National Transportation Safety Board - Aircraft Accident/Incident Database

Transcription

1 Accident Rpt# CEN14LA287 06/12/ CDT Regis# N8593S Pearsall, TX Apt: N/a Acft Mk/Mdl AIR TRACTOR INC AT 301-NO SERIES Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl P&W R 1340-AN-1 Acft TT 8357 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 137 Opr Name: SMITH COMPANY FLYING SERVICE FITCH FLYING SERVICE Aircraft Fire: NONE 1. Maneuvering - Loss of engine power (partial) On June 12, 2014, about 1200 central daylight time, the pilot of an Air Tractor AT 301, N8593S, made a forced landing in a field near Pearsall, Texas, following a loss of engine power. The pilot, the sole occupant on board, was not injured. The airplane was substantially damaged. The airplane was registered to Matt Fitch and operated Smith Flying Service, doing business as Fitch Flying Service, of Pearsall, Texas, under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The local flight originated from Pearsall about According to the pilot, he returned to the airport after spraying a corn field and noticed the cylinder head temperature was high. After landing the engine cylinders were checked for discrepancies; none were found, so he decided to continue spraying. He took off and returned to the corn field. As he pulled up from a spray run, the engine started to vibrate and lose power. He made a forced landing in a nearby field. Examination of the airplane revealed both wings had sustained substantial damage during the forced landing. According to the operator, the engine had accrued about 11 hours since the engine received extensive maintenance, including the replacement of a crankshaft. The engine was shipped to Tulsa Engines in Tulsa, Oklahoma, where, on September 3, it was partially disassembled and examined under the auspices of a Federal Aviation Administration inspector. According to the FAA inspector's report, there was a large amount of metal in the oil drain. It was noted that the number 2 cylinder front spark plug was loose. After removing all the spark plugs, an attempt was made to rotate the engine. It was seized. Numbers 4, 5, 6, and 7 cylinders had oil; number 4 cylinder had more oil. After some difficulty in removing the no. 1 cylinder, it was discovered that the piston rod had broken at the link pin. No other rods were broken. The link pin was scored and there was evidence of oil starvation of the rod bearing. Page 1 Copyright 1999, 2015,

2 Accident Rpt# CEN14LA253 05/26/ CDT Regis# N188DP Rockdale, TX Apt: H.h. Coffield Regional KRCK Acft Mk/Mdl BEECH A36 Acft SN E-1476 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONTINENTAL IO-520-BB87 Acft TT 5360 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: PILOTS CHOICE AVIATION INC Aircraft Fire: NONE 1. Enroute-cruise - Loss of engine power (total) On May 26, 2014, about 1840 central daylight time, a Beech A36, N188DP, was substantially damaged when the engine lost power and the pilot made a forced landing on a road near Rockdale, Texas. The pilot and three passengers on board were not injured. The airplane was registered to and operated by Pilots Choice Aviation, Inc., Georgetown Texas, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan had been filed. The flight originated from Huntsville Municipal Airport (KUTS), Huntsville, Texas, at 1825, and was en route to Georgetown Municipal Airport (KGTU), Georgetown, Texas. According to the pilot's statements, both main fuel tanks were filled to capacity, but the auxiliary tanks were not serviced. The first leg of the flight from New Orleans, Louisiana, to Huntsville, Texas, was uneventful. The pilot elected to go to Huntsville due to the weather conditions in the Austin, Texas, area. After spending several hours at Huntsville, the pilot and his family departed for Georgetown. About 20 minutes into the flight, the engine made "an abrupt change in sound" and the engine began to lose power. All cylinder EGTs (exhaust gas temperature) were above 1500 degrees Celsius (C.) Switching from the right tank to the left tank did not restore power, so the pilot returned the selector to the right tank. The pilot advanced the mixture, throttle, and propeller control full forward and noticed the cylinder EGTs were registering 200 degrees. He advised air traffic control that his engine was losing power and was given radar vectors to the H.H. Coffield Regional Airport (KRCK), about 4 miles southwest of the flight's position. The pilot subsequently declared an emergency. Unable to glide to the runway, the pilot made a forced landing on uneven terrain near County Road 322. The right main landing gear did not extend fully prior to touch down and the airplane ground looped. The fuselage was buckled and the outboard portion of the right wing was torn off. Under the auspices of the National Transportation Safety Board, the engine was functionally tested at Air Salvage of Dallas in Lancaster, Texas, on July 21. The engine tested satisfactory at all power settings and no anomalies were noted. Page 2 Copyright 1999, 2015,

3 Accident Rpt# CEN14CA458 08/26/ CDT Regis# N8176M Houston, TX Apt: West Houston IWS Acft Mk/Mdl BEECH A36-UNDESIGNAT Acft SN E-2602 Acft Dmg: Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl TELEDYNE IO-550-B Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: Aircraft Fire: AW Cert: STN Page 3 Copyright 1999, 2015,

