National Transportation Safety Board - Aircraft Accident/Incident Database

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1 Accident Rpt# ERA11CA163 07/20/ EDT Regis# N9120E Randolph, NY Apt: Campbell Field Airport 85NK Acft Mk/Mdl AERONCA 11AC Acft SN 11AC-754 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONT MOTOR A&C65 SERIES Acft TT 1022 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: LINN DENNIS R Acft Owner: LINN DENNIS R According to the certificated flight instructor (CFI), the student pilot was receiving instruction in a tailwheel equipped airplane. During the takeoff roll, the airplane began to veer to the right, exited the runway, and impacted the corner of a building, resulting in substantial damage to the forward and aft spars of the left wing.. The CFI reported that during the takeoff roll, the student pilot was pushing heavily on the right brake. According to the student pilot, about 300 feet into the takeoff roll, the airplane veered to the right a few degrees and the CFI took control of the airplane. The airplane continued to veer to the right and prior to impacting the building, the student pilot retarded the throttle. Both pilots reported that there were no mechanical malfunctions with the airplane prior to the accident. The National Transportation Safety Board was notified of this accident on February 25, Page 1 Copyright 1999, 2010,

2 Accident Rpt# WPR10LA053 11/10/ PST Regis# N9617Y Chico, CA Apt: Chico CIC Acft Mk/Mdl BEECH 35-B33 Acft SN CD-583 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued Eng Mk/Mdl TELEDYNE CONTINENTAL MOTORS Acft TT 3774 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: WILLIAM P AND MAUREEN GRIGGS Acft Owner: WILLIAM P AND MAUREEN GRIGGS Summary According to the pilot, she filled the fuel tanks prior to departure for the cross-country flight. She switched the fuel selector position every 30 minutes during the flight in an effort to alternate between tanks. She switched to the fullest (left) tank while on approach to the airport. The airplane was on a stable glide path with the gear and flaps down, mixture rich, and propeller at low pitch. On final approach, about 100 feet above ground level, the engine experienced a loss of power. Despite the pilot's efforts, which included switching to the right tank and turning the fuel boost pump to the "on" position, the engine would not restart. The pilot banked to the right to avoid the runway approach lights and the wing tip subsequently struck the ground. The airplane tumbled in a cartwheel-type maneuver before coming to a stop in a nose-down attitude. First responders observed no fuel in the right wing fuel tank and drained about 12.5 gallons of fuel from the left wing fuel tank. During a postaccident examination, with the airplane in a level attitude, investigators drained 10 gallons of fuel from the right fuel tank and found fuel in the gascolator. Investigators discovered no anomalies that would have precluded normal operation of the airframe or engine. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of engine power during final approach for undetermined reasons. Events 1. Approach-VFR pattern final - Loss of engine power (total) 2. Landing-landing roll - Off-field or emergency landing 3. Landing-landing roll - Collision with terr/obj (non-cfit) Findings 1. Aircraft-Aircraft power plant-(general)-(general)-not specified 2. Not determined-not determined-(general)-(general)-unknown/not determined - C On November 10, 2009, about 1735 Pacific standard time, a Beech 35-B33, N9617Y, made a forced landing short of runway 13L at Chico Municipal Airport, Chico, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certificated private pilot and one passenger sustained minor injuries; the airplane sustained substantial damage to the fuselage and right wing from impact forces. The cross-country personal flight departed Portland, Oregon, about 1430, with Chico as a planned fuel stop. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. The pilot stated that the fuel tanks were topped off at Portland, and she switched tanks every 30 minutes during the flight. She switched to the fullest tank (left) while completing the pre-landing checklist on approach to Chico. The pilot was cleared inbound for a straight in approach to runway 13L. She stated that she was on a stable glide path with the landing gear and flaps down, mixture rich, and propeller in. On final approach at 100 feet above ground level (agl), the engine lost power. She was initially restrained by her shoulder harness, but was able to move and switched to the right fuel tank; the engine did not respond. The last row of the runway approach lights were in her path, so she raised the flaps. She tried, but was not sure that she activated the fuel boost pump, because she had to maneuver away from the approach lights. As the airplane banked to the right, the wing tip dug in, and the airplane cartwheeled to the right before coming to a stop. The airplane touched down about 200 yards short of the runway on airport property. The pilot stated that the windscreen was broken, the doors were jammed, and the pilot window was broken. The two occupants had to break remaining pieces from the pilot window in order to exit the airplane. First responders reported that the airplane came to rest nose down with the tail about 20 feet in the air. The magnetos and battery switch were still on. They observed a fuel and oil leak from the engine. The emergency locator transmitter (ELT) was on, and could not be shut off by the reset button on the instrument panel. The right wing was damaged; they observed no fuel in it, and could not determine if fuel had leaked out during the impact sequence. They drained 12.5 gallons of fuel from the left wing tank, but could not determine how much fuel remained in the tank, because of the steep angle of the wing. Page 2 Copyright 1999, 2010,

