weight of 630 pounds.
According to FAA records, the airplane had already accumulated 195 hours when it received its experimental airworthiness certificate on November 23, 2007,
by a designated airworthiness representative. A digital hour meter found in the wreckage indicated that the airplane had accumulated 253 hours total time at the
time of the accident. The airplane maintenance records were not located during the on-scene investigation.
METEOROLOGICAL INFORMATION
The closest weather observing station was located at the Midwest National Air Center Airport (GPH), about 28 miles south of the accident site. At 1855, the
GPH automatic weather observing station reported: calm wind conditions, clear sky, surface visibility 10 miles, temperature 22 degrees Celsius, dew point 16
degrees Celsius, and an altimeter setting of 29.97 inches of mercury.
Astronomical data obtained from the United States Naval Observatory indicated that the local sunset was at 1923, about 31 minutes after the accident, and the
end of civil twilight was at 1950.
AIRPORT INFORMATION
The Cameron Memorial Airport (EZZ), a public-use airport, located about 2 miles southwest of Cameron, Missouri, was served by a single runway: 17/35 (4,000
feet by 75 feet, concrete). The airport elevation was 1,040 feet mean sea level (msl). According to airport data, there were trees, measuring 23 feet tall, located
1,200 feet from the departure end of runway 17 and 326 feet west of the extended runway centerline.
WRECKAGE AND IMPACT INFORMATION
A postaccident investigation, completed by FAA inspectors, confirmed that all airframe structural components were located at the accident site. The main
wreckage was located about 94 feet north of the runway end and about 27 feet east of the runway edge. The entire wreckage was contained within an area
comparable to the lateral dimensions of the aircraft. The lack of a wreckage debris path was consistent with a near vertical impact angle. A portion of a wing
leading edge rib was found embedded into the ground. The angle between the rib and the surrounding terrain was about 75 degrees. Elevator and rudder flight
control continuity was established from the control surfaces to their associated cockpit controls. Aileron flight control continuity could not be established due to
damage; however, all observed separations were consistent with overstress failure. Both wing fuel tanks appeared undamaged and were about 1/2 full. The
airframe examination revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation.
The engine remained partially attached to the fuselage; however, the carburetor and fuel pump had separated from the engine. Internal engine and valve train
continuity was confirmed as the engine crankshaft was rotated. Compression and suction were noted on both cylinders in conjunction with crankshaft rotation.
The spark plugs were removed and exhibited features consistent with normal engine operation. All three composite propeller blades remained attached to the
metal hub assembly and exhibited damage consistent with ground impact. The engine examination revealed no evidence of mechanical malfunctions or
anomalies that would have precluded normal operation.
MEDICAL AND PATHOLOGICAL INFORMATION
On September 19, 2012, an autopsy was performed on the pilot at the First Call Morgue, located in Kansas City, Kansas. The cause of death for the pilot was
attributed to multiple blunt-force injuries sustained during the accident.
The FAA Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on samples obtained during the pilot's autopsy.
Carbon monoxide, cyanide, and ethanol were not detected. Pseudoephedrine was detected in blood and urine samples. Pseudoephedrine, brand name
Sudafed, is a non-sedating over-the-counter medication that is used to relieve nasal congestion and pressure caused by colds, allergies, and hay fever.
Printed: October 15, 2014
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Prepared From Official Records of the NTSB By:
Air Data Research
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210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN12LA634
09/14/2012 1615 CDT Regis# N850GB
Vermillion, SD
Apt: Harold Davidson Field Airport VMR
Acft Mk/Mdl NORTH WING DESIGN APACHE SPORT
Acft SN 51188
Acft Dmg: DESTROYED
Eng Mk/Mdl ROTAX 582 UL DCDI
Acft TT
Fatal
Opr Name: LOWELL L. RAHN
Opr dba:
211
1
Ser Inj
Rpt Status: Factual Prob Caus: Pending
0
Flt Conducted Under: FAR 091
Aircraft Fire: GRD
Summary
Witnesses reported seeing the weight-shift-control light-sport aircraft shortly after takeoff in a steep climb before it rolled left and entered a near-vertical descent
into terrain. Two witnesses reported that the engine was not operating normally before the aircraft departed controlled flight. The aircraft was subsequently
destroyed during a postimpact ground fire. An examination of the remaining airframe components and the engine revealed no preimpact mechanical
malfunctions or failures that would have precluded normal operation. Although the propeller was partially consumed by fire, it exhibited impact damage
consistent with rotation at the time of impact. However, a functional test of the engine was not possible because both carburetors and the dual electronic
ignition system were destroyed during the postimpact fire.The pilot had a history of coronary artery disease, an aortic heart valve replacement, a craniotomy
following a skiing accident, and multiple episodes of transient ischemic attack. However, insufficient evidence existed to determine if the pilot had become
impaired or incapacitated at the time of the accident. The pilot had never applied for a Federal Aviation Administration (FAA) medical certificate. According to
FAA regulations, a pilot operating a light-sport aircraft does not need to apply for nor possess an FAA medical certificate. In lieu of a medical certificate, a pilot
can operate light-sport aircraft if they possess a valid driver's license; the pilot had a valid driver's license when the accident occurred. Per FAA regulations, a
pilot must not know of or have reason to know of any medical condition that would make them unable to operate a light-sport aircraft in a safe manner. The
pilot's documented medical conditions would likely have precluded him from holding an FAA medical certificate of any class. Additionally, the pilot had been
diagnosed with dizziness by his personal physician who counseled him against driving and flying. The pilot's spouse reported that her husband had no recent
complaints of fatigue, shortness of breath, or chest pain. On the day of the accident, the pilot was reportedly alert with no noticeable fatigue or complaints and
was looking forward to his upcoming cross-country flight.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
control of the weight-shift-control aircraft during initial climb, which resulted in an aerodynamic stall/spin.
Events
1. Initial climb - Loss of control in flight
2. Initial climb - Aerodynamic stall/spin
3. Uncontrolled descent - Collision with terr/obj (non-CFIT)
4. Post-impact - Fire/smoke (post-impact)
Findings - Cause/Factor
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
3. Personnel issues-Physical-Health/Fitness-Predisposing condition-Pilot
Narrative
HISTORY OF FLIGHT
On September 14, 2012, about 1615 central daylight time, an experimental North Wing Design model Apache Sport light sport aircraft, N850GB, was destroyed
when it collided with terrain shortly after takeoff from the Harold Davidson Field Airport (VMR), Vermillion, South Dakota. A postimpact ground fire ensued. The
sport pilot, who was the sole occupant, was fatally injured. The weight-shift-control aircraft was registered to and operated by the pilot under the provisions of
14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the personal flight. The cross-country flight was
originating at the time of the accident and was en route to a private airstrip near Kimball, South Dakota.
A witness to the accident reported that he was working outside his residence when he heard the weight-shift-control aircraft depart the airport. He initially heard
the sound of the aircraft's engine before he spotted the aircraft climbing at a steep angle. He reported that the aircraft then rolled to the left and entered a near
vertical descent. The aircraft descended below his sightline before he heard a sound similar to a ground impact and saw smoke rising-up from the same general
area.
Another witness reported that he was working in his garage when he heard the sound of an aircraft engine "having trouble." He looked up and saw the
weight-shift-control aircraft in a steep bank angle as it descended toward the ground. He stated that the engine was making a loud noise during the descent.
Printed: October 15, 2014
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Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Another witness reported that he was watching the weight-shift-control aircraft takeoff from the airport. He stated that the engine initially sounded like it was
operating normally, but as the aircraft continued to climb the engine began to run roughly. He noted that the airplane then descended below a nearby tree line.
PERSONNEL INFORMATION
According to Federal Aviation Administration (FAA) records, the pilot, age 75, held a sport pilot certificate with weight-shift-control and powered-parachute
ratings. He also held a repairman certificate, which allowed him to maintain the accident weight-shift-control aircraft and two other light-sport aircraft. According
to FAA records, the pilot had never applied for an aviation medical certificate; however, the operation of a light-sport aircraft only required a valid driver's
license. A search of FAA records showed no previous accidents, incidents, or enforcement proceedings.
The most recent pilot logbook entry was dated September 11, 2012. At that time, the pilot had accumulated 571.3 hours total flight time, of which 375.7 hours
were logged as pilot-in-command. He had logged 375.7 flight hours in weight-shift-control aircraft and 195.6 hours in powered-parachutes. All of his documented
flight experience was in daytime visual meteorological conditions. He had logged 44.5 hours during the past year, 27.2 hours during the prior 6 months, 16.3
hours during previous 90 days, and 3.7 hours in the last 30 days. The pilot did not log a flight within 24 hours of the accident. His last flight review was
completed on September 9, 2011, in an Edge XT-582-L weight-shift-control aircraft.
AIRCRAFT INFORMATION
The weight-shift-control aircraft was a 2005 North Wing Design model Apache Sport, serial number (s/n) 51188. A two-stroke, two-cylinder, water cooled,
65-horsepower, Rotax model 582 UL DCDI engine, s/n 5743300, powered the aircraft. The engine was equipped with a ground-adjustable, three blade, Ivoprop
model Quick Adjust propeller. The aircraft could seat two individuals, and had an empty weight and a maximum takeoff weight of 473 pounds and 950 pounds,
respectively.
The weight-shift-control aircraft was issued an experimental airworthiness certificate on April 24, 2007. The pilot purchased the aircraft on February 23, 2011.
According to available information, the airframe and engine had accumulated a total service time of 210.6 hours at the time of the accident.
The last conditional inspection was completed on April 10, 2012, at 184.1 hours airframe total time. A postaccident review of the maintenance records found no
history of unresolved airworthiness issues.
METEOROLOGICAL INFORMATION
At 1555, the VMR automatic weather observing station reported the following weather conditions: wind from 280 degrees at 2 knots, visibility in excess of 10
miles, temperature 28 degrees Celsius, dew point 4 degrees Celsius, and an altimeter setting of 30.24 inches of mercury. Review of photographs taken by local
law enforcement immediately following the accident revealed no appreciable cloud cover or visibility restrictions at the accident site, consistent with visual
meteorological conditions.
A pilot reported experiencing moderate turbulence, updrafts, and dust-devils while flying near the accident site about 30 minutes before the accident occurred.
AIRPORT INFORMATION
The Harold Davidson Field Airport (VMR), a public-use airport, located about 1 mile south of Vermillion, South Dakota, was served by a single runway: 12/30
(4,105 feet by 75 feet, concrete). The airport elevation was 1,147 feet mean sea level (msl).
WRECKAGE AND IMPACT INFORMATION
A postaccident on-scene examination, completed by a FAA Airworthiness Inspector, confirmed that all airframe structural components were located at the
accident site. The main wreckage was located on the extended runway 30 centerline, about 1/2 mile past the end of the runway. The entire wreckage was
contained within an area comparable to the lateral dimensions of the aircraft. The lack of a wreckage debris path or any lateral impact damage to the
surrounding corn crop was consistent with a near vertical impact angle. A majority of the fuselage structure and wing were consumed during the postimpact fire.
Printed: October 15, 2014
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Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Flight control continuity could not be established due to damage; however, all observed separations were consistent with either an overstress failure or
prolonged exposure to fire.
The engine exhibited damage consistent with prolonged exposure to fire. The dual electronic ignition system and both carburetors were destroyed during the
fire. A postaccident engine examination confirmed internal engine and valve train continuity as the engine crankshaft was rotated. Compression and suction
were noted on both cylinders in conjunction with crankshaft rotation. The spark plugs were removed and exhibited features consistent with normal engine
operation. All three composite propeller blades remained attached to the metal hub assembly and exhibited damage consistent with impact and prolonged
exposure to fire. The engine examination revealed no preimpact mechanical malfunctions or failures that would have precluded normal engine operation.
MEDICAL AND PATHOLOGICAL INFORMATION
On September 17, 2012, an autopsy was performed on the pilot at Sanford Health Pathology Clinic, located in Sioux Falls, South Dakota. The cause of death
for the pilot was attributed to multiple blunt-force injuries sustained during the accident. The autopsy report also described extensive postmortem thermal
injuries. Additionally, the autopsy report indicated that there was significant blunt-force damage to the heart that precluded a detailed examination.
The FAA Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on samples obtained during the pilot's autopsy.
Ethanol and n-propanol were detected in muscle samples, but was not detected in brain tissues. The presence of ethanol and n-propanol was attributed to
sources other than ingestion. Metoprolol was detected in muscle and liver samples. Metoprolol, brand name Lopressor or Toprol XL, is a prescription
medication used to treat high blood pressure, angina, and to control heart rate in some arrhythmias. Rosuvastatin was detected in liver samples. Rosuvastatin,
brand name Crestor, is a prescription medication used to treat high cholesterol and prevent heart disease. Tamsulosin was detected in muscle and liver
samples. Tamsulosin, brand name Flomax, is a prescription medication used to treat benign prostatic hyperplasia. Warfarin was detected in muscle and liver
samples. Warfarin, brand name Coumadin, is a prescription anticoagulant.