4 Accident Rpt# CEN14LA458 08/26/ CDT Regis# N8176M Houston, TX Apt: West Houston IWS Acft Mk/Mdl BEECH A36-UNDESIGNAT Acft SN E-2602 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl TELEDYNE IO-550-B Acft TT 4107 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: N8176M LLC Aircraft Fire: NONE AW Cert: STN 1. Takeoff - Loss of control in flight On August 26, 2014, at 1800 central daylight time, N8176M, a Beechcraft A-36 single-engine airplane, sustained substantial damage on takeoff from West Houston Airport (IWS), Houston, Texas. The private pilot and the three passengers were not injured. An instrument flight rules flight plan was filed for the personal flight that was destined for Monroe, Louisiana. Visual meteorological conditions prevailed for the personal flight that was conducted under the provisions of 14 Code of Federal Aviation Regulations Part 91. The pilot stated that he conducted a preflight inspection and engine run-up before takeoff and everything was normal. He then departed and rotated at 80 knots and the airplane began to climb. The pilot said, "A couple of seconds into the climb, I seemed to have a performance/power loss - no ability to climb. I leveled the nose in an attempt to gain airspeed - then slightly down. I engaged the landing gear up-switch, the plane began to descend." The airplane then landed back on its belly and slid off the runway and struck the runway's precision approach path indicator (PAPI) lights. A Federal Aviation Administration (FAA) inspector was at the airport and witnessed the accident. He said he watched the airplane depart and cross in front of him from left to right "with a nose high attitude and in an exaggerated cross control condition." The inspector estimated the tail of the airplane was about 10 feet above the surface of the runway. The airplane disappeared from the inspector's view for a brief second and the next time he saw the airplane it was sliding on its belly. The inspector later examined the airplane and reported that it had sustained substantial damage to the fuselage, empennage and firewall. The three bladed propeller was also damaged. One blade was missing approximately 4 inches from the tip and bent backwards in an arc covering approximately 2/3's of the blade. The other two blades where intact and were both bent backwards over 2/3 of the blade. No mechanical deficiencies were identified that would have precluded normal operation of the airplane and engine at the time of the accident. According to the Beech Bonanza A-36 Pilot Operating Handbook (POH), Section IV, TAKEOFF checklist, the landing gear is only to be retracted once a positive rate-of-climb is established. The pilot held a private pilot certificate for airplane single-engine land. He reported a total of 928 hours, of which, 149 hours were in the same make/model as the accident airplane. Page 4 Copyright 1999, 2015,

5 Accident Rpt# ERA14LA008 10/05/ EDT Regis# N8715U Gainesville, FL Apt: N/a Acft Mk/Mdl CESSNA F-F Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-360 Acft TT 4989 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: BEACH BANNERS INC Aircraft Fire: NONE 1. Maneuvering-low-alt flying - Loss of engine power (total) On October 5, 2013, about 1600 eastern daylight time, a Cessna 172F, N8715U, was substantially damaged during a forced landing following a total loss of engine power near Gainesville, Florida. The commercial pilot and pilot-rated passenger sustained minor injuries. The local banner tow flight departed Gainesville Regional Airport (GNV) about Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot stated that a preflight inspection of the airplane revealed no anomalies, and he subsequently departed on the flight and performed the banner pick-up. He proceeded toward the stadium around which he was to tow the banner, leveled the airplane at 1,200 feet above ground level (AGL), reduced engine power to 2,250 rpm, and leaned the mixture. He then extended the wing flaps to 10 degrees, and slowed the airplane to 50 mph. About 20 minutes into the flight, the pilot noticed that the airplane had descended about 100 feet, and he responded by increasing engine power and enriching the mixture, while observing that the oil temperature gauge indicated "hotter than normal." The airplane continued to descend and the oil temperature continued to rise into the red arc, and the engine subsequently experienced a total loss of power. The pilot released the banner, attempted to restart the engine to no avail, and then conducted a forced landing to a nearby field. He stated that due to "excessive airspeed" upon touchdown, the airplane bounced and impacted a parked truck, resulting in substantial damage to the fuselage and both wings. The pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land, as well as an instrument rating; and flight instructor certificate with ratings for airplane single- and multi-engine, and instrument airplane. His most recent first-class Federal Aviation Administration (FAA) medical certificate was issued in September Following the accident, he reported 2,513 total hours of flight experience, of which 1,402 hours were in the accident airplane make and model. The airplane was manufactured in 1965, and was equipped with a Lycoming O-360-A1A, 200 hp, reciprocating engine. Its most recent annual inspection was completed July 24, At the time of the accident, the airplane had accumulated 4,989 total hours of operation. According to the operator, the airplane was being operated on automotive fuel. Review of the airplane's airworthiness records showed that no supplemental type certificate had been issued authorizing the use of automotive fuels. Following the accident, the airplane was removed from the site and subsequently examined by an FAA inspector. The engine exhibited little impact damage. The carburetor remained attached; however, the carburetor heat cable was disconnected and hanging free from the firewall. The magnetos remained attached and undamaged. The engine contained 7 quarts of oil. The oil filter was removed and opened, with no anomalies observed. The spark plugs were removed and appeared "blackish" in color. The electric fuel pump and starter were replaced, and the engine was secured for a test run. Utilizing the fuel onboard at the time of the accident, the engine started and ran for several minutes with no anomalies observed. A fuel sample was taken from the carburetor prior to the test run, and sent for analysis at an aviation fuel testing laboratory. According to the laboratory, a Karl Fisher water test revealed "high" water content, and a microbial test was negative for bacteria and fungus. The quantity of the sample provided was insufficient to conduct distillation and flash point tests; therefore it could not be determined if the sample contained ethanol. The 1553 recorded weather at GNV, 5 miles southwest of the accident site included wind from 090 degrees at 6 knots, 10 miles visibility, sky clear, temperature 31 degrees C, dew point 19 degrees C, and a barometric altimeter setting of inches of mercury. Review of an FAA carburetor icing probability chart revealed the potential for serious icing at glide power given the atmospheric conditions present about the time of the accident. Page 5 Copyright 1999, 2015,