3 TEST AND RESEARCH Investigators from the National Transportation Safety Board and Teledyne Continental Motors examined the wreckage at a recovery facility. Airframe A visual examination revealed that the left and right main fuel tanks were not breached. The fuel selector valve (FSV) was positioned to the right main tank. The FSV moved freely from the right to the left and to the OFF positions. The boost pump was in the ON position. Approximately 10 gallons of a blue fluid that smelled like aviation fuel was drained from the right tank. Fluid that smelled like aviation fuel was drained from the gascolator; the screen was clean. Fuel check valves in both wings and in the engine compartment worked properly. The vents were open. The fuel line was disconnected at the selector valve, air was blown through the line, and fluid came out of the fuel line to the inlet side of the fuel pump in the engine compartment. Engine The engine separated in the collision sequence. The spark plugs were removed and all appeared clean with no mechanical deformation. The spark plug electrodes were elliptical, slightly oily, and gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. The crankshaft was manually rotated with the propeller. The crankshaft rotated freely, and the valves moved in firing order. The gears in the accessory case turned freely. Thumb compression was obtained on all cylinders in firing order. The magnetos were manually rotated, and both magnetos produced spark at all posts. The engine driven fuel pump drive gear was undamaged, and the pump rotated freely. The fuel pump functionally tested satisfactory; fluid flowed freely through the pump with rotation. Liquid was in the fuel distribution valve. The rubber diaphragm in the fuel distribution valve was unbroken, the screen was clean, and no contaminants were observed. The fuel injector nozzles for cylinders number one, two, and three were clean; nozzles four, five, and six were oily. The fuel control screen was clear. No anomalies were noted that would have precluded normal operation. Page 3 Copyright 1999, 2010,

4 Accident Rpt# CEN11FA302 04/22/ CDT Regis# N580EA Topeka, KS Apt: Philip Billard Municipal TOP Acft Mk/Mdl BEECH 58 Acft SN TH-316 Acft Dmg: DESTROYED Rpt Status: Prelim Prob Caus: Pending Eng Mk/Mdl CONT MOTOR IO 520 SERIES Acft TT Fatal 4 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: PRECISION AG & SEED SERVICES LLC Aircraft Fire: GRD Acft Owner: PRECISION AG & SEED SERVICES LLC On April 22, 2011, at 1213 central daylight time, a Beech 58, N580EA, collided with the ground while executing a missed approach at the Philip Billard Municipal Airport (TOP), Topeka, Kansas. The private pilot and three passengers were fatally injured. The airplane was destroyed. The airplane was registered to Precision Ag and Seed Services LLC., and operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed and an instrument flight rules flight plan was filed. The flight originated from Scott City Municipal Airport (TQK), Scott City, Kansas, about Two pilot witnesses at TOP reported observing the accident airplane flying in a level flight attitude about halfway down runway 31. The airplane's landing gear was extended and they estimated its altitude to be around 200 to 300 feet above the runway. When the airplane was near the runway's end the landing gear was retracted and the airplane began a slow climb into the clouds. The witnesses estimated the overcast to be at 500 feet above ground level (AGL) with a visibility of 2.5 miles. Numerous people on the ground reported hearing the airplane impact the ground and reported seeing a fireball; however, there were no reported eyewitnesses to the actual impact. According to air traffic control (ATC) recordings and radar data, the pilot had attempted the localizer back course approach to runway 31 before executing a missed approach. During the missed approach the airplane entered a steep descending left turn and impacted terrain. There were no reported distress calls from the pilot. The airplane wreckage was located in a harvested cornfield 4 miles northeast of TOP. Page 4 Copyright 1999, 2010,

5 Accident Rpt# NYC82DA033 02/07/ EST Regis# N41694 Marthas Vineyar, MA Apt: Marthas Vineyard Acft Mk/Mdl BELLANCA 7KCAB 7KCAB Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued Eng Mk/Mdl LYCOMING AEIO-320-E1B Acft TT 1720 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: BAY AERO CLUB INC. Acft Owner: BAY AERO CLUB INC. Summary AFTER ARRIVING AT THE DESTINATION, THE PILOT LANDED ON RUNWAY 24. THE WIND WAS FROM 330 DEGREES GUSTING TO 20 KTS. DURING THE LANDING ROLL-OUT, THE AIRCRAFT GROUND LOOPED WHEN A CROSSWIND GUST WAS ENCOUNTERED. THE PLANE RAN OFF THE RUNWAY INTO A ROUGH GRASSY AREA WHERE THE LEFT MAIN GEAR COLLAPSED. Sequence of Events Type of Occurrence - Phase of Flight Cause/Factor - Text LOSS OF CONTROL - ON GROUND/WATER - LANDING - ROLL FACTOR WEATHER CONDITION - CROSSWIND - FACTOR WEATHER CONDITION - GUSTS - CAUSE WRONG RUNWAY - SELECTED - PILOT IN COMMAND CAUSE DIRECTIONAL CONTROL - NOT MAINTAINED - PILOT IN COMMAND GROUND LOOP/SWERVE - INADVERTENT - PILOT IN COMMAND MAIN GEAR COLLAPSED - LANDING - ROLL FACTOR TERRAIN CONDITIONS - HIGH VEGETATION - FACTOR TERRAIN CONDITIONS - ROUGH/UNEVEN LANDING GEAR, MAIN GEAR - OVERLOAD - Page 5 Copyright 1999, 2010,

6 Accident Rpt# CEN11CA256 03/25/ CDT Regis# N68117 Wichita, KS Apt: Westport 71K Acft Mk/Mdl BOEING A75N1(PT17) Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl PRATT & WHITNEY R985 Acft TT 2900 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: BENNETT L. SORENSEN Acft Owner: BENNETT L. SORENSEN While landing for the second time on the local flight, the airplane immediately veered to the right. The pilot attempted to correct the airplane's ground track by the use of rudder and brakes. After attempting to correct the ground track through the use of increased engine power, the pilot chose to bring the airplane to a stop. The airplane departed the runway, collided with a drainage ditch, and came to rest inverted. Substantial crushing damage was sustained to the airplane's upper wings. An examination of the airplane's braking system by a responding Federal Aviation Administration (FAA) inspector did not reveal any anomalies. In an interview with the FAA inspector, the passenger seated in the front seat stated that he had placed his feet away from the airplane's rudder pedals and brakes and to his knowledge had not interfered with the airplane brakes. Page 6 Copyright 1999, 2010,

