National Transportation Safety Board - Aircraft Accident/Incident Database

Transcription

1 Accident Rpt# CEN11LA549 08/04/ CDT Regis# N577JP East Troy, WI Apt: East Troy Municipal Airport 57C Acft Mk/Mdl AEROSPORT LTD IKARUS C42E Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl BOMBARDIER 912 Acft TT 777 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: SCOTT SCHUH AW Cert: LTSP Summary The student pilot reported that the accident landing was his fourth landing. He said that the landing was hard and the airplane bounced. He stated that he added power and about the same time, his door came open. He said that he initially ignored the door, but thought that the open door was causing the airplane to yaw to the left. He then tried to close the door, and the airplane veered off the left side of the runway and struck a ditch. The flight instructor reported no preimpact anomalies that would have precluded normal operation. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The flight instrctor's delayed remedial action during landing. Contributing to the accident was the student pilot's loss of directional control when he became distracted with the open door. Events 1. Landing - Abnormal runway contact 2. Takeoff - Loss of control in flight 3. Takeoff - Collision with terr/obj (non-cfit) Findings - Cause/Factor 1. Personnel issues-action/decision-action-delayed action-instructor/check pilot - C 2. Aircraft-Aircraft oper/perf/capability-performance/control parameters-directional control-not attained/maintained - F 3. Personnel issues-task performance-use of equip/info-aircraft control-student pilot - F On August 4, 2011, about 1830 central daylight time, an Aerosport Ikarus C42E, N577JP, landed hard and subsequently went off the left side of the runway and struck a ditch resulting in substantial damage. The airplane was landing on runway 8 at the East Troy Municipal Airport, East Troy, Wisconsin, when the accident occurred. The student pilot and the flight instructor were not injured. The airplane was registered to Tenerelli LLC, and operated as an instructional flight under the provisions of 14 Code of Federal Regulations Part 91. Visual flight rules (VFR) conditions prevailed for the flight, which was not operating on a flight plan. The local flight originated about The certificated flight instructor reported that the student pilot made a hard landing and the airplane bounced and became airborne again. He said that the student reached for the door and the airplane then yawed off the left side of the runway and impacted a ditch. The flight instructor listed no mechanical malfunctions of the airplane. The student pilot reported that the accident landing was his fourth landing. He said that the landing was hard and the airplane bounced. He stated that he added power and at about the same time, his door came open. He said that he initially ignored the door but felt that the open door was causing the airplane to yaw to the left. He then tried to close the door and the airplane went off of the runway. The student pilot listed "unknown" in regard to any mechanical malfunctions of the airplane. Examination of the airplane after the accident revealed propeller damage, separated left main landing gear, collapsed nose landing gear, a fractured main keel tube in the fuselage, and a bent fuselage. No preimpact anomalies were found. Page 1 Copyright 1999, 2012,

2 Accident Rpt# WPR12LA149 03/29/ PDT Regis# NONE Indio, CA Acft Mk/Mdl POWRACHUTE SKY RASCAL Acft SN None Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 503 Fatal 0 Ser Inj 1 Flt Conducted Under: FAR 091 Opr Name: PAUL HARRISON Aircraft Fire: GRD AW Cert: SPX Summary The non-certificated pilot reported that he waited for the wind to subside before taking off. The pilot said that when the wind subsided, he departed, but during the initial climb, the powered parachute encountered either a downdraft or a gust of wind and collided with a set of powerlines. The powered parachute was subsequently consumed by fire after becoming entangled in the wires. The pilot reported no mechanical malfunctions or failures with the aircraft that would have precluded normal operation. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The operation of an airplane by a non-certificated pilot. Contributing to the accident was the non-certificated pilot's failure to maintain clearance from powerlines during initial climb in gusty wind conditions. Events 1. Initial climb - Turbulence encounter 2. Initial climb - Collision with terr/obj (non-cfit) Findings - Cause/Factor 1. Aircraft-Aircraft oper/perf/capability-performance/control parameters-altitude-not attained/maintained - F 2. Environmental issues-conditions/weather/phenomena-wind-gusts-effect on operation 3. Environmental issues-physical environment-object/animal/substance-wire-effect on operation 4. Personnel issues-experience/knowledge-experience/qualifications-qualification/certification-pilot - C On March 29, 2012, about 1835 Pacific daylight time, an unregistered Powrachute Sky Rascal experimental powered parachute sustained substantial damage following a collision with powerlines during initial climb near Indio, California. The non-certificated pilot, the sole occupant of the aircraft, received serious injuries. Visual meteorological conditions prevailed for the local flight, which was being operated in accordance with 14 Code of Federal Regulations (CFR) Part 91, and a flight plan was not filed. The aircraft departed a private strip about 2 minutes prior to the accident. In a telephone interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the non-certificated pilot reported that he waited for the wind to subside down before taking off. The pilot stated that after taking off either a downdraft or a gust of wind blew him into a set of powerlines, in to which the aircraft became entangled. The pilot revealed that he eventually jumped to the ground, but was not sure if the aircraft was on fire or not when he jumped. The pilot reported no mechanical failures or malfunctions with the aircraft. When asked if he was a licensed pilot, he said he wasn't, and when asked why he had not registered the aircraft, he replied that he didn't think that he needed to, as it was exempt, but that he could not remember "how that worked." Subsequent attempts to interview the pilot during the course of the investigation were not successful, as he was moved to an assisted living facility due to the extent of his injuries. Additionally, the Pilot/Operator Aircraft Accident/Incident Report, NTSB Form , was not obtained during the investigation, due to the pilot's incapacitated condition. According to a Federal Aviation Administration (FAA) airworthiness inspector, after the aircraft was inspected to determine if it was in compliance with Federal Aviation Regulation (FAR) Part 103, the regulation that governs ultralight vehicles, it was discovered that the stock 5 gallon fuel tank had been replaced with a 10 gallon tank, and that the stock 407 engine had been replaced with a heavier 503 engine, which put the weight of the aircraft outside of the FAR 103 limits. The aircraft would then be required to be certificated. When the inspector confronted the accident pilot about the modifications, the pilot stated that he was unaware of them and blamed the individual who sold him the aircraft. According to the inspector, when the previous owner was interviewed he stated that he had made no modifications to the aircraft, and that the only thing he changed prior to its sale was the propeller. At 1852, the automated weather reporting system at the Jacqueline Cockran Regional Airport (TRM), which was located about 8 nautical miles south-southeast of the accident site, reported wind calm, visibility 10 miles, sky clear, temperature 25 degrees Celsius (C), dew point 4 degrees C, and an altimeter setting of Page 2 Copyright 1999, 2012,