6 Accident Rpt# ERA14LA147 03/08/ CST Regis# N2755U Fairhope, AL Apt: H L Sonny Callahan CQF Acft Mk/Mdl CESSNA 172D Acft SN Acft Dmg: DESTROYED Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONTINENTAL MOTORS O-300-D Acft TT 2097 Fatal 0 Ser Inj 1 Flt Conducted Under: FAR 091 Opr Name: GONE BROKE LLC Aircraft Fire: GRD 1. Approach-VFR pattern final - Aircraft wake turb encounter HISTORY OF FLIGHT On March 8, 2014, about 1400 central standard time, a Cessna 172D airplane, N2755U, was destroyed when it impacted terrain while attempting to land at H L Sonny Callahan Airport (CQF), Fairhope, Alabama. The private pilot sustained serious injuries. Visual meteorological conditions prevailed, and no flight plan was filed for flight, which originated from Ferguson Airport (82J), Pensacola, Florida and was destined for CQF. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot was returning to CQF after completing youth introductory flights at 82J. The enroute portion of the flight was uneventful, and upon arriving in the vicinity of CQF, the pilot entered the downwind leg of the traffic pattern for runway 19. While on the downwind leg of the traffic pattern the pilot observed a large helicopter that was approaching the airport and was "almost on the ground." As the pilot was on the short final leg of the approach to the runway, at an altitude of about 30 feet agl, he noted that the helicopter was flying over the runway's parallel taxiway at about the mid-field point. Once the airplane reached the approach end of the runway the pilot observed the helicopter just past the mid-field point of the runway. About that time, one of the airplane's wings "went straight up," which is the last thing the pilot remembered about the flight. The pilot reported that prior to the upset, there were no mechanical malfunctions or other anomalies of the airplane that would have precluded normal operation According to witnesses, the accident airplane was following the large helicopter in the airport traffic pattern. While on final approach, the accident airplane appeared to be "way too close" to the helicopter and was observed performing S turn maneuvers. The pilot of the helicopter then made a radio call to announce that he was going to fly to the south end of the field in a hover. While the helicopter was still in forward flight over the runway, the airplane reached the approach end of the runway and, at an approximate altitude of 30 feet above ground level (agl), the airplane suddenly rolled into a right wing low attitude followed by a left wing low attitude. The airplane then leveled out, impacted the ground in a level attitude forward of the runway threshold and a post impact fire ensued near the engine cowling. A witness reported that the large helicopter was "50 ft above the ground" when the accident airplane was upset. According to the pilot of the helicopter, following an initial low approach to the runway that terminated in a hover, the co-pilot maneuvered the helicopter around the traffic pattern for a second landing. The crew observed the accident airplane while it was on the downwind leg of its approach, and commented that the airplane seemed to be flying closer than customary to the runway and the helicopter. The pilot subsequently advised the copilot to stop his descent at an altitude of between 300 and 500 feet agl, and commence his final landing approach further down the runway. As the helicopter continued its final descent, this time about 3/4 down the runway the crew heard via radio that the accident airplane had crashed. WRECKAGE AND IMPACT INFORMATION The airframe and engine were examined at the accident site by representatives of the airframe and engine manufacturers under the supervision of a Federal Aviation Administration inspector. The initial impact point was slightly forward of the runway 19 numbers and the main wreckage was located 800 feet past the initial impact point and 50 feet west of the runway edge. Abrasions of the runway surface consisting of brake rotor scars and propeller strikes were traced from the initial impact point to the location of the main wreckage. The cabin, tailcone, and wing roots exhibited signs of thermal damage. All flight control surfaces remained attached to their respective airframe components, and flight control continuity was traced from each flight control surface to the cockpit. The flap handle was observed in the retracted position and due to post-crash fire the flap setting could not be determined at the accident site. The elevator trim actuator was in the neutral position, but the elevator trim indicator could not be examined due to fire damage. The fuel system was also damaged from the post-crash fire and could not be examined. Both propeller blades remained attached to the hub, which was found attached to the crankshaft. One blade displayed thermal damage and twisting. The other blade was separated at the tip and exhibited chordwise scoring and curling. Page 6 Copyright 1999, 2015,