7 Accident Rpt# ERA10CA469 09/06/ EDT Regis# N3650V Levant, ME Apt: Griffin Field Leavant NONE Acft Mk/Mdl CESSNA 140 Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued Eng Mk/Mdl CONT MOTOR C90 SERIES Acft TT 1810 Fatal 0 Ser Inj 1 Flt Conducted Under: FAR 091 Opr Name: GILLIS IAN J M Acft Owner: GILLIS IAN J M Summary According to a witness the airplane touched down and lifted off, but did not appear to gain much altitude. Near the end of the runway, the airplane wavered right and then left before the left wing struck the ground. As a result of the impact, the fuselage, left wing, firewall, and elevator incurred substantial damage. The pilot stated that he could not recall the events that transpired during the accident sequence; he reported no mechanical malfunctions or failures with the airframe or engine that would have precluded normal operation. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to obtain adequate airspeed during takeoff, which resulted in an aerodynamic stall. Events 1. Takeoff - Abrupt maneuver 2. Takeoff - Dragged wing/rotor/float/other Findings 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 According to a witness, the accident airplane touched down over halfway down the up-sloped, 2,300-foot grass runway 27. It then transitioned to a takeoff, but during the climb, the airplane "wavered left and right" before the left wing struck the ground. The fuselage, left wing, firewall, and elevator incurred substantial damage. The pilot stated that he could not recall the events that transpired during the accident sequence, and did not report that there were any mechanical failures or malfunctions of the airplane. A review of the accident airplane's information manual revealed, under the conditions that existed at the time of the accident, that the landing and takeoff distance required was approximately 900 feet, and was based on the use of a "hard surface, level runway." The winds reported at an airport 11 miles to the southeast of the accident location were from 290 degrees at 10 knots. Page 7 Copyright 1999, 2010,

8 Accident Rpt# MKC90LA087 04/17/ CDT Regis# N714EB Salina, KS Apt: Salina SLN Acft Mk/Mdl CESSNA Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued Eng Mk/Mdl CONTINENTAL O-200-A Acft TT 5435 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: HESSTON COLLEGE Acft Owner: HESSTON COLLEGE Summary AFTER SHOOTING INSTRUMENT APPROACHES IN SEVERAL LOCATIONS, UNDER VFR CONDITIONS, THE PVT PLT SAID THAT DURING THE SECOND PRACTICE APPROACH, THE ENGINE FAILED. AN EMERGENCY LANDING WAS ATTEMPTED IN A WHEAT FIELD WHICH RESULTED IN SUBSTANTIAL DAMAGE TO THE ACFT. POST ACCIDENT INVESTIGATION REVEALED NO MECHANICAL MALFUNCTIONS, HOWEVER THE FUEL TANKS WERE EMPTY OF USABLE FUEL. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: FUEL EXHAUSTION, FUEL CALCULATIONS MISJUDGED AND REFUELING NOT PERFORMED BY THE PILOT IN COMMAND. Sequence of Events Type of Occurrence - Phase of Flight Cause/Factor - Text LOSS OF ENGINE POWER (TOTAL) - NONMECHANICAL - APPROACH CAUSE FLUID, FUEL - EXHAUSTION - CAUSE FUEL CONSUMPTION CALCULATIONS - MISJUDGED - PILOT IN COMMAND CAUSE REFUELING - NOT PERFORMED - PILOT IN COMMAND FORCED LANDING - DESCENT - EMERGENCY - - IN FLIGHT COLLISION WITH TERRAIN/WATER - LANDING FACTOR TERRAIN CONDITIONS - NONE SUITABLE - Page 8 Copyright 1999, 2010,