During the postaccident investigation, the NTSB Investigator-In-Charge and a FAA Medical Officer interviewed the pilot's spouse to ascertain the pilot's
previous medical history. The pilot had an artificial aortic heart valve replacement for the past 38 years and was on a daily regimen of Coumadin. Additionally,
he had coagulation studies done monthly, which were reportedly normal and there were no known issues with his replacement heart valve.
The pilot had heart bypass surgery in the 1990's. In 2006 he had a cardiac catheterization to evaluate ischemia and to install a stent in an artery that was
90-percent occluded; however, the location of the occlusion prevented stenting and his previous surgeries prevented additional surgical intervention. The pilot
was reportedly receiving medical treatment for his ischemic coronary artery disease.
The pilot had a craniotomy after developing slurred speech resulting from a slowly expanding subdural hematoma sustained during a ski accident about 10
years before his fatal aviation accident. Following the craniotomy, his slurred speech resolved and he had no residual neurological symptoms.
The pilot's spouse reported that the pilot had 4 or 5 episodes of transient ischemic attack; however, the symptoms of each episode were always different. More
than 10 years before the accident flight and before his craniotomy surgery, the pilot experienced double vision while driving. Then about a year later he had
another episode when he told his wife that he was experiencing eye problems and his wife noted that his eyes were bulging; however, the symptoms resolved
after a few seconds. Since his craniotomy procedure, while operating an automobile, the pilot reportedly lost vision and had to pull over and let his wife drive.
The final episode occurred 3 or 4 years before the accident flight, when the pilot told his wife that he felt the table was tipping, but she noted he was leaning
instead. The pilot's spouse reported that each episode lasted only a few seconds and after which, the pilot exhibited no residual symptoms. Following his most
recent episode, which occurred 3 to 4 years before the accident flight, the pilot's spouse asked her husband to tell his physician about his latest episode;
however, she did not know if he indeed told his doctor or not.
The pilot was evaluated by his personal physician in February 2008 and was diagnosed with dizziness and counseled him against driving or flying. However,
records show that in April 2010, the pilot passed an exam for a commercial driver's license.
The pilot's spouse reported that her husband had no recent complaints of fatigue, shortness of breath or chest pain. On the day of the accident, the pilot was
reportedly alert with no noticeable fatigue or complaints, and was looking forward to his upcoming cross country flight.
According to FAA regulations, a pilot operating light-sport aircraft does not need to apply for nor possess a FAA medical certificate. In lieu of a FAA medical
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certificate, a pilot can operate light-sport aircraft if they possess a valid driver's license; although, a pilot must not know of or have reason to know of any
medical condition that would make them unable to operate a light-sport aircraft in a safe manner.
TESTS AND RESEARCH
A handheld GPS device was recovered from the wreckage and sent to the NTSB Vehicle Recorder Laboratory for further examination. The GPS device
exhibited significant thermal damage, consistent with a prolonged exposure to fire. The damage to the GPS device prevented a normal download via a cabled
connection to a host computer. A nonvolatile memory chip, which normally contains recorded position data, was extracted from the damaged GPS; however,
the NTSB Vehicle Recorder Laboratory was unable to perform a chip-level download due to heat damage sustained to the memory chip.
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14CA190
04/10/2014 1100 EDT Regis# N657G
Acft Mk/Mdl PROGRESSIVE AERODYNE INC SEAREY Acft SN 1004
Eng Mk/Mdl ROTAX 914
Acft TT
Opr Name: W. E. HARTMAN
Opr dba:
55
Tavares, FL
Apt: N/a
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: LTSP
Narrative
According to the pilot, he positioned his airplane to land in an area on a lake with light ripples. During the landing attempt, the airplane bounced and the pilot
attempted to continue the landing instead of immediately initiating a go around. The pilot stated that he then elected to perform a go around; however, there
was not enough room to clear the trees at the end of the lake. The airplane subsequently impacted the tree line and came to rest.
Post-accident examination of the airplane revealed that both wing leading edges and the empennage incurred substantial damage. The pilot did not report any
pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
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Accident Rpt# WPR12LA176
04/19/2012 1039 HST Regis# N5089F
Ookala, HI
Apt: N/a
Acft Mk/Mdl SKYKITS USA CORP SAVANNAH ADV
Acft SN 05-10-51-427
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: CAPTAIN CRUISE INC
Opr dba:
630
0
Ser Inj
1
Aircraft Fire: NONE
Summary
The owner/pilot topped off both fuel tanks in the special light-sport airplane, flew uneventfully to another airport, and departed shortly thereafter. About 75
minutes after the initial departure, while in cruise flight at an altitude that the pilot estimated as between 2,500 and 3,000 feet, the engine lost power. Due in part
to the airplane's low altitude, the pilot did not attempt any corrective actions, and focused on finding a suitable landing location. The pilot selected a young
cornfield for the landing but stalled the airplane a few feet above the ground, which resulted in a near vertical impact trajectory in a flat attitude. The pilot
reported that he believed that the power loss was due to asymmetric fuel feed from the two wing-mounted fuel tanks due to a plugged fuel vent in the left tank.
Although the fuel vents were not examined, no mechanical failures or deficiencies that would have precluded continued engine operation were observed during
examination of the airplane. Accordingly, the investigation did not determine a specific reason for the power loss, or the specific reason(s) why the pilot stalled
the airplane.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of engine power during
cruise for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal operation.
Contributing to the accident was the pilot's failure to avoid an aerodynamic stall at low altitude during the forced landing.
Events
1. Enroute-cruise - Loss of engine power (partial)
2. Landing - Aerodynamic stall/spin
Findings - Cause/Factor
1. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
2. Aircraft-Aircraft power plant-Engine (reciprocating)-(general)-Not specified - C
3. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - F
Narrative
HISTORY OF FLIGHT
On April 19, 2012, about 1039 Hawaiian standard time, a special light-sport Skykits Savannah ADV airplane, N5089F, was substantially damaged when it
impacted terrain near Ookala, Hawaii, following a partial loss of engine power in cruise flight. The pilot/owner was seriously injured. The personal flight was
conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no Federal Aviation
Administration (FAA) flight plan was filed for the flight.
Two witnesses working at a dairy farm heard the airplane fly overhead. One noticed that the engine did not sound right, saw the airplane descending, and
believed that it was going to crash. The witnesses tracked it visually and then got in a car to follow, but lost sight of it. Shortly thereafter they saw that the
airplane had impacted in a field of young corn plants. On reaching the wreckage, they saw that the pilot was seriously injured, and telephoned 911 for
assistance.
According to the pilot, he based the airplane at Hilo International Airport (ITO) Hilo, Hawaii. Prior to departing ITO, the pilot topped off both fuel tanks. He
departed ITO, flew northwest along the coast, and landed at Upolu Airport (UPP), Hawi, Hawaii. He did not exit the airplane, and departed UPP a few minutes
later. About 75 minutes after the departure from ITO, while in cruise flight at an estimated altitude between 2,500 and 3,000 feet, the engine decreased to
"about 25 percent" of its normal cruise power. It briefly returned to near-normal, and then lost power again. The pilot immediately began seeking a place to land.
After the power loss, he did not attempt any corrective actions, troubleshoot the problem, or attempt to restart the engine.
PERSONNEL INFORMATION
The pilot held a private pilot certificate that was issued on the basis of his Canadian pilot's license. Examination of the pilot's records indicated that he had a
total flight experience of about 596 hours, including about 548 hours in the accident airplane make and model. His most recent FAA second-class medical
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certificate was issued in 2006.
No records of any FAA-required flight review were located. According to the pilot, he was unaware of the FAA flight review requirements. He did not participate
in the FAA "Wings" program, and he had never attended any aviation safety seminars or clinics.
AIRCRAFT INFORMATION
The airplane was manufactured in 2006, and was equipped with a Rotax 912 ULS engine, and a Kiev Prop three blade composite propeller. The airplane was
equipped with carburetor heat and a fuel boost pump. The airplane had two equal-size fuel tanks, one in each wing. The total fuel quantity was variously listed
in the airplane documentation as 19 and 21 gallons. The fuel selector valve had two positions, ON and OFF. A placard in the cockpit indicated that the fuel
consumption at 75 percent power was "19 lt/h," which equates to about 5 gallons per hour.
The pilot operated the engine on "mogas" (automotive fuel) which the pilot purchased from a local automobile service station, and which was the
manufacturer-recommended fuel for the engine. The engine manufacturer's operating manual stated that the fuel must comply with ASTM D4814, which
permits up to 10 percent ethanol. The pilot reported that he filtered the fuel with a "Mr. Funnel" device prior to putting it in the airplane. It was not determined
whether the pilot was aware of, or verified, the ethanol content of the fuel.
Although registration information indicated that the pilot had purchased the airplane in November 2010, the airplane journey log and pilot's log information
indicated that he was the primary pilot of the airplane since 2006.
METEOROLOGICAL INFORMATION
The ITO 1053 automated weather observation included winds from 320 degrees at 4 knots, visibility 10 miles, few clouds at 7,500 feet, temperature 24 degrees
C, dew point 18 degrees C, altimeter setting of 30.01 inches of mercury, and rain showers in the vicinity.
Temperature and dew point information from a nearby airport indicated that carburetor icing would only be expected when the engine was being operated at
"glide" (low) power settings.
WRECKAGE AND IMPACT INFORMATION
On-scene examination by an FAA inspector revealed that the wreckage was located in a soft, lightly-vegetated field. The field was situated at an elevation of
about 1,500 feet, and about 21 miles northwest of ITO. There were no ground or vegetation scars anywhere except immediately under the airplane. The
airplane came to rest upright. All three landing gear were deformed upward, so that the fuselage rested on the ground. The aft fuselage was buckled and folded
down about 30 degrees. The empennage was mostly intact, and the left wing was deflected slightly down. All three blades of the composite propeller were
fractured.
According to the responding FAA inspector, the left fuel tank was about two-thirds full. The right tank was compromised, and contained very little fuel, but the
inspector was unable to accurately determine the quantity.
The FAA examination of the airplane did not reveal any obvious reason for the loss of engine power. In his written submission to the NTSB regarding the
accident, the pilot stated that the fuel "tanks did not equalize" due to a plugged vent in the left fuel tank, which led to the power loss and his forced landing.
The airplane was equipped with a Dynon Avionics EFIS D100 model electronic flat-panel display, and several mechanical instruments. No mechanical airspeed
indicator was present; the airspeed information was presented on the D100. The validity of either the airspeed or stall speed information was not determined by
the investigation. The airplane was not equipped with a stall warning system.
The airplane was equipped with a "Kiev Prop" brand, Model 283 composite propeller. One fractured blade appeared to contain newspaper, with Cyrillic-like text,
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that was embedded into it during fabrication. The text was not translated, and the propeller blade was not examined further, since the fracture was
impact-related, and not a factor in the loss of engine power.
The examination of the airplane did not reveal any mechanical deficiencies or failures that would have precluded normal operation and continued flight.
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Accident Rpt# WPR12FA395
09/03/2012 0 MDT
Regis# N9764J
Murtaugh, ID
Acft Mk/Mdl SKYKITS USA CORP SAVANNAH ADV
Acft SN 07-07-51-621
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: JOSEPH TUGAW
Opr dba:
276
1
Apt: N/a
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot was flying over his mountainous ranch property to check on his cattle following a fire. When he did not return, the family reported him overdue. The
wreckage was subsequently found on the ranch property at an elevation of about 7,115 feet mean sea level. The density altitude at ground level was estimated
to be about 12,495 feet; the operating limitations for the airplane state that the maximum ceiling is about 14,000 feet pressure altitude at maximum weight.
On-site wreckage documentation indicated that the airplane collided with terrain in a nearly vertical attitude. Because of the high density altitude on the day of
the accident and the elevation of the terrain, the pilot had little altitude within which to operate before reaching the airplane's maximum ceiling. It is likely that,
while maneuvering the airplane near or above the airplane's maximum ceiling, the pilot failed to maintain adequate airspeed, which resulted in a stall and a
subsequent loss of control. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have
precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
adequate airspeed while maneuvering at or above the airplane's maximum ceiling, which resulted in a stall and a subsequent loss of airplane control.
Contributing to the accident was the pilot's decision to operate the airplane in the high density altitude conditions, which placed the airplane near or above its
maximum ceiling.
Events
1. Maneuvering - Loss of control in flight
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
4. Aircraft-Aircraft oper/perf/capability-Aircraft capability-(general)-Capability exceeded - C
5. Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-High density altitude-Effect on equipment - C
6. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot - F
7. Environmental issues-Physical environment-Terrain-Wet/muddy-Not specified
Narrative
HISTORY OF FLIGHT
On September 3, 2012, at an undetermined time, a Skykits USA Corp Savannah ADV, N9764J, collided with terrain near Murtaugh, Idaho. The pilot/owner was
operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot sustained fatal injuries; the airplane
sustained substantial damage. The local personal flight departed Twin Falls, Idaho, about 1200. Visual meteorological conditions prevailed, and no flight plan
had been filed.