7 There was significant fire and impact damage to the engine. The carburetor separated from the engine and was melted by postcrash fire. Both magnetos remained attached to the crankcase. All spark plugs contained varying amount of thermal and impact damage, but also remained installed on the engine. The top spark plugs were removed and examined, with all exhibiting normal wear signatures. The bottom spark plugs were inspected with a borescope and no anomalies were noted. The magnetos exhibited significant thermal damage; one magneto could not be rotated by hand and the other magneto was rotated, but did not produce a spark. Both magnetos were disassembled and no abnormalities were noted. The cylinders were examined using a borescope. The pistons and cylinder bores exhibited signs of normal combustion and all of the valve faces and seats were in place. The crankshaft was rotated at the propeller flange, and thumb compression was confirmed on each of the six cylinders. All rocker arms and valves operated normally during crankshaft rotation. Valvetrain continuity was confirmed on all of the cylinders and to the accessory drive gears. The oil screen was found on the runway about halfway between the initial impact point and the main wreckage. The screen did not contain any contaminates. PERSONNEL INFORMATION The pilot held a private pilot certificate with a rating for airplane single engine land. He had accumulated about 633 total hours of flight time, of which 173 hours were in the accident airplane make and model. METEOROLOGICAL INFORMATION The 2000 recorded weather observation at the MBLA1 buoy, located 7 nautical miles southeast of the accident site, included wind from 120 degrees at 5 knots, temperature 15 degrees C, and an altimeter setting of inches of mercury. Two witnesses reported winds at the time of the accident at CQF were from the south straight down the runway at approximately 5-7 knots. AIRPORT INFORMATION The single asphalt runway at CQF was 6,604 feet long by 100 feet wide and was configured in a 1/19 orientation. A parallel taxiway spanning the full length of the runway was present on the west side of the runway. The airport was not served by a local air traffic control tower. ADDITIONAL INFORMATION Rotorcraft Trailing Vortices The flight profile of the large helicopter, a CH-53E, provided by the helicopter pilot was sent to Sikorsky Aircraft Corporation and a proprietary analysis was conducted to examine the trailing vortex dissipation of the helicopter. The data, which included a heading of 190 degrees magnetic, 80 knots airspeed, altitude of 400 ft. agl, and a gross weight of 48,100 lbs. were programmed in a simulation. Data points for the blade radius and tip vortex core radius were then estimated and two videos were produced. One video was used to simulate 5 knot winds out of the southeast and another video was used to simulate a no wind scenario. The wake evolution simulation was modeled as an unsteady two-dimensional vortex interaction problem. A differential equation was used to update the tip vortex position given its initial position and strength, which then produced the vortex trajectory. The helicopter heading and wind direction were used to map the two-dimensional wake to three dimensions including the runway position. The results of both simulations showed a main rotor blade wind velocity of 60 knots. The simulations assumed the accident airplane trailed about 30 seconds (+/- 6 seconds) behind the helicopter. The study found that based on the airplane's altitude, the helicopter would need to be less than 200 ft above the ground for a vortex interaction to occur. A similar outcome would be expected for winds aligned with the runway heading at a velocity of 0 knots. Given the weather conditions at the time of the accident, along with the gross weight of the helicopter, the analysis concluded that trailing vortices were likely Page 7 Copyright 1999, 2015,

8 present over the approach end of the runway at the time of the accident. FAA Aeronautical Information Manual, Helicopter Trailing Vortices According to the FAA's Aeronautical Information Manual, section 7-3-7: "In forward flight, departing or landing helicopters produce a pair of strong, high-speed trailing vortices similar to wing tip vortices of larger fixed wing aircraft. Pilots of small aircraft should use caution when operating behind or crossing behind landing and departing helicopters." Page 8 Copyright 1999, 2015,

9 Accident Rpt# ERA14LA158 03/18/ EDT Regis# N46603 Elizabethton, TN Apt: Elizabethton Muni 0A9 Acft Mk/Mdl CESSNA 172K Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320-E2D Acft TT 6688 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: SKYPARK INC Aircraft Fire: NONE 1. Enroute-climb to cruise - Controlled flight into terr/obj (CFIT) HISTORY OF FLIGHT On March 18, 2014, about 1930 eastern daylight time, a Cessna 172K airplane, N46603, was substantially damaged after it impacted mountainous terrain in Elizabethton Municipal Airport (0A9), Elizabethton, Tennessee. The private pilot and a passenger sustained serious injuries and another passenger received minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which originated from 0A9 about 1915 and was destined for Weltzien Skypark (15G), Wadsworth, OH. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. According to the pilot, he departed 15G three days prior to the accident to fly a family friend to South Carolina. The pilot originally intended to return to 15G the following day, but was delayed due to weather. On the day of the accident, the pilot and his passengers left South Carolina bound for 15G. The pilot made an unscheduled stop for fuel at 0A9, after discovering the fuel services at his intended airport were closed. After refueling at 0A9 he departed runway 06 and flew the airport traffic pattern. He maintained an altitude of 500 feet above ground level (agl) and exited the traffic pattern on the left downwind leg on a course direct towards Holston Mountain. The pilot followed the upslope of the mountain at a 500 feet per minute rate of climb. Concerned that the airplane would not clear the approaching terrain, the pilot decided to turn the airplane towards a small valley to his right that appeared to have a lower terrain elevation. During the turn the airplane descended, impacted trees and then terrain before coming to rest. During the pilot's interview with a Federal Aviation Administration (FAA) inspector and the NTSB investigator-in-charge, the pilot stated he should have "gained more altitude" before starting his climb over the mountain. In an interview with an FAA inspector the pilot was asked if he had any mechanical issues with the aircraft, to which the pilot replied "No." PERSONNEL INFORMATION According to the pilot and FAA records, he held a private pilot certificate for airplane single-engine land. The pilot's most recent third-class medical certificate was issued on May 4, The pilot reported 90 hours of total flight experience, of which 10 hours were in the accident airplane make and model. AIRPLANE INFORMATION The airplane was manufactured in 1968 and was equipped with a Lycoming O-320-E2D, 150-hp, carbureted reciprocating engine. According to maintenance records, the airplane's most recent 100-hour inspection was completed on November 20, The airplane's most recent engine overhaul was completed on September 9, At the time of the accident, the engine had accumulated 6,688 hours of total time in service, and 61 hours of time in service since the most Page 9 Copyright 1999, 2015,