3 29.81 inches of mercury. Page 3 Copyright 1999, 2012,

4 Accident Rpt# CEN11LA449 06/30/ CDT Regis# N59VA Leander, TX Apt: Kittie Hill Airport 77T Acft Mk/Mdl ABBEY VICTOR RV9-A Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl EGGENFELLNER E-6 Acft TT 310 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: HATCH AARON M On June 30, 2011, about 1615 central daylight time, an experimental amateur built RV9A airplane, N59VA, experienced a partial loss of engine power on initial climb after takeoff from the Kittie Hill Airport (77T), Leander, Texas. The commercial rated pilot sustained minor injuries and the airplane sustained substantial damage during the forced landing. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. According to the pilot, following the installation of an Eggenfellner Subaru E6 engine, he flew the airplane three times before the accident flight. During the first flight, the engine overheated and the pilot returned to the airport and landed. A second flight of 30 to 45 minutes was performed maintaining higher airspeeds and the engine performed with no observed anomalies. After takeoff on the third flight, the pilot noted that the engine didn't sound right, so he returned to the airport and landed. The pilot, along with his mechanic, examined the engine and could not locate any issues, so the pilot departed for his forth flight. After takeoff from runway 17, when the airplane reached an altitude of 200 to 300 feet, the engine lost partial power. The pilot elected to make a left turn and performed a landing to runway 30. As the airplane neared the end of its landing rollout, the nose gear impacted a depression in the turf runway and the airplane nosed over. Examination of the engine by a Federal Aviation Administration (FAA) inspector revealed that the airplane sustained substantial damage to its vertical stabilizer and damage it the left wing tip, canopy, nose gear, and propeller. Examination of the engine did not reveal a reason for the loss of engine power. Page 4 Copyright 1999, 2012,

5 Accident Rpt# CEN11LA464 07/07/ EDT Regis# N7808M East Liverpool, OH Apt: Columbiana County Airport 02G Acft Mk/Mdl BURTNER CHARLES W DERJAGER D IX Acft SN 97 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-290 Acft TT 50 Fatal 0 Ser Inj 1 Flt Conducted Under: FAR 091 Opr Name: RONALD R. HIRKALA AW Cert: SPE Summary The pilot had recently purchased the amateur-built airplane and had little experience with the flight and ground handling characteristics of the airplane. During the accident flight, while landing, the airplane porpoised, and the propeller struck the runway surface. The pilot aborted the landing attempt, and when the airplane was about 100 feet above the ground, the propeller disintegrated and the engine began to vibrate violently. The pilot executed a forced landing and struck trees and the ground during the off-airport landing. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's improper landing flare, which resulted in a porpoised landing and propeller contact with the runway, which caused an in-flight disintegration of the propeller during the go-around, and subsequent collision with trees. Events 1. Landing-flare/touchdown - Abnormal runway contact 2. Landing-aborted after touchdown - Powerplant sys/comp malf/fail 3. Landing - Collision with terr/obj (non-cfit) Findings - Cause/Factor 1. Aircraft-Aircraft oper/perf/capability-performance/control parameters-landing flare-not attained/maintained - C 2. Aircraft-Aircraft propeller/rotor-(general)-(general)-damaged/degraded On July 7, 2011, about 1800 eastern daylight time, an amateur-built Burtner Derjager D IX, N7808M, sustained substantial damage when it impacted trees and terrain during a forced landing after an aborted landing from runway 7 at the Columbiana County Airport, East Liverpool, Ohio. The pilot received serious injuries. The airplane was registered to an individual and operated by a commercial pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual flight rules (VFR) conditions prevailed for the flight which was not operating on a flight plan. The local flight originated about The pilot reported that he had purchased the airplane several months prior to the accident and had made modifications to the cockpit to provide more room. He stated that he had discussed the flight characteristics of the airplane with the previous owner on several occasions. On the day of the accident, the pilot performed high-speed taxi tests on runway 25. On the third high-speed taxi test, he pulled the airplane into the air. The pilot reported that the airplane had a positive rate of climb and that the controls were sensitive. He stated that he made several touch and goes during the flight. During the final touch and go, the airplane porpoised and the landing gear struck the runway hard. The pilot applied power and aborted the landing. When the airplane was about 100 feet above the ground, the propeller disintegrated and the engine began to vibrate violently. The pilot reported that he pulled the throttle control back and looked for a place to land. He stated that he had no further recollection of the accident. Page 5 Copyright 1999, 2012,