The pilot had indicated to family members that he was going to fly up to his mountain ranch property to check on his cattle following a fire. When he did not
return, the family reported him overdue, and the Federal Aviation Administration (FAA) issued an Alert Notice (ALNOT). The Cassia County Sheriff reported
that the wreckage was discovered about 2030 MDT.
PERSONNEL INFORMATION
A review of Federal Aviation Administration (FAA) airman records revealed that the 81-year-old pilot held a commercial pilot certificate with ratings for airplane
single-engine land and instrument airplane. The pilot held a third-class medical certificate issued on January 7, 2010. It had the limitation that the pilot must
wear corrective lenses. The pilot's medical certificate had expired, but he was operating a light-sport airplane.
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No personal flight records were located for the pilot. The IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical
records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total
time of 3,000 hours with 11 hours logged in the last 6 months.
AIRCRAFT INFORMATION
The single-engine, high-wing airplane was a Skykits USA Corporation Savannah ADV, serial number 07-07-51-621. A review of the airplane's logbooks revealed
that the airplane had a total airframe time of 300.1 hours at the last engine maintenance performed (an oil change) on August 12, 2012. The last annual
inspection was on June 1, 2012, at a total airframe time of 276.6 hours.
The engine was a 100-horsepower ROTAX 912 ULS, serial number 5649340. Total time recorded on the engine at the last annual conditional inspection was
276.6 hours.
The operating limitations state that the maximum ceiling is about 14,000 feet pressure altitude at maximum weight. However, if the pilot is operating under sport
pilot privileges, FAR Part 61.315 (C) (11), restricts the airplane to 10,000 feet msl, or 2,000 feet above ground level (agl), whichever is higher.
METEOROLOGICAL CONDITIONS
The closest official weather observation station was Twin Falls, Idaho (KTWF), which was 21 nautical miles (nm) northwest of the accident site at an elevation
of 4,154 feet mean sea level (msl). An aviation routine weather report (METAR) for KTWF issued at 1153 MDT stated: wind from 030 degrees at 5 knots;
visibility 10 miles; sky clear; temperature 23/73 degrees Celsius/Fahrenheit; dew point -1/30 degrees Celsius/Fahrenheit; altimeter 30.16 inches of mercury.
The elevation of the accident site was approximately 7,115 feet, which was about 3,000 feet higher than the reporting weather station. Using a dry adiabatic
lapse rate of 3 degrees F per thousand feet; the accident site temperature would be 67 degrees F with a dew point of 21 degrees F. Using a pressure
differential (between 5,000 and 10,000 feet) of 0.86 inches per 1,000 feet, the atmospheric pressure would decrease from 30.16 to 27.20 inches. Using those
numbers in a density altitude calculator, the calculated density altitude was 12,495 feet.
WRECKAGE AND IMPACT INFORMATION
An FAA inspector examined the wreckage on scene. The airplane came to rest nose down in a stand of willow trees in a marshy area. Only the trees in the
immediate area of the wreckage had broken branches. The cabin area was crushed aft, and the leading edges of the wings were in contact with the ground.
The fuselage buckled 90 degrees aft of the cabin so that the empennage was in a horizontal upright position. He established control continuity for the rudder
and elevators to the crushed cabin area. The ailerons remained connected.
MEDICAL AND PATHOLOGICAL INFORMATION
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The Cassia County Coroner, Burley, Idaho, completed an autopsy, and found blunt force trauma as the cause of death.
The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained
no findings for carbon monoxide, cyanide, or volatiles. The report contained the following findings for tested drugs: amlodopine detected in urine; amlodipine
detected in blood (cavity); metoprolol detected in liver; metoprolol detected in blood (cavity).
TESTS AND RESEARCH
The National Transportation Safety Board investigator-in-charge (IIC), the FAA, and an investigator representing ROTAX examined the wreckage at the owner's
hangar on October 31, 2012. A detailed report is part of the public docket.
The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal
operation.
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Accident Rpt# ERA14CA410
08/27/2014 1530 EDT Regis# N61148
Acft Mk/Mdl BERTAGNA JOHN JUST HIGHLANDER-NO Acft SN JA2890213
Birdsboro, PA
Acft Dmg: DESTROYED
Fatal
Opr Name: BERTAGNA JOHN
Printed: October 15, 2014
Page 20
Apt: Bert's Airport PS38
0
Ser Inj
Opr dba:
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Rpt Status: Prelim
0
Prob Caus: Pending
Flt Conducted Under: FAR 091
Aircraft Fire: GRD
Copyright 1999, 2012, Air Data Research
All Rights Reserved
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Accident Rpt# WPR14CA306
07/21/2014 1100 PDT Regis# N83007
Mount Vernon, WA
Apt: N/a
Acft Mk/Mdl BOSCO DON SEAREY
Acft SN 1DK319C
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 914UL
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: LATOURETTE
Opr dba:
169
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPX
Summary
While practicing step taxiing on the river the pilot under instruction attempted to transition from step taxi to plow taxi. During the transition the right wing dropped
and contacted the water, which damaged the right sponson. The flight instructor added power and proceeded to takeoff. The airplane climbed to 10 feet above
the water when it then started a slow uncontrollable turn to the right. The airplane lost altitude and impacted the water. Both pilots egressed the airplane unhurt.
The airplane's hull/fuselage was substantially damaged and it took on water.
The pilot reported no preimpact mechanical malfunction or failure with the airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
lateral control while taxiing. Contributing to the accident was the incorrect decision to takeoff once the sponson had been damaged.
Events
1. Taxi - Dragged wing/rotor/float/other
Findings - Cause/Factor
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Lateral/bank control-Not attained/maintained - C
2. Personnel issues-Action/decision-Action-Incorrect action selection-Instructor/check pilot - F
Narrative
While practicing step taxiing on the river the pilot under instruction attempted to transition from step taxi to plow taxi. During the transition the right wing dropped
and contacted the water, which damaged the right sponson. The flight instructor added power and proceeded to takeoff. The airplane climbed to 10 feet above
the water when it then started a slow uncontrollable turn to the right. The airplane lost altitude and impacted the water. Both pilots egressed the airplane unhurt.
The airplane's hull/fuselage was substantially damaged and it took on water.
The pilot reported no preimpact mechanical malfunction or failure with the airplane that would have precluded normal operation.
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Accident Rpt# WPR13LA318
06/28/2013 1930 PDT Regis# N2812
Newbury Park, CA
Apt: N/a
Acft Mk/Mdl CHICCO QUICKSILVER SPORT II
Acft SN 0001763
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 503 DCDI
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: JOHN R SCHIDEL
Opr dba:
2261
0
Ser Inj
2
Aircraft Fire: NONE
Narrative
On June 28, 2013, about 1930 Pacific daylight time, a Quicksilver MXL-II light sport airplane,
N2812, was substantially damaged during a forced landing following a partial loss of engine power near Newbury Park, California. The light sport pilot and his
sole passenger sustained serious injuries. Visual meteorological conditions prevailed for the local flight, which was conducted in accordance with 14 Code of
Federal Regulations Part 91, and a flight plan was not filed. The flight departed the Camarillo Airport (CMA), Camarillo, California, about 1900.
In a post-accident interview with the National Transportation Safety Board investigator-in-charge, the pilot reported that the purpose of the flight was to check
the operation of the engine, as it had been missing and running rough on a previous flight. The pilot stated that during the flight the engine began to run rough,
and when he could not obtain an increase in power with the throttle and extra electric fuel pump, he elected to make an emergency landing. The pilot added
that after landing on uphill sloping terrain, the airplane nosed over and came to rest inverted.
On July 18, 2013, under the supervision of a Federal Aviation Administration aviation safety inspector, a Rotax field technician performed a detailed
examination of the engine. The engine was a Rotax 503, dual carburetor, dual ignition, fan cooled engine, equipped with electric and pull start systems. The
engine is a twin cylinder, 2 stroke engine with a tuned exhaust and a reduction gearbox.
The examination revealed that the engine remained attached to the airframe, and that the exhaust muffler had been previously removed from the exhaust
Y-pipe and placed on the floor next to the aircraft. The Warp Drive propeller was also previously removed from the engine and placed next to the aircraft. The
exhaust system was the correct type but was in very poor condition with previous weld repairs and several cracks were observed. The technician noted during
the investigation, while Rotax does not state that the exhaust muffler cannot be welded or repaired if cracks are found, they also do not supply instructions on
how to complete a repair of this nature. The technician added that if an exhaust system had an existing crack which was obviously leaking exhaust, and in
addition had multiple prior cracks repaired, this should be an indication that it is time to replace the exhaust system. The technician referred to the Rotax
Operators Manual, Section 10.3.3, Pre-Flight Checks, page 10-13, which provides the warning ".to repair as necessary all discrepancies and shortcomings
before flight." Further, it states to inspect exhaust for cracks, security of mounting, springs and hooks for breakage and wear, and to verify the safety wiring of
springs.
The technician reported that during handling of the exhaust it sounded like there may have been broken baffles inside the exhaust system. Any broken internal
baffles would affect the running condition and reliability of the engine, as they could block the exhaust system resulting in an immediate engine failure or loss of
power. The technician further reported that after the exhaust system was cut open the internal baffles were examined. It was observed that the exhaust system
was found to be very poor condition, with several broken internal components and baffles. The technician stated that the broken baffles and components can
shift their position depending on the flight attitude of the aircraft and block the exit of the exhaust, which could result in an immediate engine failure or loss of
power. The technician concluded that the cause of the loss of power was due to a blockage of the exhaust system due to broken engine baffles that had shifted
from the original location during flight. The technician added that the internal and external examination of the exhaust system revealed that the system was in
very poor condition and was not suitable for flight.
A review of the engine logbook revealed that the engine was installed on the aircraft on February 12, 2013, at a Hobbs reading of 2,268.3 hours. On June 23,
2013, five days prior to the accident and at a Hobbs time of 2,323.7 hours, the engine's spark plugs and exhaust gaskets were changed.
The pilot reported in a follow-up interview with the NTSB IIC that the exhaust system had been inspected for cracks about 20 hours prior to the accident flight,
with none observed. The pilot stated that the system was completely removed and then reinstalled after the detailed inspection had been performed. He also
stated that with respect to the welds discussed in the Rotax investigation report, they were not done subsequent to his club purchasing the system, and that he
had no idea of when or where the repair took place, or by whom they were performed. The pilot added that when an anomaly with the exhaust system is
detected, it is removed from the aircraft and replaced.
The engine was subsequently test run. In preparation, and as the aircraft's fuel tank was breached, a secondary container was used with the same fuel that
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Copyright 1999, 2012, Air Data Research
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was captured from the original fuel tank. The aircraft's fuel line was then placed inside of the container to supply fuel to the engine. The battery was connected
in the original location, which allowed the ignition system to be used during the test run. The original exhaust muffler was not installed for this engine test run,
nor was an exemplar exhaust muffler installed.
The aircraft's electric fuel pump was turned on and fuel could be seen traveling through the fuel line to the carburetors. The magneto switch was turned on and
the starter was engaged. After several rotations the engine started and ran without issues. The RPM was manipulated with use of the throttle cables. After
several seconds of running the engine was then shut down by turning off the magneto switches. No anomalies were noted during the test run.
The original exhaust muffler, which was still in its original state, was then installed on the engine for a second test run. The engine, which was started in the
same matter as the first test run, ran for several seconds before it was manually shut down. No anomalies were noted during the test run. (Refer to the Rotax
Investigation Report, which is included in the public docket for this report.)
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Copyright 1999, 2012, Air Data Research
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14CA385
08/04/2014 1930 EDT Regis# N502CW
New Berlin, PA
Apt: Saurers Field 4PA1
Acft Mk/Mdl COTE JAMES RANS S 6S
Acft SN 08051681
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 912ULS
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: BEACHY MARTIN JR
Opr dba:
112
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Summary
The pilot stated that just after takeoff, the airplane entered "uncoordinated flight to the left." He applied right rudder to correct, but felt that the rudder was
ineffective. After clearing trees at the end of the runway, the pilot elected to conduct a precautionary landing in a field. He stated that the airplane's rate of
descent was "high," and that the nose landing gear collapsed upon touchdown. The airplane subsequently nosed over and came to rest inverted. Postaccident
examination revealed substantial damage to the engine firewall, both wings, and the vertical stablilizer. Examination of the rudder controls revealed no
anomalies. According to the pilot, his passenger was "apprehensive" about the flight, and inadvertently applied pressure to the left rudder pedal with his foot
throughout the takeoff and accident sequence.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The passenger's inadvertent
interference with the rudder controls during the takeoff.