10 recent inspection. METEOROLOGICAL INFORMATION The 1856 recorded weather at 0A9, located about 3 nautical miles south of the accident site, included calm wind, clear skies, 10 miles visibility, temperature 13 degrees C, dewpoint 4 degrees C, and an altimeter setting of inches of mercury. WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA and the airframe manufacturer, the airplane came to rest on its left side about 3000 feet above mean sea level (msl) in a wooded area and was oriented on a 221 degree heading, the debris path was oriented on a 141 degree heading. All major components of the airplane were accounted for at the accident site. A section of the fuselage was bent downward and partially separated just aft of the main cabin. The vertical stabilizer and left horizontal stabilizer remained attached to the empennage, which was co-located with the main wreckage. The right horizontal stabilizer was located about 200 ft. from the main wreckage with the elevator attached. Both wings remained attached to the fuselage and sustained leading edge crush damage along their entire length. The right wing was bent in the positive direction about 45 degrees. Both propeller blades remained attached to the hub. One blade exhibited S-bending with some polishing and chordwise scratching. The outboard section of another propeller blade was bent and the tip was fractured and separated. The airframe was examined at the accident site by a representative of the airframe manufacturer under the supervision of a FAA inspector. Control continuity was traced from the cockpit area to each of the flight control surfaces. The flap actuator measured 0 degrees, which was consistent with a flaps retracted positon. The engine was recovered to a secure facility in Springfield, Tennessee and a follow-up engine examination took place on May 5, 2014 and supervised by a NTSB investigator. Continuity of the engine's crankshaft and valvetrain were confirmed through rotation at the vacuum pump drive pad, and thumb compression was confirmed on all cylinders. The top and bottom spark plugs were removed and inspected; the top plugs and two of the bottom plugs exhibited normal wear and two of the bottom plugs were oil soaked. Both magnetos rotated freely by hand and exhibited normal sparking on all leads. The fuel strainer contained fuel and the strainer screen was free of debris. The carburetor fuel inlet screen was free of debris and no fuel stains were present on the carburetor surfaces. AIRPORT INFORMATION Page 10 Copyright 1999, 2015,

11 The single asphalt runway at 0A9 was 4529 feet long by 70 feet wide and was configured in a 6/24 orientation at an elevation of 1593 feet msl. A parallel taxiway spanning the full length of the runway was present on the west side of the runway. The airport was not served by a local air traffic control tower. According to the FAA Airport/Facility Directory, effective February 6, 2014 to April 3, 2014, departures from runway 06 were required to make right traffic. ADDITIONAL INFORMATION Airplane Performance The distance between the airport pattern and the top of the mountain is about 1.8 nautical miles (nm) and the elevation at the top of the mountain is about 3,000 feet msl. Based on the values reported by the pilot, at 78 knots the airplane would have travelled to the top of the mountain, 1.8nm, in 1 minute 23 seconds; however, at a 500 feet per minute climb rate, the airplane required 1 minute 48 seconds of flight time to reach the 3,000 foot mountain peak. Density altitude at the airport around the time of departure was about 1,800 feet. Research According to the FAA publication "Tips on Mountain Flying"(FAA-P , AFS-803), "a normally aspirated engine will lose 3% of its power per thousand feet of density altitude increase. Next, as density altitude increases, the wings have less dense air which to create lift. Since a propeller is an airfoil, it, too, will be less efficient." The FAA also recommends that pilots cross mountain passes at an altitude at least 1000 feet above the pass elevation. Page 11 Copyright 1999, 2015,

12 Accident Rpt# CEN15CA105 01/17/ EST Regis# N7061G Holland, MI Apt: West Michigan Rgnl BIV Acft Mk/Mdl CESSNA 172K-P Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320-E2D Acft TT Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: PRIVATE INDIVIDUAL Aircraft Fire: NONE AW Cert: STN 2. Landing-landing roll - Loss of control on ground The pilot was performing a full stop landing to runway 26 at his home airfield. During the landing roll, a strong gusty crosswind lifted the airplane's left wing, the airplane veered right, and the pilot lost control. The airplane exited the runway and impacted a snow bank where it nosed over and came to rest inverted.. The pilot reported no mechanical malfunctions or failures contributed to the accident. A review of weather information revealed a prevailing wind from 210 degrees at 21 knots gusting to 28 knots, with a peak wind gust of 30 knots occurring prior to the pilot's landing. Page 12 Copyright 1999, 2015,

13 Accident Rpt# CEN14CA353 07/10/ CDT Regis# N4842G Edgewood, NM Apt: Sandia Airpark 1N1 Acft Mk/Mdl CESSNA 172N Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-360-A4M Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: GLENN W ZIMMERMANN Aircraft Fire: NONE AW Cert: STN 2. Takeoff - Loss of control in flight The pilot reported that the airplane encountered a crosswind gust just as it lifted off during takeoff, which caused the airplane to drift toward the south side of the runway. The pilot described the encounter as uncontrollable; full aileron and rudder inputs were unable to maintain control. The airplane subsequently impacted the ground and came to rest inverted about 50 feet from the initial impact point. The pilot did not report any failures or malfunctions associated with the airplane before the accident. Page 13 Copyright 1999, 2015,