9 Accident Rpt# CHI94LA298 08/25/ CDT Regis# N6307S Centralia, IL Acft Mk/Mdl CESSNA Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Issued Eng Mk/Mdl CONTINENTAL O-200A Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: JAMES R. MINEER Acft Owner: JAMES R. MINEER Summary THE AIRPLANE DEPARTED ON A NIGHT VFR FLIGHT WITH FULL FUEL TANKS (22.5 GALLONS USABLE). THE PILOT CLIMBED TO 6500 FEET MSL, AND SET 2350 RPM. AFTER APPROXIMATELY 3.3 HOURS, IN A DESCENT TO THE DESTINATION AIRPORT, THE ENGINE STOPPED AND WOULD NOT RESTART. THE AIRPLANE STRUCK A HOUSE DURING THE FORCED LANDING. POST CRASH INSPECTION REVEALED NO USABLE FUEL ON BOARD, AND NO EVIDENCE OF AN IN FLIGHT LEAK. THE PILOT STATED HE BELIEVED HE IMPROPERLY LEANED THE MIXTURE, RESULTING IN A HIGHER THAN FORECAST FUEL CONSUMPTION. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: fuel exhaustion as a result of the pilots improper fuel calculation and improper use of fuel mixture. Sequence of Events Type of Occurrence - Phase of Flight Cause/Factor - Text LOSS OF ENGINE POWER (TOTAL) - NONMECHANICAL - CRUISE - NORMAL CAUSE FUEL CONSUMPTION CALCULATIONS - IMPROPER - PILOT IN COMMAND CAUSE MIXTURE - IMPROPER USE OF - PILOT IN COMMAND CAUSE FLUID, FUEL - EXHAUSTION - FORCED LANDING - DESCENT - EMERGENCY - - IN FLIGHT COLLISION WITH OBJECT - DESCENT - EMERGENCY OBJECT - RESIDENCE - On August 25, 1994, at 2215 hours central daylight time, a Cessna 150, N6307S, operated by James Mineer of Prestonsburg, Kentucky, impacted a residence 1/4 mile short of the Centralia Municipal Airport, Centralia, Illinois, and was substantially damaged. The instrument rated commercial pilot received minor injuries and no fire occurred. No injuries occurred to persons on the ground. Night visual meteorological condition existed at the time of the accident and no flight plan was filed. The flight operated under 14 CFR Part 91 and originated from the Big Sandy Regional Airport, Prestonburg, Kentucky, at 1900 hours central daylight time. The airplane was refueled with 16.1 gallons of 100LL aviation gasoline and was described as "topped off" by servicing personnel at the Big Sandy Regional Airport the afternoon of August 25, Fuel capacity of the airplane was 26.0 gallons, of which 22.5 gallons is usable. The pilot reported that had climbed to 6,500 feet above Mean Sea Level (MSL), and cruised at an engine power setting of 2,350 Revolutions Per Minute (RPM). His Global Positioning System (GPS) indicated a ground speed of 92 to 94 knots. The Cessna 150 cruise performance chart in the Pilot Operating Handbook indicates an estimated fuel burn of 4.0 gallons per hour at these settings when the fuel mixture is leaned to maximum RPM. The pilot stated that he must have improperly leaned the mixture, resulting in a higher than expected fuel consumption rate. The pilot reported that the engine stopped while at 3,000 feet, 5 miles from the destination airport, he was unable to restart it and unsuccessfully attempted to glide to the airport. A witness on the ground, who was the chief instructor pilot for a flight school at the Centralia airport, reported hearing the impact but no engine sound. Post crash inspection revealed 1 1/2 gallons of fuel remaining in the wing tanks, 1 pint of fuel in the belly strainer, no visible contaminants, and the fuel selector valve in the "ON" position. No fuel leakage was evident at the accident site. No evidence of fuel venting or leakage was found, and the fuel vents were unobstructed. Page 9 Copyright 1999, 2010,

10 Accident Rpt# WPR10LA384 08/05/ PDT Regis# N9730H Roche Harbor, WA Apt: Roche Harbor WA09 Acft Mk/Mdl CESSNA 172-M M Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: ROBERT FRASER Acft Owner: WHIDBEY ISLAND NAVY FLYING CLUB HISTORY OF FLIGHT On August 5, 2010, about 1714 Pacific daylight time, a Cessna 172M, N9730H, was substantially damaged when it struck trees shortly after takeoff from Roche Harbor Airport (WA09), Roche Harbor, Washington. The certificated flight instructor and one passenger received minor injuries, and one passenger was uninjured. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. According to the pilot, the airplane belonged to the Whidbey Island Navy Flying Club (WINFC) and was based at Whidbey Island Naval Air Station (NUW), Oak Harbor, Washington, located about 27 miles southeast of the accident airport. The accident flight was to be the return leg of a round trip flight from NUW to WA09 and back, with a stop for dining at WA09. The two passengers, who were husband and wife, won the flight in a raffle. Until the day of the flight, the pilot and passengers were unknown to one another. The flight from NUW to WA09 was uneventful, and the preflight and run-up for the return leg were normal. The pilot elected to depart on runway 7, since the windsock indicated approximately 20 degrees crosswind from the right, at about 5 knots. Since a hill topped with trees began about 1,000 feet beyond the east end of the runway, the pilot decided to conduct what he referred to as a short field takeoff, and set the flaps to between 10 and 15 degrees. In his verbal recount to the National Transportation Safety Board (NTSB) investigator, the pilot stated that he planned to lift off at an indicated airspeed of 55, but the airplane became airborne at slightly slower speed. He then leveled the wings to accelerate before beginning the climb, and when he passed the end of the runway he started the climb. At that point, he observed that the airspeed indicator (ASI) registered 60 knots instead of the value of 67 that he expected. The pilot reported that the airplane then, "got a negative gust" and "wobbled a bit," and he adjusted the pitch attitude to continue the climb. The pilot observed that the airspeed had decreased to approximately 60 to 55 knots, and he then heard a "very distinct pop," which he associated with the engine. He told the passengers that there was a problem. The pilot thought that the engine speed was slightly lower than normal, and observed that the tachometer indicated no more than approximately 2,400 rpm. He reported that the airplane was approximately 150 feet above ground level at that time. The pilot realized the airplane was not going to clear the hill and trees just beyond the departure end of the runway, and he started looking for a place to put down. He observed that the airplane was losing airspeed, and that the ASI indicated about 55 to 50 knots. The pilot stated that the stall warning horn sounded momentarily at least one time. Since the pilot did not observe any suitable landing areas, he focused on managing the airspeed. He stated that just before the airplane struck the trees, he extended the flaps further, with the expectation of "ballooning" the airplane over the trees. The airplane struck trees, and came to rest on the ground about 1,500 feet beyond the departure end of the runway. The pilot and both passengers extricated themselves from the airplane. PERSONNEL INFORMATION According to information provided by WINFC, the pilot was the WINFC Chief Pilot. He held multiple Federal Aviation Administration (FAA) certificates and ratings, including flight instructor and airline transport pilot. He had a total flight experience of about 21,600 hours, which included over 500 hours in the accident airplane make and model. The pilot's most recent FAA third-class medical certificate was issued in October 2008, and his most recent flight review was completed in September He indicated that he had flown into WA09 about 10 times prior to the accident. AIRPLANE INFORMATION According to FAA records, the airplane was manufactured in 1975, and was first registered to the WINFC in The airplane was equipped with a Lycoming O-320 series piston engine, and a fixed-pitch propeller. Supplemental type certificates for the use of automotive gasoline in the airplane and engine were issued in The airspeed indicator registered in knots on the outer scale, and mph on the inner scale. A representative of WINFC estimated the airplane weight at Page 10 Copyright 1999, 2010,