Events
1. Initial climb - Miscellaneous/other
2. Initial climb - Flight control sys malf/fail
3. Landing - Off-field or emergency landing
4. Landing - Nose over/nose down
Findings - Cause/Factor
1. Aircraft-Aircraft systems-Flight control system-Rudder control system-Related operating info - C
2. Personnel issues-Action/decision-Action-(general)-Passenger - C
Narrative
The pilot stated that just after takeoff, the airplane entered "uncoordinated flight to the left." He applied right rudder to correct, but felt that the rudder was
ineffective. After clearing trees at the end of the runway, the pilot elected to conduct a precautionary landing in a field. He stated that the airplane's rate of
descent was "high," and that the nose landing gear collapsed upon touchdown. The airplane subsequently nosed over and came to rest inverted. Postaccident
examination revealed substantial damage to the engine firewall, both wings, and the vertical stablilizer. Examination of the rudder controls revealed no
anomalies. According to the pilot, his passenger was "apprehensive" about the flight, and inadvertently applied pressure to the left rudder pedal with his foot
throughout the takeoff and accident sequence.
Printed: October 15, 2014
Page 24
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Copyright 1999, 2012, Air Data Research
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14LA213
04/22/2014 1055 CDT Regis# N48MK
Acft Mk/Mdl CROW MUSTANG II
Acft SN MII2129
Eng Mk/Mdl ENGINE COMPONENTS INTERNATIONA Acft TT
Opr Name: FRED N. CROW
9
Morton, TX
Apt: Cochran County Airport F85
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
Opr dba:
1
Aircraft Fire: NONE
Summary
The pilot reported that the accident occurred during the third flight test of the recently completed amateur-built airplane. The pilot stated that there were no
anomalies with the airplane during his preflight inspection or before-takeoff engine run-up. After an uneventful takeoff, he proceeded to a nearby practice area
where he completed basic flight maneuvers and measured cruise performance parameters before returning to the airport for a full-stop landing. Upon returning
to the airport, the pilot decided to land on runway 22 because it was longer and wider than the other runway, and the prevailing wind from the south-southwest
favored either runway. The airplane landed hard, bounced, and then veered off the left side of the runway before the pilot could regain control. The airplane
subsequently nosed over after encountering soft terrain located alongside the runway. Postaccident wreckage examinations revealed no evidence of
mechanical malfunctions or failures that would have precluded normal operation. A review of available wind data indicated that a gusting left crosswind
component of 9 to 14 knots existed during the landing.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's improper landing flare
after encountering a gusting crosswind and his inadequate recovery from the subsequent bounced landing.
Events
1. Landing-flare/touchdown - Hard landing
2. Landing - Loss of control on ground
3. Landing - Runway excursion
4. Landing - Nose over/nose down
Findings - Cause/Factor
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Incorrect use/operation - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained - C
3. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
4. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Ability to respond/compensate
5. Environmental issues-Conditions/weather/phenomena-Wind-Gusts-Ability to respond/compensate
Narrative
On April 22, 2014, at 1055 central daylight time, an experimental amateur-built Crow model Mustang II airplane, N48MK, was substantially damaged while
landing at Cochran County Airport (F85) near Morton, Texas. The commercial pilot sustained serious injuries. The airplane was registered to and operated by a
private individual, under the provisions of 14 Code of Federal Regulations Part 91, without a flight plan. Day visual meteorological conditions prevailed for the
local test flight that departed F85 about 0945.
The pilot reported that the airplane had been recently issued an experimental airworthiness certificate and that the accident occurred during the third flight test.
He stated that there were no anomalies with the airplane during his preflight inspection or before takeoff engine run-up. After an uneventful takeoff, he
proceeded to a nearby practice area where he completed basic flight maneuvers and measured cruise performance parameters before returning to the airport
for a full-stop landing. Upon returning to the airport, the pilot decided to land on runway 22 (2,710 feet by 60 feet, asphalt) because it was longer and wider than
the second runway and the prevailing wind from the south-southwest favored either runway. The pilot stated that the airplane bounced after a hard landing and
veered off the left side of the runway before he could regain control. The airplane subsequently nosed-over after encountering soft terrain located alongside the
runway, resulting in substantial damage to the firewall and vertical stabilizer. The pilot reported no preaccident mechanical malfunctions or failures with the
airplane that would have precluded normal operation. Additionally, the pilot stated that he had accumulated about 3 hours of flight time in the accident airplane
when the accident occurred.
The nearest weather reporting station (MNST2) was located adjacent to the airport property, about 0.3 miles northwest of the accident site. At 1055, the
weather observing system reported: wind from 162 degrees at 10 knots, gusting 16 knots; temperature 20 degrees Celsius; dew point 9 degrees Celsius; and
an altimeter setting of 30.21 inches-of-mercury.
A postaccident wreckage examination completed by Federal Aviation Administration inspectors established flight control continuity from the cockpit controls to
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National Transportation Safety Board - Aircraft Accident/Incident Database
the respective flight control surfaces. The rudder/brake pedals had been displaced upward into the lower instrument panel; however, actuation of the individual
brake pedals resulted in the proper operation of the wheel brakes. The postaccident examinations of the airplane revealed no evidence of mechanical
malfunctions or failures that would have precluded normal operation.
Printed: October 15, 2014
Page 26
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210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA380
07/14/2014 1145 CDT Regis# N482FD
Acft Mk/Mdl DANTONIO 404-NO SERIES
Acft SN X69
Eng Mk/Mdl POLARIS
Acft TT
Opr Name: PILOT
Opr dba:
44
Wichita Falls, TX
Apt: Wichita Valley F14
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Narrative
The pilot took off for a local flight in his experimental amateur-built biplane. During climb out, near 250 feet above ground level, the engine lost power. The pilot
performed a forced landing to a field that contained small trees. The lower wing sustained substantial damage on impact with a tree. An examination of the
engine revealed that a spark plug wire had detached from its spark plug's terminal. The pilot's safety recommendation stated that installing an Adel clamp on
one of the cylinder bolts will prevent the spark plug wire from vibrating off the spark plug terminal.
Printed: October 15, 2014
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Copyright 1999, 2012, Air Data Research
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR11LA207
04/23/2011 1200
Regis# N59TD
Marsing, ID
Acft Mk/Mdl DAVISON RV-7A
Acft SN 72688
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl LYCOMING O-360-A1D
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: TERRY DAVISION
Opr dba:
45
0
Apt: Sunrise Skypark Airport ID40
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Summary
The pilot reported that the run-up and takeoff were normal but that, during climbout, the engine sputtered and began to lose power. He kept the airplane straight
and level and continued straight ahead. The pilot switched fuel tanks, turned on the fuel pump, and positioned the engine controls full forward; however, the
engine continued to lose power. He then retarded the mixture and made a controlled descent between two ponds. The airplane stalled and landed hard on flat
terrain, which resulted in structural damage to the left wing. The pilot stated that he had refueled the airplane several weeks before the accident but that he had
not flown the airplane since that time. The pilot stated that, when he departed on the accident flight, the fuel tanks were full. Law enforcement personnel
reported that, upon arrival at the accident site, fuel was leaking from the airplane. Postaccident examination of the engine revealed no mechanical malfunctions
or failures that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of engine power during
initial climb for reasons that could not be determined because postaccident examination did not reveal any anomalies that would have precluded normal
operation.
Events
1. Initial climb - Loss of engine power (partial)
2. Emergency descent - Off-field or emergency landing
3. Emergency descent - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
Narrative
On April 23, 2011, about 1200 mountain daylight time, an experimental amateur built Davison RV-7A, N59TD, experienced a loss of engine power on takeoff
from the Sunrise Skypark Airport (ID40), Marsing, Idaho. The pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91 as a
personal flight. The pilot/owner and a passenger were not injured. The airplane sustained substantial damage to left wing and fuselage during an off-airport
forced landing. Visual meteorological conditions prevailed for the local area flight, and no flight plan had been filed.
According to the pilot, he performed a normal run-up, and indicated that the takeoff was also normal. On climb out, the engine sputtered and lost power. He
kept the airplane straight-and-level, and continued straight ahead. He did not initiate a turn back to the runway. The pilot switched fuel tanks, turned on the fuel
pump, and made sure the engine controls were full forward. He stated that he then pulled the mixture back, made a controlled descent, and aimed the airplane
between two ponds. The airplane stalled, and made a hard landing. Prior to exiting the airplane, he turned everything off.
The pilot stated that he had refueled the airplane a couple of weeks prior to the accident, and had not flown it before the accident due to bad weather. When he
departed on the accident flight, the fuel tanks were full. The pilot also stated that he keeps the airplane in a hangar.
Responding law enforcement personnel stated that the airplane came to rest upright in a marsh area near two fish ponds off of highway 78. The area was flat
terrain. The airplane sustained substantial damage to the left wing. Also damaged was the engine cowling, and the main landing gear was bent aft. The two
ponds were located about 2/3 mile east of the runway. Fuel was observed leaking out of the airplane, and buckets were placed underneath the wings to capture
it.
According to the pilot, he had built the airplane from a kit in 2010. At the time of the accident, the airplane had accrued a total of 45.6 flight hours. A Lycoming
O-360-A1D, 180-horsepower engine had been installed on the airplane. The pilot had purchased the engine used. At the time of purchase, the engine had a
total time of 940 hours.
The airplane and engine were inspected by a Federal Aviation Administration (FAA) inspector. A visual examination of the engine revealed no obvious holes in
the case or disconnects of the electrical wires, fuel lines, or hoses. He noted that the ignition was electronic with automotive ignition wires and auto spark plugs.
The FAA inspector stated that there was nothing obviously wrong with the engine.
Printed: October 15, 2014
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Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14CA408
08/16/2014 910 EDT
Acft Mk/Mdl DAY WILLIAM L MINICOUPE
Opr Name: DAY WILLIAM L
Regis# N853WD
Baltimore, MD
Acft SN WD00001
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Acft TT
Fatal
Flt Conducted Under: FAR 091
1
0
Apt: Martin State MTN
Ser Inj
0
Opr dba:
Aircraft Fire: NONE
AW Cert: SPE
Summary
According to the pilot/owner/builder of the airplane, he conducted taxi tests, and then a final engine run-up and flight control check prior to takeoff on the
airplane's second flight. After rotation, the airplane reached approximately 3 feet above the runway when the nose dropped, and application of full up elevator
had no effect. The airplane struck the runway nose first, which resulted in substantial damage to the firewall. This was the identical outcome as the first flight
several months prior. An FAA inspector estimated that the builder had added about 63 pounds with his modifications to the original airplane plans. The pilot
performed the weight and balance on the airplane using bathroom scales and stated that there were no mechanical deficiencies that would have precluded
normal operation of the airplane. His NTSB Form 6120.1 Operator/Owner Safety Recommendation was: "Re-weigh aircraft with calibrated scales to determine
weight and balance. Fix apparent nose heavy aircraft with appropriate movement of the battery or additional weight in the tail section."
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot/owner/builder's
improper weight and balance calculations, which rendered the airplane uncontrollable in the pitch axis.
Events
1. Prior to flight - Aircraft inspection event
2. Takeoff - Nose over/nose down
3. Takeoff - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Personnel issues-Action/decision-Action-Incorrect action performance-Owner/builder - C
2. Aircraft-Aircraft oper/perf/capability-Aircraft capability-CG/weight distribution-Capability exceeded - C
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Pitch control-Attain/maintain not possible - C
Narrative
According to the pilot/owner/builder of the airplane, he conducted taxi tests, and then a final engine run-up and flight control check prior to takeoff on the
airplane's second flight. After rotation, the airplane reached approximately 3 feet above the runway when the nose dropped, and application of full up elevator
had no effect. The airplane struck the runway nose first, which resulted in substantial damage to the firewall. This was the identical outcome as the first flight
several months prior. An FAA inspector estimated that the builder had added about 63 pounds with his modifications to the original airplane plans. The pilot
performed the weight and balance on the airplane using bathroom scales and stated that there were no mechanical deficiencies that would have precluded
normal operation of the airplane. His NTSB Form 6120.1 Operator/Owner Safety Recommendation was: "Re-weigh aircraft with calibrated scales to determine
weight and balance. Fix apparent nose heavy aircraft with appropriate movement of the battery or additional weight in the tail section."
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Copyright 1999, 2012, Air Data Research
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14CA265
05/25/2014 1930 EDT Regis# N403WD
Acft Mk/Mdl DIVIS S L/WALTRIP A J RV 4
Acft SN 641
Eng Mk/Mdl LYCOMING O-360-A4M
Acft TT
Opr Name: THOMAS SPENCER S
Opr dba:
260
Harpswell, ME
Apt: Farr Field Airport ME33
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Summary
The pilot stated that the flight planning indicated the time en-route to be 3.0 hours, which allowed for a 45 minute fuel reserve. After takeoff the flight remained
at 1,500 feet until clear of Special Flight Rules Area (SFRA) at PALEO exit Gate, then climbed on course to 7,500 feet mean sea level (msl). Course deviations
en-route due to weather occurred, and when the flight was 15 nautical miles south of Portland, Maine, he descended to 5,500 feet msl and continued at that
altitude towards the destination airport until, ".indications of pending engine failure at approximately 10 NM northeast of Portland." He established best glide
airspeed, declared an emergency with air traffic control and confirmed the distance to Portland and his destination airports. He proceeded towards another
airport (Farr Field Airport) and flew over it at "High Key" position, or over the runway, and turned east for "Base Key." While on final approach he maneuvered
between trees and touched down on runway 32. After touchdown he intentionally applied left rudder and brake to avoid runway overrun into water past the
departure end of the runway. After coming to rest, both occupants exited the airplane; the total flight duration was reported to be 2 hours 45 minutes. The pilot
reported there was no preimpact failure or malfunction that would have precluded normal operation. During the accident sequence, the airplane sustained
damage to the firewall and left side of the aft fuselage near the tailwheel assembly.