6 Accident Rpt# WPR12LA113 02/21/ PST Regis# N72PD Mariposa, CA Apt: Mariposa-yosemite Airport MPI Acft Mk/Mdl HAYCRAFT SPORT HORNET Acft SN 055 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 912ULS Acft TT 97 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: OLIVER HAYCRAFT Aircraft Fire: IFLT AW Cert: SPE Summary The pilot was returning to the airport when he noticed the smell of smoke in the cockpit. The smoke intensity increased, and after about 15 seconds, he opted to perform a forced landing into a pasture. During the landing roll, the nosewheel separated from the airplane, which slid to a stop. The pilot stated that after egressing, he observed fire emanating from underneath the engine area. A postaccident examination revealed that the engine's predominant area of thermal deformation was around the No. 4 cylinder (right side). Examination of the bottom of the engine revealed that the right side exhibited hotter thermal exposure signatures than the rest of the engine. Due to the thermal destruction, it could not be determined precisely where the fire originated; however, the area where the damage was the greatest was where the fuel lines, coolant lines, ignition harness, and carburetor were located. It was also noted that no heat shielding was installed between the exhaust system and the engine, which more than likely had an effect on the initiation of the fire. Both the engine and the exhaust manufacturers recommended installing heat shielding between the exhaust and engine components. The limits section of the Installation Manual states that if there is not proper heat shielding to protect the modules and fuel lines from the exhaust heat, the engine may be susceptible to a fire. However, because this airplane is experimental, there is no requirement for the installation of the heat shield. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: Improper clearance and inadequate heat shielding between engine components and the exhaust system, which resulted in an in-flight fire. Events 1. Enroute - Fire/smoke (non-impact) Findings - Cause/Factor 1. Aircraft-Aircraft power plant-engine exhaust-(general)-related operating info - C 2. Personnel issues-task performance-maintenance-fabrication-owner/builder - C HISTORY OF FLIGHT On February 21, 2012, about 1440 Pacific standard time, a Haycraft Sport Hornet, N72PD, experienced an in-flight fire near Mariposa-Yosemite Airport, Mariposa, California. The airplane was substantially damaged during an off-airport landing and consumed by fire. The owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The sport pilot and sole passenger were not injured. The local personal flight departed from Mariposa about Visual meteorological conditions prevailed, and no flight plan had been filed. In a written statement, the pilot reported that after taking photographs of property, he began to return back to the airport. With the airport about 5 miles to the north, he noticed the smell of smoke in the cockpit. He maneuvered the airplane directly toward the airport and noted that all the engine temperature and pressure cockpit gauges indicated normal operation. The smoke intensity increased and after about 15 seconds, he opted to perform a forced landing into a pasture below. During the landing roll, the nose wheel separated from the airplane and slid to a stop. The pilot and passenger egressed and watched the airplane burn. The pilot further stated that he first observed the fire underneath the engine area. AIRCRAFT INFORMATION The Haycraft Sport Hornet single-engine amateur built airplane, serial number 0054, was completed in The airplane was equipped with the originally installed Rotax 912ULS engine. The pilot stated that the airframe and engine had accumulated a total time of 97 hours. The last conditional inspection was dated as having been completed August 07, The airplane had accrued approximately 10 hours since that inspection. TESTS AND RESEARCH Page 6 Copyright 1999, 2012,

7 The airplane was configured in a pusher-type style, with the engine mounted above and aft of the cockpit. The airframe fabric covering was burned from its steel tubular structure with the exception of panels that remained covering the left wing and several panels on the outboard right wing. The engine, a Rotax 912ULS, remained affixed to the three-bladed propeller. The engine had sustained thermal damage and the firewall was melted, with the only identifiable pieces being molten material clumped in the wreckage. A postaccident examination revealed that the predominant area of thermal deformation was around the No. 4 cylinder (right side) and concentrated around its forward inboard section where several cylinder fins were bent. Examination of the bottom of the engine revealed that the right side was white in coloration and the left side was black, consistent with more thermal exposure and hotter temperatures reached on the right side. The housing on the exhaust pushrod of the No. 4 cylinder was thermally destroyed exposing the charred pushrod. According to the Rotax representative, the exhaust system installed on the engine was manufactured by Titan Aircraft. There was no evidence that there was heat shielding between the exhaust system and engine. The distance between the exhaust pipe and the ignition module was about 3 inches; the module was consumed by fire as was the ignition harness. In the area that had sustained the greatest thermal damage (above the No. 4 cylinder) was where the following components were routed near an exhaust pipe: fuel and cylinder head coolant lines, an ignition harness, and a Bing Carburetor (mounted via a rubber carburetor socket). ADDITIONAL INFORMATION According to the Rotax Installation Manual section 11, "Exhaust system," the "shape and execution of the exhaust system is determined essentially by the free space available in the aircraft." A caution notes to, "fit heat shields near carburetors or as required," and "because of high temperatures occurring, provide suitable protection against unintentional contact." The Rotax representative stated that there is no defined maximum or minimum distance the components need to be from the exhaust system, but the installer must take into account that a certain amount of back pressure will occur during takeoff, which will affect that distance. He noted that keeping the exhaust system closer to the engine is most desirable as long as the installer does not exceed the minimum bend radius on the exhaust pipe and that the proper heat shielding is used. The Rotax representative further stated that the exhaust system reaches temperatures of 1,560 to 1,616 degrees Fahrenheit, as explained in the limits section of the Installation Manual. The ignition modules have a maximum ambient temperature of 176 degrees Fahrenheit, and the representative stated that if there isn't proper heat shielding to protect the modules and fuel lines from the exhaust heat, the engine may be susceptible to a fire. Titan Aircraft, the exhaust manufacturer, issued an advisory in July 2010 for another aircraft equipped with Rotax 912 series engines, stating that an ignition module failure can occur due to heat from the exhaust. The advisory states, "Installation of exhaust/header wrap on the muffler and outlet pipes or fabrication of a heat shield to cover the ignition module is required." Page 7 Copyright 1999, 2012,