14 Accident Rpt# WPR14LA147 03/26/ LCL Regis# N9551L Inarajan, GU Apt: N/a Acft Mk/Mdl CESSNA 172P Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320 SERIES Acft TT Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: TREND VECTOR AVIATION INT Aircraft Fire: NONE AW Cert: STN 1. Maneuvering - Loss of engine power (total) HISTORY OF FLIGHT On March 26, 2014, at 1743 local time, a Cessna 172P, N9551L, landed in a field following a loss of engine power near Inarajan, Guam. The airplane was registered to, and operated by, Trend Vector Aviation International, under the provisions of 14 Code of Federal Regulations Part 91 as an introductory flight lesson. The flight instructor (CFI) and two passengers were not injured. The airplane sustained substantial damage to the forward fuselage and left wing during the accident sequence. The local flight departed Guam International Airport, Barrigada, Guam, about Visual meteorological conditions prevailed, and no flight plan had been filed. The CFI reported that after takeoff he initiated a left turn, and having reached an altitude of 1,500 feet mean sea level (msl), he began a turn to the southwest towards Apra Harbor. He continued the flight while maintaining an altitude of about 1,500 feet msl, an airspeed of between 95 and 100 knots indicated, and an engine speed of 2,300 rpm. About 20 minutes after takeoff the engine speed began to decrease. He confirmed the mixture control was set to full rich, and then applied full forward throttle control. The engine speed increased momentarily, but then decreased such that only partial power was being produced. He then applied full carburetor heat, but the engine did not respond. The airplane would not maintain altitude, so the pilot initiated an approach to a landfill for a forced landing. As he approached the landing area he could see heavy equipment on the intended landing zone, so he turned the airplane towards a tall-grass field for a tailwind landing. He stated that during the final approach the engine was no longer producing any power, and the propeller appeared to be wind-milling. The airplane came to rest nose-down after the nose gear dug into the ground. AIRPLANE INFORMATION Maintenance records revealed that the airplane had undergone an annual inspection that was completed on January 30, At that time the airframe had accrued a total of 18,766.1 flight hours since manufacture in 1986, with the engine accruing 2,360 hours since overhaul. The airplane flew for 90 hours between the annual inspection and the accident. METEOROLOGICAL INFORMATION The closest aviation weather observation station was located at Guam International Airport, which was 14 miles north-northwest of the accident site. An aviation routine weather report was recorded at It reported: wind from 070 degrees at 13 knots gusting to 20 knots; visibility 10 miles with clear skies; temperature 28 degrees C; dew point 23 degrees C; altimeter inches of mercury. TESTS AND RESEARCH The airplane was recovered from the accident site and examined by a local mechanic. The mechanic reported that each fuel tank contained about 12 gallons of fuel, and that no fuel or oil leaks were apparent. Oil was present in the sump, and the oil was free of contamination or metal particles. The carburetor bowl was full of fuel, the spark plugs all exhibited signatures consistent with normal operation, and both magnetos were intact and set to the correct engine timing. The cylinder compressions were all about 64/80, and the engine controls were intact at their respective linkages, with the carburetor heat control observed in the full forward (carburetor heat off) position. The examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. A mechanic from Trend Vector Aviation subsequently examined the airplane and reported that the left wing fuel tank vent line allowed passage of air, but appeared to offer greater resistance when compared to other Cessna 172 airplanes in their fleet. Page 14 Copyright 1999, 2015,

15 According to representatives from Trend Vector Aviation, the airplane was refueled on the morning of the accident, and subsequently performed an uneventful flight. Another Cessna 172 was refueled from the same pump, and flew all day without experiencing any problems. After the accident the fuel storage facility was checked for possible contamination, and none was found. ADDITIONAL INFORMATION According to the Cessna 172 service manual, fuel tank venting is accomplished by an overboard vent line incorporated in the left fuel tank. The vent line protrudes through the bottom of the left wing into the airstream. In addition, a vent crossover line connects the airspace in the left tank to the airspace in the right tank where a vented fuel tank cap is installed. The Cessna 172P Pilots Operating Handbook, "EMERGENCY PROCEDURES, Rough Engine Operation or loss of power, Carburetor Icing" section states the following: "A gradual loss of engine RPM and eventual engine roughness may result from the formation of carburetor ice. To clear the ice, apply full throttle and pull the carburetor heat knob full out until the engine runs smoothly; then remove carburetor heat and readjust the throttle. If conditions require the continued use of carburetor heat in cruise flight, use the minimum amount of heat necessary to prevent ice from forming and lean the mixture for smoothest engine operation." The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin: CE Carburetor Icing Prevention, June 30, 2009, shows a probability of serious icing at glide power at the temperature and dew point reported at the time of the accident. Page 15 Copyright 1999, 2015,