Postaccident inspection of the airplane by a Federal Aviation Administration airworthiness inspector revealed the fuel tanks were empty and were not breached.
A copy of the FAA Inspector Statement and photographs depicting the damage are contained in the NTSB public docket.
The pilot further stated that factors that resulted in increased fuel consumption for which he did not take into account included a recent propeller change which
increased engine rpm, fuel consumption planning for the accident flight based on a previous flight flown at a higher altitude and less weight, and finally course
deviations.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate preflight
and in-flight planning which resulted in total loss of engine power due to fuel exhaustion.
Events
1. Enroute-cruise - Fuel exhaustion
2. Enroute-cruise - Loss of engine power (total)
3. Landing-landing roll - Miscellaneous/other
Findings - Cause/Factor
1. Personnel issues-Task performance-Planning/preparation-Fuel planning-Pilot - C
2. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid management - C
Narrative
The pilot stated that the flight planning indicated the time en-route to be 3.0 hours, which allowed for a 45 minute fuel reserve. After takeoff the flight remained
at 1,500 feet until clear of Special Flight Rules Area (SFRA) at PALEO exit Gate, then climbed on course to 7,500 feet mean sea level (msl). Course deviations
en-route due to weather occurred, and when the flight was 15 nautical miles south of Portland, Maine, he descended to 5,500 feet msl and continued at that
altitude towards the destination airport until, ".indications of pending engine failure at approximately 10 NM northeast of Portland." He established best glide
airspeed, declared an emergency with air traffic control and confirmed the distance to Portland and his destination airports. He proceeded towards another
airport (Farr Field Airport) and flew over it at "High Key" position, or over the runway, and turned east for "Base Key." While on final approach he maneuvered
between trees and touched down on runway 32. After touchdown he intentionally applied left rudder and brake to avoid runway overrun into water past the
departure end of the runway. After coming to rest, both occupants exited the airplane; the total flight duration was reported to be 2 hours 45 minutes. The pilot
reported there was no preimpact failure or malfunction that would have precluded normal operation. During the accident sequence, the airplane sustained
damage to the firewall and left side of the aft fuselage near the tailwheel assembly.
Postaccident inspection of the airplane by a Federal Aviation Administration airworthiness inspector revealed the fuel tanks were empty and were not breached.
A copy of the FAA Inspector Statement and photographs depicting the damage are contained in the NTSB public docket.
The pilot further stated that factors that resulted in increased fuel consumption for which he did not take into account included a recent propeller change which
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Copyright 1999, 2012, Air Data Research
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increased engine rpm, fuel consumption planning for the accident flight based on a previous flight flown at a higher altitude and less weight, and finally course
deviations.
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Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# ERA14FA461
09/28/2014 1520 CDT Regis# N7062U
Gallatin, TN
Apt: N/a
Acft Mk/Mdl EAGLE R&D INC HELICYCLE
Acft SN 4-13-E2413
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Eng Mk/Mdl SOLAR T-62
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: JAMES E. LEE
Opr dba:
15
1
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: SPE
Narrative
On September 28, 2014, about 1520 central daylight time, an experimental amateur built Eagle R & D Helicycle helicopter; N7062U, was substantially damaged
when it impacted terrain after a loss of control while maneuvering in Gallatin, Tennessee. The private pilot was fatally injured. Visual meteorological conditions
prevailed, and no flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91, destined for Sumner County
Regional Airport (M33), Gallatin, Tennessee.
According to a friend of the pilot, the pilot had departed M33 earlier in the day and had flown out to his property to visit with him. The landing was uneventful,
and while the pilot was there he borrowed some tools from the property owner and increased the tension on the drive belts.
Later on he started the helicopter and took off and departed to the southwest. The property owner assumed at this point that the pilot was heading back to M33
but, a little while later he observed the helicopter coming toward him in a nose low attitude, at approximately 400 feet above ground level, and at a "high rate of
speed." The helicopter then suddenly pitched over, began to tumble, and then impacted in an inverted attitude, and a postcrash fire ensued.
Examination of the accident site and wreckage revealed that during the impact sequence the helicopter first made ground contact with the forward portion of the
cockpit. It then tumbled along the ground on an approximate magnetic heading of 030 degrees for approximately 90 feet before coming to rest on its left side.
Examination of the engine revealed no evidence of preimpact failure or malfunction that would have precluded normal operation of the engine.
Examination of the helicopter's structure and flight control system also did not reveal evidence of any preimpact failures or malfunctions which would have
precluded normal operation of the flight control system. During the examination however, a piece of angle iron was discovered in the debris field along with
numerous broken cable ties.
According to the property owner, he observed that the piece of angle iron was attached to the helicopter when the pilot landed and took off from his property
and advised that the pilot had attached it to the helicopter's tail boom for weight and balance purposes.
Preliminary review of weight and balance data supplied by the kit manufacturer indicated that the center of gravity of the helicopter was dependent on the pilot's
weight, installed position of the battery, and position and weight of any ballast installed.
Preliminary calculations based on the supplied weight and balance data, weight of the pilot, and weight and position of where the angle iron was observed to
have been mounted on the helicopter's tailboom, indicated that the helicopter's center of gravity was outside of the manufacturer's approved envelope.
The pilot held a Federal Aviation Administration (FAA) private pilot certificate with a rating for airplane single-engine land. He did not possess a rotorcraft
helicopter rating or an endorsement for solo flight in a helicopter. His most recent FAA third-class medical certificate was issued on August 19, 2014. He
reported on that date, that he had accrued approximately 1,200 total flight hours.
According to FAA records, the helicopter was issued a special airworthiness certificate on October 6, 2008. According to aircraft maintenance records, the
helicopter's most recent conditional inspection was completed on May 5, 2011. At the time of accident, the helicopter had accrued approximately 51 total hours
of operation.
Printed: October 15, 2014
Page 32
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR14CA347
08/16/2014 900 MDT
Acft Mk/Mdl EIPPER FORMANCE INC MXII
Regis# N1624Z
Salt Lake City, UT
Acft SN 1764
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
Eng Mk/Mdl ROTAX 503
Opr Name: JUDD TRENTEN M
0
Ser Inj
Opr dba:
Apt: N/a
0
Aircraft Fire: NONE
AW Cert: SPE
Summary
The pilot stated that he was flying the airplane at 50 feet above ground level. He spotted a coyote and dropped to a lower altitude to take a closer look. He
circled the coyote and was aware of the power lines near by, however, he did not compensate for the wind drift, which pushed the airplane toward the power
lines. While in a 40-degree angle of bank the lower wing struck the power line. The wing folded upward and the airplane impacted the ground in an upright
position substantially damaging the fuselage. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded
normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
clearance from power lines while maneuvering at low altitude.
Events
1. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
2. Maneuvering-low-alt flying - Low altitude operation/event
Findings - Cause/Factor
1. Personnel issues-Psychological-Attention/monitoring-Monitoring environment-Pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
3. Environmental issues-Physical environment-Object/animal/substance-Wire-Contributed to outcome
Narrative
The pilot stated that he was flying the airplane at 50 feet above ground level. He spotted a coyote and dropped to a lower altitude to take a closer look. He
circled the coyote and was aware of the power lines near by, however, he did not compensate for the wind drift, which pushed the airplane toward the power
lines. While in a 40-degree angle of bank the lower wing struck the power line. The wing folded upward and the airplane impacted the ground in an upright
position substantially damaging the fuselage. The pilot reported no preimpact mechanical malfunctions or failures with the airplane that would have precluded
normal operation.
Printed: October 15, 2014
Page 33
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14LA146
02/15/2014 1730 EST Regis# N94567
Acft Mk/Mdl FOGG QUICKSILVER MX II
Acft SN 001
Eng Mk/Mdl ROTAX 582DCDI
Acft TT
Opr Name: PRIVATE INDIVIDUAL
Opr dba:
290
Holland, MI
Apt: N/a
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that, after a local flight, he decided to land on a snow-covered frozen lake. The airplane landed in 18-inch-deep snow and nosed down shortly
after touchdown, which resulted in damage to the fuselage and right wing. The pilot reported that, earlier in the day, he had been flying a powered-parachute
(not the accident airplane) from a different area of the same frozen lake that only had 1 to 2 inches of snow cover, which led him to believe it would be safe to
land during the accident flight. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal
operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inability to maintain
airplane control after inadvertently landing in an area of deep snow on a frozen lake.
Events
1. Landing-flare/touchdown - Abnormal runway contact
2. Landing-flare/touchdown - Nose over/nose down
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Attain/maintain not possible - C
3. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Snow/slush/ice covered-Effect on operation - C
4. Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Snow/slush/ice covered-Awareness of condition - C
Narrative
On February 15, 2014, at 1730 eastern standard time, an experimental amateur-built Fogg model Quicksilver MX II airplane, N94567, was substantially
damaged while landing on a snow-covered frozen lake near Holland, Michigan. The pilot and passenger were not injured. The airplane was registered to and
operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91, without a flight plan. Day visual meteorological conditions
prevailed for the personal flight, which departed Park Township Airport (HLN), Holland, Michigan, at 1700.
The pilot reported that after a local flight he decided to land on the snow-covered frozen lake. The airplane landed in 18 inch deep snow and nosed down
shortly after touchdown. The fuselage and right wing were substantially damaged during the accident. The pilot reported that earlier in the day he had been
flying a powered-parachute (not the accident airplane) from a different area of the same frozen lake that only had 1-2 inches of snow cover. The pilot reported
no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Printed: October 15, 2014
Page 34
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR15LA001
10/03/2014 1330
Acft Mk/Mdl GASTON THOMAS D THUNDER
Regis# N51TG
Council, ID
Acft SN EITM027
Acft Dmg: DESTROYED
Fatal
Opr Name: GASTON THOMAS D
1
Apt: Council Muni U82
Ser Inj
Opr dba:
Rpt Status: Prelim
0
Prob Caus: Pending
Flt Conducted Under: FAR 091
Aircraft Fire: NONE
Narrative
On October 3, 2014, about 1330 mountain daylight time (MDT), an experimental Thomas Gaston, Thunder Mustang, N51TG, crashed during approach to
landing at Council, Idaho. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airline
transport pilot was the sole occupant, and sustained fatal injuries; the airplane was destroyed by impact forces. The local personal flight departed Council at an
undetermined time. Visual meteorological conditions prevailed, and no flight plan had been filed.
Witnesses reported that the pilot radioed that he was having engine oil pressure issues and was returning to the airport.
The airplane impacted terrain about 1,945 feet northwest of runway 17 at Council municipal airport. The debris path was on a heading of 318 degrees, and
about 60 feet in length. The airplane wreckage was contained in a small area. Investigators who responded to the accident site indicated that the accident
appeared to be a low angle of attack and low energy, with the first impact point being the left elevator and left main landing gear.
The airplane was recovered for further examination.
Printed: October 15, 2014
Page 35
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14LA195
04/12/2014 1045 EDT Regis# N87JL
Amelia, OH
Apt: Clermont County Airport I69
Acft Mk/Mdl LARSEN MARK V
Acft SN .001
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl SUBARU EA81
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: KARLA GOODHOUSE
Opr dba:
710
0
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot reported that the engine experienced a sudden and total loss of power during cruise climb. He was unable to restart the engine by isolating the ignition
systems and the two fuel pumps. The propeller would rotate while he engaged the starter, but the engine would not restart. Subsequently, the pilot completed a
forced landing on a nearby golf course. After an uneventful touchdown on a fairway, the airplane collided with a sand bunker that preceded the green.A
postaccident examination revealed that the experimental amateur-built airplane was equipped with a converted automobile engine that had two ignition
systems. The two ignition systems combined at a common distributor before terminating at the spark plugs. Although both ignition coils provided voltage while
the engine crankshaft was rotated, a corresponding spark was not produced at the individual spark plugs. An examination of the distributor assembly revealed
that the electrode contact had separated from the distributor rotor, which would have resulted in an immediate and total loss of engine power and prevented the
engine from being restarted.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The distributor failure, which
resulted in a total loss of engine power during cruise climb.