8 Accident Rpt# CEN13CA017 10/20/ CDT Regis# N589DH Bourland, TX Apt: Bourland Field K50F Acft Mk/Mdl HUNTHROP AUTOGYRO MTO SPORT Acft SN M0098 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 912ULS Fatal 0 Ser Inj 1 Flt Conducted Under: FAR 091 Opr Name: HUNTHROP WILLIAM D While performing touch-and-go training, the gyrocraft impacted terrain during a takeoff from the runway. The gyroplane's fuselage was substantially damaged. The Federal Aviation Administration inspector reported that the solo private pilot sustained a broken arm and a concussion; the pilot could not recall the accident sequence. In addition, the pilot was training to obtain a gyrocraft endorsement and had been signed off by his flight instructor to operate solo in winds up to 9 knots. Winds at the time of the accident were 20 degrees from runway heading at 19 knots gusting to 27 knots. At the time of the accident, the pilot had accumulated about 271 hours total time with 10 hours dual and 1.5 hours solo in make and model. A visual examination of the gyrocraft did not reveal any preimpact anomalies. Page 8 Copyright 1999, 2012,

9 Accident Rpt# WPR12LA146 03/24/ PDT Regis# N238RV Bow, WA Acft Mk/Mdl JACOBS RV-6A Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-360-EXP Acft TT 682 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: RANDALL WATTS AW Cert: SPE Summary The pilot performed two touch-and-go landings then departed to his destination airport. As the airplane climbed through 2,300 feet mean sea level, the pilot heard a loud "clunk." The engine experienced a total loss of power, and the airplane began to descend. The pilot maneuvered the airplane to a field in an effort to perform an off-airport, emergency landing. Prior to touchdown, the landing gear collided with a barbed wire fence and the airplane nosed over. During the wreckage recovery, the right fuel tank was found empty and the left tank contained about 22 gallons of aviation fuel. The pilot reported that he believed that the fuel selector was positioned on the left tank at the time of the loss of power. He did not attempt to restart the engine following the loss of power due to the airplane's low altitude. At the time of the airframe examination, the fuel selector was found in the off position. A postaccident examination of the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the fuel selector was in fact positioned to the empty fuel tank and the reason for the loss of engine power was due to fuel starvation. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The total loss of engine power due to fuel starvation as a result of the pilot's mismanagement of the fuel supply. Events 1. Enroute-climb to cruise - Loss of engine power (total) 2. Enroute-climb to cruise - Fuel starvation 3. Emergency descent - Collision with terr/obj (non-cfit) 4. Emergency descent - Off-field or emergency landing Findings - Cause/Factor 1. Personnel issues-task performance-planning/preparation-fuel planning-pilot - C 2. Aircraft-Fluids/misc hardware-fluids-fuel-fluid management - C HISTORY OF FLIGHT On March 24, 2012, about 1530 Pacific daylight time, a Jacobs RV-6A, N238RV, experienced a loss of engine power near Bow, Washington. The owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot, the sole occupant, was not injured; the airplane was substantially damaged. The local personal flight departed from Skagit Regional Airport, Burlington, Washington, about 1510, with a planned destination of Bellingham International Airport, Bellingham, Washington. Visual meteorological conditions prevailed and no flight plan had been filed. In a telephone conversation with a National Transportation Safety Board investigator, the pilot reported that he performed two touch-and-go practice takeoffs and landings at Skagit and then departed en route to Bellingham. As the airplane climbed through 2,300 feet mean sea level (msl) to the pilot's planned altitude of 3,000 feet, he heard a loud "clunk." The engine experienced a total loss of power and the airplane began to descend. The pilot maneuvered the airplane to a field in an effort to perform an off-airport, emergency landing. While landing, the airplane's landing gear collided with a barbed wire fence and nosed over. The pilot further stated that just prior to the accident he noted that the right fuel tank was empty and the left tank was about _ full. He believed that the fuel selector was positioned on the left tank. He did not attempt to restart the engine following the loss of power due to the airplane's low altitude. TESTS AND RESEARCH Maintenance personnel reported that prior to transporting the wreckage to the storage facility they had removed approximately 22 gallons of fuel from the left fuel tank and less than a cup from the right fuel tank. During the wreckage examination both fuel tanks were empty and there was no evidence of a fuel system breach or staining that would indicate fuel leakage. The fuel selector was found in the forward "off" position. Air was blown from the fuel selector inlet tubes and flow continuity was established to the wing root Page 9 Copyright 1999, 2012,

10 fuel lines that connect to the right and left fuel tanks. A small amount of fuel exited the line at both wing roots. Air was also blown from the fuel selector to the carburetor and continuity was confirmed. The gascolator bowl was removed from its attachment point; it was full of a blue liquid consistent with 100LL fuel. The gascolator screen was clear of debris. The airplane was equipped with a Lycoming O-360 engine. The engine remained attached to the engine mount assembly and firewall with minimal damage noted. Examination of the engine revealed that the engine case and all four cylinders were intact. The accessory gear case and associated accessories were present and there was no evidence of oil leakage. The engine oil sump was intact and contained about 6.25 quarts of oil. The spark plug ignition leads and the top four spark plugs were removed from the engine. The leads were intact and undamaged. The spark plug electrodes were dry and grey in color. As compared to the Champion Check-A-Plug comparison card, the top spark plugs displayed normal operating wear signatures. The engine crankshaft was manually rotated via rotation of the propeller and all four cylinders developed thumb compression. The ignition leads for the top four spark plugs sparked normally when the crankshaft was manually rotated. During the post accident examination, no evidence of mechanical malfunction or failure with the airplane was found. A complete examination report is contained in the public docket for this accident. Page 10 Copyright 1999, 2012,