16 Accident Rpt# CEN14LA451 08/23/ CDT Regis# N3202T Gordonville, TX Apt: Cedar Mills Airport 3T0 Acft Mk/Mdl CESSNA 177 Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING SERIES Acft TT 2966 Fatal 0 Ser Inj 2 Flt Conducted Under: FAR 091 Opr Name: SINGLETARY KENNETH Aircraft Fire: NONE AW Cert: STN 1. Landing-landing roll - Loss of control on ground On August 23, 2014, about 1015 central daylight time, a Cessna 177 airplane, N3202T, impacted trees during landing rollout at Cedar Mills Airport (3T0), Gordonville, Texas. The pilot and front seat passenger were seriously injured and the two rear seat passengers received minor injuries. The airplane sustained substantial damage. 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. Day visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight originated from Lakeview Airport (30F), Lake Dallas, Texas about The pilot stated that during a visual approach to Runway 25 at 3T0 he utilized left aileron and right rudder control inputs, based on a crosswind from the south. As the airplane descended below a tree line, the wind decreased and the airplane drifted to the left. During touchdown and rollout on the turf runway, the airplane continued to drift to the left. The pilot attempted to input right rudder, but felt like his input was not having any effect. The airplane subsequently departed the left side of the runway and impacted multiple trees. Examination of the airplane revealed extensive damage to both wings and the fuselage. After the accident, the pilot stated that the lack of rudder effect may have been due to the front seat passenger's foot blocking a rudder pedal. At 1015 the weather observation station at North Texas Regional Airport (GYI), Denison, Texas, located about 10 miles southeast of the accident site, reported the following conditions: wind 200 degrees at 11 knots, visibility 10 miles, clear skies, temperature 31 degrees Celsius (C), dew point 17 degrees C, altimeter setting inches of mercury. Examination of the airplane revealed normal flight control continuity. The pilot seat was found fully engaged on the rails and locked in position. No secondary seat stop was observed. The front passenger seat was displaced to the left and separated from the rails. The aft bench was secured to the floor. All seat restraint belts were still attached to the corresponding structure and no torn stitches were observed. There airplane was not equipped with shoulder harnesses. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Page 16 Copyright 1999, 2015,

17 Accident Rpt# CEN15CA125 01/26/ MST Regis# N8997T Fort Morgan, CO Apt: N/a Acft Mk/Mdl CESSNA 182C Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONT MOTOR O-470 SERIES Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: THEODORE M. LARSON Aircraft Fire: NONE AW Cert: STN 1. Enroute-cruise - Fuel exhaustion The pilot reported that before departing on the cross-country flight, he determined by visual inspection, that the fuel level was about 1/2-inch below the top of the filler neck on each wing fuel tank. While established in cruise flight, after about 4 hours of flight, the airplane experienced a total loss of engine power. The pilot was unable to restore engine power and a forced landing was made to a nearby pasture. Shortly after touchdown, the airplane collided with a snow-covered depression that caused the airplane to bounce. The airplane subsequently impacted the terrain in a nose low attitude, collapsing the nose landing gear. The engine firewall and right wing sustained substantial damage during the forced landing. A postaccident examination of the airplane established that the wing fuel tanks appeared to be undamaged and void of any useable fuel. During an interview, the pilot acknowledged that the loss of engine power was likely due to fuel exhaustion. He stated that he did not use the Pilot Operating Handbook procedures to lean the fuel mixture during the accident flight. He recently had to replace a burnt engine cylinder valve, so he was operating the engine at a slightly-rich fuel mixture setting to keep the cylinders from overheating. The pilot stated that the airplane departed with about 65 gallons of fuel, which he believed would provide about 5 hours of fuel endurance while maintaining an average fuel consumption rate of 13 gallons per hour. However, following the accident, the pilot acknowledged that he did not properly account for the entire 10 gallons of unusable fuel within the fuel system. Page 17 Copyright 1999, 2015,

18 Accident Rpt# CEN15CA067 12/01/ CST Regis# N9452T Edinburg, TX Apt: N/a Acft Mk/Mdl CESSNA 210 Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONTINENTAL IO-470 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: JAVIER BOCANEGRA Aircraft Fire: NONE AW Cert: STN 2. Enroute - Loss of engine power (total) The non-certificated pilot and passengers were on a local flight when the engine lost power. The pilot conducted a forced landing, about 10 miles from the airport. Examination of the airplane revealed damage to the landing gear and substantial damage to the wings and fuselage. Further examination of the airplane revealed that wing fuel tanks were empty, and not breached in the accident. Page 18 Copyright 1999, 2015,