11 the time of the accident to be about 100 pounds below the maximum certificated gross weight of 2,300 pounds. According to information provided by the operator, the airplane had a total time in service of approximately 12,440 hours. The engine had a total time in service of approximately 2,820 hours, and had accumulated approximately 900 hours since its most recent overhaul. The most recent 100-hour inspection of the airplane was completed on June 24, 2010, and the most recent annual inspection was completed in February The airplane had accumulated approximately 135 hours in service since the most recent annual inspection, and approximately 35 hours in service since the most recent 100-hour inspection. METEOROLOGICAL INFORMATION No weather broadcast or recording facilities were located at WA09. There were at least two windsocks at WA09; the one closest to airplane during the run-up was located about 410 feet east of the runway 7 threshold, and about 80 feet south of the runway centerline. That windsock was situated about 200 feet northwest of a stand of trees. The next closest windsock was approximately 2,400 feet east of the runway 7 threshold. Commercially available recorded weather information for the town of Roche Harbor included winds of 5 knots from 270 degrees, and a temperature of about 25 degrees C. About the time of the accident, the recorded weather at an airport 5 miles north of WA09 included winds of about 13 knots from 160 degrees. The recorded weather at an airport 7 miles southeast of WA09 included calm winds, and a temperature of about 21 degrees C. The recorded weather at an airport 10 miles northeast of WA09 included winds of about 11 knots from 220 degrees, and a temperature about 20 degrees C. AIRPORT INFORMATION According to commercially available information, WA09 was a private airport with a single runway, and required pilots to have prior permission to land. The runway dimensions were listed as 3,593 feet by 30 feet, and the surface was cited as "asphalt, in fair condition." The published obstacle information for runway 7 was stated as "160 ft. tree, 1136 ft. from runway, 75 ft. left of centerline." Although no FAA data regarding the runway slope was available, commercially available topographic data indicated that the runway 7 threshold elevation was 87 feet above mean sea level (msl), and the runway 25 threshold elevation was 156 feet msl, for an elevation difference of 69 feet. WRECKAGE AND IMPACT INFORMATION According to information provided by law enforcement and FAA personnel, the airplane struck trees, descended to the ground, and came to rest in a steep nose-down attitude. The fuselage was buckled at the tailcone and in the cabin area. The left wing was displaced aft, crumpled, and partially separated from the fuselage. The nose, right wing, and horizontal stabilizer were crumpled in the aft direction. Both wing flaps remained extended equally, and the cockpit flap position indicator reading registered approximately 22 degrees. One blade of the propeller was bent forward, and one was bent aft; both exhibited some chordwise scoring. Recovery personnel reported that tree branch segments with cut ends were found in the immediate vicinity of the wreckage. The terrain elevation at the accident location was approximately 180 feet msl, and the trees were approximately 50 feet tall. TESTS AND RESEARCH Engine Post accident examination of the engine was conducted by an FAA inspector about 5 weeks after the accident. The airplane's cowling was removed and the engine was visually inspected; no anomalies were noted. According to the dipstick, the engine contained 7 quarts of oil. The spark plugs were removed and examined, and no anomalies were observed. Fuel was found in the fuel strainer. To facilitate an engine run, the spark plugs were reinstalled, and the accident propeller was removed and replaced with a straight but non-airworthy propeller. A supplemental fuel tank was attached and plumbed into the fuel line for the airplane's right fuel tank. The engine was successfully started. A small amount of oil smoke was emitted on startup, the oil pressure was observed to be in the green arc on the oil pressure gauge, and the ammeter indicated a charging condition. Due to the non-airworthy propeller and other safety concerns, the engine was not run above 1,000 rpm. Page 11 Copyright 1999, 2010,