Events
1. Enroute-climb to cruise - Powerplant sys/comp malf/fail
2. Enroute-climb to cruise - Loss of engine power (total)
3. Landing - Off-field or emergency landing
4. Landing-landing roll - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Aircraft-Aircraft power plant-Ignition system-Magneto/distributor-Failure - C
Narrative
On April 12, 2014, at 1045 eastern daylight time, an experimental amateur-built Larsen model Mark V airplane, N87JL, was substantially damaged during a
forced landing near Amelia, Ohio. The commercial pilot and his pilot-rated-passenger were not injured. The airplane was registered to and operated by a private
individual, under the provisions of 14 Code of Federal Regulations Part 91, without a flight plan. Day visual meteorological conditions prevailed for the personal
cross-country flight that had departed Clermont County Airport (I69), Batavia, Ohio, at 1035, and was en route to French Lick Municipal Airport (FRH), French
Lick, Indiana.
The pilot reported that after an uneventful takeoff from I69, the flight continued to climb toward its initial cruise altitude of 2,500 feet mean sea level (msl). As
the flight climbed through 2,100 feet msl, the pilot established cruise-climb by making a reduction to engine power. The pilot reported that shortly after making
the power reduction, the engine experienced a sudden loss of power and the propeller stopped rotating. He was unable to restart the engine by isolating the
ignition systems and the two fuel pumps. He reported that the propeller would rotate while he engaged the starter, but the engine would not restart. Ultimately,
the pilot completed a forced landing on a nearby golf course. After an uneventful touchdown on a fairway, the airplane collided with a sand bunker that
preceded the green. The airplane sustained substantial damage to the fuselage, empennage, and right wing during the impact sequence. Following the
accident, the pilot and his passenger released their restraints and exited the airplane through the cabin doors uninjured.
The pilot reported that the airplane had been topped-off with automotive fuel (26 gallons total capacity) before the previous flight leg from Mount Vernon Airport
(MVN), Mount Vernon, Illinois. He stated that the previous flight leg from MVN had consumed about 7 gallons of fuel during the approximately 2 hour flight. He
reported that the airplane departed on the accident flight with about 18 gallons of fuel available and expected an average fuel consumption rate of about 3.5
gallons per hour.
An engine examination was completed by Federal Aviation Administration (FAA) inspectors after the wreckage had been recovered to a secured location. The
engine, a Subaru model EA-81, was a converted automobile engine. The engine produced suction/compression at each cylinder in conjunction with crankshaft
rotation. The engine was equipped with two ignition systems that combined at a common distributor before terminating at the spark plugs. Although both
ignition-coils provided voltage while the engine crankshaft was rotated, a corresponding spark was not produced at the individual spark plugs. An internal
examination of the distributor assembly revealed that the electrode contact had separated from the distributor rotor.
Printed: October 15, 2014
Page 36
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA368
07/13/2014 1630 EDT Regis# N792MC
Dodgeville, MI
Apt: Mckenzie Highland Stables NONE
Acft Mk/Mdl MCKENZIE DOUGLAS E STOL CH750
Acft SN 75-8144
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl JABIRU 3300A
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: DOUGLAS E MCKENZIE
Opr dba:
93
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Narrative
The pilot reported that he was performing a normal takeoff in the short take-off and landing (STOL) airplane on a short narrow grass runway. After the airplane
became airborne about midfield it encountered unexpected crosswind turbulence near the edge of a tree line. The airplane drifted to the side, contacted the top
of a tree, entered an aerodynamic stall, impacted terrain and came to rest on its nose resulting in substantial damage to the engine mount, forward fuselage,
both wings, and both flaperons. The pilot credited the shoulder harness installation with saving him from more serious injury. The pilot also reported that there
was no preimpact malfunction or failure.
Printed: October 15, 2014
Page 37
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA413
08/06/2014 1930 EDT Regis# N2552S
Acft Mk/Mdl PHANTOM AIRCRAFT CO PHANTOM X
Acft SN 602
Eng Mk/Mdl ROTAX 503 DCDI
Acft TT
Opr Name: WILKINS PETER E
Opr dba:
17
Three Rivers, MI
Apt: Three Rivers Municipal HAI
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPX
Summary
The pilot flew a visual traffic pattern to a grass runway utilized by a combination of light sport aircraft, powered parachutes, and radio controlled aircraft. While
on downwind at 400 feet above ground level, the pilot noticed three ground vehicles parked in a lot often used by pilots when they flew radio controlled aircraft.
As he searched for possible radio controlled aircraft, the pilot became distracted and allowed his airspeed to decrease, which resulted in an aerodynamic stall.
The pilot was unable to regain control and the airplane subsequently impacted a line of trees.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot did not maintain
adequate airspeed while flying a visual pattern, which resulted in an aerodynamic stall and subsequent loss of control.
Events
1. Approach-VFR pattern downwind - Loss of control in flight
Findings - Cause/Factor
1. Personnel issues-Psychological-Attention/monitoring-Monitoring equip/instruments-Pilot - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
Narrative
The pilot flew a visual traffic pattern to a grass runway utilized by a combination of light sport aircraft, powered parachutes, and radio controlled aircraft. While
on downwind at 400 feet above ground level, the pilot noticed three ground vehicles parked in a lot often used by pilots when they flew radio controlled aircraft.
As he searched for possible radio controlled aircraft, the pilot became distracted and allowed his airspeed to decrease, which resulted in an aerodynamic stall.
The pilot was unable to regain control and the airplane subsequently impacted a line of trees.
Printed: October 15, 2014
Page 38
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA483
09/03/2014 1530
Regis# N211AL
Longmont, CO
Acft Mk/Mdl ROSS ALFRED K/ONEILL TERRENCE
Acft SN 11
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl LYCOMING IO-320 B2B
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: ONEILL TERRENCE
Opr dba:
187
0
Apt: Vance Brand Airport LMO
Ser Inj
0
Aircraft Fire: UNK
AW Cert: SPE
Summary
The pilot reported that during the landing roll, at a point about two-thirds the way down the runway, the airplane veered to the left. The airplane continued off the
left side of the runway, through the rough terrain, over a bump, and into a ditch. The left wing sustained substantial damage. The pilot reported that there was
no mechanical failure/malfunction of the airplane, and that due to the tight foot space; he most likely inadvertently applied the left brake which resulted in the
airplane veering to the left.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadvertent
application of the brake which resulted in the loss of directional control during the landing roll.
Events
1. Landing-landing roll - Runway excursion
2. Landing-landing roll - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
Narrative
The pilot reported that during the landing roll, at a point about two-thirds the way down the runway, the airplane veered to the left. The airplane continued off the
left side of the runway, through the rough terrain, over a bump, and into a ditch. The left wing sustained substantial damage. The pilot reported that there was
no mechanical failure/malfunction of the airplane, and that due to the tight foot space; he most likely inadvertently applied the left brake which resulted in the
airplane veering to the left.
Printed: October 15, 2014
Page 39
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14LA251
05/24/2014 1030 CDT Regis# N998DS
Acft Mk/Mdl SMYTHE DONALD F KITFOX CLASSIC IV Acft SN C9508-0124
Eng Mk/Mdl ROTAX 582LC
Acft TT
Opr Name: ROHN ASHLEY
Opr dba:
308
Slaughter, LA
Apt: N/a
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
1
Aircraft Fire: NONE
Narrative
On May 24, 2014, about 1030 central daylight time, a Smythe Kitfox Classic IV experimental, amateur-built airplane, N998DS, impacted terrain after takeoff
from a private airstrip near Slaughter, Louisiana. The pilot was not injured; however, the passenger sustained serious injuries. The airplane was substantially
damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual
meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight was originating at the time of the accident. The intended
destination was the Slaughter Airpark (LS77), Slaughter, Louisiana.
The pilot reported that the accident occurred during a takeoff attempt to the northwest from an open field. He stated that during the takeoff roll he realized the
airplane was not going to be able to clear the trees. In his attempt to avoid the trees, the right wing contacted the ground and the airplane cartwheeled. Although
the engine was at full power, the airplane would not climb more than 20 feet above ground level (agl). According to the pilot, the field was comprised of 8-inch
high grass. A 3-foot high fence was located about 1,000 feet from where he initiated the takeoff, and 60-foot tall trees were about 650 feet from the fence. The
takeoff roll for the accident airplane was normally about 700 feet.
The accident airplane was powered by a 65-horsepower Rotax model 582LC two-cylinder, two-stroke engine. The maximum gross weight for the airplane was
1,200 lbs. The pilot reported that the airplane weight at the time of the accident takeoff was 1,105 lbs. He stated that there were no mechanical failures or
malfunctions associated with the airplane prior to the accident.
The pilot reported a total flight time of 200 hours, with 45 hours in Kitfox airplanes. He had flown 34 hours and 12 hours within the preceding 90 days and 30
days, respectively. He held a private pilot certificate that was issued in January 2012. He had completed a flight review in a Kitfox airplane in March 2014.
Federal Aviation Administration records indicated that the pilot purchased the accident airplane in January 2014.
Weather conditions recorded at the Baton Rouge Metropolitan Airport (BTR), located about 15 miles south of the accident site, at 0953, were: wind from 120
degrees at 5 knots; scattered clouds at 1,900 feet agl, scattered clouds at 3,800 feet agl, broken clouds at 4,500 feet agl; 10 miles visibility, temperature 25.0
degrees Celsius, dew point 20.6 degrees Celsius, altimeter 30.12 inches of mercury. The associated station pressure was 30.04 inches of mercury. The
calculated density altitude was 1,350 feet.
At 1053, the recorded weather conditions included: wind from 190 degrees at 5 knots; scattered clouds at 2,300 feet agl, broken clouds at 3,000 feet agl; 10
miles visibility; temperature 26.1 degrees Celsius; dew point 19.4 degrees Celsius; altimeter 30.11 inches of mercury; station pressure 30.03 inches of mercury.
The associated density altitude was 1,464 feet.
The Federal Aviation Administration (FAA) Airplane Flying Handbook (FAA-H-8083-3A) noted that ground effect is a condition of improved performance
encountered when the airplane is operating very close to the ground. Due to the reduced drag in ground effect, the airplane may seem to be able to take off
below the recommended airspeed. However, as the airplane rises out of ground effect with an insufficient airspeed, initial climb performance may prove to be
marginal because of the increased drag. Under conditions of high-density altitude, high temperature, and/or maximum gross weight, the airplane may be able to
become airborne at an insufficient airspeed, but unable to climb out of ground effect. Consequently, the airplane may not be able to clear obstructions, or may
settle back on the runway.
Printed: October 15, 2014
Page 40
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA514
09/14/2014 1430 CDT Regis# N710DM
Fremont, NE
Apt: Fremont Muni FET
Acft Mk/Mdl STANLEY ARTHUR FREEMAN ZODIAC
Acft SN 5636
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl GENERAL MOTORS CORVAIR
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: FREEMAN STANLEY A
Opr dba:
22
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Narrative
The pilot reported that during the landing flare, he over-controlled and the airplane climbed. He then pushed forward on the elevator control and over-corrected.
He said that before he knew it he was porpoising and the airplane landed hard. He stated that there were no mechanical problems with the airplane prior to the
event. The airplane incurred damage to the firewall.
Printed: October 15, 2014
Page 41
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Prepared From Official Records of the NTSB By:
Air Data Research
9865 Tower View, Helotes, Texas 78023
210-695-2204 - [email protected] - www.airsafety.com
Copyright 1999, 2012, Air Data Research
All Rights Reserved
National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR13FA393
08/31/2013 1357 PDT Regis# N43259
Acft Mk/Mdl STUART VORTEX
Acft SN 058
Apt: Scappoose Industrial Airpark SPB
Acft Dmg: DESTROYED
Fatal
Eng Mk/Mdl ROTAX 618
Opr Name: LAFAYETTE JAMES R
Scappoose, OR
1
Ser Inj
Opr dba:
Rpt Status: Factual Prob Caus: Pending
0
Flt Conducted Under: FAR 091
Aircraft Fire: GRD
Narrative
HISTORY OF FLIGHT
On August 31, 2013, at 1357 Pacific daylight time, a single-seat experimental amateur-built Sport Copter Vortex, N43259, collided with the ground near
Scappoose Industrial Airpark, Scappoose, Oregon. The gyroplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal
Regulations Part 91. The student pilot was fatally injured. The gyroplane sustained substantial damage during the accident sequence, and was subsequently
destroyed by post impact fire. The local personal flight departed Scappoose about 2 minutes prior to the accident. Visual meteorological conditions prevailed,
and no flight plan had been filed.
A friend of the pilot reported that they had performed minor maintenance earlier that morning to the nosewheel. The pilot did not intend to take off, but rather
had planned on performing a series of high speed taxi tests, and "crow hops." The friend further stated that the pilot had never soloed in a gyroplane before,
with his only prior solo experience being a series of "crow hops" the previous weekend.
The friend witnessed and video-recorded the initial segment of the accident flight while positioned midfield on the west ramp. He stated that the gyroplane
began the ground roll while traveling north on the parallel taxiway west of the runway 33. It took off, and seemed to be flying normally; however, as the pilot
initiated the landing attempt, it became unstable and began to wobble. The pilot applied engine power and the gyroplane started to climb, and began a left turn
towards the crosswind leg.