11 Accident Rpt# ERA12LA541 09/01/ EDT Regis# N70415 Mcveytown, PA Acft Mk/Mdl JOHNSTON DOUGLAS S SAFARI Acft SN 0442N Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-320 Acft TT 442 Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: KEN SMITH AW Cert: SPE HISTORY OF FLIGHT On September 1, 2012, at 0900 eastern daylight time, N70415, experimental amateur-built Safari helicopter was substantially damaged when it impacted the ground while maneuvering in McVeytown, PA. The non-certificated pilot was fatally injured. Visual meteorological conditions prevailed for the personal, local flight that was conducted under the provisions of 14 CFR Part 91. According to a witness, he observed the helicopter flying away from him, and then made a 180-degree turn toward the hangar it was kept in. The helicopter then made another 180-degree turn and "started to go down." The witness observed a puff of smoke as the helicopter disappeared from his view. PILOT INFORMATION A review of the Federal Aviation Administration (FAA) database revealed the pilot did not hold a pilot certificate. According to a pilot logbook provided by the pilot's wife, he logged three flights on: August 14, 2010, August 21, 2010, and October 9, The total flight time for these flights was 3.2 hours. AIRCRAFT INFORMATION The helicopter was built from a kit, by the previous owner, and received its first airworthiness certificate on April 10, It was equipped with a Lycoming O-320, 160-horsepower engine. The accident pilot purchased the helicopter in March 2012; however, there was no evidence that he attempted to acquire an airworthiness certificate or register the helicopter with the FAA. A review of the helicopter and engine logbooks revealed the most recent condition inspection was completed on June 30, 2011 by the previous owner/builder. No anomalies were noted in the entry, and a tachometer time of 395 hours was noted. The tachometer time at the accident site was 442 hours. According to the kit manufacturer, they brokered the sale of the helicopter between the accident pilot and the widow of the previous owner/builder. After the accident pilot purchased the helicopter, the kit manufacturer performed some maintenance on it to assure it was in a flyable condition. The work they performed included: replacing the main rotor spindle, and performing an annual condition inspection. This work was completed on May 11, METEOROLOGICAL INFORMATION The weather recorded at the nearest airport, at 0853, included wind from 280 degrees at 7 knots, 10 miles visibility, a broken cloud layer at 7,000 feet, temperature 23 degrees C, dew point 19 degrees C, and altimeter setting inches mercury. WRECKAGE INFORMATION Examination of the accident site confirmed the helicopter impacted the ground in a vertical attitude with minimal forward speed. Inspection of the main rotor blades and tail rotor blades revealed damage consistent with low or minimal rotor speed (RPM) impact with terrain. Main and tail rotor control system continuity was confirmed from the cockpit to the control surfaces. Inspection of the fuel system revealed no fuel in the right fuel tank and approximately 2 pints in the left Page 11 Copyright 1999, 2012,

12 fuel tank. A sample of fuel from the left tank was found to be free of contamination and consistent with 100LL aviation fuel. The carburetor bowl drain was opened and fuel was observed. No obstructions were noted in the fuel system, or the air induction system. The fuel selector was in the ON position. The engine crankshaft was rotated at the propeller flange and thumb compression and valve train continuity was confirmed on all four cylinders. No mechanical anomalies were noted during the engine examination. [Additional information regarding the on-scene helicopter examination can be found in the FAA Inspector Statement located in the public docket.] MEDICAL AND PATHOLOGICAL INFORMATION The Mifflin County Coroner performed an autopsy on the pilot on September 1, The cause of death was listed as blunt force trauma. The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. No drugs or alcohol were noted in the testing. ADDITIONAL INFORMATION A witness who spoke with the pilot prior to the flight reported that the pilot had "five and a half inches" of fuel in the helicopter prior to departure. He reported the pilot intended to "make a couple of laps," and then they were going to fly to the local airport to purchase more fuel. According to the kit manufacturer, when the pilot arrived at their facility to acquire the helicopter in May 2012, the owner of the kit manufacturing company flew with the pilot for about 15 hours (both in a company helicopter and in the accident helicopter). The purpose of these flights was for the pilot to practice hovering the helicopter. Because the pilot did not have a pilot's license and was not familiar with this type of helicopter, the company owner told him not to lift the helicopter more than 2 feet off the ground, once he arrived home, until he received instruction in it. According to the pilot's wife, she believed the pilot flew the helicopter for the first time after it arrived at their home from the manufacturer's facility, on July 4, She estimated the pilot flew approximately every other weekend since then (three times in July and two in August).The pilot's wife believed the flights only included the pilot practicing lifting the helicopter off the ground and setting it back down again. He may have circled the field where he kept the helicopter, but she believed that would have been the longest duration of a flight. The pilot's wife was not aware that he intended to fly the helicopter on the day of the accident. A review of the Height-Velocity diagram contained in the Safari Helicopter Flight Manual revealed that operations below an altitude of 400 feet and below airspeeds of 50 knots should be avoided. According to the FAA Rotorcraft Flying Handbook, FAA-H , the height/velocity (H/V) diagram depicts critical combinations of airspeed and altitude should an engine failure occur. Operations in crosshatched or shaded areas of the H/V diagram may not allow enough time for the critical transition from powered flight to autorotation. Page 12 Copyright 1999, 2012,