12 Another examination of the engine by NTSB personnel was conducted 10 days after the FAA examination; that examination also did not reveal any anomalies. All ignition leads and spark plugs were examined and measured for electrical resistance; all measurements and component conditions were unremarkable. The magnetos were removed and disassembled; all components were secure and intact, and no evidence of damage, carbon tracking or shorting was found. The carburetor was removed and disassembled; the fuel inlet screen was clean, the throttle valve moved properly, and no contamination was found in the float bowl. The float was intact and did not contain any fuel. The nozzle, needle valve and venturi all exhibited normal characteristics, condition and security. The gascolator was removed; the screen was inspected and found to be clean. The engine drive train was manually rotated, continuity was established for all rocker arm and valve assemblies, and "thumb compression" was obtained in all cylinders. ADDITIONAL INFORMATION Takeoff Procedures and Performance Information The "Normal Procedures" section of the airplane manufacturer's Pilot's Operating Handbook (POH) appropriate for the accident airplane serial number contained two different takeoff checklists, one for "normal take-off" and one for "maximum performance take-off." The normal takeoff checklist specified that the nose wheel was to be lifted at 55 knots indicated air speed (KIAS), and that the climb was to be conducted at 70 to 80 KIAS. The maximum performance takeoff checklist specified that the elevator was to be used to maintain a "slight tail low" attitude during the takeoff roll, and that the climb was to be conducted at 59 KIAS "until all obstacles are cleared." Both checklists stated that the wing flaps should be "UP" for takeoff. The POH amplified procedures stated that "Normal and obstacle clearance take-offs are performed with wing flaps up," and that "the use of 10 [degrees] flaps will shorten the ground run approximately 10 [per cent], but this advantage is lost in climb to a 50-foot obstacle." The POH stated that the 10 degree takeoff flap setting "is reserved for minimum ground runs or for takeoff from soft or rough fields." It also stated that if 10 degrees of flaps "are used for minimum ground runs, it is preferable to leave them extended.in the climb to the obstacle," and that an "obstacle clearance speed of 55 KIAS" was to be used. The operator developed a checklist specific to the accident airplane for use by its pilots, and copies were provided to the NTSB. Comparison of the operator's checklist with the airplane manufacturer's POH checklist revealed several significant differences. The operator's checklist included three sections entitled "Before Takeoff, After Takeoff, and Cruise," while the POH included four sections "Before Takeoff, Takeoff, Enroute Climb, and Cruise" for the same flight regime. The operator's "Before Takeoff and After Takeoff" sections contained a total of 15 line items, while the POH "Before Takeoff, Takeoff and Enroute Climb" sections contained a total of 28 line items. The operator's checklist did not address or differentiate between a normal takeoff and a maximum performance takeoff. The only reference to the use of flaps for takeoff in the operator's checklist was located in the "Before Takeoff" checklist, which stated "Flaps - SET." Subsequent to the accident, the operator compared each self-developed checklist to its respective POH counterpart for each airplane in its fleet; no other discrepancies were identified. Exact POH based performance calculations for the takeoff roll and distance to climb over a 50-foot obstacle, which accounted for all the actual conditions of the flight, could not be accomplished because the actual conditions were either not addressed by, or exceeded the parameter ranges of, the manufacturer's data. The POH data did not account for flap settings other than retracted, tailwinds greater than 10 knots, or sloped runways. The actual conditions were 10 to 15 degrees of flaps, a tailwind of about 5 to 11 knots, and an upsloping runway. Each of these conditions would have an adverse effect on takeoff and climb performance, and their effect would be cumulative in combination. Zero wind calculations for takeoff ground roll and 50-foot obstacle clearance distances, based on the available POH data, a gross weight of 2,200 pounds, and a sea level pressure altitude, resulted in values of 810 feet and 1,430 feet respectively for a temperature of 20 degrees C, and 840 feet and 1,480 feet respectively, for a temperature of 25 degrees C. Calculations for the same conditions, but with an 8-knot tailwind, resulted in values of 1,134 feet and 2,002 feet respectively, for a temperature of 20 degrees C, and 1,176 feet and 2,072 feet respectively, for a temperature of 25 degrees C. These values did not account for the actual flap setting or the runway slope. Page 12 Copyright 1999, 2010,

13 Accident Rpt# ERA11CA138 02/07/ EST Regis# N9622Q Meriden, CT Apt: Meriden Markham Municipal MMK Acft Mk/Mdl CESSNA 172-M M Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O320 Acft TT 2105 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: SKY JANE, LLC Acft Owner: SKY JANE, LLC The student pilot stated that he was on his first solo cross country flight. He executed a go-around on the first approach for landing at the destination airport, and the second approach for landing was normal. He stated that as the airplane touched down, the wind pushed the airplane to the right. The airplane traveled off the right side of the runway and impacted a snow bank,, resulting in substantial damage to the left wing spar. The pilot reported to a Federal Aviation Administration inspector that the airplane bounced, and that he was attempting to correct for a left crosswind. He also stated that there were no mechanical malfunctions or anomalies with the airplane. Page 13 Copyright 1999, 2010,