A second witness, who stated that he was a certified flight instructor with extensive helicopter and gyroplane flight experience, was located in his hangar at a
similar vantage point, further north along the runway. He heard the sound of a gyroplane on the taxiway, and initially thought it was the aircraft of the accident
pilot's hangar partner. He looked out and saw the gyroplane "crow hopping" down the taxiway, and then take off. It departed towards the north, and then began
a left turn, climbing just over the hangars and trees, where it joined the downwind leg at what he considered to be a slow airspeed. He reported the engine
sound as normal, and he did not see any smoke or vapor trailing at any time. He continued to be alarmed about the gyroplane's airspeed, and noted it was
flying in a fairly "aggressive" nose-up attitude, while "mushing" through the sky. He was concerned that the pilot did not have complete control of the gyroplane.
It then made what appeared to be a left base turn, while descending at a rapid rate. He assumed that the pilot was performing an "aggressive" descent to land,
and thinking no more of it, went back into his hangar. A short time later he came back outside and saw smoke in the vicinity of where he last observed the
gyroplane descending.
A third witness, located on an access road at the departure end of runway 33, about 1 mile from the accident site, observed the downwind portion of the flight.
He reported that the gyroplane was flying 200 feet above the surrounding trees. He looked away briefly, and as his gaze returned, the gyroplane shape had
changed. He could now see the full disc of the rotor blades, and the fuselage appeared to spin. The gyroplane then tumbled, and rapidly descended to the
ground.
Video
Review of the video footage revealed that it closely matched the witnesses' statements. It depicted the gyroplane taxing south along the taxiway with the engine
running and rotor blades spinning appropriately. In the next video segment, the gyroplane was airborne and flying north directly over the taxiway, about 30 feet
above ground level (agl). As it passed midfield while still over the taxiway, the engine tone decreased in pitch, and the gyroplane yawed to the left and began a
rapid descent to about 25 feet agl. The engine tone then increased, the gyroplane recovered, and began to climb. Once the gyroplane reached the end of the
taxiway, it began a climbing left crosswind turn to about 150 feet agl. In the final video segment the gyroplane was about 300 feet agl, and was proceeding
south on the downwind leg. The video resolution prevented an accurate assessment of the gyroplane's attitude, but the main rotor blades were turning, and the
engine was operating. The gyroplane was not trailing any smoke or vapor in any of the recordings.
PERSONNEL INFORMATION
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The 59-year-old-pilot held a combined student pilot and third-class aviation medical certificate issued October 29, 2012, with limitations that he must have
available glasses for near vision. An examination of his logbook indicated a total flight experience of 26.8 hours since his first training flight on July 30, 2012,
through to his most recent logbook entry 11 days prior to the accident. His initial flight training took place in a Cessna 152 fixed wing airplane for the period of
July 30, 2012, to December 1, 2012, during which time he accumulated 17 hours of dual flight instruction. He began dual flight instruction in a Calidus gyroplane
in Utah on July 23, and by August 15, had accumulated 8.7 hours of flight time.
His last flight entry was for dual instruction in a Vortex II gyroplane, which took place in Scappoose. Neither his flight logbook, nor student pilot certificate
contained any entries endorsing him for solo flight, and the flight instructor who provided him with his most recent flight training stated that he was not ready for
solo flight. No entries were located indicating any flight experience in the accident gyroplane.
AIRCRAFT INFORMATION
The single engine gyroplane was comprised of a tubular aluminum and steel primary structure with composite cabin fairings, and aluminum-skinned vertical and
horizontal stabilizers. It was equipped with a Rotax 618 series two-stroke engine, and a three-blade composite propeller.
The gyroplane was manufactured as a kit, and built by the original owner, receiving its special airworthiness certificate in May 2005. Federal Aviation
Administration (FAA) records indicated that the accident pilot purchased the gyroplane from this owner in July 2010. No maintenance logbooks were recovered.
METEOROLOGICAL INFORMATION
An automated surface weather observation from Scappoose was issued 4 minutes before the accident. It indicated calm wind and clear skies, with a
temperature of 29 degrees C, dew point 12 degrees C, and an altimeter setting at 29.87 inches of mercury.
AIRPORT INFORMATION
The FAA Airport/Facility Directory entry for Scappoose warned of extensive ultralight activity on the west side parallel taxiway. Witnesses also stated that
gyroplane traffic typically utilize this taxiway for takeoffs and landings.
WRECKAGE AND IMPACT INFORMATION
The NTSB investigator traveled in support of this investigation, and performed an examination of the engine and airframe following recovery.
The gyroplane came to rest on an easterly heading in a field, about 950 feet west-northwest of the approach end of runway 33. The entire structure was
contained within the immediate vicinity of the impact site. A group of 130-foot-tall trees bordered the area 50 feet to the north; all of the trees were intact, and
did not show any indications of recent damage.
The fuselage was positioned on its left side, and had sustained extensive thermal damage from the aft section of the tail keel through to the rotor mast,
consuming most of the cabin structure, flight controls, and structural members. The gyroplane displayed damage signatures consistent with striking the ground
in a left-side-low, nose-down attitude, with the vertical stabilizer and rudder bending over the left horizontal stabilizer.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed by the Oregon State Police, State Medical Examiner. The cause of death was reported as the result of multiple fractures and
internal injuries.
Toxicological tests on specimens recovered from the pilot were performed by the FAA Civil Aerospace Medical Institute. Analysis revealed no findings for
carbon monoxide, and the results were negative for all screened drug substances and ingested alcohol. Refer to the toxicology report included in the public
docket for specific test parameters and results.
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TESTS AND RESEARCH
The gyroplane was recovered from the accident site, and examined by the NTSB investigator-in-charge, along with an inspector from the FAA, and a
representative from Sport Copter. The examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The
following is a summary of the airframe and engine examination; a detailed report is located within the public docket.
Mast and Rotor Assembly
The rotor assembly sustained minimal thermal damage, and remained largely intact. The folding mast clamp remained intact, and connected to the mast
support tubes. The support tubes and mast were thermally consumed about three feet below the clamp. The rotor head pivot bolts remained intact, and the
assembly could be pivoted by hand to the stops in both the longitudinal and lateral directions.
All rotor assembly bump stops, bushings, plastic washers, and pivot plates, exhibited significant contact damage, gouge marks, and grazing consistent with
over-travel of the primary rotor system components.
Main Rotor Blades
Both main rotor blades remained attached to the blade hub bar, which was connected to the teetering hinge within the rotor head. The first blade exhibited a
10-degree downward curve along its entire length. No leading edge or chord wise scratches or gouges were present, and the trailing edge exhibited wrinkles
along the inboard 2/3 of its length.
The hub bar section of the second rotor blade was bent downwards about 5 degrees at the teeter hinge point. The blade exhibited similar trailing edge wrinkles
along the inboard 2/3 of its length with a 30-degree upwards bend starting about midspan. A semicircular puncture was present on the lower skin of the blade,
about 100 inches from the teeter hinge bolt, and just aft of the leading edge spar. The puncture was consistent with the blade striking the pilots footrest
crossbar. Three scour marks coated in grey dust-like material were present on the lower blade surface, about 57 inches from the root. Eight chordwise
scratches spaced at 2-inch-intervals emanated outboard from these marks. The marks and scratches were consistent with the main rotor blade and engine
propeller blade tips coming into contact with each other while both still rotating.
Fuselage Structure
The majority of the main landing gear support components were consumed by fire, with only the steel attachments and fittings remaining. The keel boom
separated from the fuselage just forward of the landing gear trailing arm. Crush damage and a black transfer mark were present on the right side of the keel
boom, in the area adjacent to the engine driven propeller rotational plane.
Engine
The engine sustained extensive thermal damage, and the carburetors and most ancillary components were consumed. The engine mounting bolts were in
place. The reduction gearbox was intact, and no indication of catastrophic engine or gearbox failures were noted. The engine spark plugs were removed, and all
exhibited light gray deposits, with no mechanical damage. The engine cylinders were examined with a borescope, and were free of catastrophic damage.
Propeller
The propeller hub remained attached to the gearbox output drive. All blades had separated about 4 inches from the hub and exhibited tip damage. Two blades
sustained thermal damage and were located in the airframe remnants; the third blade was free of thermal damage, and was located about 25 feet north of the
engine. This blade exhibited white transfer marks and crush damage to the outboard leading edge.
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Accident Rpt# CEN14LA433
07/29/2014 1300 CDT Regis# N76WS
Acft Mk/Mdl SUTTON WILLIAM J STITS PLAYMATE
Opr Name: FALLIS ROBERT P
Acft SN 75
Bridgeport, TX
Acft Dmg: SUBSTANTIAL
Rpt Status: Prelim
Fatal
Flt Conducted Under: FAR 091
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: SPE
Narrative
On July 29, 2014, about 1230 central daylight time, a Stits Playmate SA-11Aairplane, N76WS, impacted terrain at the Bridgeport Municipal Airport (KXBP),
Bridgeport, Texas. The airline transport rated pilot was not injured, and the airplane was substantially damaged. The airplane was registered to and operated by
a private individual, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and a flight
plan was not filed.
The pilot reported to the responding Federal Aviation Administration (FAA) inspector, that he was doing touch-and-go landings. During takeoff, when the
airplane was 10-15 feet in the air, the airplane made a descending left turn. He then stayed in the traffic pattern and landed on the runway. The pilot checked
the flight controls and the controls appeared to respond correctly. He then departed for another takeoff, again the airplane made a descending left turn after
becoming airborne. The airplane did not respond to his control inputs, so he reduced power and landed in the grass near the runway.
Examination of the airplane revealed that substantial damage to the left and right wings, and fuselage.
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National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN11LA582
08/20/2011 1341 CDT Regis# N2BJ
Acft Mk/Mdl VERTICAL UNLIMITED LLC 12
Acft SN 297
Eng Mk/Mdl VENDENYEV M14P
Acft TT
Opr Name: VERTICAL UNLIMITED LLC
Opr dba:
207
Kansas City, MO
Apt: Charles B. Wheeler Downtown MKC
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Fatal
Flt Conducted Under: FAR 091
1
Ser Inj
0
Aircraft Fire: GRD
Summary
The accident occurred during an air show performance. Video footage and photographs of the final portion of the accident routine revealed that the airplane
exited a Lomcevak maneuver into a right-hand, inverted spin. The pilot recovered from the inverted spin, but the airplane immediately entered a left upright
spin. (Most of the time, a recovery from the Lomcevak maneuver would be straight ahead, but occasionally recovery from an inverted spin would be
necessary.) The airplane appeared to yaw left during the final descent, completing about 1 1/2 revolutions before impacting the ground and then coming to rest
upright. The photographs indicated that the airplane was intact; however, the elevators were deflected upward, which was inconsistent with a spin recovery.
The pilot's friend reported that the pilot appeared to initiate the Lomcevak maneuver more aggressively than he had seen during previous airshow
performances. Another friend, who had trained with the pilot and was familiar with the routine, reported that the Lomcevak maneuver completed during the
accident flight included an extra rotation. All major airframe components were observed in place relative to the overall airframe. A postaccident examination of
the airplane and a teardown examination of the engine did not reveal any anomalies consistent with a preimpact failure or malfunction. No evidence of an
in-flight structural failure was observed.
Toxicology testing indicated the distant use of Valium by the pilot; however, it is not likely to have been directly impairing at the time of the accident. A review of
the pilot's medical records indicated that he had sought treatment for vertigo after feeling off-balance and nauseated while conducting aerobatics; additionally,
the pilot reported that he had fallen after getting out of the airplane. An initial medical evaluation was conducted, and further treatment was prescribed;
however, the records indicated that the pilot did not return for treatment. In addition, autopsy results revealed that the pilot suffered from severe coronary artery
disease and had an enlarged heart and a congenital valve anomaly. Histology of the right and left ventricle walls was consistent with myocardial ischemia.
These conditions placed the pilot at an increased risk of an acute coronary event, including a cardiac arrhythmia and sudden cardiac death, although
insufficient evidence exists to determine whether the pilot experienced an acute cardiac event at the time of the accident. The extent that vertigo might have
caused the accident could not be determined; however, the persistence of the vertigo symptoms after completion of aerobatic maneuvers suggested that it
might have played a role in the pilot's loss of control.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's impairment during an
aerobatic airshow performance for reasons that could not be determined based on available information, which resulted in an in-flight loss of airplane control.