13 Accident Rpt# CEN13CA026 10/09/ Regis# N764JM Durango, CO Apt: Animas Air Park 00C Acft Mk/Mdl MACE JUSTIN I DRAGONFLY Acft SN 764 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONT MOTOR SERIES Acft TT 1350 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: ANTHONY VOWELS The pilot reported that while attempting to land at the airport, he encountered turbulence just before the airplane touched down. The airplane alignment prior to touchdown was approximately 20 degrees off of runway centerline due to over-correction of the rudder. The pilot applied power to execute a go-around and the airplane began to porpoise as the pilot attempted to climb away from the runway. The airplane collided with trees and the wing and canard sustained substantial damage. The pilot reported that there were no mechanical anomalies with the airplane that would have precluded normal operation. Page 13 Copyright 1999, 2012,

14 Accident Rpt# ERA13LA136 02/17/ CST Regis# NONE Poplarville, MS Apt: Private Field Acft Mk/Mdl QUICKSILVER MX II-NO SERIES Acft Dmg: SUBSTANTIAL Rpt Status: Prelim Prob Caus: Pending Eng Mk/Mdl ROTAX Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: RON DESANTIS On February 17, 2013, about 1530 central standard time, an unregistered experimental amateur-built Quicksilver MX II airplane, was substantially damaged when it impacted the ground following a loss of control while maneuvering near Poplarville, Mississippi. The non-certificated pilot, the sole occupant, was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to a Federal Aviation Administration (FAA) inspector, witnesses reported it was the pilot's first flight in the aircraft. Witnesses stated the pilot made a low pass over an open field, attempted to climb over a tree line, entered a spin at about 75 feet and impacted the ground inverted. Page 14 Copyright 1999, 2012,

15 Accident Rpt# CEN13LA177 02/21/ EST Regis# N613TX Indianapolis, IN Acft Mk/Mdl TTX AIR LLC LANCAIR-EVOLUTION Acft SN EVO-0039 Acft Dmg: SUBSTANTIAL Rpt Status: Prelim Prob Caus: Pending Eng Mk/Mdl P&W CANADA PT6A-135 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: TTX AIR, LLC AW Cert: SPE On February 21, 2013, about 0850 eastern standard time, a Lancair Evolution airplane, N613TX, was substantially damaged during a gear up landing at the Eagle Creek Airpark (EYE), Indianapolis, Indiana. The pilot and flight instructor were not injured. The airplane sustained damage to the fuselage, right wing, vertical stabilizer, and rudder. The aircraft was registered to and operated by TTX Air, LLC under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The local flight originated from EYE about The pilot reported that they were conducting takeoffs and landings in the airport traffic pattern when the accident occurred. He noted that the first two landings were uneventful. He stated that after the third takeoff, the landing gear position indicator lights remained green (indicating gear down) after the selector handle was moved to the retracted position. The selector handle was cycled and the landing gear appeared to retract normally at that time. The next takeoff and landing were routine. On the subsequent landing, he intended to execute a no-flap (flaps up) full stop landing. He stated that the landing gear selector handle was lowered on the downwind traffic pattern leg, abeam the end of the runway. However, the landing gear was not properly extended on touchdown and the airplane was landed with the gear retracted. A postaccident examination of the landing gear system is pending. Page 15 Copyright 1999, 2012,

16 Accident Rpt# WPR12FA001 10/04/ Regis# N91BV West Jordan, UT Apt: South Valley Regional U42 Acft Mk/Mdl VAUGHN PULSAR Acft SN 146 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX Acft TT 248 Fatal 2 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: JARED K. DESPAIN Summary On the morning of the accident, the pilot and the new owner arrived at the airport to pick up the airplane. The previous owner saw that their total weight was greater than he had been told during an earlier inquiry and advised the flight instructor and the new owner that their total weight might put the airplane near its maximum allowable gross weight. He also advised them not to add any more fuel than was already onboard, and then handed them the weight and balance sheet for the airplane. Subsequently, witnesses saw the airplane take off and ascend at an extremely low rate of climb. When another pilot waiting to take off asked whether they were having any technical difficulties, the accident pilot responded that there was nothing wrong but that it was just a "weak airplane." About 1/2 mile after passing the departure end of the runway, the pilot initiated a right turn but failed to maintain sufficient airspeed, resulting in the airplane stalling and descending into the terrain. The postaccident investigation determined that the airplane was being operated above its maximum allowable gross weight and that it was being operated in a density altitude that was 2,120 feet higher than the field elevation. An engine teardown examination determined that both of its carburetors had jet needles installed that produced a richer-than-normal fuel-air mixture. This was due to an incorrect reassembly after an overhaul of the carburetors. The weight of the airplane, the high density altitude, and the overly rich fuel-air mixture most likely combined to significantly reduce the performance of the airplane. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain sufficient airspeed and airplane control while initiating a turn during the initial climb after takeoff in a high density altitude environment, above the airplane's maximum allowable gross weight, and with an overly rich fuel-air mixture due to improper carburetor maintenance. Events 1. Initial climb - Loss of control in flight 2. Initial climb - Aerodynamic stall/spin 3. Uncontrolled descent - Collision with terr/obj (non-cfit) Findings - Cause/Factor 1. Aircraft-Aircraft oper/perf/capability-performance/control parameters-airspeed-not attained/maintained - C 2. Personnel issues-task performance-use of equip/info-aircraft control-pilot - C 3. Environmental issues-conditions/weather/phenomena-temp/humidity/pressure-high density altitude-contributed to outcome 4. Aircraft-Aircraft oper/perf/capability-aircraft capability-maximum weight-capability exceeded - C 5. Personnel issues-action/decision-action-incorrect action performance-maintenance personnel - C 6. Aircraft-Aircraft power plant-engine fuel and control-fuel control/carburetor-incorrect service/maintenance - C 7. Personnel issues-task performance-planning/preparation-weight/balance calculations-pilot HISTORY OF FLIGHT On October 4, 2011, about 1315 mountain daylight time, an experimental Vaughn Pulsar airplane, N91BV, impacted the terrain about one-half mile south of the departure end of Runway 16, at South Valley Regional Airport, West Jordon, Utah. Both the certified flight instructor and his passenger received fatal injuries, and the airplane, which had been purchased earlier that day by the passenger, sustained substantial damage. The pilot of the 14 Code of Federal Regulations Part 91 personal flight was departing South Valley Regional Airport in visual meteorological conditions, with an intended destination of Nephi, Utah. No flight plan had been filed. According to the previous owner, the individual who he sold the airplane to on the day of the accident had come to see it about two weeks earlier. Although the airplane was not flown at that time, the owner, accompanied by the potential buyer, started it up, taxied it along the taxiway, performed an engine run-up check, and then taxied it back to the hangar. Reportedly, the engine ran well on that day, and subsequently, the potential buyer advised the owner that he was going to purchase the airplane. The buyer also told the owner that he would have to make arrangements for someone else to come pick up the airplane because he was not a rated pilot. He later advised the owner that he and a flight instructor would come pick up the airplane, and that the flight instructor would later be using the airplane to give him the instruction necessary to earn his Sport Pilot license. Page 16 Copyright 1999, 2012,