14 Accident Rpt# WPR10FA384 08/05/ PDT Regis# N9730H Roche Harbor, WA Apt: Roche Harbor WA09 Acft Mk/Mdl CESSNA 172-M M Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320 Acft TT Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: ROBERT FRASER Acft Owner: WHIDBEY ISLAND NAVY FLYING CLUB HISTORY OF FLIGHT On August 5, 2010, about 1714 Pacific daylight time, a Cessna 172M, N9730H, was substantially damaged when it struck trees shortly after takeoff from Roche Harbor Airport (WA09), Roche Harbor, Washington. The certificated flight instructor and one passenger received minor injuries, and one passenger was uninjured. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. According to the pilot, the airplane belonged to the Whidbey Island Navy Flying Club (WINFC) and was based at Whidbey Island Naval Air Station (NUW), Oak Harbor, Washington, located about 27 miles southeast of the accident airport. The accident flight was to be the return leg of a round trip flight from NUW to WA09 and back, with a stop for dining at WA09. The two passengers, who were husband and wife, won the flight in a raffle. Until the day of the flight, the pilot and passengers were unknown to one another. The flight from NUW to WA09 was uneventful, and the preflight and run-up for the return leg were normal. The pilot elected to depart on runway 7, since the windsock indicated approximately 20 degrees crosswind from the right, at about 5 knots. Since a hill topped with trees began about 1,000 feet beyond the east end of the runway, the pilot decided to conduct what he referred to as a short field takeoff, and set the flaps to between 10 and 15 degrees. In his verbal recount to the National Transportation Safety Board (NTSB) investigator, the pilot stated that he planned to lift off at an indicated airspeed of 55, but the airplane became airborne at slightly slower speed. He then leveled the wings to accelerate before beginning the climb, and when he passed the end of the runway he started the climb. At that point, he observed that the airspeed indicator (ASI) registered 60 knots instead of the value of 67 that he expected. The pilot reported that the airplane then, "got a negative gust" and "wobbled a bit," and he adjusted the pitch attitude to continue the climb. The pilot observed that the airspeed had decreased to approximately 60 to 55 knots, and he then heard a "very distinct pop," which he associated with the engine. He told the passengers that there was a problem. The pilot thought that the engine speed was slightly lower than normal, and observed that the tachometer indicated no more than approximately 2,400 rpm. He reported that the airplane was approximately 150 feet above ground level at that time. The pilot realized the airplane was not going to clear the hill and trees just beyond the departure end of the runway, and he started looking for a place to put down. He observed that the airplane was losing airspeed, and that the ASI indicated about 55 to 50 knots. The pilot stated that the stall warning horn sounded momentarily at least one time. Since the pilot did not observe any suitable landing areas, he focused on managing the airspeed. He stated that just before the airplane struck the trees, he extended the flaps further, with the expectation of "ballooning" the airplane over the trees. The airplane struck trees, and came to rest on the ground about 1,500 feet beyond the departure end of the runway. The pilot and both passengers extricated themselves from the airplane. PERSONNEL INFORMATION According to information provided by WINFC, the pilot was the WINFC Chief Pilot. He held multiple Federal Aviation Administration (FAA) certificates and ratings, including flight instructor and airline transport pilot. He had a total flight experience of about 21,600 hours, which included over 500 hours in the accident airplane make and model. The pilot's most recent FAA third-class medical certificate was issued in October 2008, and his most recent flight review was completed in September He indicated that he had flown into WA09 about 10 times prior to the accident. AIRPLANE INFORMATION According to FAA records, the airplane was manufactured in 1975, and was first registered to the WINFC in The airplane was equipped with a Lycoming O-320 series piston engine, and a fixed-pitch propeller. Supplemental type certificates for the use of automotive gasoline in the airplane and engine were issued in The airspeed indicator registered in knots on the outer scale, and mph on the inner scale. A representative of WINFC estimated the airplane weight at Page 14 Copyright 1999, 2010,

15 the time of the accident to be about 100 pounds below the maximum certificated gross weight of 2,300 pounds. According to information provided by the operator, the airplane had a total time in service of approximately 12,440 hours. The engine had a total time in service of approximately 2,820 hours, and had accumulated approximately 900 hours since its most recent overhaul. The most recent 100-hour inspection of the airplane was completed on June 24, 2010, and the most recent annual inspection was completed in February The airplane had accumulated approximately 135 hours in service since the most recent annual inspection, and approximately 35 hours in service since the most recent 100-hour inspection. METEOROLOGICAL INFORMATION No weather broadcast or recording facilities were located at WA09. There were at least two windsocks at WA09; the one closest to airplane during the run-up was located about 410 feet east of the runway 7 threshold, and about 80 feet south of the runway centerline. That windsock was situated about 200 feet northwest of a stand of trees. The next closest windsock was approximately 2,400 feet east of the runway 7 threshold. Commercially available recorded weather information for the town of Roche Harbor included winds of 5 knots from 270 degrees, and a temperature of about 25 degrees C. About the time of the accident, the recorded weather at an airport 5 miles north of WA09 included winds of about 13 knots from 160 degrees. The recorded weather at an airport 7 miles southeast of WA09 included calm winds, and a temperature of about 21 degrees C. The recorded weather at an airport 10 miles northeast of WA09 included winds of about 11 knots from 220 degrees, and a temperature about 20 degrees C. AIRPORT INFORMATION According to commercially available information, WA09 was a private airport with a single runway, and required pilots to have prior permission to land. The runway dimensions were listed as 3,593 feet by 30 feet, and the surface was cited as "asphalt, in fair condition." The published obstacle information for runway 7 was stated as "160 ft. tree, 1136 ft. from runway, 75 ft. left of centerline." Although no FAA data regarding the runway slope was available, commercially available topographic data indicated that the runway 7 threshold elevation was 87 feet above mean sea level (msl), and the runway 25 threshold elevation was 156 feet msl, for an elevation difference of 69 feet. WRECKAGE AND IMPACT INFORMATION According to information provided by law enforcement and FAA personnel, the airplane struck trees, descended to the ground, and came to rest in a steep nose-down attitude. The fuselage was buckled at the tailcone and in the cabin area. The left wing was displaced aft, crumpled, and partially separated from the fuselage. The nose, right wing, and horizontal stabilizer were crumpled in the aft direction. Both wing flaps remained extended equally, and the cockpit flap position indicator reading registered approximately 22 degrees. One blade of the propeller was bent forward, and one was bent aft; both exhibited some chordwise scoring. Recovery personnel reported that tree branch segments with cut ends were found in the immediate vicinity of the wreckage. The terrain elevation at the accident location was approximately 180 feet msl, and the trees were approximately 50 feet tall. TESTS AND RESEARCH Engine Post accident examination of the engine was conducted by an FAA inspector about 5 weeks after the accident. The airplane's cowling was removed and the engine was visually inspected; no anomalies were noted. According to the dipstick, the engine contained 7 quarts of oil. The spark plugs were removed and examined, and no anomalies were observed. Fuel was found in the fuel strainer. To facilitate an engine run, the spark plugs were reinstalled, and the accident propeller was removed and replaced with a straight but non-airworthy propeller. A supplemental fuel tank was attached and plumbed into the fuel line for the airplane's right fuel tank. The engine was successfully started. A small amount of oil smoke was emitted on startup, the oil pressure was observed to be in the green arc on the oil pressure gauge, and the ammeter indicated a charging condition. Due to the non-airworthy propeller and other safety concerns, the engine was not run above 1,000 rpm. Page 15 Copyright 1999, 2010,