Events
1. Maneuvering-aerobatics - Low altitude operation/event
2. Maneuvering-aerobatics - Loss of control in flight
3. Maneuvering-aerobatics - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Personnel issues-Physical-Impairment/incapacitation-Illness/injury-Pilot - C
Narrative
HISTORY OF FLIGHT
On August 20, 2011, at 1341 central daylight time, a Vertical Unlimited LLC model 12 airplane, N2BJ, was substantially damaged when it impacted terrain at
the Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The pilot was performing an aerobatic routine at the Kansas City Aviation Expo at the
time of the accident. The pilot was fatally injured. The airplane was registered to Vertical Unlimited LLC and operated by the pilot. The aerobatic exhibition (air
show) flight was being conducted under the provisions of 14 Code of Federal Regulations Part 91 and a Certificate of Waiver issued for the air show. Visual
meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local exhibition flight originated from MKC about 1336.
The air show performance appeared to proceed normally until shortly before the accident. A review of video footage of the final portion of the accident routine
indicated that the pilot appeared to have exited a Lomcevak maneuver into a right, inverted spin. Upon recovery from the inverted spin, as the airplane began to
pitch up from a nose-down attitude, it rolled to the left and the nose dropped. The airplane appeared to yaw to the left (counterclockwise) during the final
descent, completing about one and one-half revolutions before impacting the ground. The resolution of the video did not permit any assessment of flight control
surface deflections.
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A series of six photographs taken at approximately one-second intervals immediately before the accident depicted the airplane in a nose low pitch attitude. It
was upright, with the wings level to a slight left bank angle. The consecutive sequence of photos suggested that the airplane was yawing to the left
(counter-clockwise) as it descended. The airshow/aerobatic performance smoke was on at the time. In the fifth photograph in the series, the smoke stream was
oriented approximately vertically in the frame. The angle between the wing chord and the smoke orientation appeared to be about 30 degrees.
The airplane appeared intact, with no anomalies apparent in any of the photos. The elevator control surfaces appear to be deflected upward relative to the
airframe. The right ailerons appeared to be deflected upward/left ailerons downward. The rudder appeared to be neutral or deflected slightly right in the first and
second photos. It is deflected to the left in the third and fourth photos; and appeared to be deflected left in the fifth photo. The airshow smoke obscured the
rudder in the final photo. All control surfaces appeared to be intact and deflected within the normal range of travel; however, the exact deflection angles were
not determined.
A friend and colleague of the pilot stated that a Lomcevak maneuver was initiated on an inverted 45-degree up-line, followed by full forward elevator and then
full left rudder control inputs. He added that most of the time recovery from the maneuver would be straight ahead, but occasionally recovery from an inverted
spin would be necessary. He noted that the pilot appeared to initiate the maneuver more aggressively in the accident performance than he had seen during
previous airshow performances.
A second friend and colleague of the pilot, who had trained with him and was familiar with his routine, reported that the Lomcevak maneuver completed during
the accident flight included an extra rotation. The airplane subsequently exited the maneuver into an inverted spin, which was not unusual.
PERSONNEL INFORMATION
The accident pilot held an Airline Transport Pilot certificate with single and multi-engine land airplane ratings. The certificate also included type ratings for
A-320, B-747-4, DC-9, and SA-227 airplanes. The single-engine airplane class rating was limited to commercial pilot privileges. He also held a current Acrobatic
Competency card with a minimum altitude limitation of 250 feet above ground level (agl).
The pilot was issued a first class airman medical certificate on March 1, 2011, with a restriction for corrective lenses. On the application for that certificate, he
reported an estimated 22,000 hours total flight time and 300 hours of that flight time within the previous 6 months.
The pilot had reportedly been flying aerobatics for 15 years, with experience in Christen Eagle, Laser 200, Pitts S1S, and Extra 300L airplanes. The pilot was
reportedly involved in the development and construction of the accident airplane. He had signed the registration and airworthiness documents submitted to the
FAA to support certification.
AIRCRAFT INFORMATION
The accident airplane, an amateur-built Vertical Unlimited model 12, serial number 297, was a modified single-place, aerobatic biplane. The airplane was based
on the 2-place Pitts model 12 airplane design. The front cockpit position was removed, and smoke and auxiliary fuel tanks were installed in that location. The
wing fuel tank was also eliminated. In addition, the ailerons were lengthened and another aileron hinge point was added.
The airplane was powered by a 412-horsepower modified Vedeneyev M14P radial engine, and a 3-bladed MT Propellers model MTV-9-K-C propeller assembly.
The airplane was issued an experimental exhibition category airworthiness certificate on March 5, 2009.
Maintenance records indicated that the most recent condition inspection was completed on February 1, 2011, at 196.1 hours total airframe time. Testing of the
transponder and altitude encoder was conducted on March 8, 2011. The records indicated that the engine oil and filter were changed on June 16, 2011, at
207.0 hours. There were no subsequent entries in the aircraft maintenance logbooks.
METEOROLOGICAL CONDITIONS
The MKC Automated Surface Observation System (ASOS), at 1354, recorded the following weather conditions: calm wind; 10 miles visibility with light rain;
clear skies; temperature 24 degrees Celsius; dew point 20 degrees Celsius; altimeter 29.97 inches of mercury. According to documentation provided by the
National Weather Service, ASOS will not report cloud heights greater than 12,000 feet above ground level.
A friend and colleague of the pilot noted that the accident airplane was moved into a hangar briefly when it began to rain shortly before his scheduled
performance. After about 15 minutes, the rain has stopped. The airplane was removed from the hangar and the pilot began his performance. She noted that the
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cloud cover was high enough not to have affected the pilot's air show routine.
AIRPORT INFORMATION
The Charles B. Wheeler Downtown Airport (MKC) is a publicly-owned facility, located along the Missouri River, adjacent to downtown Kansas City, at an
elevation of 757 feet. It is served by two hard surfaced runways: runway 1-19 is 6,827 feet by 150 feet; and runway 3-21 is 5,050 feet by 100 feet. Air traffic
services in the immediate vicinity of MKC are provided by the Airport Traffic Control Tower (ATCT). The surrounding airspace is controlled by the Kansas City
Terminal Radar Approach Control (TRACON) facility located at the Kansas City International Airport (MCI), about 12 miles north-northwest of MKC.
The airport was hosting the Kansas City Aviation Expo at the time of the accident. Air show operations were being conducted under a Certificate of Waiver
issued by the Federal Aviation Administration (FAA) for the event. The waiver authorized day and night aerobatic demonstrations, high speed flight, and
parachute demonstrations within 5 miles of the airport and up to 16,000 feet msl.
WRECKAGE AND IMPACT INFORMATION
The accident site was located on the airport in the grass infield area about 280 feet west of the runway 1-19 and 3-21 intersection. The airplane came to rest
upright and all major airframe components were observed in place relative to the overall airframe. The fuselage, engine, and wings exhibited damage consistent
with impact forces. The forward fuselage, engine, cockpit, and the inboard portion of the upper and lower wings were consumed by a postimpact fire. The aft
fuselage and empennage remained intact; the majority of that portion of the airframe structure was unaffected by the postimpact fire. The engine and propeller
assembly were partially embedded into the ground. The main landing gears had collapsed and were located under the airframe.
A postaccident airframe examination was conducted at MKC by Federal Aviation Administration (FAA) inspectors. A subsequent engine teardown examination
was conducted under the direct supervision of an FAA inspector. No anomalies consistent with a preimpact failure or malfunction were observed.
The flight controls remained attached to their mating airframe structure. The upper and lower ailerons were partially compromised by the postimpact fire. Aileron
control continuity was confirmed from the cockpit control stick to the lower ailerons; however, the push-pull control tube rod end at the left lower aileron
bellcrank was separated. The fracture surface appeared consistent with an overstress failure. The left wing aileron slave strut was separated at the lower
aileron rod end. The fracture surface appeared consistent with an overstress failure. The right wing aileron slave strut remained attached to both the upper and
lower aileron. The elevators and rudder remained attached to the horizontal and vertical stabilizers, respectively. Each control surface appeared intact. Elevator
and rudder control continuity was confirmed from each control surface to their respective cockpit controls; although, the elevator push-pull control tube and the
rudder cables had been cut to facilitate recovery. The elevator trim tabs remained attached to the elevators; however, the trim cables were separated in a
manner consistent with an overload failure.
Engine mixture and propeller control continuity was confirmed from the cockpit controls to the throttle body and propeller governor, respectively. The throttle
cable was separated at the throttle body; however, the separation appeared consistent with impact forces. The throttle cable remained attached to the cockpit
throttle control.
The engine assembly exhibited damage consistent with impact forces. The nose case and no. 6 cylinder were displaced, but remained attached to the engine.
The reduction gear was removed with the nose case. The reduction gearing appeared intact and rotated freely. Once the crankcase was parted, the crankshaft
rotated freely. The case halves appeared undamaged. The master rod and articulated rods rotated freely on the crankpin. The no. 6 cylinder articulated
connecting rod was bent consistent with the damage to that cylinder. The master rod bearing appeared intact. The pistons did not exhibit any scoring. The
cylinder rocker boxes were deformed consistent with impact; however, the rocker arms appeared to be intact. The front sparkplugs were damaged. The rear
spark plugs were removed; they exhibited normal combustion signatures and proper electrode gaps. The oil pump rotated freely; the oil screen did not contain
any foreign material. The accessory gears appeared intact and the rotated freely. The supercharger rotated freely by hand. The supercharger contained
ingested soil and appeared to contain residual fuel.
The propeller assembly remained attached to the engine. Two propeller blades had separated at the blade root; the third blade separated about mid-span. The
separation of all three propeller blades appeared consistent with overstress/impact forces.
The Data Acquisition Unit (DAU) and Electronic Flight Information System (EFIS) installed in the accident airplane were recovered and sent to the NTSB
recorders lab for examination. Data recovered from the EFIS was not relevant to the accident flight. No data was recovered from the DAU.
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MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy of the pilot was performed by the Jackson County Medical Examiner's Office, Kansas City, Missouri, on August 21, 2011. The autopsy report
attributed the pilot's death to blunt force traumatic injuries sustained in the accident.
The FAA Civil Aerospace Medical Institute forensic toxicology report stated:
Nordiazepam detected in urine;
Nordiazepam NOT detected in Blood (Cavity);
Oxazepam NOT detected in Blood (Cavity);
0.021 (ug/ml, ug/g) Oxazepam detected in Urine;
Temazepam detected in Urine;
Temazepam NOT detected in Blood (Cavity).
Nordiazepam, oxazepam, and temazepam are metabolites of diazepam, which is commonly marketed under the trade name Valium.
According to the pilot's medical records, he had sought treatment for vertigo in March 2010. He reported feeling off-balance and nauseated while conducting
aerobatics. In addition, he had fallen after getting out of the airplane. The pilot independently obtained some treatment information and reported feeling better;
however, the dizziness returned when he flew a few days later. During a subsequent office evaluation, a physical therapist was able to reproduce some of the
vertigo sensations and prescribed further treatment. According to the records, the pilot never returned to the therapist.
A colleague of the pilot noted that he had initially experienced the vertigo condition during an aerobatic practice session. The pilot abruptly terminated the
practice session. Ultimately, the pilot ceased flying for about three months following the initial event and had completed treatment for the condition. Based on
her observations at the time of the accident, the pilot showed absolutely no signs of impairment and appeared to be completely healthy.
The autopsy report noted the presence of atherosclerotic disease with one coronary artery occluded up to 99-percent. In addition, the autopsy revealed that the
pilot's heart was enlarged and exhibited a congenital anomaly of the aortic valve. Histology of the right and left ventricle walls revealed the presence of
transmural hypereosinophilic myocytes, many of which exhibited contraction bands. The left ventricle exhibited an interstitial edema in the wall of the heart.
The pilot's available medical records did not contain any record related to a diagnosis of heart disease.
TESTS AND RESEARCH
A Garmin 496 GPS unit was recovered from the accident airplane. The data was successfully downloaded from the unit and a copy of the data file is included
with the docket material associated with this investigation. The recorded data included date, time, position, and GPS altitude. Calculated ground speed and
ground track information was also recorded in the data file.
The data appeared to be associated with two flights. The first portion of the data was dated August 19, 2011, the day before the accident, beginning about 1326
and ending about 1411. The position data originated and terminated at MKC. An increase in ground speed, consistent with takeoff, began about 1348. A
decrease in ground speed, consistent with landing, occurred about 1408.
The second portion of the data was dated August 20, 2011, the day of the accident. The initial data point was recorded at 1333:35 (hhmm:ss) and the final data
point was recorded at 1341:40. Based on the recorded groundspeed information, the takeoff began about 1336. Variations in the altitude, ground speed, and
ground track data appeared consistent with aerobatic flight maneuvers.
ADDITIONAL INFORMATION
The FAA Airplane Flying Handbook describes a spin as an aggravated aerodynamic stall that results in the airplane following a downward corkscrew path. Spin
recovery is completed by reducing the throttle to idle, holding a neutral aileron position, applying full rudder opposite the direction of spin rotation, and applying
forward movement of the elevator control in order to break the stalled condition. Once rotation has stopped, the rudder control should be neutralized and the
airplane recovered to level flight. The handbook notes that excessive use of the elevator on recovery can cause a secondary aerodynamic stall and result in
another spin.
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