17 According to the previous owner, who knew the gross weight limitations of the airplane, when the purchaser called to advise him that he and the flight instructor would be picking up the airplane together, he asked him what their approximate weights were. Reportedly, the purchaser said that they were each in the 180 to 190 pound range. But, when the buyer and the flight instructor arrived on the day of the accident, it appeared to the owner that the weight of the flight instructor was higher than he had been told. He therefor advised the new owner and the flight instructor that they may be near the maximum gross weight limit of the airplane, and told them they should not add any more fuel to the 9 gallons already onboard. The seller also handed the instructor pilot a copy of the weight and balance sheet, so that he could perform an accurate gross weight calculation. Then, after giving the new owner the keys to the airplane and a box full of airplane associated paperwork, the seller spent a little time talking to both individuals about the airplane and its systems. He then left the airport to go back to work. He was not there when the new owner and the instructor pilot entered the airplane to prepare for departure. Although the investigation did not find any witnesses who observed the two individuals again until they taxied out for takeoff, no records where found at the airport of any additional fuel being added prior to departure. The next time the airplane and its occupants were spotted was about 5 minutes before they took off, when the airplane was seen taxiing to the northern end of runway 16. There, according to witnesses, the pilot stopped in the run-up area before taking off, but it is unknown whether an engine run-up check was completed. The pilot then taxied onto runway 16, where he initiated the takeoff roll. When the instructor pilot was taxiing out for takeoff, the airplane passed near a flight instructor who had seen it fly before, and who had a friend who had expressed a possible interest in purchasing the airplane. After the airplane taxied by, the flight instructor went inside a nearby building to advise his friend that it appeared the airplane was taxiing out for takeoff. Then the flight instructor and his friend went back outside for the specific purpose of watching the airplane takeoff. According to that flight instructor, when it came by their location, which was about half way down the 5,860 foot runway, the airplane had already lifted off the runway, and its engine sounded to them like it was making full power. At that point the airplane was just above the runway surface and still appeared to be in ground effect. It was reportedly just barely climbing, and was in a repeated porpoising sequence; whereupon each time the airplane's nose was raised, it would climb only a few feet before the pilot lowered it again to near a level flight attitude. As the airplane neared the departure end of the runway, another flight instructor, who was waiting to takeoff next, transmitted over the radio, "Experimental aircraft on departure, are you having technical difficulties?" To that transmission, the accident pilot responded, "No, it's just a weak aircraft." The porpoising sequence then continued until the airplane reached a point about one-half mile off the end of the runway about 75 feet above ground level (agl). It then appeared that the pilot established a shallow right turn, followed soon thereafter by an increase of the bank angle to near 90 degrees and a drop of the nose to about 45 degrees below the horizon. The airplane then made a rapid descent into the terrain. PESONNELL INFORMATION The pilot was a 28 year old male, who held both a commercial pilot certificate and a certified flight instructor certificate. His pilot ratings were for single-engine land airplanes and multi-engine land airplanes, and he held an airplane instrument rating. His instructor ratings were for instruction in single-engine airplanes, multi-engine airplanes, and instrument instruction in airplanes. His last airman's medical, a Class 1 without waivers or limitations, was completed on September 16, Based upon information provided by his airman's medical, it is estimated that he had accumulated a total of about 2,100 hours of flight time. It is not known if he had accumulated any flight time in the make and model of airplane involved in the accident. AIRCRAFT INFORMATION The airplane was a 1992 kit-built experimental Vaughn Pulsar with a total engine and airframe time of about 250 hours. Its engine was a Rotax 582 Mod 90 of 65 horsepower, with a model 3M23 fixed-pitch composite propeller. Its last recorded 100 hour inspection was signed off on June 30, Its original maximum allowable gross weight was 870 pounds, but an undated pen and ink notation on the original weight and balance sheet indicated that the maximum allowable gross weight had been increased to 1,000 pounds as per information from Aero Designs (the kit manufacturer). The investigation also discovered a weight and balance calculation sheet from an earlier undated dual instructional flight which listed the actual total ramp weight for that fight as 963 pounds, and the maximum allowable gross weight as 1,000 pounds. METEOROLOGICAL INFORMATION About 20 minutes prior to the accident, the 1253 recorded aviation surface weather observation (METAR) at Salt Lake City International Airport (KSLC), which is located about 10 miles north of South Valley Regional Airport, indicated a wind from 200 degrees at 14 knots gusting to 19 knots, 10 miles visibility, few clouds at 6,000 feet, scattered towering cumulus clouds with bases at 9,000 feet, scattered clouds at 20,000 feet, a temperature of 23 degrees C, a dew point of 08 degrees C, and an altimeter setting of inches. Page 17 Copyright 1999, 2012,