16 Another examination of the engine by NTSB personnel was conducted 10 days after the FAA examination; that examination also did not reveal any anomalies. All ignition leads and spark plugs were examined and measured for electrical resistance; all measurements and component conditions were unremarkable. The magnetos were removed and disassembled; all components were secure and intact, and no evidence of damage, carbon tracking or shorting was found. The carburetor was removed and disassembled; the fuel inlet screen was clean, the throttle valve moved properly, and no contamination was found in the float bowl. The float was intact and did not contain any fuel. The nozzle, needle valve and venturi all exhibited normal characteristics, condition and security. The gascolator was removed; the screen was inspected and found to be clean. The engine drive train was manually rotated, continuity was established for all rocker arm and valve assemblies, and "thumb compression" was obtained in all cylinders. ADDITIONAL INFORMATION Takeoff Procedures and Performance Information The "Normal Procedures" section of the airplane manufacturer's Pilot's Operating Handbook (POH) appropriate for the accident airplane serial number contained two different takeoff checklists, one for "normal take-off" and one for "maximum performance take-off." The normal takeoff checklist specified that the nose wheel was to be lifted at 55 knots indicated air speed (KIAS), and that the climb was to be conducted at 70 to 80 KIAS. The maximum performance takeoff checklist specified that the elevator was to be used to maintain a "slight tail low" attitude during the takeoff roll, and that the climb was to be conducted at 59 KIAS "until all obstacles are cleared." Both checklists stated that the wing flaps should be "UP" for takeoff. The POH amplified procedures stated that "Normal and obstacle clearance take-offs are performed with wing flaps up," and that "the use of 10 [degrees] flaps will shorten the ground run approximately 10 [per cent], but this advantage is lost in climb to a 50-foot obstacle." The POH stated that the 10 degree takeoff flap setting "is reserved for minimum ground runs or for takeoff from soft or rough fields." It also stated that if 10 degrees of flaps "are used for minimum ground runs, it is preferable to leave them extended.in the climb to the obstacle," and that an "obstacle clearance speed of 55 KIAS" was to be used. The operator developed a checklist specific to the accident airplane for use by its pilots, and copies were provided to the NTSB. Comparison of the operator's checklist with the airplane manufacturer's POH checklist revealed several significant differences. The operator's checklist included three sections entitled "Before Takeoff, After Takeoff, and Cruise," while the POH included four sections "Before Takeoff, Takeoff, Enroute Climb, and Cruise" for the same flight regime. The operator's "Before Takeoff and After Takeoff" sections contained a total of 15 line items, while the POH "Before Takeoff, Takeoff and Enroute Climb" sections contained a total of 28 line items. The operator's checklist did not address or differentiate between a normal takeoff and a maximum performance takeoff. The only reference to the use of flaps for takeoff in the operator's checklist was located in the "Before Takeoff" checklist, which stated "Flaps - SET." Subsequent to the accident, the operator compared each self-developed checklist to its respective POH counterpart for each airplane in its fleet; no other discrepancies were identified. Exact POH based performance calculations for the takeoff roll and distance to climb over a 50-foot obstacle, which accounted for all the actual conditions of the flight, could not be accomplished because the actual conditions were either not addressed by, or exceeded the parameter ranges of, the manufacturer's data. The POH data did not account for flap settings other than retracted, tailwinds greater than 10 knots, or sloped runways. The actual conditions were 10 to 15 degrees of flaps, a tailwind of about 5 to 11 knots, and an upsloping runway. Each of these conditions would have an adverse effect on takeoff and climb performance, and their effect would be cumulative in combination. Zero wind calculations for takeoff ground roll and 50-foot obstacle clearance distances, based on the available POH data, a gross weight of 2,200 pounds, and a sea level pressure altitude, resulted in values of 810 feet and 1,430 feet respectively for a temperature of 20 degrees C, and 840 feet and 1,480 feet respectively, for a temperature of 25 degrees C. Calculations for the same conditions, but with an 8-knot tailwind, resulted in values of 1,134 feet and 2,002 feet respectively, for a temperature of 20 degrees C, and 1,176 feet and 2,072 feet respectively, for a temperature of 25 degrees C. These values did not account for the actual flap setting or the runway slope. Page 16 Copyright 1999, 2010,

17 Accident Rpt# ERA11CA144 02/14/ EST Regis# N2593L Plattsburgh, NY Apt: Plattsburgh International KPBG Acft Mk/Mdl CESSNA 172H Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONT MOTOR O-300D Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: VERMONT FLIGHT ACADEMY, INC Acft Owner: JUST PLANE NUTS FLYING CLUB LLC The flight instructor and student reported that they were practicing touch-and-go takeoffs and landings, and during the second approach, the airplane's airspeed and altitude decreased further than intended. Subsequently, the left wing contacted the runway resulting in substantial damage to the left wing tip. The flight instructor took control and landed the airplane. While taxiing to the ramp, they observed that the winds had increased more than reported. The winds recorded at the airport, prior to and after the accident, were variable from the west and south at 7 to 10 knots, and gusting up to 17 knots. The flight instructor reported that there were no mechanical failures or malfunctions of the airplane. Page 17 Copyright 1999, 2010,