19 Accident Rpt# ERA13LA188 04/01/ EDT Regis# VQTIN Fort Lauderdale, FL Apt: Fort Lauderdale Executive FXE Acft Mk/Mdl CESSNA 402C Acft SN 402C0227 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONTINENTAL TSIO-520-VB1F Acft TT 8524 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR NUSN Opr Name: CAICOS EXPRESS AIRWAYS Aircraft Fire: NONE 8. Landing - Landing gear collapse HISTORY OF FLIGHT On April 1, 2013, at 1635 eastern daylight time, a Cessna 402C, Turks and Caicos Islands registration VQ-TIN, operated by Caicos Express Airways (CEA), was substantially damaged when the nose landing gear collapsed during landing rollout at Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The airline transport pilot was not injured. Visual meteorological conditions prevailed and an IFR flight plan was filed for the positioning flight, destined for Providenciales International Airport (MBPV), Providenciales, Turks and Caicos Islands. The flight was conducted under the provisions of Article 14 of the United Kingdom Air Navigation (Overseas Territories) Order According to the pilot, the airplane had just had maintenance completed and the purpose of the flight was to return the airplane to MBPV to place it back in service. After departing from runway 26 at FXE, the pilot selected the landing gear to the "UP" position. The pilot noticed however, that the main landing gear retracted but, the nose landing gear did not. He then "completed the emergency check" and immediately selected "gear down". He then observed three "gear down and locked lights". After discussing the situation with air traffic control the pilot decided to return for landing on runway 13. The touchdown was normal, however during the rollout, as the airplane decelerated through 60 knots, the nose landing gear collapsed and the airplane's nose and propellers made contact with the pavement. The pilot also advised that prior to the nose landing gear collapse, he never heard a gear warning horn. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with a rating for airplane multi-engine land. His most recent FAA first-class medical certificate was issued on October 23, He reported that he had accrued 10,566 total hours of flight experience, 3,507 of which were in the accident airplane make and model. AIRCRAFT INFORMATION According to Turks and Caicos Islands Civil Aviation Authority (TCI-CAA) and CEA records, the airplane was manufactured in Its most recent annual inspection was completed on March 16, At the time of the inspection, the airplane had accrued 8,524 total hours of operation. METEOROLOGICAL INFORMATION The recorded weather at FXE at 1653, included: wind 180 degrees at 5 knots, visibility 10 miles, sky clear, temperature 26 degrees C, dew point 17 degrees C, and an altimeter setting of inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the airplane revealed that the fuselage nose structure behind the radome had been substantially damaged. Examination of the nose landing gear assembly revealed that the nose landing gear actuator was intact, extended, and undamaged, but the rod end with its castellated nut still threaded onto it was not connected to the nose landing gear drag brace. Further examination of the nose landing gear assembly also revealed that it would have been difficult for the pilot to discover that the nose landing gear actuator was disconnected from the nose landing gear drag brace, as the disconnected actuator was in an area that would be difficult for him to see or access. TESTS AND RESEARCH Page 19 Copyright 1999, 2015,

20 Review of Maintenance Records According to FAA and TCI-CAA records, the repair station which performed the maintenance on the airplane; EA Management Services Inc. (EAMS), was authorized to perform both airframe and powerplant repair on CEA aircraft. Review of the airplane's maintenance records revealed however, no evidence of any maintenance being performed on the nose landing gear assembly. Review of the EAMS defect work cards for the maintenance performed on the airplane also did not reveal any evidence of maintenance being performed on the nose landing gear assembly. Review of the additional worksheets (Form CEA-124) which had been given to EAMS to be used to document additional inspections as part of the maintenance requested by CEA, indicated that the nose landing gear drag brace (Supplemental Inspection Number: ) was requested to be performed. The documents however were discovered to have not been filled out by EAMS. Review of a work order (Work Order: ) that was sent to CEA by Ultimate NDT Inc. indicated however that non-destructive testing (NDT) had been performed on the nose landing gear drag brace in the form of a fluorescent penetrant inspection and that no cracks were noted at the time of the inspection. CHIEF INSPECTOR'S STATEMENTS According to EAMS's chief inspector, on March 24, 2013, the accident airplane was flown into FXE by the pilot and one of CEA's mechanics to have maintenance performed, which included an engine change and numerous Supplemental Inspections in accordance with Chapter 4 of the airplane maintenance manual. One of the mechanics that normally worked for the repair station was also contracted by CEA to assist in performing the maintenance for the duration. According to the chief inspector, upon the airplane's arrival, they immediately began to prepare the airplane for the inspection and engine change as they had tentatively scheduled March 27, 2013 as the date that non-destructive testing (NDT) inspections were to be performed by a contractor. Using the work order instructions as a guide, the chief inspector prepared a list of the NDT inspections to be carried out by the NDT contractor. This list was compiled based on the chief inspector's knowledge of the airplane and his familiarity with its maintenance history. The chief inspector's list included some additional inspections that were not originally included on the work order instruction supplied by CEA. This list was presented and after discussions with the mechanic from CEA and the pilot, it was decided that the repair station did not need to be involved in the inspection of the nose landing gear drag brace, because it did not necessitate the dismantling or separation of any parts. According to the chief inspector, this discussion happened on March 24, 2013 but, he was unable to recall the specific details, though according to him, "it was unequivocal that we had agreed that our help will not be needed in the performance of this inspection at this time." On previous inspections of the nose landing gear drag brace, the repair facility had always completely removed the drag brace from the airplane and the inspection was carried out with the part removed from the airplane. The chief inspector also advised that they discussed the unavailability of paint stripper and the need to purchase some to carry out the inspection. After he was informed that this was not required he did not transfer that inspection to the out shop defect work cards (discrepancy sheets). According to the chief inspector, they proceeded to complete the inspections, installations and other additional maintenance as required by CEA and on their work order. He advised that he was responsible for the supervision of all tasks and upon their completion; he did a final inspection, ground runs for the engine installation, and the control adjustments and release to service. After the accident, when the examination found that the bolt that connected the nose gear drag link to the nose gear actuator was disconnected, initial questioning of all parties that were involved in the maintenance of the aircraft, as to whether anyone may have worked on and therefore disconnected the nose actuator bolt, was conducted. Everyone involved answered in the negative. No one at the time could remember anyone working on the nose landing gear or working in the vicinity of the nose landing gear. Further questioning revealed that a mechanic had indeed disconnected and removed the bolt at the request of the NDT technician to facilitate an inspection on the nose landing gear. The mechanic and NDT technician at no time communicated this to anyone and did not take any further actions that may have alerted anyone to the bolt not being in place. According to the chief inspector, they had performed this inspection numerous times at their facility and the contracted NDT technician had always had the Page 20 Copyright 1999, 2015,