18 The KSLC special METAR taken at 1338, approximately 25 minutes after the accident, indicated a wind varying in direction from 200 degrees to 270 degrees at 09 knots gusting to 21 knots, 10 miles visibility, thunderstorms with light rain, few cumulonimbus clouds with bases at 4,300 feet, scattered clouds at 7,000 feet, a broken layer at 10,000 feet, a broken layer at 20,000 feet, a temperature of 22 degrees C, a dew point of 08 degrees C, and an altimeter setting of inches. The METAR also included the remark that the peak wind since the last METAR had been from 170 degrees at 27 knots at It further remarked that there was occasional lightening in clouds to the southwest and west, and that there were thunderstorms to the west and southwest moving north. According to the flight instructor who made the aforementioned radio transmission and then took off as soon as he saw the airplane descend into the terrain, the Automated Weather Observation System (AWOS) information being transmitted at the time of the accident indicated a wind from 150 degrees at 12 knots gusting to 18 knots, a visibility of 10 miles, scattered clouds at 10,000 feet, a temperature of 23 degrees C, a dew point of 7 degrees C, and an altimeter setting of inches. He also remarked that during his takeoff, and while he was overhead the accident site, the air was smooth, without a single bump or downdraft. The flight instructor, who with his friend, had watched the takeoff from the ground, reported that he had been working around the airport since 0700, and had witnessed multiple small rain cells move through the area. But, he further reported that at the time of the accident, there was no cell over the airport or the accident area, and that the wind was nearly steady about 15 knots (varying about 1 to 3 knots), and almost directly down the runway. He did observe one rain cell to the southwest, but he did not believe that it had resulted in any wind gusts or microburst activity in the area of the airport at the time of the accident. Based upon a field elevation of 4,670 feet, a temperature of 23 degrees C, a dew point of 8 degrees C, and an altimeter setting of inches, the density altitude at the time of takeoff was calculated to be 6,790 feet. COMMUNICATIONS The only known radio communication between an occupant of the accident airplane and someone else, was what appeared to be the instructor pilot's response to transmitted question from the instructor pilot waiting to take off. In response to that query about whether they were having any technical difficulties, the response was, "No, it's just a weak aircraft." There were no further transmissions from the accident airplane. AIRPORT INFORMATION South Valley Regional Airport is a non-controlled airport with a single runway (16-34). The surface of the 5,860 foot runway was paved with asphalt, with a 238 foot displaced threshold at its southern end. The airport's field elevation is 4,607 feet above sea level. WRECKAGE AND IMPACT INFORMATIONS The airplane impacted flat grassy terrain in a complex of soccer fields about one-half mile south-southeast of the departure end of runway 16. The initial point of impact was at 40 degrees, 36 minutes, seconds North, by 111 degrees, 59 minutes, seconds West. At the point of initial impact there was one primary ground scar which had cut through the grass to a depth of about 6 inches. The scar was about one foot wide and about three feet long. From that point, to a point about 40 feet west of the initial impact, there was a 20 foot wide swath of wreckage material comprised primarily of broken pieces of wing skin, lower engine cowling, and blue colored Styrofoam associated with the structure of the wing ribs. The majority of the remainder of the aircraft structure came to rest in one location about 40 feet to the west of the initial point of impact. The wings, which were broken into numerous pieces, had separated from the fuselage. The cabin, which was no longer connected to the fuselage aft of the pilot and passenger seats, had broken into several separate pieces, and both the main landing gear structure and the engine had separated from the cabin section. Both occupants had been thrown from the cockpit. The fuselage, from just forward of the baggage area to the aft end of the empennage, maintained its undamaged structural integrity, except for a crack in the skin that ran vertically down from the bottom of the left baggage compartment window to the belly of the airplane. The left horizontal stabilizer and elevator, as well as the vertical stabilizer and rudder were undamaged and still attached to the fuselage. The right horizontal stabilizer and elevator had been torn loose from the empennage, and were lying on the ground adjacent to where they had been attached. All portions of the airframe structure were present at the accident site. After an on-site examination by the FAA and local law enforcement officials, the wreckage was recovered by airport personnel to a hangar owned by South Valley Regional Airport, where it later underwent further examination by the NTSB Investigator-In-Charge (IIC). That examination revealed flight control continuity from the aft part of the cockpit to the rudder and left elevator, as well as to the remaining structure of the right elevator actuating system. Flight control continuity to the ailerons could not be established due to the extent of the damage to the wings. The fuel selector was found in the FUEL (on) position, Page 18 Copyright 1999, 2012,